METHODS OF LUNG EXPANSION THERAPY IN PHYSIOTHERAPY METHODS OF AIRWAY CLEARANCE

1. LUNG EXPANSION THERAPY
PREMKUMAR .K

2. Lung Expansion Therapy
• Group of medical treatment modalities (I.S,
IPPB, CPAP or EzPAP) designed to prevent or
treat pulmonary atelectasis and associated
problems caused from post-op thoracic or
abdominal surgery, heavy sedation,
neuromuscular diseases, weaken breathing
muscles, chest trauma or chest wall injury.
3/29/2023 PK 2

3. INDICATIONS
• Postoperative patients (highest risk) -Upper
abdominal, thoracic, cardiac surgery
• Acute respiratory failure due to pneumonia Post
traumatic ARF: Pulmonary contusions, Flail chest
• Neuro-compromised patients -Heavily sedated
patients ,Spinal cord injury
• Patients with reduced lung volumes and
ineffective cough resulting from chest wall
deformity, such as Scoliosis
• Respiratory muscle weakness or prolonged
immobility
• Patients unable to take a deep breath
3/29/2023 PK 3

4. • Modalities used to administer lung expansion
therapy to increase the patient's lung volume
by increasing the transpulmonary pressure
gradient (the difference between the alveolar
pressure and the pleural pressure).
• The transpulmonary pressure gradient results
alveoli expand.
3/29/2023 PK 4

5. Contraindications
• Pneumothorax
• ICP >15mmHg
• Active haemophytsis
• Haemodynamic instability
• Recent esophageal surgery & fistula
• Hiccups & air swallowing
• Nausea
3/29/2023 PK 5

6. 3/29/2023 6
MECHANISAM OF LUNG EXPANSION
THERAPY
1)Increasing trans pulmonary pressure
gradient
Trans pulmonary
Pressure
gradient
0
-1
-2
-6
+1
Intrapulmonary
pressure
Intra alveolar
pressure

7. To increase the transpulmonary
pressure gradient:
1.By decreasing the surrounding pleural
pressure (A spontaneous deep inspiration
increases the transpulmonary pressure
gradient by decreasing the pleural pressure.)
2.By increasing the alveolar pressure (Positive
pressure increases the transpulmonary
pressure gradient by raising the pressure
inside the alveoli.)
3/29/2023 PK 7

8. INSPIRATION EXPIRATION
+1
0
-1
-2
-6
Trans Pulmonary
Pressure
Gradient
3/29/2023 8

9. 3/29/2023 9
2)Addition of inspiratory hold to breathing
exercise will improve collateral ventilation of
alveoli
Interbronchial
Channels of
martini
Bronchoalveolar
Channels of
lambert
Interalveolar
Pores of kohn

10. 3/29/2023 10
Mucous
plug
alternate route for gas
flow when peripheral
airways obstructed

11. 3/29/2023 11
3)Interdependence-If a group of alveoli have a
tendency to collapse, the adjacent expanded
alveoli produces forces that tend to prevent
collapse

12. 3/29/2023 12
TECHNIQUES
• Controlled mobilization
• Position
• Breathing exercise
• Neuro physiological facilitation of respiration
• Incentive spirometry
• Intermittent positive pressure breathing(IPPB)
• Positive pressure therapy(PEP)
• Continuous positive airway pressure(CPAP)

13. 3/29/2023 13
CONTROLLED MOBILIZATION
• Reduces pressure on the diaphragm and
encourages basal distribution of air,with
natural deep breathing

14. 3/29/2023 PK 14

15. 3/29/2023 PK 15

16. 3/29/2023 PK 16

17. 3/29/2023 17
Therapeutic Positioning
• Functional resudal capacity (FRC) decreases from
standing to slumped sitting
• Lung compliance decrease and work of breathing
increases progressively from standing, to sitting
,to supine
• Increase shunt
• Arterial oxygenation is usually higher in side lying
postion than supine
• Supine is unhelpful for lung volume

18. 3/29/2023 PK 18

19. Effect of positioning
• Improve 02 transport in acute/ chronic
cardiopulmonary dysfunction
• Prevent the – ve effect of restricted che wall mobility
• Application of positioning to optimize 02 transport ,
primary by manipulation effects of gravity on
cardiopulmonary
• mobilization and exercise further enhances 02
transport
• Note- therapeutic positioning for PD are based on
anatomy of lung and tracheobronchial tree
3/29/2023 19

20. 3/29/2023 20
• Time should be spent in side lying, well
forward so that the diaphragm is free from
abdominal pressure
• Positioning also affects the V/Q ratio
• Lying with the affected lung uppermost means
that the better ventilation of the dependent
normal lung is matched with better perfusion

21. Incentive spirometry
• Incentive spirometry (IS) enhances lung expansion
through a spontaneous and sustained decrease in
pleural pressure.
• IS designed to mimic natural sighing or yawning by
encouraging the patient to take long, slow, deep
breaths.
• This is accomplished by using a device that provides
patients with visual or other positive feedback when
they inhale at a predetermined flow rate or volume
and sustain the inflation for a minimum of 3 seconds.
3/29/2023 PK 21

22. 3/29/2023 PK 22

23. 3/29/2023 23
Spontaneous
breathing
Incentive
spirometer
inspiration expiration inspiration expiration

24. Intermittent Positive Pressure Breathing
(IPPB)
• Intermittent positive pressure breathing (IPPB)
is a technique used to provide short-term or
intermittent mechanical ventilation for the
purpose of augmenting lung expansion,
delivering aerosol medication, or assisting
ventilation
3/29/2023 PK 24

25. 3/29/2023 PK 25

26. 3/29/2023 26
IPPB increase alveolar pressure during inspiration or expiration
PEP and EPAP
IPPB

27. Continuous positive airway pressure
• Continuous Positive Airway Pressure (CPAP) is
a simple approach using a device which
maintains some positive pressure in the
airway at the end of exhalation to keep the
airways continuously open
• Indications for CPAP:
- Mild to moderate RDS
- After extubation
- Alternative to mechanical ventilation
3/29/2023 PK 27

28. 3/29/2023 PK 28

29. 3/29/2023 29
CPAP during both inspiration and
expiration
CPAP

30. Positive Airway Pressure System
(EzPAP)
• Positive Airway Pressure System (EzPAP) is the
easy option for the prevention and treatment
of atelectasis and a medical need for lung
expansion therapy.
3/29/2023 PK 30

31. AMBU BAG / SELF INFLATING BAG
• Instruments used to provide oxygen during
intermittent positive pressure respiration
(IPPR) via an endotracheal tube or a facemask.
• Used in emergencies when somebody is facing
breathing difficulties to provide artificial
ventilation.
3/29/2023 PK 31

32. 3/29/2023 PK 32

33. • It is a compressible, self-inflating, non-rebreathing
silicon bag, which has an inlet through which air and
additional O2 is supplied and an outlet through this can
be transferred to the patient
• The gas enters in the self-expanding bag through one
way valve which restricts the flow back from the inlet.
When the bag is compressed, the air is pushed forward
through the mask in the pharynx or throat which in
turn leads to wind pipe and then in the lungs, hence
assisting in artificial ventilation.
3/29/2023 PK 33

34. • There are other valves which prevent rebreathing of the expired air
and excessive pressure from developing. It basically increases the
FIO 2 of the inspired O2 from 40% to almost 90% (if used with a
reservoir).
Some of these self-inflating bags come with pressure restrictor or
manometer tube connector or pressure gauge connector.
• The manometer connector (or the pressure gauge connector) can
be used to connect manometer tube (or pressure gauge) to monitor
the airway pressure.
• It is strongly recommended to have one of these safety features in
self-inflating bags when they are used in pediatric cases.
3/29/2023 PK 34

35. • various sizes as per the age group: -
- Neonate: - 250ml
- Pediatric: - 500ml
- Adults: - 1600 ml
3/29/2023 PK 35

36. 3/29/2023 36
Technique administered LET
Depends on level of consciousness
• If patient unconscious-PNF respiration
• If patient not alert-IPPB therapy
• If patient having problem with excess
secretions-PEP therapy
• If patient conscious and cooperative-incentive
spirometer
• If problem still not resolved-intermittent CPAP

37. OUTCOME LET
• Prevents or reverses atelectasis
• Aides in the mobilization of secretions
• Reduces air-trapping in asthma and COPD patients
• Optimizes the delivery of bronchodilator therapy
• Decreases work of breathing
• Improves inspiratory muscle strength
• Increases lung volumes
• Recruitment of collapsed alveoli by increasing FRC
• Creates a positive airway pressure gradient that will
prevent premature airway closure and expand
collapsed lung regions.
3/29/2023 PK 37

38. 3/29/2023 38
Summary LET
• Evidence shown that breathing exercises is
always beneficial than any other mechanical aids
• Deep breathing
• Localized breathing exercises
• End-inspiratory hold
• Abdominal breathing
• Sniff
• Stacked inspiration
• Rib springing

39. 3/29/2023 PK 39
Neuro physiological facilitation of
respiration
Externally applied proprioceptive and tactile
stimuli produce reflex respiratory movement
response and that appear to alter the rate and
depth of breathing

40. Rationale
• Shallow respiration leads to inadequate
ventilation
Which leads to atelectasis and retention of
secretions
• Lack of muscle tone leads to instability of
chest wall which leads to deranged
mechanical respiratory dysfunction
3/29/2023 PK 40

41. Perioral pressure
• Stimulus Applying firm
maintined pressure to the
patients on upper lip
• Response 5 second apnea
followed by epi gastric excursion
,deep breathing
mouth closure, swallowing
snout phenomena
• Suggested mechanism
Primitive reflex response related
to sucking breathing and
swallowing
3/29/2023 PK 41

42. Intercostal stretch
• Stimulus applying
pressure to upper border
of rib inorder to stretch
the intercostals muscle in
downward direction
• Response
gradual increase in
respiratory movements in
area under and around
stretch
• Suggested mechanism
intercostals stretch
receptors
3/29/2023 PK 42

43. Manual vertebral pressure (High)
• Stimulus
manual pressure to thoracic
vertebral region of T2 – T5
• Response: Increased epigastric
excursion
Deep breathing
• Suggested mechanism
Dorsal root mediated inter
segmental reflex
3/29/2023 PK 43

44. Manual vertebral pressure(low)
• Stimulus Manual pressure
to thoracic vertebral region
of T 7– T10
• Response Increased
respiratory movements of
apical thorax
• Suggested mechanism
Dorsal root mediated inter
segmental reflex
3/29/2023 PK 44

45. Co contraction of abdomen
Stimulus
• Therapist placing one hand on patients
lower ribs and one pelvis on same side
and pushing with moderate pressure so
that force is applied right angle to the
patient
• Response Increased epigastric
excursion
Increased muscle contraction – rectus
abdominis
Decrease girth in obese
Increase firmness to palpation
Coughing
• Suggested mechanism
Stretch receptors of abdominal muscles
Intercostal to phrenic reflexes
3/29/2023 PK 45

46. Anterior stretch basal lift
• Stimulus Procedure is performed by
placing hands under posterior ribs
of supine patient and lifting gently
upwards
• Response
Increased expansion of posterior
basal area
• Suggested mechanism
Dorsal root mediated inter
segmental reflex stretch receptors
in intercostals and back muscles
3/29/2023 PK 46

47. Maintained moderate manual pressure
• Stimulus
Mild pressure of open hands is maintained
over the area in which expansion is desired
• Response
gradually increased excursion on area of
contact
• Suggested mechanism
Cutaneous afferent
3/29/2023 PK 47

48. Factors that that alter response
• Patients pre existing muscle tone
• Level of consciousness
• Adequacy of ventilation
• Obesity
3/29/2023 PK 48

49. General effects of all the procedure
• Changes in breath sound as determined by
auscultation have been noted with all
procedure
• Some patients appear to become improved
from level of unconscious during respiratory
facilitation
• Response such as fluttering eye lids , head
movements, spontaneous movements ,
opening of eyes
3/29/2023 PK 49

50. Contra indications
• Abdominal co-contractions is avoided in
patients with decerebrate rigidity, young
children
• Inter costal stretch in fractured rib
• In children except peri oral stimulation all
others procedures are contraindicated
3/29/2023 PK 50

51. Incentive Spirometry (IS) or Sustained
Maximal Inspiration (SMI)
• Most widely used form of lung expansion
therapy.
• Mimics a natural sigh by encouraging the
patient to take a deep breath.
• Helps avoid atelectasis and pneumonia.
3/29/2023 PK 51

52. 3/29/2023 PK 52

53. • Incentive spirometry is to facilitate a sustained
slow deep breath involves the patient take a
sustained maximal inspiration (SMI).
• An SMI is a slow, deep inspiration from the
Functional Residual Capacity up to the total
lung capacity followed by ≥5 seconds breath
hold.
3/29/2023 PK 53

54. Types
• Flow oriented – mediflow& triflow
• Volume oriented – cough spirometer& volydyme
Volume calculation by flow spirometer
Flow= volume/time
Volume= flow * time
Eg- rising 1 ball for 1sec
Volume = 600* 1 = 600 ml
Rising 1st ball upon half in the 1st column for 1 sec
Volume = 600/2* 1= 300 ml
Raising 11/2 ball for 2 sec ( 900/1.5 *2= 450
3/29/2023 PK 54

55. Guideline
• Therapist demonstrates prescription of uses
and cleaning advice based on manufacturers
instructions.
• Patient should be in a relaxed position suitable
for deep breathing (e.g. sitting upright in a
chair or side lying if extra volume is required
in one lung due to ventilation perfusion
matching).
3/29/2023 PK 55

56. • Patient creates a tight seal around the
mouthpiece and inhales deeply and slowly.
• The patient watches the flow meter for visual
feedback. If possible the patient sustains the
inhalation to create an end-inspiratory hold.
Ideally, the inhalation is sustained for 4-5
seconds.
• Patient relaxes seal around the mouthpiece and
exhales; normal breathing is resumed with
relaxed shoulder girdle.
3/29/2023 PK 56

57. Indications
• Pre-operative screening of patients at risk of postoperative
complications to obtain a baseline of inspiratory flow and
volume
• Presence of pulmonary atelectasis
• Conditions predisposing to atelectasis such as:
– Abdominal or thoracic surgery[
– Prolonged bed rest
– Surgery in patients with COPD
– Presence thoracic or Abdominal binders
– Lack of pain control
• Restrictive lung disease associated with a dysfunctional
diaphragm or involving respiratory musculature
• Patients with inspiratory capacity less than 2.5 liters
• Patients with neuromuscular disease or spinal cord injury
3/29/2023 PK 57

58. Contraindications
• Patients who cannot use the device appropriately or
require supervision at all times
• Patients uncooperative
• pediatrics with developmental delay
• Hyperventilation
• Hypoxaemia secondary to interruption of oxygen
therapy
• Fatigue
• Patients unable to take deep breathe effectively due to
pain, diaphragmatic dysfunction, or opiate analgesia.
• Patients who are heavily sedated or comatose
• The device is not suitable for people with severe
dyspnoea
3/29/2023 PK 58

59. Precautions
• The technique is inappropriate major lung
collapse or consolidation.
• Hyperventilation
• barotrauma in emphysematous lung
• secondary to uncontrolled pain.
• bronchospasm
3/29/2023 PK 59

60. IPPB
• Therapeutic application, usually via a mask or
mouthpiece of inspiratory positive pressure to
the airway of a spontaneously breathing
patient on an intermittent
• Short-term use is for purposes of assisting
ventilation
3/29/2023 PK 60

61. IPPB
intermittent positive pressure breathing /
ventilation
• Non invasive, Pneumatic devices that involves
the patient triggering the delivery of a positive
inspiratory pressure breath during inspiration
& expiration .
• Once triggered, the IPPB machine will deliver
a positive inspiratory breath to the patient
based on the set peak airway pressure
• intermittent treatments usually last 15 to 20
minutes given several times each day.
3/29/2023 PK 61

62. 3/29/2023 PK 62

63. Physiologic effects of IPPB
• An increase in mean airway pressure
• A decrease in the work of breathing (WOB)
• Manipulation of the inspiratory-expiratory
ratio
• Increase in tidal volume (VT)
• Correct atelectasis
3/29/2023 PK 63

64. Indications
• Removal secretions ( IPPB)
• To improve lung expansion (IPPV)
• To provide short-term ventilatory support
• To aid in the delivery of aerosolized drugs
3/29/2023 PK 64

65. Contraindications
• Tension pneumothorax
• Subcutaneous or mediastinal emphysema
• Active untreated tuberculosis
• Intracranial pressure
3/29/2023 PK 65

66. Precautions
• Decrease pleural pressure and raise alveolar
pressure.
• Positive pressure can compress the lung's
vascular beds increase pulmonary vascular
resistance, impede venous return and
decrease cardiac output
3/29/2023 PK 66

67. Hazards
• Increased intracranial pressure
• Impeded venous return
• Increased airway resistance
• Pulmonary barotrauma
• Nosocomial infection
• Hemoptysis
• Hypocapnia and respiratory alkalosis
• Hypoventilation, hyperoxia, and respiratory acidosis
• Gastric distention
• Air trapping, auto-PEEP, overdistention
• Psychological dependence
3/29/2023 PK 67

68. OUTCOMES
• Improved VC
• Improved FEV1
• Cough & secretion cleaner
• Improved CXY & breath sound
• Improved oxygenation
3/29/2023 PK 68

69. CPAP
• Continuous positive airway pressure
• Non invansive
• Positive pressure is given during both
inspiration & expiration
• Ip=Ep, CPAP is given spontaneously breathing
patients who cannot perform incentive
spirometry
• Cpap given through face mask
• Flow constant inspiration and expirations
3/29/2023 PK 69

70. 3/29/2023 PK 70

71. Effects
• Increased FRC
• Improve gas exchange
• Delay the need of intubation
• Prevention of atectasis
• Re-expansion of collapsed alveoli
3/29/2023 PK 71

72. Complications
• Aspiration
• Abdominal distension
• Noisy sound
• Decreased venous return
• Coughing with mask produce ear damage
Contraindications
• Untrained pneumothorax
• Emphysema sx& bullae
3/29/2023 PK 72

73. BIPAP
• Bi level positive airway pressure, non invasive
• + ve pressure in both inspiration & expiration
• Inspiratory pressure > expiratory pressure
• Inspiratory pressure – 10- 14 cm H2o
• Expiratory pressure- 2- 4 cm H2o
• Setting IP = EP acts as CPAP
• Flow triggered pressure control flow cycle
3/29/2023 PK 73

74. Effects
• Improves sleep
• Reduces breathlessness
3/29/2023 PK 74

75. PEEP
Defined as that positive pressure which is
applied during the end of expiration – which
increases the end expiratory pressure to more
than atmospheric pressure.
Often used to improve patient’s oxygen status
especially in patients with refractory
hypoxemia.
3/29/2023 PK 75

76. 3/29/2023 PK 76
P
T

77. Indications of PEEP :
1. Refractory hypoxemia to any cause
2. Intra pulmonary shunts
3. Decreased FRC & lung compliance
3/29/2023 77
PREMKUMAR

78. Refractory hypoxemia:
Hypoxemia which responds poorly to moderate to
high levels of oxygen (FiO2 = 1)
Useful clinical guide is a PaO2 -60mm Hg or less at
FiO2 = > 0.5
3/29/2023 78
PREMKUMAR

79. • Intrapulmonary Shunts & hypoxemia : Caused
by decreased FRC, atelectasis, V/Q mismatch.
• Decreased FRC & lung compliance: PEEP, here
increases FRC and decreases the work of
breathing, hence improves the symptoms.
3/29/2023 PK 79

80. PHYSIOLOGY OF PEEP:
• Positive pressure at the end of expiration ->
reinflates the collapsed alveoli -> maintains
the alveolar inflation even during expiration ->
increases FRC -> improves ventilation.
• Once the recruitment of these alveoli has
occurred, PEEP lowers the alveolar distending
pressure and facilitates the gas diffusion and
oxygenation.
3/29/2023 PK 80

81. Auto PEEP:
• Incomplete expiration prior to the initiation of
the next breath causes progressive air
trapping (hyperinflation).
• This accumulation of air increases alveolar
pressure at the end of expiration
• which is referred to as auto-PEEP or intrinsic
PEEP.
3/29/2023 PK 81

82. • Auto-PEEP develops commonly in high minute
ventilation(hyperventilation), expiratory flow limitation
(obstructed airway) and expiratory resistance (narrow
airway).
• The PEEP value range commonly used ranges from 5-10
cm H2O, though the upper limit has been posted at 20
cm H2O.
• Levels above that is associated with increased
incidence of complications especially barotrauma. PEEP
is increased at the rate of 2-3cm H2O depending on the
clinical condition of the patient.
3/29/2023 PK 82

83. Complications of PEEP
1. Decreases venous return
2. Decreased cardiac output
3. Barotrauma
4. Increased intra cranial pressure
5. Alters renal metabolism and water balance
3/29/2023 PK 83

84. Lung Expansion Modalities
Positive Expiratory Pressure (PEP)
• Fixed orifice flow resistors
3/29/2023 PK 84

85. Fixed orifice flow resistor PEP therapy
• Patients exhales through a fixed orifice flow
resistor.
• The patient is taught to exhale actively but not
forcefully through the flow resistor.
• This positive expiratory pressure (5-25 cmH20)
helps to keep the airways open through
exhalation, thus lengthening the expiratory
phase.
3/29/2023 PK 85

86. Positive expiratory pressure
3/29/2023 PK 86

87. Mechanism
• Administration of + ve pressure allows air to
enter behind the area of mucus obstruction and
keep the airways open during exhalation
• PEP therapy does not utilize a pressurized gas
source, it is dependant upon the expiratory flow
rate of the patient.
• Can accommodate virtually any patient’s lung
capacity.
• May be used with a mask or mouthpiece with a
nebulizer for bronchodilator therapy.
3/29/2023 PK 87

88. Techniques
• Patient sitting leaning forward with elbow
supported on table
• Exhalation through mouth piece / mask
• Breathing cycle rapid 10-20 times , instruct at
end to do huff
• limitation is patient cooperation and ability to
follow directions
3/29/2023 PK 88

89. FLUTTER
MECHANISM
• Vibration applied to the airways facilitates the
losing secretion
• Increase bronchial pressure and avoid air
trapping , expiratory airflow facilitates upward
movements of mucus
3/29/2023 PK 89

90. Stages of flutter
• Stage1- mucus mobilization & loosening
• Stage 2- mucus elimination by cough or huff
3/29/2023 PK 90

91. Acapella
• Principal of PEP & FLUTTER delivered with
nebuliser
• 2 types * green 15 l/m for > 3 sec
• Blue 15l/m min 3 sec
3/29/2023 PK 91

92. • Patient position – Patient sitting instructed to
breath out 3-4 sec
• perform breath then ask pt to cough /huff
3/29/2023 PK 92

93. Other Devices
pk 93
Aerobika
Quake

94. Indication PEP, FLUTTER& ACAPELLA
• To reduce air trapping in asthma& copd
• To Aid mobilize retrained secretion
• To Prevent or reverse atlectasis
• To optimize deliver of bronchodilator
Contraindication & hazards - same to IS& IPPB
3/29/2023 PK 94

95. Techniques of chest
physiotherapy
PREMKUMAR

96. Chest physiotherapy
• CPT is a form of bronchial hygiene which
includes postural drainage ,autogenic
drainage, deep breathing exercises, manual
chest percussion and active cycle breathing
techniques
3/29/2023 PK 96

97. Chest Physiotherapy techniques
• Airway clearance techniques
• Facilitating airway clearance technique with
effective coughing techniques
• Technique to facilitate ventilation pattern
• Mobilization and Exercises
3/29/2023 PK 97

98. Airway Clearance Techniques
Chest Physiotherapy or CPT
• Postural Drainage
• Chest Percussion
• Chest Vibration
• Turning/Positioning
• Deep Breathing Exercises
• Active cycle of breathing technique
• Autogenic drainage
• Positive expiratory pressure
• High frequency chest compression
• Coughing
CPT consists of 2 separate mechanisms
• Mucociliary Clearance
• Cough Clearance
3/29/2023 PK 98

99. Postural Drainage
• PDis a technique in which different positions are
assumed to facilitate the drainage of secretions
from the bronchial airways.
• Gravity helps to move the secretions to the
trachea to be coughed up easily.
• The goal of postural drainage is to help drain
mucus from the affected lobes into the larger
airways of the lungs so it can be coughed up
more readily.
3/29/2023 PK 99

100. Postural drainage
3/29/2023 PK 100

101. …Postural drainage
• All the patients do not require postural
drainage for all the lung segments. So the
procedure must be based on the clinical
findings.
• In postural drainage, the person is tilted or
propped at an angle to help drain secretions
from the lungs.
3/29/2023 PK 101

102. 3/29/2023 PK 102

103. …Postural Drainage
• Postural drainage treatments are scheduled
two or three times daily, depending on the
degree of lung congestion.
• The best times include before breakfast,
before lunch, in the late afternoon, and before
bedtime.
• It is best to avoid hours shortly after meals
because postural drainage at these times can
be tiring and can induce vomiting
3/29/2023 PK 103

104. …Postural Drainage
• Help the patient assume the appropriate
position, based on the lung field that requires
drainage.
3/29/2023 PK 104

105. ….Postural Drainage
• After positioning the client Have the patient
remain in the desired position for 10 to 15
minutes, if tolerated.
• Perform percussion and vibration by keeping
the client in position.
• The sequence for chest physiotherapy is
usually as follows:
Positioning, percussion, vibration, and removal
of secretions by coughing or suction
3/29/2023 PK 105

106. Chest percussion
• Chest percussion involves rhythmically
clapping on the chest wall over the area being
drained to force secretions into larger airways
for expectoration.
• Position the hand so the fingers and thumb
touch and the hands are cupped
3/29/2023 PK 106

107. …..Percussion
• Perform chest percussion by vigorously
striking the chest wall alternately with cupped
hands. begin with non dominant hand
• The procedure should produce a hollow sound
and should not be painful.
• Perform percussion over a single layer of
clothing, not over buttons or zippers.
3/29/2023 PK 107

108. • Percussion is contraindicated - patients with
bleeding disorders, osteoporosis, fractured ribs
and open& unhealed wounds .
• Precautions over the spine, sternum, stomach or
lower back as trauma can occur to the spleen,
liver, or kidneys.
• Typically, each area is percussed for 30 to 60
seconds several times a day.
• If the patient has tenacious secretions, the area
must be percussed for 3-5 minutes several times
per day.
3/29/2023 PK 108

109. Percussion
3/29/2023 PK 109

110. Vibration/shaking
3/29/2023 PK 110

111. Vibration
• Vibration is a gentle, shaking pressure applied
to the chest wall to move secretions into larger
airways.
• The uses rhythmic contractions and relaxations
of arm and shoulder muscles over the patient’s
chest.
• During vibration, place your flat hand firmly
against the chest wall, on the appropriate lung
segment to be drained.
• Vibrate the chest wall as the patient exhales
slowly through the pursed lips.
3/29/2023 PK 111

112. …..Vibration
• After each vibration, encourage the client to
cough and expectorate secretions into the
sputum container.
3/29/2023 PK 112

113. Manual hyperinflation
3/29/2023 PK 113

114. AMBU- Air Mask Bag Unit
• A bag valve mask, abbreviated to BVM and
sometimes known by the proprietary name
Ambu bag or generically as a manual
resuscitator or "self-inflating bag", is a hand-
held device commonly used to provide
positive pressure ventilation to patients who
are not breathing or not breathing adequately
3/29/2023 PK 114

115. • Inflating the lung with oxygen and manual
compression to total volume (Vt) of liter
requiring a peak inspiratory pressure of b/n 20
and 40 cmH20
• Providing a larger Vt than baseline Vt to the
patient and using a Vt which is 50% greater
than that delivered by the ventilator
3/29/2023 PK 115

116. Manual ventilation
Squeezing gas into the patients lungs at tidal
volume
For eg when changing ventilator tubing
Manual hyper ventilation
Delivers rapid breaths
For eg if patient is hypercapnic
3/29/2023 PK 116

117. Indication
• To help clinical assessment of air entry into
lungs
• To improve oxygenation pre and post
suctioning
• To mobilize excess bronchial secreation
• To re-inflate areas of collapsed lungs
• To maintain ventilation when mechanical is
interupted
3/29/2023 PK 117

118. Techniques
• Mapleson circuit-absence of valves to direct
from or to the patient
• When inspiratory gas flow exceeds fresh gas
flow rebreathing occurs
• Self inflating bag-has inbuilt valve that’s
prevent rebreathing
3/29/2023 PK 118

119. Feedback
• Manual hyper inflation may increase the risk
of trauma if high peak airway pressure and
volumes are delivered
• It should be >20 cmH2o to be clinically
effective and < 40 cm H2o to prevent baro-
trauma
3/29/2023 PK 119

120. Effects
• BENEFICIAL EFFECTS
Increase static compliance
Increase removal of secretion
• ADVERSE EFFECTS
Decrease cardiac output – increase intrathoracic
volume causes decrease venous return by
compression great veins
Increase intracranial pressure - increase
intrathoracic volume causes decrease venous
return – cause increases stasis in brain
3/29/2023 PK 120

121. Precaution & CI
• PC- Fall CO, Barotrauma, severe
bronchospasm
• CI- Unstable cvs, pneumothorax, hypoxia
3/29/2023 PK 121

122. Ventilator sign mode vs MH
• A sign mode is perferred in a ventilated
patient instead of AMBU bag
• To get better result 1- PT will do AMBU & 1 –
PT will do chest physio & suctioning
• To expand the lung –slow inspiration hold
• To remove secretion – faster expiratory flow
with short inspiratory time
3/29/2023 PK 122

123. Documentation
• Following chest physiotherapy , the should
auscultation the client’s lungs, compare the
findings to the baseline data, and document
the amount, color, and character of
expectorated secretions.
3/29/2023 PK 123

124. ACBT
• ACBT are a specific set of breathing exercises
designed to remove excess bronchial
secretions
• Combinations of breathing control, thoracic
expansion control and FET
3/29/2023 PK 124

125. Active cycle of breathing technique
3/29/2023 PK 125
Breathing control
Thoracic expansion
FET

126. 3/29/2023 PK 126

127. 3/29/2023 pk 127

128. Breathing control
• relaxed breathing between manoeuvre efforts
• Shoulders relaxed, gentle breathing with lower chest
• Abdomen should move slightly
3/29/2023 PK 128

129. Thoracic expansion
*Deep breaths in. use a three-second breath-hold to
get more air behind the mucus.
• This may be done with chest clapping or vibrating,
followed by breathing control
* Typically limited to 3-4 deep breaths
• Larger lung volume increases airflow through
peripheral airways and collateral ventilation
channels, which increases the gas volume available
to mobilize secretions during expiration.
• Avoid fatigue and hyperventilation.
3/29/2023 PK 129

130. FET
• Combination of manoeuvres described as a
‘milking action’
• Directed Cough
• Forced Huff Exhalation
3/29/2023 PK 130

131. Directed Cough
• Standard procedure
• Deep breath
• Hold, using abdominal muscles to force air against a
closed glottis
• Cough with single exertion
• Several relaxed breaths before next effort
3/29/2023 PK 131

132. • 3-5 slow, deep breaths, inhaling through nose, exhaling
through pursed lips, using diaphragmatic breathing.
• Deep breath and hold for 1-3 seconds
• Exhale from mid-to-low lung volume.
• Normal breath in squeeze it out by contracting the
abdominal and chest wall muscles with the mouth
open while whispering the word ‘huff’ during
exhalation. Repeat several times.
• When secretions enter larger airways, exhale from
high-to-mid lung volume to clear secretions
• Repeat process 2-3 times.
• Take relaxed breaths before next efforts
3/29/2023 PK 132

133. ACBT – A High volumes of mucus production
Breathing
Control
Thoracic
Expansion
Exercises
Breathing
Control
Huff
pk 133
Fink, J.B. (2007). Forced Expiratory Technique, Directed Cough and Autogenic Drainage. Respiratory Care, 52(9), p. 1216, Fig. 6.

134. ACBT–B(Bronchospastic )
Breathing
Control
Thoracic
Expansion
Exercises
Breathing
control
Huff
Huff
pk 134
Fink, J.B. (2007). Forced Expiratory Technique, Directed Cough and Autogenic Drainage. Respiratory Care, 52(9), p. 1216, Fig. 6.
Forced
Expiratory
Technique

135. ACBT – C
airway collapse & mucus plugging
Breathing
Control
Thoracic
Expansion
Exercises
Breathing
Control
Thoracic
Expansion
Exercises
Breathing
Control
Huff
Breathing
Control
pk 135
Fink, J.B. (2007). Forced Expiratory Technique, Directed Cough and Autogenic Drainage. Respiratory Care, 52(9), p. 1216, Fig 6.
Repeat
Forced
Expiratory
Technqiue

136. Equipment
• Patient or care givers hands to percuss or
shake vibrate the chest wall during thoracic
expansion used.
- Mechanical percussors or vibrations may be
required
- If PD positions are used equipment for
positioning will be required
- To teach huffing maneuver
Peak flow meter mouth piece may be used –
game of huffing at the cotton balls
• ‘Chicken breath’
3/29/2023 PK 136

137. Advantages
1.Patient can actively participate in secretion
moblisation
2. Independently managing airway clearance
3. Technique may be adapted for patients with
gastro oesophagial reflex, bronchospasm and
acute exacerbation of pulmonary disease
4. Decrease in oxygen saturation caused by
chest percussion can be avoided by ACBT
5. Cost of ACBT is minimal.
3/29/2023 PK 137

138. Disadvantages
• young children and extremely ill adults a care
giver will be necessary to assist the patient
this technique
• care must be taken to adapt technique in
patient with hyperactive airways
3/29/2023 PK 138

139. Autogenic drainage
3/29/2023 PK 139

140. Autogenic Drainage
• It’s an airway clearance technique characterized
by breathing control, where the person adjusts
the rate, depth, and location of respiration to
clear chest secretions independently.
• Aim of breathing is to achieve highest possible
expiratory flow simultaneously in different
generations of the bronchi, keeping bronchial
resistance low, and avoiding bronchospasm and
dynamic airway collapse.
3/29/2023 PK 140

141. • Important to note, this technique requires a
great deal of patient cooperation, and is
recommended for patients >8yrs old who have
a good sense of their own breathing, and can
actively participate in the process. Very
difficult clearance technique to master, but
well worth the time and effort to learn.
3/29/2023 PK 141

142. Preparation & Position
• Clear upper airways, ie, nose & throat –
huffing or coughing
• Take prescribed nebulizers or inhalers
• Find comfortable, unrestricted position
pk 142

143. Inspiration
• Performed slowly, through the nose
• Held for 2-4 seconds
• Up to twice the size of normal tidal breath
pk 143

144. Expiration
• Active, silent sigh
• At least as long as inspiration, but exhaling a
little longer helps to achieve low lung volume
stage
• Urge to cough should be suppressed until
secretions are high enough to expectorate
successfully
• Utilize controlled cough or huff for
expectoration
pk 144

145. The process
• ‘unstick’ – low volume breathing
• ‘collect’ – breathe based on frequency
vibrations
• ‘evacuate’ – only when secretions have made
their way to upper/central airways or mouth
pk 145
Agostini, P. & Knowles, N. (2007) Autogenic drainage: the technique, physiological basis and evidence. Physiotherapy, 93, p. 159.

146. pk 146
UNSTICK

147. High frequency chest compression
3/29/2023 PK 147

148. Exercises for airway clearance
• 6-
• 7-very very light
• 8-
• 9- very light
• 10-
• 11- fairly light
• 12-
• 13- somewhat hard
• 14-
• 15- hard
• 16-
• 17- very hard
• 18-
• 19- very very hard
• 20- extremely hard
Brog scale
3/29/2023 PK 148

149. Indications and cautions
• Cystic fibrosis
• Atelectasis
• Asthama
• Respiratpry muscle weakness
• Bronchiectasis
• Mechanical ventilation
• Neonatal respiratory distress syndrome
3/29/2023 PK 149

150. Contraindications
• Intracranial pressure (ICP) > 20 mm Hg
• Head and neck injury until stabilized
• Active hemorrhage with hemodynamic instability
• Recent spinal surgery (e.g .• laminectomy) or acute spinal
injury
• Active hemoptysis Empyema
• Bronchopleural fistula
• Large pleural effusions
• Pulmonary embolism
• Aged, confused, or anxious patients
• Rib fracture. with or without flail chest
• Surgical wound or healing tissue
3/29/2023 PK 150

151. Trendelenburg Position is Contraindicated
• Patients in whom increased ICP is to be
avoided
• Uncontrolled hypertension
• Distended abdomen
• Esophageal surgery
• Recent gross hemoptysis related to recent
lung carcinoma
• Uncontrolled airway at risk for aspiration
3/29/2023 PK 151

152. • Subcutaneous emphysema
• Recent epidural spinal infusion or spinal anesthesia
• Recent skin grafts, or flaps, on the thorax
• Burns.
• open wounds. and skin infections of the thorax Recently
placed pacemaker
• Suspected pulmonary tuberculosis
• Lung contusion
• Bronchospasm
• Osteomyelitis of the ribs
• Osteoporosis
• Coagulopathy Complaint of chest-wall pain
3/29/2023 PK 152

153. Treatment prescription.
• Motivation
• Patient’s goals
• Physician/caregiver’s goals
• Effectiveness ( of considered technique
• Patient’s age
• Ease (of learning and of teaching)
• Skill of therapist/teachers
• Fatigue or work required
• Need for assistants or equipment
• Limitations of technique based on disease type and
severity
• Costs (direct and indirect)
• Desirability of combing methods
3/29/2023 PK 153

154. Facilitating airway clearance with
effective coughing technique
• What is cough….???
• Stages of cough
• Techniques of teaching effective coughing
self assisted coughing
manual coughing
3/29/2023 PK 154

155. Self assisted coughing technique
3/29/2023 PK 155

156. 3/29/2023 PK 156

157. Manual coughing technique
3/29/2023 PK 157

158. 3/29/2023 PK 158

159. 3/29/2023 PK 159

160. Technique to facilitate ventilation
pattern
• Body positioning
• Breathing technique
• Mobilizing the thorax
• Facilitating the accessory muscles of
respiration
3/29/2023 PK 160

161. Body positioning
• Standing upright position
• Erect sitting (self supported or with assist) with feet moving
(e.g., active, active assisted or passive cycling motion)
• Erect silting (self-supported or with assist) with feet
dependent
• Lean forward sitting with arms supported and feet
dependent
• 24S degree sitting with legs dependent
• Erect long sitting (legs non dependent)
• < 4S degrees sitting (legs non dependenl)
• Prone and semi prone/side lying
• Supine
3/29/2023 PK 161

162. Breathing exercise
• BE also called as ventilatory training.
• Levenson classified breathing exercise into 3
categories:
1. BE includes to increase lung volume& capacities
( FRC), redistribute ventilation& gas exchange
Outcomes
• Improve ventilation& gas exchange
• Decrease work of breathing
• Maintain or improve chestwall mobility
• Prevent pulmonary compromise
3/29/2023 PK 162

163. 2nd category BE includes improve strength,
endurance& efficiency of ventilatory muscle
3rd category of BE includes to decrease the work
of breathing and facilitation of relaxation
3/29/2023 PK 163

164. Breathing techniques
• Diaphragmatic breathing pattern
• Segmental expansion
• Glossopharyngeal breathing technique
• Pursed lip breathing
• Paced breathing
3/29/2023 PK 164

165. Diaphragmatic breathing
3/29/2023 PK 165

166. 3/29/2023 PK 166

167. Segmental breathing
3/29/2023 PK 167

168. 3/29/2023 PK 168

169. Pursed lip breathing
3/29/2023 PK 169

170. Facilitating the accessory muscles of
respiration
3/29/2023 PK 170
Pectoralis Major
Sternocleido mastoid
Trapezius
Serratus anterior

171. Indications
• To increase ventilation
• Respiratory muscle weakness
3/29/2023 PK 171

172. Mobilization and exercises
• Mobilization is defined as the therapeutic and
prescriptive application of low-intensity exercise in the
management of cardiopulmonary dysfunction usually
in acutely ill patients.
• Primarily, the goal of mobilization is to exploit the
acute effects of exercise to optimize oxygen transport.
• Even a relatively low intensity mobilization stimulus
can impose considerable metabolic demand on the
patient with cardiopulmonary compromise.
3/29/2023 PK 172

173. • In addition, mobilization is performed in the
upright position, that is the physiologic
position, whenever possible,
• to optimize the effects of being upright on
central and peripheral hemodynamics and
fluid shifts.
• Thus mobilization is prescribed to elicit both a
gravitational stimulus and an exercise stimulus
3/29/2023 PK 173

174. exercise
• What are the exercises given-Exercise is the
term used to describe the therapeutic and
prescriptive application of exercise in the
management of subacute and chronic
cardiopulmonary and cardiovascular
dysfunction. Primarily, the goal of exercise is
to exploit the cumulative effects of and
adaptation to long-term exercise and thereby
optimize the function of all steps in the
oxygen transport pathway.
3/29/2023 PK 174

175. Treatment prescription for
mobilization and exercises
• It depends on the patient’s condition
• Whether the patient is in patient or in out
patient department
• Also it depends on the functionality of the
patient at the present stage
• It is decided on the basis of the exercise
testing protocol
• Also on the basis of METs
3/29/2023 PK 175

176. 3/29/2023 PK 176

177. • Step 1
Identify all the factors underlying the pathology
causing deficits in oxygen supply.
• Step 2
Determine whether mobilization and exercise are
indicated and if so, which form of either will
specifically address the oxygen transport deficits
identified in Step I.
3/29/2023 PK 177

178. 3/29/2023 PK 178
Step 3
Match the appropriate mobilization or exercise
stimulus to patient's oxygen transport capacity.
Step 4
Set the intensity within therapeutic and safe
limits of the patient's oxygen transport
capacity.
Step 5
Combine the various body positions especially
in the erect position with the following
maneuvers:

179. • Step 6
Set the duration of the mobilization sessions based on the
patient's responses (i.e., changes in measures and
indices of oxygen transport) rather than time.
• Step 7
Repeat the mobilization session as often as possible
based on its beneficial effects and on is being safely
tolerated by the patient.
• Step 8
Increase the intensity of the mobilization stimulus.
duration of the session, or both comml!l1surate with
the patient's capacity to maintain optimal oxygen
transport when confronted with an increased
mobilization stressor, and in the absence of distress;
monitored variables to remain within predetermined
threshold range.
3/29/2023 PK 179

180. Heiarchy of treatment for oxygen
supply treatment
• PREMISE: Position of optimal physiological function is
being upright and moving. Mobilization and Exercise
• Body Positioning
• Breathing Control Maneuvers
• Coughing Maneuvers
• To minimize the work of breathing. of the heart. and
oxygen demand overall
• ROM Exercises (Cardiopulmonary indications)
• Postural Drainage Positioning
• Manual Technique
• Suctioning
3/29/2023 PK 180

181. Parameters for treatment prescription
in the management of
cardiopulmonary patients
• Define parameters of treatment based on history,
laboratory investigations, tests, and assessment
• Treatment type
• Intensity (if applicable)
• Duration
• Frequency
• Instruct patient in "between treatment" treatment,
and if applicable the nurse. a family member. or both
• Reassessment every treatment
• Modify as necessary within each treatment
• Progress between treatments as indicated
3/29/2023 PK 181

182. • Define treatment outcomes
• Determine when treatment is to be discontinued
• Request for additional supportive information. tests,
and investigations as indicated
• Predict time course for optimal effects and course of
treatment to determine treatment efficacy; modify as
necessary
• In conjunction with other interventions (e.g., medical,
surgical, nursing, respiratory therapy (weaning oxygen
supplementation.
• sympathomimetic drugs, ADLs, balance with sleep and
rest periods. peak of nutrition and feeds. Peak energy
times. peak of drug potency and effects (e.g., pain,
reduced sedation. reduced neuromuscular blockade)
3/29/2023 PK 182

183. references
• Principles and practice of cardiopulmomary
physical therapy 3rd edition Donna Frownfelter
• Tidy’s physiotherapy
• Physiotherapy for respiratory and cardiac
problems 3rd edition by Jenifer A Pryor
3/29/2023 PK 183

184. Thank you
3/29/2023 PK 184