CHEST PHYSIOTHERAPY 1.

Define the following terms: ATELECTASIS refers to the collapse or airless condition of the alveoli caused by hypoventilation, obstruction to the airways or compression. (source: Brunner &Suddarths, Med-Surg p.551) EMPHYSEMA is a pathologic term that describes an abnormal distention of the airspaces beyond the terminal bronchioles and destruction of the walls of the alveoli (source: Brunner &Suddarths, Med-Surg p.603) BRONCHIECTASISchronic dilation of a bronchus or bronchi, the dilated airways become saccular and are a medium for chronic infection (source: Brunner &Suddarths, Med-Surg p.601) CHEST PHYSIOTHERAPY a group of therapies used to mobilize pulmonary secretions. (source: Potter-Perry, Fundamentals of Nursing p.930) Deep Breathing exercise exercises used to improve ventilation and oxygenation Coughing is effective for maintaining a patent airway; permits the client to remove secretions from both the upper and lower airways Chest Vibration - is a fine, shaking pressure applied to the chest wall only during exhalation; is thought to increase the velocity and turbulence of exhaled air, facilitating secretion removal Chest Tapping/Percussioninvolves striking the chest wall over the area being drained Postural Drainage it consists of drainage, positioning and turning and is sometimes accompanied by chest percussion and vibration; it improves the secretion clearance and oxygenation

INCENTIVE SPIROMETRY encourages voluntary deep breathing by providing visual feedback to clients about inspiratory volume; it promotes deep breathing and prevents or treats atelectasis in the post-operative client (source: Potter-Perry, Fundamentals of Nursing p. 942) NEBULIZATION adds moisture or medications to inspired air by mixing particles of varying sizes with the air; used for the administration of bronchodilators and mucolytic agents (source: Potter-Perry, Fundamentals of nursing p.930)

2.

IMPORTANCE OF THE DIFFERENT TECHNIQUES A. Chest Physiotherapy

improves ventilation removes secretions from the bronchial tree increases the efficiency of the respiratory muscles relieves bronchial obstruction B. Incentive Spirometry

prevents or treats atelectasis in the post-operative client loosen respiratory secretions facilitates in respiratory gaseous exchange expand collapsed alveoli improve pulmonary ventilation counteracts the effects of anesthesia or hypoventilation C. Nebulization

helps in the administration of bronchodilators and mucolytic agents improves the clearance of pulmonary secretions humidification through nebulization enhances mucociliary clearance D. Postural Drainage

improves secretion clearance and vibration helps drain the secretions from specific segments of the lungs and bronchi into the trachea prevents or relieves bronchial obstruction caused by accumulations of secretions

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INDICATIONS AND CONTRAINDICATIONS OF THE DIFFERENT TECHNIQUES Chest Physiotherapy Indications Patients who produce >30mL of sputum per day Patients who have evidence of atelectasis by chest x-ray examination Bedridden patients Patients with bronchial secretions Patients with increased risk of aspiration due to certain diseases (cerebral palsy, muscular dystrophy) Incentive Spirometry
Indications Patients who underwent surgery (thoracic and abdominal) Patients who have evidence of atelectasis by chest x-ray examination Bedridden patients Patients with bronchial secretions Patients with increased risk of aspiration due to certain diseases (cerebral palsy, muscular dystrophy) Contraindications Patients with fractured ribs Patients with pulmonary hemorrhage Patients with lung contusions Fatigued patients Patients with osteoporosis

Contraindications Patients with fractured ribs Patients with pulmonary hemorrhage Patients with lung contusions Fatigued patients Patients with osteoporosis

Nebulization Indications
Patients with difficulty in clearing respiratory secretions Patients with reduced vital capacity with ineffective deep breathing and coughing Patients with unsuccessful trials of simpler and less costly methods for clearing secretions or expanding the lungs Patients with COPD

Contraindications
Patients who are allergic to the medications given Patients with nose obstruction Patients with mouth obstruction

Postural Drainage Indications

Patients with bronchial secretions Patients who are on prolonged bedrest Patients with chronic lung diseases (pneumonia, COPD, atelectasis)

Contraindications
Patients with increased ICP Patients with spinal cord injuries Patients with active hemorrhage Patients with thoracic trauma or surgery Patients with underlying physical conditions that contraindicate specific positions such as Trendelenburgs

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GUIDELINES OF THE DIFFERENT PROCEDURES A. Chest Physiotherapy - Know the clients normal range of vital signs. Conditions such as atelectasis and pneumonia requiring CPT affect vital signs - Conduct a respiratory assessment to confirm need for chest physiotherapy - Know the clients medications. Certain medications (diuretics and anti-hypertensive drugs) cause fluid and hemodynamic changes. - Know the clients medical history - Know the clients level of cognitive function. Participation in controlled coughing techniques requires the client to follow instructions - Be aware of the clients exercise tolerance. CPT maneuvers are fatiguing. B. Incentive Spirometry - Administration of pain medications before the procedure will help the client achieve deep breathing by reducing pain and splinting - Client should be assisted into an upright position in bed or a chair, to facilitate maximum ventilation - Let the client hold or place the spirometer in an upright position - For a flow-oriented device, avoid brisk, low volume breaths that snap the balls to the top of the chamber - A nose clip may be provided to a client who has difficulty breathing only through the mouth - Cough after the incentive effort. Deep ventilation may loosen secretions - Let the patient relax and take normal breaths before using the spirometer again - Clean the mouthpiece with water and shake to dry C. Nebulization - Instruct the patient to breathe through the mouth, taking slow, deep, breaths, and then to hold the breath for a few seconds at the end of the inspiration - Encourage the patient to cough and to monitor and effectiveness of the therapy - Inform the patient and the family about the therapy procedure, its purpose, equipment setup, medication additive, and proper cleaning and storage of the equipment

D. Postural Drainage - Instruct the patient to inhale bronchodilators & mucolytic agents, if prescribes, before postural drainage, because these medications improve drainage of the bronchial tree - Auscultate the patients chest before and after the procedure, to identify the areas that need drainage and to assess the effectiveness of the treatment - Explore strategies that will enable the patient to assume the indicated positions at home with te use of readily available objects such as pillows, cushions or cardboard boxes - Perform procedure before meals (to prevent nausea, vomiting and aspiration) and at bedtime - Provide comfort to the patient as much as possible in each position - Provide an emesis basin, sputum cup and paper tissues for the patient to utilize - Instruct the patient to remain in each position for 10-15 minutes and to breath slowly through pursed lips to help keep the airways open so that secretions can drain in each position

Explain how to cough and remove secretions Suction the secretions mechanically if the patient is unable to cough After the procedure, note the amount, color, viscosity and character of the expelled sputum It is important to evaluate the patients skin color and pulse the first few times the procedure is performed It may be necessary to administer oxygen during postural drainage Perform the procedure in a room far away from other patients or family members if the sputum is foul-smelling After the procedure, the patient may find it refreshing to brush the teeth and use mouthwash before resting

5.

NURSING REPONSIBILITIES BEFORE, DURING OR AFTER THE PROCEDURE

CHEST PHYSIOTHERAPY BEFORE Check the doctors order Prepare needed materials Identify the patient Perform medical handwashing Provide Privacy Explain the procedure to the patient Auscultate the lungs to determine baseline status Make sure that patient is adequately hydrated before performing procedure DURING Provide tissues and a cup for the sputum Maintain privacy Position the patient comfortably AFTER Evaluate effectiveness of procedure Watch for signs of fatigue Auscultate breath sounds Do necessary documentation

INCENTIVE SPIROMETRY BEFORE Check the doctors order Prepare needed materials Identify the patient Perform medical handwashing Provide Privacy Explain the procedure to the patient Auscultate the lungs to determine baseline status Ensure that spirometer is properly functioning DURING AFTER Evaluate effectiveness of procedure Check patients vital signs, lung sounds and sputum production Encourage deep breathing, coughing and ambulation Do necessary documentation Perform after care

Instruct patient to exhale slowly and completely after each breath Have him place the mouthpiece between his teeth and close to his lips Have him take a slow, deep breath through his mouth until he reaches the preset goals. Tell him to remove mouthpiece, hold his breath for 3-5 sec., and exhale slowly. Encourage him to repeat this procedure 10 times each hour as ordered.

NEBULIZATION BEFORE Check the doctors order Prepare needed materials Identify the patient Check if you have the right medication Perform medical handwashing Explain the procedure to the patient Position the mask comfortably Auscultate lung sounds DURING AFTER Evaluate effectiveness of procedure Suction any secretions Encourage patient to cough to expel secretions Monitor the patient closely for certain drug effects Do necessary documentation Perform after care

Provide adequate ventilation to maintain humidity in the room Tell the patient to breathe deeply while inhaling the medication Maintain comfort of the patient

POSTURAL DRAINAGE BEFORE Check the doctors order Prepare needed materials Identify the patient Perform medical handwashing Provide Privacy Explain the procedure to the patient Auscultate the lungs to determine baseline status Perform procedure before meals and at bedtime Position the patient comfortably DURING Provide an emesis basin, sputum cup and paper tissues for the patient to utilize Instruct the patient to remain in each position for 10-15 minutes and to breath slowly through pursed lips to help keep the airways open so that secretions can drain in each position Maintain comfort of the patient AFTER Evaluate effectiveness of procedure Encourage deep breathing and coughing to expel sputum Suction the secretions mechanically if the patient is unable to cough Do necessary documentation Perform after care

SOURCES: 1. 2. 3. Fundamentals of Nursing 7 edition, by Potter & Perry th Fundamentals of Nursing 8 edition, by Berman, Synder, Kozier&Erb th Brunner &Suddarths textbook of medical-Surgical Nursing 12 edition vol. 1, by Suzanne Smeltzer, Brenda Bare, Janice Hinkle & Kerry Cheever
th

DEEP BREATHING EXERCISES Diaphragmatic Breathing Goal: To use and strengthen the diaphragm during breathing Place one hand on the abdomen (just below the ribs) and the other hand on the middle of the chest to increase the awareness of the position of the diaphragm and its function in breathing Breathe in Slowly and deeply through the nose, letting the abdomen protrude as far as possible Breathe out through pursed lips while tightening (contracting) the abdominal muscles Press firmly inward and outward on the abdomen while breathing out Repeat for 1 minute; follow with a rest period of 2 minutes Gradually increase duration up to 5 minutes, several times a day (before meals and at bedtime)

1. 2. 3. 4. 5. 6.

Pursed-Lip Breathing Goal: To prolong exhalation and increase airway pressure during expiration, thus reducing the amount of trapped air and the amount of airway resistance 1. Inhale through the nose while slowly counting to 3- the amount of time needed to say Smell a Rose 2. Exhale slowly and evenly against pursed lips while tightening the abdominal muscles 3. Count to 7 slowly while prolonging expiration through pursed lips 4. While sitting In a chair: Fold arms over the abdomen Inhale through the nose while counting to three slowly Bend forward and exhale slowly through pursed lips while counting to 7 slowly 5. While walking: Inhale while walking 2 steps Exhale through pursed lips while walking four or 5 steps COUGHING Cascade Cough = this technique promotes airway clearance and a patent airway in clients with large volumes of sputum 1. 2. Client takes a slow, deep breath and holds it in for 2 seconds while contracting expiratory muscles Client opens mouth and performs a series of coughs throughout exhalation, thereby coughing at progressively lowered lung volumes

Huff Cough = stimulates a natural cough reflex and is generally effective only for clearing central airways 1. 2. While exhaling, the client opens the glottis by saying the word huff. With practice the client inhales more air and is able to progress to the cascade cough.

Quad Cough = is for clients without abdominal muscle control, such as those with spinal cord injuries 1. While the client breathes out with a maximal expiratory effort, the client or nurse pushes inward and upward on the abdominal muscles toward the diaphragm, causing the cough.

VIBRATIONS = is a series of vigorous quivering produced by hands that are placed flat against the client's chest wall. Vibration is used after percussion to increase the turbulence of the exhaled air and thus loosen thick secretions. It is often done alternately with percussion. 1. 2. 3. 4. 5. 6. Place hands, palms down, on the chest area to be drained,one hand over the other with the fingers together and extended Alternatively, the hands may beplaced side by side. Ask the client to inhale deeply and exhale slowly through thenose or pursed lips, During the exhalation, tense all the hand and arm muscles,and using mostly the heel of the hand, vibrate (shake) thehands, moving them downward. Stop the vibrating when theclient inhales. Vibrate during five exhalations over one affected lung segment. After each vibration, encourage the client to cough and expectoratesecretions into the sputum container. PERCUSSIONS = involves striking the chest wall over the area being drained. 1. 2. 3. Position the hand so that the fingers and thumb touch and cup the hands. Perform chest percussion by striking the chest wall alternatively with cupped hands Perform percussion over a single layer of clothing, not over buttons, snaps or zippers POSTURAL DRAINAGE 1. 2. The sequence for PVD is usually as follows: positioning, percussion, vibration, and removal of secretions by coughing or suction. Each position is usually assumed for 10 to 15 minutes,although beginning treatments may start with shorter times andgradually increase INCENTIVE SPIROMETRY 1. 2. 3. 4. 5. 6. 7. 8. 9. Hold or place the spirometer in an upright position. (A tilted floworienteddevice requires less effort to raise the balls or discs; avolume-oriented device will not function correctly unless upright.) Exhale normally. Seal the lips tightly around the mouthpiece. Take in a slow, deep breath to elevate the balls or cylinder, andthen hold the breath for 2 seconds initially, increasing to 6 seconds, to keep the balls or cylinder elevated if possible. Remove the mouthpiece and exhale normally. Cough after the incentive effort. Deep ventilation may loosensecretions, and coughing can facilitate their removal. Relax and take several normal breaths before using the spirometeragain. Repeat the procedure several times and then four or five timeshourly. Practice increases inspiratory volume, maintains alveolarventilation, and prevents atelectasis (collapse of the air sacs). Clean "the mouthpiece with water and shake it dry.