Chest Physiotherapy, by Susan Hamilton.
Health care workers in all health care settings should always adhere to the latest World Health
Organization guidelines on hand hygiene and barrier precautions before and after contact
with the patient, bodily fluids, or patient surroundings. For more information, please
watch our video entitled Hand Hygiene.
Introduction.
Hi, I'm Sue Hamilton. I'm a nurse educator at Children's Hospital Boston. I'm here to
talk to you today about some techniques of chest physical therapy that include percussion,
vibration and postural drainage.Indications. Chest physiotherapy is used to help improve
a patient's pulmonary function, including gas exchange and lung compliance. This is
accomplished through mobilizing secretions, which are present in the artificial airways
and/or lungs of a critically-ill child. You would want to perform this procedure in order
to stimulate a productive cough and improve aeration in patients with disorders that result
in mucus production. These disorders include, but are not limited to, pneumonia, acute atelectasis,
bronchiolitis, cystic fibrosis.
Contraindications. Some health care providers would refrain from performing this procedure
in patients with active hemoptysis or coagulopathy, which is characterized by a platelet count
of less than 50,000. You should also exercise caution in patients with rib fractures or
metastases, an active pulmonary embolism, an untreated pneumothorax, a bone density
deficiency, or recent spinal injury or surgery.
Equipment. You will need the following equipment to perform the procedure. Suction catheter,
connection tubing, suction source with a receptacle, oxygen source, manual ventilation bag and
mask with manometer, stethoscope, personal protective equipment, clean gloves.
Pre-Procedure Assessment and Monitoring.
Before starting, you should do an assessment of the patient's lungs and listen for wheezing
or crackles or aeration that is not equal on either side. I'm just going to listen to
this baby now.
Also, assess the patient's ability to be placed into the different postural drainage positions.
If the patient has lines, tubes, IVs, that may keep you from doing that, or if the patient
happens to lower their oxygen level in one particular position, you would want to know
that prior to starting.
Get a set of baseline vital signs and a baseline pain score and make sure that the patient
doesn't have any causes of pain in the chest area that would keep you from doing this procedure.
Also, make sure to explain the procedure to the patient and family. As I said, parents
can sometimes be a little bit concerned when they hear the noise of percussion and think
that it may be hurting their child.
Procedure. I'm going to start first by just talking about postural drainage. I'm going
to talk about each of the techniques, and then I'm going to demonstrate them on this
baby. So first would be postural drainage. And that just means the positioning of the
patient to allow gravity to help to mobilize secretions. This is done in conjunction with
the percussion and vibration.
And if a patient can't tolerate all of the position changes that may be involved, modification
certainly can be made, or the patient can be kept either in a flat or elevated position
through the entire. There are generally six positions or basic positions that you can
use, and I'm going to demonstrate those after the end of this talk.
Now I'm going to talk about percussion. Percussion is a painless, rhythmic clapping with a cupped
hand over an area of the chest. You basically want to take your hand and make almost a C
with it. And you want to have a loose wrist. And the way to percuss is to go over an area
of the chest and getting the full-- the C-- against the chest so that there is a pocket
of air there that creates a nice seal for doing the percussion.
You would perform percussion for 1-2 minutes in each of the given areas, and that is done
to help assist mobilization of secretions. Following that, you can go ahead and do vibration,
which is basically a sustained downward vibrating motion with the flat part of the palm. It's
important to only do the vibration piece of this when the patient is exhaling. It also
helps with mobilization of secretions.
So after you're done percussing, you can put your hand flat. You can use your other hand
to help you. And when the patient has an exhalation, you can just vibrate very gently.
I find that most babies actually are very soothed by this procedure. Some people, because
you can end up making a loud clapping noise, patient or parents can be afraid that children
are being hurt. But they're not being hurt. And as I said, most babies actually find this
to be very soothing.
When doing the actual procedure, you want to continue to look at the patient's vital
signs, how they're oxygenation is doing, the patient's tolerance to the different position
changes, the tolerance to the actual percussion and vibration, how strong the patient's cough
is, their ability to cough and mobilize secretions, and how their overall comfort is. I'm going
to go ahead and start to get ready to do the actual procedure by putting on my personal
protective equipment.
Now that I've assessed my patient and prepared the family and the patient for the procedure,
I'm going to go ahead and start. I'm going to do six different positions on the patient.
As I mentioned before, you would normally go for 1-2 minutes in each position. For the
sake of this video, I'm not going to do the full 1-2 minutes, but that would be expected
of what you would do.
I'm going to start with the anterior segments of the upper lobes. The patient should start
out supine in a flat position. And I'm going to start with percussing above, between the
nipple line and the clavicle line, first, on the right for 1-2 minutes and then on the
left for 1-2 minutes.
So I would start on the right. I would do percussion. I'd be noting how the patient
is tolerating it, be looking for any color changes or oxygenation changes in the patient.
I would continue that for 1-2 minutes. And then I would follow that with some vibrations.
I would wait for the patient to exhale and vibrate. You'd do that three or four times
and see if you're starting to get any productive secretions from the patient. Then you would
move on to the left side and continue to do that for 1-2 minutes as well.
After finishing the anterior upper lobes, you want to move on to the posterior segments
of the upper lobes as well. If you start with using the right side, you can keep the patient
flat. But when you come over to the left side, you want to elevate the head of the bed some
and go ahead and percuss basically between the spine and the axilla, and again, using
that cupping motion for 1-2 minutes as such.
And at the end, you want to wait for the patient to exhale and give a few good vibrations.
If the patient needs any suctioning, you could go ahead and do this at this point and before
you move on to the next position.
Point of clarification. Please note that we will now show the appropriate patient positioning
for the four remaining positions. It is expected that you would continue to perform percussion
and vibration for 1-2 minutes on each side in each position as previously demonstrated.
The next position that you'll do is the anterior mid-lung. For this position, you'd preferably
want to have the patient in about a 10 degree slope downwards as long as the patient can
tolerate that. I'm using a pillow to help position my patient, and I have one little
pillow under her head for comfort. I have her hand up over her head, but whatever is
most comfortable for your patient.
And once you have the patient in a good position and the patient's on their side, you want
to percuss this over the nipple line that is most adjacent to you. So again, you want
to do one to two minutes of percussion followed by some vibration. The next position, you'll
just move the patient back supine, keeping her head down the 10 degrees if at all possible.
I'm going to remove her pillow now to help get a better position. And now I'm going to
try to do the chest PT in the anterior bases of the lower lobes. I'm going to percuss below
the axilla over the lower ribs followed by some upward vibration and repeat on the left
side.
Now you'll go ahead and work on the lateral bases of both sides. Again, get the patient
in the head dependent position of about 10 degrees as long as the patient is comfortable.
And you want to first do percussion on the lower ribs along the side. So this is going
for the lateral bases of the lower lobes followed by vibrations on exhalation.
Then you would turn the patient to the other side and do the other side. And then the last
position would be the posterior bases. So if the patient can tolerate, you can bring
the patient a little bit more prone. If the patient doesn't tolerate a full turn, you
can do a modified turn. And again, you're going to do the cupping on the backside--
be careful not to overlie the spine or to go near the kidneys-- followed by vibration.
Once you're all done with all of the positions-- the six positions that I showed you-- you
want to bring the patient back supine and make an assessment of the baby and decide
whether the patient needs to be suctioned or to help the patient with their cough.
Post-Procedure Assessment and Monitoring.
After placing the patient back in a supine position, you want to do another overall assessment
of how the patient tolerated the procedure and also suction any secretions that may have
come up during the percussion and vibration.
My patient sounds as though she has some secretions in the back of her throat. She has a productive
cough, but I'm going to go ahead and suction her nose to see if we can get some of those
secretions up.
As I suction her, I'm going to note the color, the consistency, and if there's any odor from
the secretions that I do get up. This patient actually has very few secretions. If she will
tolerate it, I will just suction the inside of her mouth and make sure that there's no
further secretions there.
Once I'm done suctioning and I'm sure that the patient looks well, I will do another
assessment of lung sounds and see if there's any change from the beginning of the procedure.
It is important to monitor the patient's vital signs, including oxygen saturation, heart
rate, blood pressure, and respiratory rate and effort. You will also want to assess the
patient's lungs, which includes listening for the presence of any wheezing, crackles,
and whether or not aeration is equal on both sides. And the ability to place the patient
in different positions.
Finally, you will want to monitor the patient's oxygenation, tolerance of position, cough,
and comfort during the procedure.
Complications. The complications that you may observe include oxygen desaturations,
pain or injury to the patient's ribs, muscles, or spine, vomiting, aspiration of oral secretions
into the lungs, increased intracranial pressure, hypotension, bleeding in the lungs.
Documentation. Following chest physiotherapy, you should document the following information
in the patient's medical record. The indication for the procedure, the date and time of the
procedure, The characteristics of any secretions including amount, color, consistency, and
odor.
The strength and productiveness of the patient's cough. The vital signs before, during, and
after the procedure. The resolution or persistence of the indication for the procedure, the patient's
comfort during the procedure, and any adverse outcomes.
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