Chest Physiotherapy Techniques

Chest Physiotherapy (Pulmonary Rehabilitation)

• Chest physiotherapy employs physical methods to reduce breathing effort, re-educate breathing patterns, enhance gas exchange, assist coughing, and clear excess secretions.

Aims of Chest Physiotherapy

• Decrease work of breathing
• Re-educate breathing techniques
• Improve gas exchange
• Assist coughing
• Remove excess secretions

Airway Clearance Techniques (Manual Techniques with Postural Drainage)

• Percussion: A manual technique used by respiratory therapists to improve airway clearance by mobilizing secretions in one or more lung segments to the central airways. It involves cupping hands alternately on the chest wall, producing an energy wave transmitted to the lungs & airways.

Types of Percussion

• Manual Percussion: Using cupped hands
• Mechanical Percussion: Electric or pneumatic percussors (available in various intensities & frequencies for adults & children)
• Intrapulmonary Percussive Ventilation (IPV): Provides intrathoracic percussion & vibration, an alternative method for positive pressure delivery to the lungs.

Percussion Technique

• Hands move in alternating rhythmic patterns during both phases of respiration.
• Percussion rate is 100-480 times per minute.
• The sound should be hollow, not a slap.
• Consistent force application is crucial.
• Percussion should be performed for several minutes.

Precautions for Percussion

• Avoid bony prominences
• Avoid floating ribs
• Avoid performing over breast tissue

Vibration

• A fine oscillatory movement combined with chest compression, used to remove secretions.
• Gentle & high-frequency hand movements
• Apply hand on chest wall, either side-by-side or overlapping.
• Apply during exhalation, in the same direction of movement.
• Achieved by isometric contraction of the therapist's upper limb.

High-Frequency Chest Wall Oscillation (HFCWO)

• External chest wall oscillations using an inflatable vest, applied to the chest.
• These machines vary frequencies & intensities, helping loosen & thin mucus, separating it from airway walls.

Shaking (Manual Technique)

• Vigorous vibration using intermittent bouncing maneuvers, paired with wide hand movements during exhalation.

Cough & Huff

• Cough Definition: A sudden expulsion of air against a closed glottis, voluntarily or reflexively. Effective for clearing secretions in the first 7 generations of bronchi.
• Mechanism: Deep inhalation → glottis closes & vocal cords tighten → abdominal muscles contract → diaphragm elevates → increasing thoracic & abdominal pressure → glottis opens.

Cough Stimulation Methods

• Splinting: Decreasing incisional pain by applying hands or pillows.
• Tracheal Tickle: Used in children & unconscious patients using circular motion on the trachea.
• Neuromuscular Facilitation: Intermittent 3-5 second ice application on paraspinal muscles to stimulate afferent nerves.
• Suction: For patients unable to cough or who are on artificial airways, though it only clears the trachea & main bronchi.
• Humidification: Increasing hot fluid intake to mobilize thick secretions.

Cough & Huff Types

• Cough: Voluntary or reflexive, productive or non-productive, does not stimulate huffing, closed glottis, increases intra-abdominal & intrathoracic pressure, forced expiration.
• Huff: Voluntary, non-productive, stimulates coughing, open glottis, deeper than cough with less pressure, less expiratory force.

Stretching

• Elongates pathologically shortened soft tissue while increasing range of motion & mobility.
• Types:
  • 1-Active: where agonist stretch antagonist.
  • 2-Passive: external force.
• Aims:
  • Lengthen soft tissues
  • Increase joint mobility
  • Break adhesions
  • Improve respiratory functions

Pleural Stretching Techniques

• The pleura are thin membranes lining the lungs; muscles & surrounding tissues can be stretched to enhance lung expansion & reduce pleural restriction.
• Benefits: Improves lung expansion, reduces stiffness, improves breathing in conditions like asthma, COPD, or post-surgery.
• Techniques: Includes deep diaphragmatic breathing, thoracic expansion exercises, intercostal stretching, side-lying thoracic expansion, segmental breathing, cat-cow stretch (thoracic mobility), rib cage mobilization, trunk rotation stretch, pursed lip breathing, and incentive spirometry.

Relaxation Techniques

• Therapeutic exercises to decrease tension & anxiety, targeting stress-related physiological responses.
• Stress responses: increased heart rate, palpitations, excess sweating, shortness of breath, and muscle tension.
• Relaxation techniques can: slow heart rate, lower blood pressure, slow breathing rate, improve digestion, maintain blood sugar levels, reduce stress hormones, increase blood flow to major muscles, relieve muscle tension/chronic pain, improve mood, improve sleep quality, and lower fatigue.
• Techniques: Deep breathing/diaphragmatic breathing, guided imagery, progressive muscle relaxation.

Devices Used for Respiratory Muscle Training

• Weakness of respiratory muscles occurs due to a reduction in muscle contractility, impacting normal pressure & airflow during breathing. Caused by respiratory diseases (COPD, emphysema), neurological lesions, electrolyte imbalances, blood gas abnormalities, intense weight loss, or cardiac decompensation.
• Respiratory Muscle Training: Repetitive breathing exercises against an external load (controlled by time, intensity, & frequency).
  • Aims: Increase strength of respiratory muscles, improve exercise performance/capacity.
  • Overloading: Increased training duration, increasing intensities, increasing frequency.
• Muscle Response: Strength improves with high-intensity/short duration stimuli. Endurance improves with low-intensity/long duration stimuli.
• Types of Respiratory Training Devices:
  • Endurance-training devices (prolonged periods, e.g., 30 minutes).
  • Resistance-training devices (e.g., flow resistance).
• Mechanisms:
  • Passive flow-resistance uses a variable diameter orifice, resisting load. Dynamic flow-resistance continuously adjusts flow rate dependent on breath.
  • Example: Power-breath, pressure threshold valves require a pressure load exerted by the patient for respiration initiation.

Incentive Spirometer

• A device that measures inhaled air volume.
• Operation: Breathing in triggers a piston rising within the device, illustrating inhaled volume.
• Patient's inspiratory effort is assessed by visual feedback of increasing volume.
• Types: Flow-oriented (FIS) for increasing upper chest muscle work and Volume-oriented (VIS) improving diaphragm activity.

Indications of Use

• Ribcage injuries
• Bedridden patients
• Asthma
• Pneumonia
• Chronic obstructive pulmonary disease
• Cystic fibrosis
• Sickle cell anemia
• Atelectasis

Positive Expiratory Pressure (PEP)

• Breathing against resistance (device or pursed lips).
• The increase in pressure transmits to airways, creating back pressure, stenting them during exhalation.
• Role of PEP: Prevent premature airway closure, reduce gas trapping, promote collateral ventilation to areas distal to obstructions, facilitate airway clearance by promoting mucus movement proximally.
• PEP Therapy: The patient exhales against a fixed-orifice resistor, usually generating 10-20 cm H2O pressure. Devices like Acapella combine PEP & airway vibrations.

Acapella

• Combines PEP therapy & airway vibrations for pulmonary secretion mobilization.
• Allows use in any position. Facilitates airway opening.
• Facilitates opening of airways for conditions like COPD, asthma, & cystic fibrosis.
• Color-coded units for adjusting flow (15 L/min high, <15 low), based on clinical need.
• Allows inhalation & exhalation without removing the device.
• Prolongs expiratory airflows for increased secretion removal.

Flutter

• Small, pipe-shaped device with PEP & high-frequency oscillation.
• Generates vibrations during exhalation to help mobilize airway secretions.
• Facilitates clearance and improves airflow.

Peak Flow Meter

• Used for asthma management, providing information about airway openness.
• Measures small changes in airways prior to wheezing.
• Daily use helps track when peak flows drop, facilitating timely medication adjustments.

Peak Flow Zones

• Green zone (80-100% of personal best): normal peak flow
• Yellow zone (50-80% of personal best): caution, narrowing airways
• Red zone (<50% of personal best): severe airway narrowing, stop activity & seek help