Chest Physical Therapy PDF

Chest Physical Therapy CPT – Part 2 Remember Role of Physiotherapy in respiratory conditions: Treatment administered to increase Ventilation & Oxygenation Treatment administered to improve secretion clearance Treatment administered to reduce O2 consumption Treatment administere...

Chest Physical Therapy CPT – Part 2 Remember Role of Physiotherapy in respiratory conditions: Treatment administered to increase Ventilation & Oxygenation Treatment administered to improve secretion clearance Treatment administered to reduce O2 consumption Treatment administered to improve exercise tolerance (endurance exercise) Treatment administered to reduce pain Treatment administered to promote relaxation Remember Positioning Controlled Techniques Breathing Retraining 2. Treatment administered to improve secretion clearance a) To enhance cough( techniques to improve cough) b) To enhance muco-ciliary transport(Postural drainage) c) Bronchial hygiene techniques ACB, Autogenic drainage, PEP, Flutter, Acapella, High frequency chest wall oscillations Airway Clearance Techniques Coughing Techniques (Huffing, cough, forced expiration technique) Postural drainage Percussion Vibration Shaking / Rib Spring Active Cycle of Breathing Technique Autogenic Drainage Positive Expiratory Pressure High Frequency Chest wall Oscillation Manual Hyperinflation Intrapulmonary percussive ventilation (IPV) Exercise (aerobic, peripheral & respiratory muscle training)  Cough Cough is an explosive expiration that provides a normal protective mechanism for clearing the tracheobronchial tree of secretions and foreign material.  Pulmonary irritant receptors (cough receptors) in the epithelium of the respiratory tract are sensitive to both mechanical and chemical stimuli. Stimulation of the cough receptors by dust or other foreign particles produces a cough, which is necessary to remove the foreign material from the respiratory tract before it reaches the lungs. The cough receptors, or rapidly adapting irritant receptors are located mainly on the posterior wall of the trachea, pharynx, and at the main carina Coughing may be initiated either voluntarily or reflexively As a defensive reflex it has both afferent and efferent pathways Mechanism of normal cough Deep inspiration Glottis closure and tightness of vocal cords Abdominal muscles contraction and elevation of diaphragm which causes an increase in intra-abdominal and intra-thoracic pressure. Glottis opens & Sudden forced expiration of air  Stages of Cough: There are four stages involved in producing an effective cough.  The first stage requires inspiring enough air to provide the volume necessary for a forceful cough. Generally, adequate inspiratory volumes for a cough are noted to be at least 60% of the predicted vital capacity for that individual. The second stage involves closing of the glottis (vocal folds) to prepare for the abdominal and intercostal muscles to produce positive intrathoracic pressure distal to the glottis.  The third stage is the active contraction of these muscles. The fourth and final stage involves opening of the glottis and forcefully expelling the air. The patient should be able to cough three to six times per expiratory effort. A minimal threshold of (FEV1) (forced expiratory volume in 1 second) of at least 60% of the patient's actual vital capacity is a good indicator of adequate muscle strength necessary for effective expulsion. During a cough, alveolar, pleural, and sub glottal pressures may rise as much as 200 cm H2O.  Factors 1- Inability of the that patient to take deep decrease inspiration due to: the - Pain. effectiven -Weakness of the diaphragm ess of and accessory muscles of inspiration. cough mechanism 2- Inability of the patient to forcibly expel the air caused by: - Spinal cord injury above T- 10. - Tracheostomy. - Critical illness that causes excessive fatigue. 3- Decrease in normal ciliary action in the bronchial tree secondary to: General anesthesia and intubation. COPD. Smoking. 4- increase in the amount and viscosity of the mucus due to: Cystic fibrosis and Chronic bronchitis Dehydration.  Techniques to improve cough 1- Positioning for cough 2- Forced expiration (or Huffing) stimulates cough 3- Pressure applied to - over trachea to elicit cough reflex(tracheal tickle) - Mid-rectus abdominis after inspiration. - Along the lower costal border during exhalation. 4- Nuero muscular facilitation 5- Mauual –Assisted cough. 1. Positioning for cough Sitting in the forward leaning posture with the neck flexed, the arms supported, and the feet firmly planted on the floor promotes effective coughing.  A Huff Cough is a 2.Forced gentle cough, done expiratio with an open n or glottis all through huffing exhalation. stimulate s cough To keep your glottis open, keep your mouth open as you exhale. 2.Forced expiration or huffing Sit in a comfortable position. Do a few nice slow deep breaths using diaphragmatic breathing. Inhale slowly and hold your breath for two to three seconds. Exhale like you are “fogging” a mirror or your glasses. This will make a “huffing” sound, until most air is out. Use your abdominal muscles to help you exhale fully. Do several, (2-3) huff coughs and then rest. After several minutes, repeat if needed. 3. Tracheal tickle Tracheal stimulation, sometimes called a tracheal tickle, may be used with infants or disoriented patients who cannot cooperate in the treatment. This is somewhat uncomfortable maneuver, performed to elicit a reflexive cough. The therapist places two fingers at the sternal notch and applies a circular motion with pressure downward into the trachea to facilitate a reflexive cough. 4. Neuro muscular facilitation Intermittent application of ice over paraspinal muscle 3-5 sec of thoracic spine  Assisted coughing is the term used to describe the way an 5.Manua individual can replace l - the function paralysed of the expiratory Assiste muscles increased by creating pressure d underneath the working diaphragm. Coughin For example When the g spinal cord is damaged the respiratory muscles innervated below the level of the lesion become paralysed. Contraindicatio ns of Manual - Assisted Coughing Unstable angina or arrhythmia Extensive chest trauma, rib fractures / flail segment (osteoporosis, carcinoma) Manual -Assisted Coughing techniques One Person techniques I. Heimlich-type or abdominal thrust assist 2. Costophrenic assist 3. Anterior chest compression assist 4. Counter rotation assist Two people techniques Self assisted coughing techniques  1. Heimlich-type or abdominal thrust assist 1. Place the heels of your hands underneath the ribs (heel of one or both hands) 2. As the patient attempts to cough push inwards and upwards  Another Technique Place one forearm across the upper abdomen of the patient with your hand curved around the opposite side of the chest. Your other hand is placed on the near side of the chest. As the patient attempts to cough, push simultaneously inwards and upwards with your forearm, squeezing and stabilising with the other hand. Assisted coughing – in wheelchair Technique 1 Lock the brakes on the wheelchair. Stand behind the wheelchair and put your arms around the patient linking your hands together in front over the lower rib cage and upper abdomen. As the patient attempts to cough pull your hands up and inwards to assist them. Assisted coughing – in wheelchair - Technique 2 Back the wheelchair up against a wall so that it won't tip backwards and lock the brakes. Position yourself in front of the patient and place your hands over the lower ribs / upper abdomen. Push upwards and inwards as the patient attempts to cough. 2) Costophrenic assist Therapist hands on costophrenic angle While inhalation apply quick manual stretch downward and inward toward the patient navel Hold inspiration Just before asking the patient to expire and cough apply strong hand pressure downward and inward towards the navel 3) Anterior chest compression assist: The therapist puts one arm across the patient's pectoralis region to compress the upper chest and the other arm is either placed parallel on the lower chest or abdomen or placed like in the Heimlich type of maneuver.  Because of the direct manual contact on the chest, inspiration can be easily facilitated first, followed by a "hold." Thus the therapist can readily enhance the first two cough stages. The therapist then applies a quick force through both arms to simulate the force necessary during the expulsion phase. The directions of the force are (l) down and back on the upper chest, and (2) Up and back on the lower chest or abdominal arm. Performed together the compression force from both arms makes the letter V. Advantages / disadvantages of this technique: The anterior chest compression technique is more effective than the costophrenic assist for patients with very weak chest wall muscles because of the added compression of the upper anterior chest wall. However, the anterior chest compression technique is NOT appropriate for patients with a cavus condition of the upper anterior chest because it promotes further collapsing of the anterior chest wall 4) Counter rotation assist : Same technique as in costophrenic assist and Heimlich-type assist but from Side lying Where one hand of the therapist is placed on patient’s shoulder and the other placed on abdomen (as in Heimlich-type) or on costophrenic angle (as in costopherinic assist) The therapist pushes patient shoulder with one hand while applying the cough assist with the other hand thus performing counter rotation.  Two person technique Stand on either side of the bed. Each person should place one forearm across the upper abdomen of the patient with your hand curved around the opposite side of the chest. Your other hand is placed on the near side of the chest. As the patient attempts to cough, push simultaneously inwards and upwards with your forearms, squeezing and stabilising with the other hand.  For the first procedure, tetraplegic-long-sitting self- assist, the patient is positioned on a mat in a long-sitting posture (legs straight out in front of the Self patient) and with upper extremity assisted support. The therapist instructs the patient to extend his or her techniques body backward maximally while inhaling Long- sitting The therapist then tells the self- patient to cough as the patient assisted throws his or her upper body cough forward into a completely flexed posture, using shoulder internal rotation if possible.  Once again, the extension aspect of the procedure is used to maximize inhalation, whereas the flexion aspect is used to maximize expiration. The self-directed chest compression occurs mainly on the superior-inferior plane of ventilation only.  The second procedure, the paraplegic-long-sit assist, uses the same principles as the techniques described for the tetraplegic-long-sit assist. These patients have active spinal extension musculature and can achieve greater trunk extension and flexion safely, achieving greater chest expansion before the cough and greater chest compression on a superior inferior plane during the cough. The patient positions his or her upper extremities in a butterfly position or uses elbow retraction, depending on the level of injury.  During the flexion phase, patients throw themselves onto their legs, thereby compressing both the upper and lower chest. This can be taught very successful to patients with paraplegia, provided they do not have an interfering tone problems. If the patient lacks hip flexion or is worried about bony contact or skin injury, place a pillow (or two as needed) on the legs. This will limit the hip flexion and minimize trauma from the quick thrust onto the legs. Self-assisted coughing in wheel chair Leaning forwards as they cough can also help to increase the strength of the cough, but the patient must have good balance. patient uses both forearm as the abdominal thrust (Figure 1) OR- patient uses only one forearm while doing rotation to the opposite side (Figure 2) Treatment administered to improve secretion clearance as Postural drainage (PD) Gravity assisted positioning, uses different body positions to help the drainage of secretions from particular areas of the lungs and also helps to increase the air movement or ventilation to different parts of the lungs. It is often used in conjunction with other techniques e.g. ACBT or percussion.  Indications for Postural Drainage Prevent Accumulation of Secretions in Patients at Risk for Pulmonary Complications: Patients with pulmonary diseases that are associated with increased production or viscosity of mucus, such as chronic bronchitis and cystic fibrosis Patients who are on prolonged bed rest Patients who have received general anesthesia and who may have painful incisions that restrict deep breathing and coughing postoperatively Any patient who is on a ventilator if he or she is stable enough to tolerate the treatment  Indications for Postural Drainage Remove Accumulated Secretions from the Lungs: Patients with acute or chronic lung disease, such as pneumonia, atelectasis, acute lung infections, COPD Patients who are generally very weak or are elderly Patients with artificial airways.  Relative Contraindications to PD Severe hemoptysis Severe pulmonary edema Large pleural effusion Aortic Aneurysm Cardiac arrhythmia Severe hypertension or hypotension Unstable angina Recent neurosurgery (head-down position may cause  intracranial pressure)-modify position Percussion Chest percussion involves striking the chest wall over the area being drained. Percussing lung areas involves the use of cupped palm to loosen pulmonary secretions so that hey can be expectorated with ease. Percussion technique Percussing with the hand held in a rigid dome-shaped position, the area over the lung lobes to be drained in struck in rhythmic pattern. Usually the patient will be positioned in supine or prone and should not experience any pain. Typically, each area is percussed for 30 to 6o seconds several times a day. If the patient has tenacious secretions, the area must be percussed for 3-5 minutes several times per day  Cup hands with fingers and thumbs closed, use mechanical percussor, or use neonatal percussor on premature infants. Begin percussion over lung segment by flexion and extension of wrists. The therapist's shoulders and elbows should be relaxed.  Percuss back and forth or in a circular motion, not continuously over one spot. Avoid spine, kidneys, base of the rib cage, and bony prominences such as sternum, clavicle, spine, and over scapula. Use caution in areas of breast. Percussion should not be painful or uncomfortable to the patient. Amount of time for percussion varies: 30-45 seconds to 2-3 minutes per segment depending on amount of secretions and how easily moved. If using a mechanical percussor, the same precautions apply. Contraindication to Percussion bare skin or performed over surgical incisions, below the ribs, or over the spine and breasts because of the danger of tissue damage. Fractures Osteoporotic bone Tumor area If the patient has pulmonary embolus If the patient has unstable angina If the patient has chest wall pain Difference in hand position Between Percussion & Vibration Remember The Anatomy! Anatomy of the lung  I. Postural Drainage Definition: Placing the patient in certain position to allow gravity to drain a specific lung segment. This will help on better breathing and infection avoidance. Modified PD are used when a precaution or relative contraindication to the ideal position exists. For example, if an increase in intracranial pressure is a concern, the head of the bed should remain flat instead of being tipped into Trendelenburg (head down) position.  Indications: Prolonged bed rest. Pre/post operative secretion control. Lung disease with retained secretions. Patient on mechanical ventilator Neurological conditions which affect respiratory muscles  Contraindications: Unstable cardiovascular system. Pulmonary edema/embolism or congested heart failure. Recent head injuries. Presence of hemoptysis. Untreated tension pneumothorax. To get the most benefits from P-D follow these tips: Mucus must be thin ( encourage hot drinks). Use bronchodilators before positioning in sever cases. Do P-D only with empty stomach. Choose good timing (at early morning-in the evening before going to bed) Remain each position from 5-10 min and total ttt about 45-50 min.  Preparation for Postural Drainage: At first the patient must be medically stable. Loosen any tight clothes and explain to the patient what will you do. Patient must be relaxed and observed any tubes connected to him. Have suctioning equipment ready to remove secretions from an artificial airway or the patient's oral or nasal cavity after the treatment.  Identifying the secretion site: By using: Percussion. Auscultation X-ray. Asking the patient.  Discontinue Postural Drainage: If chest x-ray is relatively clear. If patient is a febrile for 24 to 48 hours. If normal or near normal breath sound are heard with auscultation. If patient is on a regular home program. Application of Postural Drainage Firstly determining the lobe of the lung to be treated. Position the patient in the appropriate position, using pillows or bed rolls. Each position should be maintained for 5 to 10 minutes, if tolerated, or longer when focusing on a specific lobe. If postural drainage is used in conjunction with another technique, the time in each position may be decreased. (3 to 5 minutes is sufficient.)  A patient who requires close monitoring should not be left unattended in a Trendelenberg position. It is not necessary to treat each affected lung segment during each treatment. The most affected lobes should be addressed with the first treatment of the day, with the other affected areas addressed at a subsequent treatment. The patient should be encouraged to take deep breaths and cough after the treatment and if possible after each position. Secretions may not be mobilized immediately after the treatment but possibly 1half hour to1 hour later.  Notes To drain middle and lower portions of the lungs, the chest must be above the head. To drain the upper portion of the lung, the patient is in sitting position at about 45 degree. Make P-D more enjoyable ( schedule P-D around TV)  Upper Lobe Apical segment Patient position Percussion site Sits in upright position ( half lying) Under the clavicle  Upper Lobe Anterior segment Patient position Percussion site Sits with slight leaning backwards (left) Just above the breast. Or supine lying ( right)  Upper Lobe Posterior segment Patient position Percussion site Prone lying or sitting with slightly leaning Above the scapula forward  Middle Lobe (Right lung) Medial segment Patient position Percussion site Side lying on left side, supported with pillows behind his back, patient leaning backward 45 degree and the Under the right breast. bed raised 14 inch from the lower end.  Middle Lobe (Right lung) Lateral segment Patient position Percussion site Side lying on left side, supported with pillows Under the right breast. anteriorly , patient leaning forward 45 degree and the bed raised 14 inch from the lower end.  Lingula (left lung) Inferior lingula Patient position Percussion site Side lying on Right side, supported with pillows Under the left breast. behind his back, patient leaning backward 45 degree and the bed raised 14 inch from the lower end.  Lingula (left lung) Superior lingula Patient position Percussion site Side lying on right side, supported with pillows anteriorly, patient leaning forward 45 Under the left breast. degree and the bed raised 14 inch from the lower end.  Lower Lobe Apical segment (Right and left lung) Patient position Percussion site Prone lying with pillow under his Below the scapulae. abdomen to flatten his back  Lower Lobe Anterior segment (Right and left lung) Patient position Percussion site Supine lying with pillows under his Over the lower portion of the ribs. knees, the bed raised 18 inch from the lower end  Lower Lobe Posterior segment (Right and left lung) Patient position Percussion site Prone lying with pillows under his Over the lower portion of the ribs. abdomin, the bed raised 18 inch from the lower end  Lower Lobe Lateral segment (Right and left lung) Patient position Percussion site Side lying on the opposite side supported with Under lateral aspect of the rib pillows anteriorly, with leaning forward 45 degree, cage of the drained segment and bed raised 18 inch from the lower end.  Lower Lobe Medial segment (Right lung) Patient position Percussion site Side lying on the Right side supported with Over lateral aspect of the right pillows behind his back, with leaning backward rib cage 45 degree, and bed raised 18 inch from the lower end. III. Vibration  III. Vibration Vibrating the chest wall to mobilize secretions toward the trachea. This technique is used in conjunction with percussion in postural drainage. Vibration is applied throughout exhalation concurrently with mild compression to the chest wall.  Vibration It is applied only during expiration to move the secretions to the larger airways. Vibration is applied by placing both hands directly on the skin and over the chest wall (or one hand on top of the other) and gently compressing and rapidly vibrating the chest wall as the patient breathes out. Pressure is applied in the same direction as that in which the chest is moving.  Application of Vibration Vibration is applied by placing both hands directly on the skin and over the chest wall ( or one hand on to of the other) and gently compressing and rapidly vibrating the chest wall as the patient breaths out.. Pressure is applied in the same direction as that in which the chest is moving. The vibrating action is achieved by the therapist’s isometric ally contracting the ms of the UL from shoulders to hands.  Shaking Definition: Shaking consists of a bouncing maneuver (sometimes referred to as "rib springing") against the thoracic wall in a rhythmic fashion throughout exhalation. A concurrent pressure is given to the chest wall, compressing the thorax..  Shaking is proposed to: mobilizing secretions to the central, larger airways from the lung periphery. Since the compressive force to the thorax is greater, producing increased chest wall displacement, the stretch to the respiratory muscles may produce an increased inspiratory effort and lung volume. The same relative contraindications for percussion should be observed for shaking, since it does involve application of force to the thorax.  NB: Vibration & Shaking Vibration involves a gentle, high frequency force, whereas shaking is more vigorous in nature. Vibration is performed by co-contracting all the muscles in the caregiver's upper extremities to cause a vibration while applying pressure to the chest wall with the hands. Shaking is a stronger bouncing maneuver, which also supplies a concurrent, compressive force to the chest wall.  Treatment with Vibration/Shaking: For shaking: instruct the patient to take in a deep breath. At the peak of inspiration, apply a slow (approximately 2 times per second), rhythmic bouncing pressure to the chest wall until the end of expiration. The hands follow the movement of the chest as the air is exhaled. For vibration, the hands may be placed side by side or on top of one another. As with shaking, the patient is instructed to take in a deep breath while in a proper PD position. A gentle but steady co- contraction of the upper extremities is performed to vibrate the chest wall, beginning at the peak of inspiration and following the movement of chest deflation.