Postural drainage (PD)

Postural Drainage is an airway clearance technique, helps in clearing of airway secretions. PD can simultaneously used with ACBT, Chest PT.

1. POSTURAL DRAINAGE Dr. t.Sunil kumar Assistant professor Department of physiotherapy

2. introduction Postural drainage consists of positioning the patient to allow gravity to assist the drainage of secretions from specific areas of the lungs . The length of time spent in each position, and the total treatment time will depend on the quantity of secretions in each area and the number of areas that have to be drained. It may be necessary to spend an average of 15 to 20 minutes in each position to allow adequate drainage and this may mean that different areas will require draining at alternate treatments.

3. The worst areas should be drained first. A recent radiograph, or bronchogram if available, is a useful adjunct in isolating the affected areas. Postural drainage should never be carried out immediately before or after a meal, for the patient will feel either too tired to enjoy his meal, or nauseated and perhaps vomit . Postural drainage can only be carried out effectively if the patient takes an active part in his treatment.

4. The treatment becomes ineffective if the patient just lies in the appropriate drainage position. If postural drainage is used in conjunction with another technique , the time in each position may be decreased. For example, if percussion and vibration are performed while the patient is in each position, 3 to 5 minutes is sufficient.

5. A patient who requires close monitoring should not be left unattended in a Trendelenberg position, but this may be appropriate if patients are alert and able to reposition themselves . The patient should be encouraged to take deep breaths and cough after the treatment and if possible after each position. Having the patient sit upright or lean forward optimizes this effort.

6. Equipment Required For Postural Drainage For the hospitalized patient, there exists a variety of beds that employ manual or electric devices to position the patient. Air therapy beds, most often used in the intensive care unit ( iCU ), are valuable aids allowing ease of positioning, especially in large or unresponsive patients. Make use of pillows or bedrolls to support body parts or relieve pressure areas. For home treatment , aids in positioning might include pillows, a slant board (or ironing board if the patient is small), a foam wedge, sofa cushions , or a bean bag chair.

7. Preparation for Postural Drainage Nebulized bronchodilators before Pd may facilitate the mobilization of sputum. An adequate intake of fluids (if allowed) decreases the viscosity of the secretions, allowing easier mobilization. Become familiar with the workings of the model of bed the patient is occupying, especially the movement of the bed into the Trendelenberg position .

8. In the ICU, it is imperative to be familiar with the multiple lines, leads, and tubes attached to the patient. Allow enough slack from each device to position a patient for postural drainage. Make sure there are enough personnel to position the patient with as little stress to both patient and staff as possible. Have suctioning equipment ready to remove secretions from an artificial airway or the patient's oral or nasal cavity after the treatment.

9. Postural drainage positions Upper lobe APICAL SEGMENTS The patient should sit upright, with slight variations according to the position of the lesion which may necessitate leaning slightly backward , forward or sideways. The position is usually only necessary for infants or patients being nursed in a recumbent position , but occasionally may be required if there is an abscess or stenosis of a bronchus in the apical region.

10. Upper lobe POSTERIOR SEGMENT (a) Right The patient should lie on his left side and then turn 45 on to his face , resting against a pillow with another supporting his head. He should place his left arm comfortably behind his back with his right arm resting on the supporting pillow; the right knee should be flexed .

11. (b) Left The patient should lie on his right side turned 45 on to his face with three pillows arranged to raise the shoulder 30cm ( i2inch) from the bed . He should place his right arm behind his back with his left are resting on the supporting pillows; both the knees should be slightly bent .

12. Upper lobe ANTERIOR SEGMENTS The patient should lie flat on his back with his arms relaxed to his side ; the knees should be slightly flexed over a pillow.

13. Middle lobe LATERAL SEGMENT & MEDIAL SEGMENT The patient should lie on his back with his body quarter turned to the left maintained by a pillow under the right side from shoulder to hip and the arms relaxed by his side; the foot of the bed should be raised 35cm ( 14inch) from the ground. The chest is tilted to an angle of 15 °.

14. Lingula ; SUPERIOR SEGMENT: INFERIOR SEGMENT The patient should lie on his back with his body quarter turned to the right maintained by a pillow under the left side from shoulder to hip and the arms relaxed by his side; the foot of the bed should be raised 35cm ( 14inch) from the ground. The chest is tilted to an angle of 15 °.

15. Lower lobe APICAL SEGMENTS The patient should lie prone with the head turned to one side, his arms relaxed in a comfortable position by the side of the head and a pillow under his hips.

16. ANTERIOR BASAL SEGMENTS The patient should lie flat on his back with the buttocks resting on a pillow and the knees bent; the foot of the bed should be raised 46cm (i8inch) from the ground. The chest is tilted to an angle of 20°.

17. POSTERIOR BASAL SEGMENTS The patient should lie prone with his head turned to one side, his arms in a comfortable position by the side of the head and a pillow under his hips. The foot of the bed should be raised 46cm ( i8inch) from the ground. The chest is tilted to an angle of 20°.

18. MEDIAL BASAL (CARDIAC) SEGMENT The patient should lie on his right side with a pillow under the hips and the foot of the bed should be raised 46cm ( i8inch) from the ground . The chest is tilted to an angle of 20°.

19. LATERAL BASAL SEGMENT The patient should lie on the opposite side with a pillow under the hips and the foot of the bed should be raised 46cm ( i8inch) from the ground . The chest is tilted to an angle of 20°.

20. ALTERNATIVE METHOD OF POSTURAL DRAINAGE FOR LOWER LOBES If it is not possible to raise the foot of the bed, an alternative position can be used. Two or three pillows are placed over a 15cm (6in) pile of newspapers or magazines and the patient can he over this so that the chest is tilted downwards. It is important that the shoulders do not rest on the pillow supporting the patient’s head. This method can be used for drainage of the lower lobe segments when necessary and is often a useful method of home postural drainage.

21. Postural drainage at home Many patients who require postural drainage at home are able to carry out their treatment effectively and independently by using the forced expiration technique. Those who are more disabled may need percussion or shaking from an assistant in conjuction with the forced expiration technique. In fact many patients can clear their secretions effectively with a correct huffing technique and do not always need percussion or shaking of the chest wall . Assistance may be needed if there is an increase in their daily sputum production, or secretions become more difficult to clear.

22. When teaching relatives or friends percussion and shaking, it is important that they understand the necessity for periods of relaxed diaphragmatic breathing. Any patient who needs to continue postural drainage at home often benefits from carrying out his own treatment for one or two days prior to discharge from hospital. The physiotherapist having carefully instructed the patient then only supervises his treatment. In this way the patient is made to realise that he can manage his physiotherapy independently at home.

23. The areas requiring drainage and the time needed for treatment must be discussed individually with each patient. In most cases treatment will be required for at least 15 to 20 minutes twice daily, A suitable drainage position will have to be discussed with the patient . Many patients will find it difficult to elevate the foot of the bed at home. Some patients have a bed permanently tipped in a spare room, while others have a portable frame to lie on at the correct angle. Another method is to place a 15cm (6in) pile of newspapers or magazines tied tightly together, in the centre of the bed and place pillows on top.

24. The patient can lie over this in various positions to drain several areas of the lung. If these methods do not provide an efficient drainage position it may be necessary to provide the patient with a hospital tipping bed. The drainage position in which the patient lies prone over the side of the bed is unsuitable. It is uncomfortable, cannot usually be tolerated for very long, and only drains the posterior segments of the Slower lobes. Babies and small children can be given postural drainage over their mother’s knee . It is usually advisable to give the treatment before a feed.

25. Indications Postural Drainage should only be recommended for certain patients under certain conditions. Here are some examples: To mobilize retained secretions so that they can be suctioned or expectorated Cystic Fibrosis Atelectasis Bronchiectasis Chronic bronchitis Foreign body obstruction

26. Contra-indications Head injuries including cerebral vascular accidents because intracranial pressure would be increased. Severe hypertension as venous return is increased with tipping and this can overload the heart. Following oesophagectomy there can be undue stress on the anastomosis and tipping may cause regurgitation. Severe haemoptysis , when all forms of physiotherapy should be discontinued until there has been discussion with the doctors. Aortic aneurysms which would be put under tension if the patient is tipped.

27. Pulmonary oedema which collects in the dependent areas; postural drainage would cause extreme dyspnoea and probably worsen the situation. Surgical emphysema which might track toward the face if the patient is tipped and might result in dyspnoea. Tension pneumothorax without an intercostal drain. This condition should not require physiotherapy, but must never be tipped as the cardiac embarrassment may lead to a cardiac arrest.| Cardiac arrhythmias which can be worsened by postural drainage ; in some positions the myocardial oxygen demand would be greater and so its sensitivity to abnormal rhythms is increased

28. Hiatus hernias should not be tipped as the patient may regurgitate gastric juices. The filling cycle of peritoneal dialysis . The descent of the diaphragm is impeded during this phase and tipping may cause more respiratory distress. Facial oedema from burns will be increased with tipping . Eye operations where there may be some associated edema which could be increased with tipping.

29. Sometimes it is vital for a patient with one of the above contraindications to have postural drainage. Care must be taken and the case discussed with the doctors. Generally it is unnecessary to tip the elderly , as they find it very distressing.

30. Thank you