physiotherapy techniques in cardiorespiratory conditions

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.


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.


• 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


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


• 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

POSTURAL DRAINAGE

• 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

POSTURAL DRAINAGE POSITONS

POSTURAL DRAINAGE POSITION

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.

physiotherapy techniques in cardiorespiratory conditions

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