Techniques of chest physiotherapy

What is chest physiotherapy…??

Types of techniques Airway clearance techniques Facilitating airway clearance technique with effective coughing techniques Technique to facilitate ventilation pattern Mobilization and Exercises

Airway clearance technique Postural drainage Percussion Vibration/shaking Manual hyperinflation Active cycle of breathing technique Autogenic drainage Positive expiratory pressure High frequency chest compression Exercises for airway clearance

Postural drainage

Percussion

Vibration/shaking

Manual hyperinflation

Active cycle of breathing technique Breathing control FET Thoracic expansion

Autogenic drainage

Positive expiratory pressure

High frequency chest compression

Exercises for airway clearance Borg’s scale

Indications and cautions Cystic fibrosis Atelectasis Asthama Respiratpry muscle weakness Bronchiectasis Mechanical ventilation Neonatal respiratory distress syndrome

contraindications Intracranial pressure (ICP) > 20 mm Hg Head and neck injury until stabilized Active hemorrhage with hemodynamic instability Recent spinal surgery (e.g .• laminectomy) or acute spinal injury Active hemoptysis Empyema Bronchopleural fistula Large pleural effusions Pulmonary embolism Aged, confused, or anxious patients Rib fracture. with or without flail chest Surgical wound or healing tissue

Trendelenburg Position is Contraindicated for the Following: . Patients in whom increased ICP is to be avoided Uncontrolled hypertension Distended abdomen Esophageal surgery Recent gross hemoptysis related to recent lung carcinoma Uncontrolled airway at risk for aspiration

Subcutaneous cmphysema Recent epidural spinal infusion or spinal anesthesia Recent skin grafts, or flaps, on the thorax Burns. open wounds. and skin infections of the thorax Recently placed pacemaker Suspected pulmonary tuberculosis Lung contusion Bronchospasm Osteomyelitis of the ribs Osteoporosis Coagulopathy Complaint of chest-wall pain

Treatment prescription. Motivation Patient’s goals Physician/caregiver’s goals Effectiveness ( of considered technique Patient’s age Ease (of learning and of teaching) Skill of therapist/teachers Fatigue or work required Need for assistants or equipment Limitations of technique based on disease type and severity Costs (direct and indirect) Desirability of combing methods

Facilitating airway clearance with effective coughing technique What is cough….??? Stages of cough Techniques of teaching effective coughing self assisted coughing manual coughing

Self assisted coughing technique

Manual coughing technique

Technique to faciliate ventilation pattern Body positioning Breathing technique Mobilizing the thorax Facilitating the accessory muscles of respiration

Body positioning Standing upright position Erect sitting (self supported or with assist) with feet moving (e.g., active, active assisted or passive cycling motion) Erect silting (self-supported or with assist) with feet dependent Lean forward sitting with arms supported and feet dependent 24S degree sitting with legs dependent Erect long sitting (legs non dependent) < 4S degrees sitting (legs non dependenl) Prone and semi prone/side lying Supine

Breathing techniques Diaphragmatic breathing pattern Segmental expansion Glossopharyngeal breathing technique Pursed lip breathing

Diaphragmatic breathing

Segmental breathing

Pursed lip breathing

Facilitating the accessory muscles of respiration Pectoralis Major Sternocleido mastoid Trapezius Serratus anterior

Indications To increase ventilation Respiratory muscle weakness

Mobilization and exercises What is mobilization.? Mobilization is defined as the therapeutic and prescriptive application of low-intensity exercise in the management of cardiopulmonary dysfunction usually in acutely ill patients. Primarily, the goal of mobilization is to exploit the acute effects of exercise to optimize oxygen transport. Even a relatively low intensity mobilization stimulus can impose considerable metabolic demand on the patient with cardiopulmonary compromise.

In addition, mobilization is performed in the upright position, that is the physiologic position, whenever possible, to optimize the effects of being upright on central and peripheral hemodynamics and fluid shifts. Thus mobilization is prescribed to elicit both a gravitational stimulus and an exercise stimulus

exercise What are the exercises given Exercise is the term used to describe the therapeu­ tic and prescriptive application of exercise in the management of subacute and chronic cardiopul­ monary and cardiovascular dysfunction. Primarily, the goal of exercise is to exploit the cumulative ef­ fects of and adaptation to long-term exercise and thereby optimize the function of all steps in the oxy­ gen transport pathway.

Treatment prescription for mobilization and exercises It depends on the patient’s condition Whether the patient is in patient or in out patient department Also it depends on the functionality of the patient at the present stage It is decided on the basis of the exercise testing protocol Also on the basis of METs

Step 1 Identify all the factors underlying the pathology causing deficits in oxygen supply. Step 2 Determine whether mobilization and exercise are indicated and if so, which form of either will specifically address the oxygen transport deficits identified in Step I. Step 3 Match the appropriate mobilization or exercise stimulus to patient's oxygen transport capacity. Step 4 Set the intensity within therapeutic and safe limits of the patient's oxygen transport capacity. Step 5 Combine the various body positions especially in the erect position with the following maneuvers:

Step 6 Set the duration of the mobilization sessions based on the patient's responses (i.e., changes in measures and indices of oxygen transport) rather than time. Step 7 Repeat the mobilization session as often as possible based on its beneficial effects and on is being safely tolerated by the patient. Step 8 Increase the intensity of the mobilization stimulus. duration of the session, or both comml!l1surate with the patient's capacity to maintain optimal oxygen transport when confronted with an increased mobilization stressor, and in the absence of distress; monitored variables to remain within predetermined threshold range.

Heiarchy of treatment for oxygen supply treatment PREMISE: Position of optimal physiological function is being upright and moving. Mobilization and Exercise Body Positioning Breathing Control Maneuvers Coughing Maneuvers To minimize the work of breathing. of the heart. and oxygen demand overall ROM Exercises (Cardiopulmonary indications) Postural Drainage Positioning Manual Technique Suctioning

Parameters for treatment prescription in the management of cardiopulmonary patients Define parameters of treatment based on history, laboratory investigations, tests, and assessment Treatment type Intensity (if applicable) Duration Frequency Instruct patient in "between treatment" treatment, and if applicable the nurse. a family member. or both Reassessment every treatment Modify as necessary within each treatment Progress between treatments as indicated

Define treatment outcomes Determine when treatment is to be discontinued Request for additional supportive information. tests, and investigations as indicated Predict time course for optimal effects and course of treatment to determine treatment efficacy; modify as necessary In conjunction with other interventions (e.g., medical, surgical, nursing, respiratory therapy (weaning oxygen supplementation. sympathomimetic drugs, ADLs, balance with sleep and rest periods. peak of nutrition and feeds. Peak energy times. peak of drug potency and effects (e.g., pain, reduced sedation. reduced neuromuscular blockade)

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references Principles and practice of cardiopulmomary physical therapy 3rd edition Donna Frownfelter Tidy’s physiotherapy Physiotherapy for respiratory and cardiac problems 3rd edition by Jenifer A Pryor

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