Marissa Lamanna

March 2013
Objectives
 Brief review respiratory anatomy and physiology
 Outline the function of the respiratory system
 Review of ventilation and respiration, and diseases
which impede their effectiveness
 Definition, purpose and indications of Chest
Physiotherapy
 Overview the different types of chest physiotherapy
 Outline the nursing process in relation to the
respiratory system
Anatomy and Physiology
Upper Tract Lower Tract
Function of the Respiratory System
 Gas exchange!!!
 Provide oxygen (O2) for aerobic metabolism
 We require O2 for cell energy (life), without O2 we rely
on anaeorbic metabolism which leads to lactic acidosis
and if prolonged, death.
 Remove carbon dioxide (CO2) a bi-product of aerobic
metabolism

 Gas exchange is reliant on Ventilation and

Respiration
Ventilation
 The physical movement of
air into and out of the
lungs
 Relies on pressure changes
within the pleural cavity
 As the chest expands
(active), the pressure drops
and air enters the lungs
 When the chest goes back
to resting state (passive),
the pressure rises and air
leaves the lungs
 Restrictions to Ventilation
 Inability to use  Inability of alveolar to re-coil
intercostal muscles  Empysema

and diaphragm  Sedation/ anaesthetic

 Neuromuscular  Peri-operative
diseases  Post operative
 Motor Neuron Disease  Intubation
 Guillain Barre Disease  Obstruction
 Diaphragm paralysis  Asthma
 Amyotrophic lateral  COPD
sclerosis
 Tumours
Respiration
 The gas exchange between
O2 and CO2
 External: Occurs in the
alveolar between the
inspired air and
surrounding blood in the
capillaries
 Internal: Occurs at a
cellular level between
blood in the capillaries and
surrounding cells
External Respiration
 Alveolar are the site of
external respiration, the
gas exchange between
O2 and CO2
 For effective respiration
we need adequate
ventilation (air flow
through the lungs) and
viable alveolar surface
area
Restrictions to External Respiration
 Poor ventilation
 All the diseases listed previously
 Loss of viable alveolar surface area due to excessive mucous
 Pneumonia
 Cystic fibrosis
 Chronic bronchitis
 Right shift on the Oxy-Haemoglobin dissociation curve
resulting in a poor affinity between haemoglobin and
oxygen
 Fever
Definition
 A series of exercises and breathing techniques that aid
with airway clearance and the removal of mucous from
the lung fields.
 Consists of:
 Breathing exercises
 Assisted exercises
General Indications
 Immobility
 Post operative
 Patients confined to bed rest
 Paraplegia/ quadriplegia/ hemiplegia
 Atelectasis
 Known mucous/ sputum plugging
 Any patient whose cough alone (voluntary or induced) cannot provide adequate
lung clearance
 Adventitious breath sounds persistent after coughing
 COPD
 Patients with neuromuscular disorders
 Patients with excessive or thick tenacious secretions
 COPD (Chronic bronchitis strain)
 Cystic fibrosis
 Pneumonia
 Bronchitis
 Bronchiectasis
Pursed-Lip
Directed coughing
Spiro Ball
Diaphragmatic breathing
Pursed-Lip
 Purpose
 Exhaling air through a
narrow orifice creates a
slightly positive pressure
in the lungs, preventing
alveolar collapse
 Indications
 COPD (Emphysema)
 Contraindications
 No known
Pursed-Lip: Procedure
 Ensure the patient is in a sitting position, at least
greater than 45 degrees.
 Reassure the patient of the benefits and risks, inform
them that they can stop if they can’t tolerate.
 Instruct the patient to inhale slowly through the nose.
 Have them hold their breath for 3-5 seconds, then
exhale slowly through pursed lips (like they are trying
to whistle). Exhalation should be about x3 longer than
inhalation
Directed coughing
 Purpose  Contraindications
 Aid in the clearance of  Absolute
mucous  Tuberculosis with negative
pressure
 Indications  Relative
 Raised ICP
 Atelectasis
 Unstable head/ neck/ spine
 Post-operative prophylaxis injury
due to impaired cough  Recent myocardial infarction
 Excessive mucous production  AAA
 Chronic bronchitis, Bronchitis,  Hiatus hernia
Pneumonia, Tracheostomy,  Pregnancy
Cystic fibrosis, Bronchiectasis  Untreated pneumothorax
 Ineffective cough  Osteoporosis of the thorax/
 Neuromuscular disease, Spinal lumber
cord injury  Coagulopathy/
thrombocytopenia
Directed cough: Procedure
 Ensure the patient is in a sitting position, at least
greater than 45 degrees.
 Reassure the patient of the benefits and risks, inform
them that they can stop if they can’t tolerate.
 Place a sputum container and/ or tissues within reach
Directed cough: Procedure cont.
 You may need to
demonstrate controlled
breathing or huffing to the
patient
 The huffing will usually
illicit a cough
 You can repeat this cycle if
the patient tolerates
 Aim to do the cycle at least
once per hour, or as often
as the patient tolerates.
Spiro Ball
 Purpose
 Improves ventilation,
patients will have a greater
tidal volume and minute
ventilation.
 Indications
 Reduced ventilation
 Neuromuscular diseases
 Asthma
 Emphysema
 Contraindications
 No known
Spiro Ball: Procedure
 Ensure the patient is in a sitting position, at least greater
than 45 degrees.
 Reassure the patient of the benefits and risks, inform them
that they can stop if they can’t tolerate.
 Connect the tube to the unit, slide the level-indicator to the
volume (mL) prescribed.
 Instruct the patient to completely expire all the air from
lungs immediately prior to exercise.
 Place the mouthpiece in the patients mouth and instruct
them to slowly inhale the maximum amount they can
tolerate, and then to hold their breath for 3-4 seconds.
 Note the level they were able to reach, document.
Spiro Ball: Procedure cont.
 Aim to reach the prescribed target
 Repeat this sequence 5-10 times during the day
 Hygiene:
 Single patient use only
 Wash the mouthpiece before and after use, keep in dry safe
place
 Precautions:
 Do not exhale into device
 Avoid humid conditions
 Keep the device vertical during exercises
 The air-intake hole should remain open during use
Diaphragmatic/ Abdominal
Breathing
 Purpose
 Increases ventilation, decreases work of breathing
 Procedure
 In this technique, the patient relaxes his belly and sticks it out
during the inhalation, then draws it back in during the exhalation.
 The mouth is either left open or the lips are pursed.
 Limitations
 Few clinical benefits compared with pursed-lip breathing (work of
breathing) and spiro ball (ventilation)
 Poorly adhered to by patients
 Please refer to the 2010 Chest Physio class or read more
at: http://www.livestrong.com/article/376029-chest-
physiotherapy-breathing-exercises/#ixzz2O3AXw6ha
Postural drainage/ Positioning
Percussion
Vibration
Nebulizing
Postural Drainage/ Positioning
 Purpose
 To encourage pulmonary
drainage of mucous into the
large airways
 Indications
 Difficulty with secretion
clearance
 Retained secretions in a
patient with an artificial
airway
 Atelectasis caused by mucus
plugging
 Cystic fibrosis,
Bronchiectasis, or Cavitary
lung disease
 Contraindication
 Absolute
 Unstable head and/ or neck
injury
 Active hemorrhage
 Relative
 ICP <20mmHg
 Spinal injury/ surgery
 Emphysema with blebs
 Pulmonary oedema
 Large pulmonary effusion
 Confusion/ anxiety
 Rib fracture
 Surgical wounbd
Postural Drainage
 Ascertain where the
mucous is concentrated,
positioning is dependent
on which lung lobes are
effected
 Instruct patient of each
position, assist them if
needed
 Attempt to hold each
position for 3-15 minutes
 Remain with the patient
until they are comfortable
Postural Drainage
Upper Lobe, Apex Upper Lobes, Posterior
Postural Drainage
Upper Lobe, Anterior Lingula
Postural Drainage
Middle Lobe Lower Lobe, Anterior Base
Postural Drainage
Lower Lobe, Posterior Base Lower Lobe, Lateral Base
Postural Drainage
Lower Lobe, Superior
Segment
Percussion and Vibration
 Purpose
 The energy created by percussing/ vibrating is transmitted through the
chest wall to the lung and is able to dislodge secretions
 Indications
 For patients requiring assistance with the movement of mucous, can
also be used with excessive mucous production
 Contraindications
 Subcutaneous emphysema
 Burns, open wounds, and skin infections of the thorax
 Suspected or known active pulmonary tuberculosis
 Lung contusion
 Worsening bronchospasm
 Osteoporosis of the thoracolumbar region, known brittle bones
 Coagulopathy or thrombocytopenia (manual vibration may be well
tolerated)
Percussion
 Place a cloth or towel over the
area to be percussed
 Begin percussion over lung
segment by flexion and
extension of wrists.
 Avoid spine, sternum, breasts,
and kidneys.
 Slowly percuss each area for 3-5
minutes
 Instruct patient to use directed
coughing breathing technique
Vibration
 Perform vibration after
percussion
 Cover the area with a cloth, place
one hand flat to the area
 Instruct patient to slowly exhale
through pursed lips
 As they exhale, vibrate you hand
by quickly contracting and
relaxing you arm and shoulder
 Vibrate for 3-4 exhalations to
every area
Hypertonic Nebulizer
 Purpose
 The high salt concentration in the hypertonic solution
draws water out of the lung cells and into the airways,
the water mixes with the mucous resulting in a thinner
mucous which is easier to expectorate
 Indication
 Cystic Fibrosis, Bronchiolitis, Bronchitis, COPD
 Contraindication
 Unable to tolerate coughing/ sore throat
 Emphysema with blebs
Assessment findings
 Please refer to Respiratory Assessment class

 Talk to your patient

 May be drowsy
 Coughing frequently (if able)
 Look at your patient
 Audible breath sounds (gurgling)
 Likely rapid respiratory rate
 Auscultation
 Crackles and creps
 SpO2
 May be decreased
Analyzing/ Diagnosis
 Hypoxia/ hypercapnia related to poor external
respiration caused by excessive mucous

 Hypoxia/ hypercapnia related to inability to

expectorate sputum (related to underlying disease
process)

 Impaired/ obstructed airways related to mucous

plugging
Planning
 You need to have goals of treatment and a way to evaluate
effectiveness
 By removing excess mucous in the alveolar the patient will
have an increase of external respiration and thus improved
oxygenation.
 The patient will have fewer crackles/creps on auscultation
 Choose the most appropriate form of CPT
 Deep breathing/coughing post-operative
 Pursed lip breathing for emphysema
 Involve patient and family via education, this includes
involving them in the goals
 Decide on an appropriate time and place to initiate
treatment
Implementation
 Only perform CPT if you are confident
 Ask for assistance with the physiotherapist if needed
 Ensure all care is performed in a safe and effective
manner
 Adhere to infection prevention
Evaluation
 Assess how well the patient tolerated the CPT
 Modify if the patient was incompliant or CPT
exacerbated cough to the point of distress
 Perform another respiratory assessment
 Improvement may not be noticeable immediately, but
there should not be a decline
 Document your findings!!
 There is no point in continuing an ineffective treatment
Reference
 ALMA, L., (2008), The Most Essential Airway Clearance Technique, About.com, Accessed 20/3/13
from URL: http://cysticfibrosis.about.com/od/treatment/a/coughing.htm
 Alma, L., (2008), Inhaled Hypertonic Saline: Thinning Secretions by Osmosis, Acessed from
About.com on 23/3/13 from URL http://cysticfibrosis.about.com/od/treatment/a/saline.htm
 Barker, A.F., (2012), Treatment of bronchiectasis in adults, Up To Date, Acessed 1/3/13
 Barson, W.J., (2011), Inpatient treatment of pneumonia in children, Up To Date, Acessed 1/3/13
 Bradford Teaching Hospital, (2010), Children’s Therapy Service, Chest Physiotherapy, National Health
Service
 Epstein, S.K., (2010), Respiratory muscle weakness due to neuromuscular disease: Management, Up To
Date, Acessed 1/3/13
 McIlweine, M., (2007), Chest physical therapy, breathing techniques and exercise in children with CF,
Pediatric Respiratory Reviews, (8) 8-16
 Miller, A., (2011), Chest Physiotherapy and Breathing Excercises, Livestrong.com, Accessed 20/3/12
from URL: http://www.livestrong.com/article/376029-chest-physiotherapy-breathing-exercises/
 National Institute of Health, (2000), Chest Physiotherapy, Policy
 Ni Made Sudiata, (2010), Chest Physiotherapy, BIMC Hospital, PPT
 Piedra, P.A., and Stark, A.R., (2012), Bronchiolitis in infants and children: Treatment; outcome;
and prevention, Up To Date, Acessed 1/3/13
 Rajalingam, B., (2012), Nebulized Hypertonic Saline Improves Lung Function in Bronchiectasis, Acessed at
eMedicineLive on 23/3/13 at URL http://emedicinelive.com/medical-news/1-pulmonology/399-nebulized-
hypertonic-saline-improves-lung-function-in-bronchiectasis
Reference
 Royal Prince Alfred Hopsital, (2000), Chest Physiotherapy, RPA Newborn Care Guidelines
 Simon, R.H., (2012), Cystic fibrosis: Overview of the treatment of lung disease, Up To Date, Acessed
1/3/13
 Smetana, G.W., (2010), Strategies to reduce postoperative pulmonary complications, Up To Date,
Acessed 1/3/13
 Stoller, J., (2011), Management of acute exacerbations of chronic obstructive pulmonary disease, Up To
Date, Acessed 1/3/13
 Taube, C., Holz, O., Mucke, M., Jorres, R.A., and Magnussen, H., (2001), Airway Response to Inhaled
Hypertonic Saline in Patients with Moderate to Severe Chronic Obstructive Pulmonary Disease,
American Journal of Respiratory and Critical Care Medicine, 164 (10) 1810-1815, Acessed online 23/3/13
at URL http://ajrccm.atsjournals.org/content/164/10/1810.full
 Texas Children’s Hospital, (1992), How to do Chest Physical Therapy, Department of Chest Physical
Therapy, Respiratory Care, Pulmonary Medicine, and Educational Resources
 University of Wisconsin-Madison, (2012), 7% Hypertonic Saline for Nebulization, Acessed from UW
Health on 23/3/13 from URL
http://www.uwhealth.org/healthfacts/B_EXTRANET_HEALTH_INFORMATION-FlexMember-
Show_Public_HFFY_1126650619326.html
 UTMB Respiratory Care Services, (2005), Chest Physiotherapy, Policy