1. Techniques of chest physiotherapy

2. What is chest physiotherapy…??

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

4. 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

5. Postural drainage

7. Percussion

8. Vibration/shaking

9. Manual hyperinflation

10. Active cycle of breathing technique
Breathing control
FET
Thoracic expansion

11. Autogenic drainage

12. Positive expiratory pressure

13. High frequency chest compression

14. Exercises for airway clearance
Borg’s scale

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

16. 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

17. 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

18. 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

19. 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

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

21. Self assisted coughing technique

23. Manual coughing technique

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

27. 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

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

29. Diaphragmatic breathing

31. Segmental breathing

33. Pursed lip breathing

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

35. Indications
To increase ventilation
Respiratory muscle weakness

36. 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.

37. 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

38. 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.

39. 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

41. 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:

42. 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.

43. 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

44. 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

45. 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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47. 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

48. Thank you