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Chest physiotherapy: Clinical skills notes

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Notes

Respiratory

Chest Physiotherapy

INTRODUCTION

Chest physiotherapy, or simply CPT, is a technique that can be performed by certain healthcare workers for people suffering from diseases that impair mucus clearance, such as chronic obstructive pulmonary disease, bronchitis, and cystic fibrosis. The goal of CPT is to help the client clear excessive mucus secretions from the lungs in order to prevent complications, like mucus plugs, infections, and atelectasis. 

COMMON CARE TIPS
  • First, gather the supplies you’ll need, including: 
    • gloves, face shield, and gown for you 
    • pillows for the client’s comfort 
  • Keep suction machine equipment available to assist in clearing airway secretions in case the client’s ability to cough and clear their airway is ineffective. 
  • Make sure you know if the client is feeling weak, anxious, or in pain; individuals in pain can take analgesics 20 minutes before beginning CPT. 
  • CPT must be scheduled according to the client’s needs and daily routine and activities. 
    • Each CPT session usually lasts between 20 and 40 minutes, which can be very exhausting, so try to schedule it between rest periods. 
    • Avoid performing CPT around one to two hours before and after meals. 
    • The best times to perform CPT are: in the morning to clear secretions that may have accumulated overnight, as well as at night to clear the lungs before bedtime. 
    • Frequency of CPT varies for each client from just once daily to as frequent as every two hours. This will depend on each client’s needs and capabilities as well as the healthcare professional orders.
Figure 1: Supplies needed for chest physiotherapy. 
PROCEDURE

CPT includes postural drainage, percussion, vibration, and shaking. It involves a lot of touching, so before you begin, make sure you always explain to the client where and how you’ll be touching. 

Postural drainage (Fig. 2a) involves placing the individual in different positions for 10–15 minutes, using gravity to help clear lung secretions. Each position drains a corresponding lung section into the trachea, so before starting, you should know which lung segments require postural drainage to ensure the therapy is appropriate to the client's needs.

Each position in postural drainage is followed by percussion (Fig. 2b) over the lung area to be drained. To perform percussion, clap on the client’s chest wall with your hands cupped for 2–5 minutes to help clear the mucus from the bronchi into the larger airways. Most movement should come from the elbows and wrists. 

Vibration (Fig. 2c) can be applied by placing both hands over the same percussed area, one over the other, and performing a fine shaking movement for about 15 seconds or five exhalations. 

Finally, tell the client to cough forcefully to eliminate the lung secretions. Perform a total of three to four CPT sets, and make sure there’s suction machine equipment available to assist the client if needed. 

Figure 2: A. Postural drainage. B. Percussion involves clap on client's chest. C. Vibration involves shaking movement by hands.
POSITIONS

Left and right upper lobes

To drain the anterior apical bronchi (Fig. 3a):
  1. Position the client leaning back in a chair or in high-Fowler’s. 
  2. Stand in front of the client. Place your hands at the shoulders and your fingers over the clavicles. 
  3. Percuss and vibrate with the heels of the hands on the client’s chest. Make sure you do both sides at the same time.

To drain the posterior apical bronchi (Fig. 3b):
  1. Position the client in a chair, leaning forward on a pillow. 
  2. Place your hands on the upper back to percuss and vibrate both sides at the same time. Remember to never percuss directly over the spine.

To drain the anterior part of the upper lobes (Fig. 3c):
  1. Position the client lying back flat with a small pillow under the knees. 
  2. To percuss and vibrate, place your hands just below the clavicles. Remember to never percuss directly over the sternum.

To drain the lingula, which is a projection in the lower part of the left upper lobe (Fig. 3d):
  1. Position the client lying on the right side with the arm overhead, and put the bed in Trendelenburg position with the foot of the bed raised 30 cm (12 inches). 
  2. Place a pillow behind the client to roll a bit onto it. 
  3. Place your hands lateral to the left nipple just below the armpit to percuss and vibrate. 

To drain the right middle lobe (Fig. 3d), follow the same steps as for the lingula, but position the client to the left side.
Figure 3: A. Anterior apical bronchi drainage B. Posterior apical bronchi drainage. C.  Anterior part of the upper lobes. D. Lingula and right middle lobe drainage.

Lower lobes

To drain the superior bronchi of the right and left lower lobes (Fig. 4a):
  1. Position the client lying flat on their stomach with a pillow underneath. 
  2. Place your hands below the scapula on both sides to percuss and vibrate. 

To drain the anterior bronchi of the left and right lower lobes (Fig. 4b):
  1. Position the client lying back with the knees bent over a pillow. 
  2. Put the bed in Trendelenburg position raised 45–50 cm, or 18–20 inches. 
  3. To percuss and vibrate, place your hands over the lower anterior ribs on both sides. 

To drain the lateral bronchi of the left lower lobe (Fig. 4c):
  1. Position the client on the right side with a pillow behind the back and the right arm raised. 
  2. Put the bed in Trendelenburg position with the foot of the bed raised 45–50 cm, or 18–20 inches. 
  3. To percuss and vibrate, place your hands on the left side of the chest below the scapula and posterior to the midaxillary line. 

To drain the lateral bronchi of the right lower lobe (Fig. 4d), follow the same steps as for the lateral bronchi of the left lower lobe, but on the opposite side.
Figure 4: Lower lobe drainage. A. Superior bronchi of the right and left lower lobes drainage. B. Anterior bronchi of the left and right lower lobes drainage. C. Lateral bronchi of the left and right lower lobe drainage.
DOCUMENTATION
  • Report any signs or symptoms of respiratory distress to the healthcare provider. 
  • Observe and document the amount and character of the sputum.
  • Auscultate the lung fields to check if mucus clearance relieves abnormal lung sounds, like inspiratory crackles, to determine if the client is able to clear the mucus properly.
ACAPELLA DEVICE
Some individuals may experience fatigue or shortness of breath due to CPT. These individuals could benefit from using an Acapella device, which is a hand-held respiratory device that clients can use independently. The device aids in mucus clearance and prevents airway collapse by combining positive expiratory pressure, or simply PEP therapy, with airway vibrations. The device is made up of a mouthpiece, cover, valve, rocker assembly, and a frequency adjustment dial to manage the flow resistance. Initially, it should be set to the lowest resistance. Over time, as the client improves, the resistance level can be adjusted upward by turning the adjustment dial clockwise. If the client needs aerosol therapy, a nebulizer can be attached to the end of the valve.

To use an Acapella device, the client should:
  1. Sit up comfortably, then inhale. The breath should be deep, but not reach maximum respiratory capacity. 
  2. Place the mouthpiece into the mouth while holding their breath for about three seconds. 
  3. Exhale through the mouthpiece for about four seconds, transmitting the pressure from the airways to the device and creating positive expiratory pressure. As the pressure increases, the expiring air forces cause the rocker to vibrate. 
  4. Repeat these steps for 5–10 breaths. 
    • If the client can’t exhale for this length of time, the dial can be adjusted accordingly. 
  5. Remove the mouthpiece and do one to two huff coughs to clear mucus.
Figure 5: Acapella device.