Manual Respiratory Techniques Guideline for Practice 2015

Version: This replaces the Manual Techniques Guideline for Practice, September 2015
Review Date: September 2018
Contact: Eleanor Douglas Lecturer/Practitioner Physiotherapist. Ext: 56142
Disclaimer
This guideline has been registered with the Nottingham University Hospitals Trust. However,
clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will
remain the responsibility of the individual clinician. If in any doubt regarding this procedure,
contact a senior colleague. Caution is advised when using guidelines after the review date.
Please contact the named above with any comments/feedback.
Introduction/Indications for Use
This guideline describes the procedure for the use of manual techniques (chest
clapping/percussion, shaking and vibrations).
Manual techniques may be of benefit in patients who have copious secretions for example in
Cystic Fibrosis and Bronchiectasis patients.
The use of manual techniques may be considered in patients when they are unable to participate
in active breathing techniques to clear secretions (e.g. ventilated patients) or to augment the
mobilisation of secretions during breathing techniques. Manual techniques may benefit people
who are exhausted e.g. those with an exacerbation of disease, weak patients, patients with
neuromuscular disease, young children, the elderly or those with learning difficulties.
Best Practice Point
Consider manual techniques if self ventilating patients using independent techniques are unable
to clear secretions effectively or if they are fatigued (Bott et al, 2009)
This guideline is to be used in conjunction with the Active Cycle of Breathing Technique
(ACBT) guideline (2015) and the Gravity Assisted Positioning (GAP) Guideline(2015)
Precautions
Bronchospasm
Hypoxaemia (prolonged chest clapping may produce hypoxaemia (Mc Donnell et al., 1986))
Chest wall incisions/wounds
Coagulopathy e.g. low platelet levels <40
Increased or labile intracranial pressure (ICP)
Contraindications
Frank/unexplained haemoptysis
Unstable rib fractures
Severe osteoporosis
Loss of skin integrity e.g. burns/skin grafts
Pain
Severe clotting disorder
Surgical emphysema
Unstable angina or arrhythmias
Complications
Breath holding
Bronchospasm
Hypoxaemia
Increased airflow obstruction

Manual Techniques Clinical Guideline 2015

Procedure
Action

Rationale

Prepare the patient by giving a clear

explanation of the treatment

Minimises distress and informs the

patient of the procedure

Obtain consent from the patient

Confirms the patient is willing to

undertake the treatment
To ensure no bronchospasm is present prior to
the treatment and to assess which area(s) of
the lung (s) is/are to be treated
To ensure the skin is intact and no areas of
skin are damaged

Auscultate the patients chest

Check the patients skin integrity over

the area of the rib cage to be treated and take
care to avoid performing manual techniques
over a portacath and lines and drains
Check the patients Sp02 level
Position the patient to optimise secretion
clearance. This may include modified postural
drainage positions (see Gravity Assisted
Positioning Guidelines)
When performing chest clapping/percussion a
towel may be placed over the area to be
treated. However, avoid too much padding
Perform clapping/percussion rhythmically with
a loose wrist and a cupped hand over the lung
area that is to be treated
A slow single handed technique or a rapid
double handed technique can be used
Observe the patient to ensure they are not
holding their breath
Encourage the patient to perform 3-4 thoracic
expansion exercises during chest clapping (if
the patient is able, see Active Cycle of
Breathing Guidelines, 2015)
If the patient is prone to desaturation, monitor
the patients oxygen saturations and respiratory
rate throughout the procedure. Supplementary
oxygen may be required during treatment
To perform shaking and vibrations the hands
are placed over the area where secretions are
to be mobilised from and oscillations directed
inwards against the chest in the direction of
bucket handle rib movement
The height of the bed should be adjusted to
allow the therapist to use their body weight to

Manual Techniques Clinical Guideline 2015

To ensure desaturation is detected if it occurs

during the treatment
Tilting or side lying the patient may use gravity
to assist the mobilisation of secretions (See
Gravity Assisted Positioning Guideline, 2015)

The technique should not be performed on

bare skin as this may be uncomfortable for the
patient, but too much padding may reduce the
effectiveness of the technique
This creates an energy wave that is transmitted
to the lung parenchyma to loosen secretions

Depending on patient preference. A slow single

handed technique may be more suitable if the
patient is at risk of bronchospasm
Breath holding may cause oxygen desaturation
This can prevent oxygen desaturation

To ensure the patient remains stable during the

treatment.

Chest compression assists the mobilisation of

secretions from peripheral to more central
airways

To augment expiratory flow and mobilise

secretions.

assist with the vibratory/compression action

Encourage the patient to take a deep inhalation
and perform the technique on their exhalation
Encourage the patient to relax their breathing
in between the technique
Use forced expiratory technique or coughing to
assist the patient to expectorate
Document the physiotherapy treatment and its
outcome in the patients medical notes

The therapist must be aware of their own

posture to protect their back
To encourage movement of secretions during
expiratory flow
To prevent airway closure, desaturation or
bronchospasm
Allows secretions that have mobilised to central
airways to be expelled
To provide a legal record of the treatment and
to communicate its outcome with other health
care professionals

References

Bott et al (2009) Guidelines for the physiotherapy management of the adult, medical,
spontaneously breathing patient. Thorax 64: (Suppl): i1-i51
Jones M & Moffatt F. (2002) Cardiopulmonary Physiotherapy.BIOS, Oxford
Pryor JA & Prasad A (2002) Physiotherapy for Respiratory and Cardiac Problems. 3rd Edition.
Churchill Livingstone, Edinburgh
Hough A. (2001) Physiotherapy in Respiratory Care. 3rd Edition. Nelson Thornes,Cheltenham
McDonnell T, McNicholas WT, and Fitzgerald MX. (1986) Hypoxaemia in chest physiotherapy in
patients with cystic fibrosis. Irish J Med Sci 155:345-348
Olson DM et al (2009) Effect of mechanical chest percussion on intracranial pressure: a pilot
study. American journal of Critical Care 18: 330-335

Manual Techniques Clinical Guideline 2015