P H YS I OT H E R A P Y T E C H N I Q U E S I N
C A R D I O R E S P I R AT O RY C O N D I T I O N S ( I )
P S T 4 2 1 – C A R D I O R E S P I R ATO RY D I S O R D E R S
A N D R E H A B I L I TAT I O N
Problem Physiotherapy technique
Dyspnoea Breathing exercise
Breathing control used to decrease the work of breathing
Pursed-lip breathing
Educating patients of ways to conserve energy
Exercise intolerance Graded exercise
Impaired airway clearance Autogenic drainage
Postural drainage and percussion
Active cycle of breathing exercise
Positioning
Positive expiratory pressure
Chest shaking and vibration
Percussion
Effective coughing technique
Respiratory muscle dysfunction Inspiratory muscle training
Respiratory muscle strength and endurance training
Upper limb exercise
Reduced lung volume Breathing exercise
Incentive spirometry
Upright positioning
Early ambulation
Impaired gas exchange Proper positioning
Breathing control
Musculoskeletal dysfunction Postural correction
Muscles stretching
Mobilization of joint
Muscle strengthening exercise
PHYSIOTHERAPY TECHNIQUES
Airway clearance techniques
• Percussion
• Shaking and vibration
• Active cycle of breathing
• Autogenic drainage
• Positive expiratory pressure breathing
AIRWAY CLEARANCE TECHNIQUES
• Airway clearance techniques or strategies are aimed at
facilitating the removal of airway secretions
• They consist of procedures used to aid mobilisation and
clearance of secretions
• Indicated in patients with ineffective cough,
AIRWAY CLEARANCE TECHNIQUES
• Patients with cystic fibrosis, COPD, critically ill patients and
patients who had just undergone major surgeries among
the categories of who benefit from chest physiotherapy
INTRODUCTION• Airway clearance techniques include:
– Manual techniques (chest shaking and vibration, percussion)
–Active cycle of breathing technique
–Postural drainage and percussion
–Autogenic drainage
–Positive expiratory pressure
–High frequency chest wall oscillation
–Oscillating PEP device
PERCUSSION
• Percussion is used to augment mobilization of secretions
by mechanically dislodging viscous or adherent mucus from
the airways
• Performed with cupped hands over the lung segment being
drained
• The cupping increases intra thoracic pressure
PERCUSSION
• The procedure should not be painful or uncomfortable
• It is helpful in patient with neuromuscular weakness or
paralysis
• It may also augment expiratory flow
• It can also be used to stimulate cough in patient
CONTRAINDICATIONS
• Over fracture site, spinal fusion, or osteoporotic bone
• Over tumour area
• Pulmonary embolism
• Unstable angina
• Chest wall pain e.g. after thoracic surgery
SHAKING AND VIBRATION
• A procedure often used with percussion to move
secretions to upper airways
• Applied in the expiratory phase of breathing
• Applied by placing both hands over the chest wall and
gently compressing and rapidly vibrating the chest wall on
expiration
SHAKING AND VIBRATION
• In infants, vibrations are performed using two fingers in
contact with the chest wall.
• Chest vibrations and shaking should never be
uncomfortable and should be adapted to suit the individual
patient.
ACTIVE CYCLE OF BREATHING(ACBT)
• Is a cycle of breathing control (tidal breathing at the
patient’s own rate and depth)
• It is used as an airway clearance technique to mobilize
secretion
• It involves breath control, thoracic expansion exercise and
forced expiratory technique
ACTIVE CYCLE OF BREATHING(ACBT)• The thoracic expansion exercise consists of 3-4 deep
breaths with inspiratory hold
• This is followed by forced expiratory technique (huffing or
coughing)
• ACBT has been shown to increase expectoration of
sputum while reducing the length of time taken for
treatment
• It also increases lung volume and reduces ventilator
resistance
ACTIVE CYCLE OF BREATHING(ACBT)Thoracic Expansion Exercise
• Thoracic expansion exercises are deep breathing exercises
emphasizing inspiration.
• Inspiration is active and may be combined with a 3-second hold
before the passive relaxed expiration.
• Thoracic expansion exercises can be encouraged with
proprioceptive stimulation by placing a hand, either the patient's or
the physiotherapist's, over the part of the chest wall where
movement of the chest is to be encouraged.
ACTIVE CYCLE OF BREATHING(ACBT)
Forced expiration technique (FET)
• The forced expiration technique is a combination of one or two
forced expirations (huffs) and periods of breathing control.
• An essential part of the forced expiration technique is the pause
for breathing control after one or two huffs which prevents any
increase in airflow obstruction.
ACTIVE CYCLE OF BREATHING(ACBT)
• ACBT should be adapted for each patient
• One set of thoracic expansion exercises may be followed by the
forced expiration technique
• If secretions loosen slowly it may be more appropriate to use two sets
of thoracic expansion exercises
• Should be done in sitting position
• For patients with a moderate amount of bronchial secretions,, a
minimum of 10 minutes in any productive position is usually necessary.
• For patients with minimal secretions, less time is required.
AUTOGENIC DRAINAGE• It is an airway clearance technique that involves breathing
at different lung volumes
• The aim is to maximize expiratory flow
• Autogenic drainage (AD) aims to maximize airflow within
the airways to improve the clearance of mucus and
ventilation
AUTOGENIC DRAINAGE
• Ventilation behind obstructed lung units is achieved by
inhaling a normal tidal volume breath followed by a 3-
second breath hold
• Exhalations is not forced but is slightly accelerated to
achieve sufficiently high airflow to overcome the shear
force with which the mucus is attached to the airway walls
AUTOGENIC DRAINAGE
• Breathing at low lung volumes is said to mobilize peripheral mucus.
This is the first or 'unstick' phase.
• It is followed by a period of tidal breathing which is said to 'collect'
mucus in the middle airways.
• Then, by breathing at higher lung volumes, the 'evacuate' phase,
expectoration of secretions from the central airways is promoted.
• A huff from high lung volume is now encouraged to clear the
secretions from the trachea
TECHNIQUE OF AUTOGENIC DRAINAGE• Firstly, correct breathing technique must by taught
Inspiration
• Patient breaths in through the nose
• The abdomen/ lower chest should be used
• The breath is held for 3 seconds to allow air get into the small
airways and behind the sputum
Expiration
• Patient breaths out through the mouth
• The abdominal muscles is tightened
• The exhalation should not be forced
TECHNIQUE OF AUTOGENIC DRAINAGE
Positioning
• Sitting or side-lying
• Shoulders and arms relaxed and neck slightly extended
• Upper airway is cleared by huffing or blowing of nose
Assessment of breath
• Crackles at the beginning of the breath means mucus is in the large
airways and patient should start at high lung volume breathing
• Fine crackles towards the end of breath means mucus is in the
smaller airways and patient should start with low lung volume
breathing
TECHNIQUE OF AUTOGENIC DRAINAGE
Low lung volume breathing (unsticking)
• Patient takes a small breath in slowly through the nose,
keeping the airways open
• Patient hold the breath for about 3 seconds
• Patient breathes out through the mouth, as far as possible
with the abdominal muscle tensed.
• Partial breath in slowly
• The procedure is repeated until secretions is felt moving
up the airways
TECHNIQUE OF AUTOGENIC DRAINAGE
• Middle lung volume (collecting)
• After maximal expiration, slightly bigger breath is taken to
get to middle lung volume
• Patient holds breath and breath partially out
• This is continued until the patient feels sputum moving or
for a set number of breaths
TECHNIQUE OF AUTOGENIC DRAINAGEHigh lung volume (evacuating)
• Bigger breath is taken to get up to a high lung volume
• Patient breaths in slowly through the nose, keeping the upper
airways open
• Breath is held for few seconds
• The patient breath partially
• Patient takes a big breath in slowly and repeat the breath out
• Patient keeps breathing until he feels sputum is ready
• 1 or 2 huffs or cough is done to clear sputum
• The cycle is interspersed with breathing control
POSITIVE EXPIRATORY PRESSURE BREATHING
• It is an airway clearance technique in which resistance to
airflow is applied during exhalation
• The patients breathe through a specialty designed
mouthpiece or mask that controls resistance to airflow
• This breathing technique is used to hold airways open
during exhalation to mobilize accumulated secretions and
improve their clearance
PROCEDURE
• The patient sits leaning forward with his elbows supported on a
table and holding the mask firmly over the nose and mouth
• The technique involves tidal inspiration and active but not forced
expiration through a mouthpiece or mask.
• The patient inhales, holds the inspiration for 2 to 3 seconds, and
then exhales, repeating the sequence approximately 10 to 15 cycles
• The patient removes the mouthpiece or mask, take several huffs
and then cough to mobilize secretions from the airways
• The breathing sequence is repeated four to six times for about 15
minutes
• It is an intervention used for airway clearance
• A means of mobilizing secretions in one lung segment to
the central airways through use of gravity
• Patients are place in various positions that enables gravity
to aids in the drainage process
• When secretions are moved to larger airways they are
cleared by suctioning or coughing
• To enhance the effectiveness of postural drainage therapy
manual techniques such as percussion, shaking and
vibration can also be incorporated
GOALS AND INDICATIONS
• Prevent accumulation of secretions in patients at risk of
pulmonary complication
–Patients with COPD, cystic fibrosis
–Patients on prolonged bed rest
–Patients on ventilator who is stable enough to receive
the treatment
–Patients who have received general anaesthesia
–Patients with painful incisions that restricts deep
breathing and coughing postoperatively
GOALS AND INDICATIONS
• Remove accumulated secretions from the lungs
–Patients with acute or chronic lung diseases
–Patients who are generally very weak or elderly
–Patients with artificial airways
RELATIVE CONTRAINDICATIONS
• Severe haemoptysis
• Untreated acute conditions
–Severe pulmonary oedema
–Congestive heart failure
–Large pleural effusion
–Pulmonary embolism
RELATIVE CONTRAINDICATIONS
• Cardiovascular instability
–Cardiac arrhythmia
–Severe hypertension or hypotension
–Recent myocardial infarction
–Unstable angina
• Recent neurosurgery
–Head down position may cause increased intracranial
pressure
CONSIDERATIONS
Time of the day
• Not after a meal
• Coordinated with aerosol therapy with humidification
• Early morning or early evening
Frequency of treatment
• Depending on type and severity of condition
• For thick and copious secretions two to four times per day
• For maintenance program once a day
PREPARATIONS
• Light weight cloths
• A sputum cup should be ready
• Sufficient pillows for positioning and comfort
• Treatment procedure should be explained to the patient
• Patient should be taught deep breathing and an effective
cough
• Patient could be suctioned prior to positioning if copious
secretions is being produced
• Adjustment for tubes and wires should be made
PROCEDURE• The segment of the lungs to be drained is determined
• Patients vital signs and breath sounds is checked
• Patient is positioned in the correct position for drainage
• Each position is maintained for 5 to 10 minutes if patient
can tolerate it
• Patient should breathe deeply during drainage. Pursed lip
breathing can be used during expiration
PROCEDURE
• The area to be drained is percussed
• Patient should be encouraged to take deep cough
whenever necessary
• Duration of treatment should not exceed 45 to 60 minutes
PROCEDURE
Concluding the treatment
• Patient sits up slowly and rest for a while after treatment
• Signs of postural hypotension should be checked
• Reassessment of breath sounds should be made
• The type, colour, consistency and amount of secretions
should be noted
• Vital signs should be checked
MODIFIED POSTURAL DRAINAGE
• Postural drainage could be modified for some categories of
patients
• Patients with congestive heart failure may have orthopnoea
• After neurosurgery, patient should not assume head down
position
• Patients may have chest tubes that limits positioning. In
these cases positions may be modified to be consistent
with patient’s medical or surgical conditions
COUGHING TECHNIQUE
•An effective cough is necessary to eliminate
respiratory obstructions and keep the lungs clear.
Airway clearance is an important part of
management of patients with acute or chronic
respiratory conditions.
THE COUGH MECHANISM
• Deep inspiration occurs.
• Glottis closes, and vocal cords tighten.
• Abdominal muscles contract and the diaphragm elevates,
causing an increase in intrathoracic and intra-abdominal
pressures.
• Glottis opens.
• Explosive expiration of air occurs.
FACTORS AFFECTING NORMAL COUGH• Decreased inspiratory capacity: Inspiratory capacity can be reduced because
of pain due to acute lung disease, rib fracture, trauma to the chest, or recent
thoracic or abdominal surgery. Weakness of the diaphragm or accessory
muscles of inspiration as a result of a high spinal cord injury or neuropathic or
myopathic disease decrease a patient’s ability to take in a deep breath.
Postoperatively, the respiratory center may be depressed as the result of
general anesthesia, pain, or medication.
• Inability to forcibly expel air: A spinal cord injury above T12 and myopathic
disease, such as muscular dystrophy, cause weakness of the abdominal muscles,
which are vital for a strong cough. Excessive fatigue as the result of critical
illness and a chest wall or abdominal incision causing pain all contribute to a
weak cough. A patient who has had a tracheostomy also has difficulty
producing a strong cough, even when the tracheostomy site is covered.
FACTORS AFFECTING NORMAL COUGH• Decreased action of the cilia in the bronchial tree: Action of the ciliated
cells may be compromised because of physical interventions such as general
anaesthesia and intubation or pathologies such as COPD including chronic
bronchitis, which is associated with a decreased number of ciliated epithelial
cells in the airway. Smoking also depresses the action of the cilia.
• Increase in the amount or thickness of mucus. Pathologies (e.g., cystic
fibrosis, chronic bronchitis) and pulmonary infections (e.g., pneumonia) are
associated with an increase in mucus production and the thickness of the
mucus. Intubation irritates the lumen of the airways and causes increased
mucus production, whereas dehydration thickens mucus
TEACHING AN EFFECTIVE COUGH• The patient’s voluntary or reflexive cough should be
assessed.
• The patient assume a relaxed, comfortable position for
deep breathing and coughing. Sitting or leaning forward
usually is the best position for coughing. The patient’s neck
should be slightly flexed to make coughing more
comfortable.
• The patient is taught breathing control
• A sharp, deep, double cough is demonstrated to the
patient.
TEACHING AN EFFECTIVE COUGH• The proper muscle action of coughing (contraction of the
abdominals) is demonstrated to the patients. The patient places the
hands on the abdomen and make three huffs with expiration to feel
the contraction of the abdominals. The patient can practice making
a “K” sound to experience tightening the vocal cords, closing the
glottis, and contracting the abdominals.
• When the patient has put these actions together, instruct the
patient to take a deep but relaxed inspiration, followed by a sharp
double cough. The second cough during a single expiration is usually
more productive.
MANUAL-ASSISTED COUGH
• If a patient has abdominal weakness (e.g., as the result of a
mid-thoracic or cervical spinal cord injury), manual
pressure on the abdominal area assists in developing
greater intra-abdominal pressure for a more forceful cough.
• Manual pressure for cough assistance can be applied by the
physiotherapist or the patient.
THERAPIST-ASSISTED TECHNIQUES• With the patient in a supine or semi-reclining position, the therapist places
the heel of one hand on the patient’s abdomen at the epigastric area just
distal to the xiphoid process.
• The other hand is placed on top of the first, keeping the fingers open or
interlocking them. After the patient inhales as deeply as possible, the
therapist manually assists the patient as he or she attempts to cough.
• The abdomen is compressed with an inward and upward force, which pushes
the diaphragm upward to cause a more forceful and effective cough. This
same manoeuver can be performed with the patient in a chair. The
physiotherapist or family member can stand in back of the patient and apply
manual pressure during expiration
SELF-ASSISTED TECHNIQUE• While in a sitting position, the patient crosses the arms across the
abdomen or places the interlocked hands below the xiphoid process.
• After a deep inspiration, the patient pushes inward and upward on the
abdomen with the wrists or forearms and simultaneously leans forward
while attempting to cough.
Splinting
• If chest wall pain from recent surgery or trauma is restricting the cough,
teach the patient to splint over the painful area during coughing, the
patient presses the hands or a pillow firmly over the incision to support
the painful area with each cough. If the patient cannot reach the painful
area, the physiotherapist should assist
TRACHEAL STIMULATION
• Tracheal stimulation, sometimes called a tracheal tickle, may
be used with infants or disoriented patients who cannot
cooperate during treatment.
• Tracheal stimulation is a somewhat uncomfortable
manoeuver, 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.
PRECAUTIONS• Patient should not gasp in air, because this increases the work of breathing,
causing the patient to fatigue more easily. It also increases turbulence and
resistance in the airways, possibly leading to increased bronchospasm and
further constriction of airways. A gasping action also may push mucus or a
foreign object deep into air passages.
• Uncontrolled coughing spasms (paroxysmal coughing) should be avoided.
• Forceful coughing should be avoided in patients with a history of a
cerebrovascular accident or an aneurysm. These patients should huff several
times to clear the airways, rather than cough.
• The patient should cough while in a somewhat erect or side-lying position.