Chest physiotherapy,

Chest physiotherapy (CPT) refers to a group of therapies used in combination to mobilize pulmonary secretions. CPT is helpful to mobilize or loosen the secretions in the lungs and respiratory tract especially for patients with large amount of secretions or ineffective cough.

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1. PROCEDURE DEMONSTRATION ON CHEST PHYSIOTHERAPY

2. Introduction Chest physiotherapy (CPT) refers to a group of therapies used in combination to mobilize pulmonary secretions. CPT is helpful to mobilize or loosen the secretions in the lungs and respiratory tract especially for patients with large amount of secretions or ineffective cough.

3. It includes postural drainage, chest percussion, vibration, coughing and deep-breathing exercises.

4. Definition Chest physiotherapy consists of external mechanical maneuvers, such as chest percussion, postural drainage, vibration, to augment mobilization and clearance of airway secretions, diaphragmatic breathing with pursed-lips, coughing and controlled coughing.

5. Anatomy and physiology The respiratory tract: The upper airways or upper respiratory tract includes the nose,  paranasal sinuses, the pharynx, vocal cords. The lungs: Located in the chest on either side of the heart

6. Conical in shape with a narrow rounded apex at the top and a broad base that rests on the diaphragm The left lung shares space with the heart, with an impression in its medial surface called the cardiac impression.

7. Blood supply: Dual blood supply: Lungs receive oxygenated blood via the bronchial circulation The pulmonary arteries that supply deoxygenated blood for purification

8. Nerve supply: Parasympathetic nervous system -  Vagus nerve Sympathetic nervous system - Phrenic nerve

9. Indications of chest physiotherapy Chest physiotherapy is indicated in the patients with Excessive bronchial secretions who has difficulty clearing secretions with expectorated sputum production greater than 25 ml per day Evidence or suggestion of retained secretions in the presence of an artificial airway

10. Lobar Atelectasis caused by or suspected of being caused by mucus plugging. To mobilize the secretions To re expand lung tissue To promote efficient use of respiratory muscles.

11. Contraindications of chest physiotherapy Chest physiotherapy is contraindicated in the patients with Hematoma Carcinoma Induced bronchospasm

12. Postural drainage facilitation Chest physiotherapy consists of percussion, vibration and postural drainage. Percussion and vibration are manual or mechanical techniques used to augment postural drainage.

13. Postural drainage uses the principle of gravity to assist in bronchial drainage. Percussion and vibration are used after the patient has assumed a postural drainage position to assist in loosening the mobilized secretions.

14. Percussion, vibration and postural drainage may assist in bringing secretions into larger, more central airways. Effective coughing is then necessary to help raise these secretions.

15. After each drainage position change, the patient should be given time to cough and deep breathe. These techniques are individualized based on the patients pulmonary condition and response to initial treatment.

16. Sometimes it takes several hours after physiotherapy for secretions to be expectorated. It is important to evaluate physiotherapy for both its effectiveness and relief of the patients symptoms.

17. Chest physiotherapy should be performed by an individual who has been properly trained.

18. Techniques Percussion It is performed in the appropriate postural drainage position with the hands in cuplike position. Then hands are cupped and the fingers and thumbs are closed. The cupped hand should create an air pocket between the patients chest and hand.

19. Both hands are cupped and used in an alternative rhythmic fashion. Percussion is accomplished with flexion and extension of the wrist. A hollow sound should be heard. The air cushion impact facilitates the movement of thick mucus.

20. A thin towel should be placed over the area to be percussed , or the patient may choose to wear a T shirt or hospital gown. The patients face should be in clear view when percussing in case a mucus plug occludes the airway and the patient is unable to speak.

21. Areas to avoid percussion Percussion should not be performed over the kidney, sternum, spinal cord, bony prominences, or any tender or painful area.

22. Vibration Vibration is accomplished by tensing the hand and arm muscles repeatedly and pressing mildly with the flat of the hand on the affected area while the patient slowly exhales a deep breath. Isometric contractions of the arm and hands are also appropriate.

23. The vibrations facilitate movement of secretions to larger airways. Mild vibration is tolerated better tolerated than percussion and can be used in situations where percussion may be contraindicated.

24. Postural drainage The lungs are divided into 5 lobes, with there on the right and two on the left side. There are 18 segments in the lungs, which can be drained in 18 positions.

25. The purpose of various positions in postural drainage is to drain each segment toward the larger airways. The postural drainage position are determined by areas of involved lungs, which are assessed by chest x ray, percussion , palpation and auscultation.

26. Aerosolized bronchodilators and hydration therapy are frequently administered before postural drainage. The chosen postural drainage position is maintained for 5-15 min or during percussion. The degree of slope can be obtained with pillows, blocks or tilt board.

27. The frequency and choice of postural drainage positions depends on location of retained secretions and patient tolerance to dependent positions. A common order is 2-4 times per day. The procedure should be planned to occur and completed at least 1 hour before meal and 3 hours after meal.

28. If patients has difficult in assuming various positions, adaptations will be needed to reduce the angle or length of time of the procedure. A side lying position can be used for patients who cannot tolerate a head down position.

29. Some positions of postural drainage (Trendelenburg should not be performed for patients with chest trauma, heart disease, head injury.)

30. Points to remember during postural drainage Instruct the patient to always inhale through the nose. This permits filtration, humidification, and warming of air. Instruct the patient to breathe slowly in a rhythmic and relaxed manner. This will help in complete exhalation and emptying of lungs.

31. Each position for postural drainage is held for 3 to 15 minutes. The procedure should be discontinued if patient is having symptoms of hypoxemia like tachycardia, palpitations, dyspnea, or chest pain.

32. Nebulize the patient with Bronchodilators or mucolytic agents before postural drainage and chest percussion to decrease thickness of mucus and sputum thereby enhancing removal of secretions.

33. Patient should be made comfortable before the procedure and while assuming each positions. Auscultation of the chest should be performed to determine the areas of needed drainage.

34. Encourage the patient to deep breathe and cough after performing postural drainage. Encourage diaphragmatic breathing throughout postural drainage as this helps to widen airways so that secretions can be drained

35. ARTICLES Stethoscope Pillows for positioning Gloves Emesis basin Face towel Kidney tray

36. Procedure of chest physiotherapy Perform procedure one hour before meal or 1-3 hours after meal Administer bronchodilator 15 minutes before procedure Collect needed equipments

37. Help patient assume correct position for postural drainage based on findings from X-ray, auscultation, palpation and percussion of chest. Position should be maintained for 5-15 min to mobilize secretion via gravity

38. Observe patient during treatment for tolerance Have patient take several deep abdominal breaths Percuss for 1-2 min keeping patients face in full view Vibrate the same area while the patient exhales 4-5 deep breaths

39. Assist the patient to cough while assuming same position. Splinting with towel or hands may be necessary to aid in effective coughing. Patient may need to assume sitting position to generate enough airflow to expel secretions. Suction may be necessary if coughing is not effective Repeat percussion, vibration and coughing until patient no longer expectorates mucus

40. After procedure help patient assume comfortable position and provide oral hygiene Monitor for hypoxemia, if patient having any respiratory difficulty or distress Evaluate and chart the effectiveness of treatment by amount of sputum secretion and patient tolerance.

41. Lower Lobes: Posterior Basal Segments

42. Lower Lobes: Lateral Basal Segments

43. Lower Lobes: Anterior Basal Segments

44. Lower Lobes: Superior Segments

45.   Right Middle Lobe: Medial and Lateral Segments

46. Left Upper Lobe: Superior and Inferior Segments, Lingular Portion

47. Upper Lobes: Anterior Segments

48. Upper Lobes: Apical Segments

49. Upper Lobes: Posterior Segments

50. After care Replace articles and dispose sputum appropriately. Monitor patients condition such as vital signs, level of consciousness. Note relief of breathing distress and subsidence of symptoms

51. Instruct for deep breathing and coughing exercises Report any adverse effects such as blood in sputum, bronchospasm, worsening of symptoms and inform physician immediately.

52. Complication Fractured ribs Bruising Hypoxemia Discomfort to patient Broncho-spasm

53. Summary Today we have discussed about chest physiotherapy, its introduction, definition, indications, contraindications, postural drainage facilitation, techniques, articles, procedure, aftercare and complications of chest physiotherapy.

54. Conclusion Chest physiotherapy is a treatment whereby breathing is improved by the indirect removal of mucus from the breathing passages of a patient. It includes percussion, vibration and postural drainage to facilitate mucus removal from respiratory tract.

55. Bibliography Lewis, textbook of medical surgical nursing, 7 th edition, Elsevier publication, page 646-648 Kozier and Erb’s , textbook of fundamental nursing, 8 th edition, Pearson publication, page 1332 Potter and Perry, textbook of fundamental nursing, 7 th edition, Elsevier publication, page 931 http://www.nsgmed.com/nursing-procedures/chest-physiotherapy-cpt-postural-drainage/

56. Thank you