What is chest physiotherapy? Explain its steps and techniques.

     CHEST PHYSIOTHERAPY

INTRODUCTION:

Chest physiotherapy is a group of techniques that mobilizes or loosens thick secretions in the lungs and respiratory tract that includes following physiotherapy treatment techniques:

• Nebulization
• postural drainage by gravity
• percussion
• chest wall vibration and shaking
• huffing and coughing
• deep breathing exercises and other therapeutic exercises

In easy words, chest physiotherapy (CPT) is a technique that can be used to clear mucus from the lungs.

AIMS OF CHEST PHYSIOLOGY:

• To facilitate removal of airway secretions.
• To optimize lung compliance and prevent it from collapsing.
• To decrease the work of breathing.
• To optimize the ventilation-perfusion ratio/ improve gas exchange (SPO2)
• strengthen the muscles used for breathing

INDICATIONS:

• Cystic fibrosis (inherited disorder that causes severe damage to lungs, digestive system and other parts of the body)
• Bronchiectasis (a long-term condition where the airways of the lungs become widened, leading to a build-up of excess mucus that can make the lungs more vulnerable to infection)
• Atelectasis (complete or partial collapse of the entire lung or any lobe of the lung)
• Lung abscess (cavity filled with pus)
• Neuromuscular diseases.
• Pneumonias in lung.
• Asthma
• mechanical ventilation
• respiratory muscle weakness
• neonatal respiratory distress syndrome
• COPD

CONTRAINDICATIONS:

1. Active pulmonary bleeding or active hemorrhage in any part of body
2. fractured rib or unstable chest wall
3. lung contusions
4. pulmonary tuberculosis
5. Untreated pneumothorax
6. Acute asthma or bronchospasm
7. pulmonary embolism
8. Lung abscess or tumor
9. Bony metastasis
10. Head or neck injury
11. Recent myocardial infarction
12. Vomiting
13. Immediately after eating (atleast 2-4 hrs.)
14. uncontrolled hypertension
15. osteogenesis imperfecta or any other bone disease causing brittleness and fragility of the bone.
16. intracranial pressure >20mm Hg
17. active spine surgery/ spinal injury
18. thoracic surgeries

TECHNIQUES OF CHEST PHYSIOTHERAPY:

• ASSESSMENT:

• Assess the chest X-ray for pulmonary findings
• Assess Respiratory rate, spO2, breathing rhythm, BP, HR and skin color of the patient.
• Assess patient's ability to take deep breaths.
• Then perform CPT and keep some factors under observation including:
• discomfort and dyspnea
• heart rate and rhythm
• sputum production and breathe sounds
• respiratory rate
• mental status
• blood pressure
• patient tolerance

• NEBULIZATION:

A nebulizer is a small machine that turns liquid medicine into a mist. It is used in respiratory conditions like COPD, Asthma etc. The medications used in nebulizers help by loosening the mucus in the lungs so it can be coughed out more easily, and by relaxing the airway muscles so that more air can move in and out of the lungs

• POSTURAL DRAINAGE:

• Postural drainage involves positioning a person for atleast 3-15 mins with the assistance of gravity to aid the normal airway clearance mechanism. 
• Before determining the postural drainage position, it is very important to auscultate the lungs and identify the lung segments where added sound (Crepitus) is heard.
• The positioning depends on specific segments of the lungs with a large amount of secretions. Postural drainage is the drainage of secretions, by the effect of gravity, from one or more lung segments to the central airways (where they can be removed by a cough or mechanical aspiration).
• Postural drainage can be facilitated with percussion and vibration in the postural drainage position.
• DRAINAGE OF LOBES: 
• The upper lobe segments have the advantage of gravity drainage both in erect as well as in semi recumbent position, so postural drainage can be facilitated in sitting or lying posture.
• A foot end elevation of 14-18 inches is requires for the drainage of middle and lower lobes.

• POSITIONS:
• Anterior apical lobes:

The patient is positioned by sitting upright, straight back.

• Posterior apical lobes:

The patient is positioned by sitting and slightly leaning on two pillows played on the lap of the patient.

• Anterior segment of upper lobes:

The patient is positioned in supine lying, and a pillow is placed under the knees for comfort.

• Posterior right side segment of upper lobes:

The patient is positioned in prone lying to the left side, with knees bend and pillow placed under the chest.

• Posterior left side segment of upper lobes:

The patient is positioned in prone lying to the right side, with knees bend and pillow placed under the chest, then slightly elevate the head.

• Middle lobe of right lung:

The patient is positioned by  lying on the left side, with knees bent, place one pillow behind the back, rotate the chest slightly backwards supported on the pillow, elevate the foot of bed to 15 degrees.

• lingula of the left lung:

The patient is positioned by lying on the right side with knees bend, place a pillow bend the back, rotate the chest slightly backwards so that it can be supported on the pillow, elevate the foot of bed to 15 degrees.

• Anterior basal in lower lobes of both lungs:

The patient is positioned in supine lying, with a pillow under the knees for comfort, elevate the foot of bed to 20 degrees.

• Superior segments of both lungs on posterior side:

The patient is positioned in prone lying, with a pillow under abdomen.

• Posterior basal of both lungs on posterior side:

The patient is positioned in prone lying, elevate the foot of bed to 20 degrees.

• Lateral basal of right lung:

The patient is positioned in prone lying to left side with knees bend, a pillow is placed under the chest, elevate foot of bed to 20 degrees.

• Lateral basal of left lung:

The patient is positioned in prone lying to right side with knees bend, a pillow is placed under the chest, elevate foot of bed to 20 degrees.

• PERCUSSION:

Chest percussion involves rhythmic alternating clapping/ cupping on the chest wall over the area being drained to force excretions into larger airways so that it can be excreted by coughing. The chest percussion is performed by a specific thumb and finger positioned into a cup (dome) shaped. It is performed during both phases of breathing, inspiration and expiration.

• PROCEDURE OF PERCUSSION:
• Assess the area that needs to be percussed through the chest X-ray. 
• A hard and fast rule for the PATIENT POSITION that needs to be acquired is, if right lung needs percussion, the patient is asked or passively rotated to left side-lying position and if the left lung needs percussion,  the patient is positioned in right side-lying. 
• In general, The patient may be in long sitting position with a pillow placed between the laps, Ask the patient to lean forward on the pillow in order to effectively perform percussion on either or both lungs.
• The hand should be cup shaped from the beginning to the end of the procedure
• The sound of the percussion should be hollow, and not a slap. If erythema occurs at the site of percussion then the procedure is not performed correctly.
• Both hands must apply same amount of force, and a rate of 100 to 300 clapping per minute.
• Cupping must be avoided on any bony protuberance like spine of vertebrae, spine of scapula, clavicle etc.
• The entire procedure ranges from 3 - 5 minutes in general. Chronic conditions may require an extended procedure time

• CHEST WALL VIBRATION AND SHAKING: 

Vibration is a technique that gently shakes the mucus so it can move into the larger airways. The caregiver places a firm hand on the chest wall over the part of the lung being drained and tenses the muscles of the arm and shoulder to create a fine shaking motion.

It is coupled with the upper enlisted techniques to effectively clear the airways.

• HISSING AND COUGHING:

Huffing is a forced expiratory technique, that involves inspiration through the nose and actively expirating with mouth and throat open, as if one is misting up a mirror. It is performed three to five times before coughing as way to prepare the airways for forceful cough.

Coughing is a forced expiratory technique that is performed to excrete the secretions from the airways, involves deep inspiration and forced expiration from the mouth. 

• THERAPEUTIC EXERCISES:

The Exercises that are effective in chest physiotherapy are enlisted below:

• Deep breathing exercises (inspire through nose, hold for 3-4 seconds,  expire through mouth) involving pursed lip and belly breathing in supine, prone, sitting and standing position.
• Forceful and deep breathing both inspiration and expiration (acquired by use of spirometer)
• Pectoral stretch
• Ribs mobilizations
• Spinal mobilizations (T1- T10)

REFERENCES:

https://www.youtube.com/watch?v=jWfaTBBZCQc&t=163s

https://www.youtube.com/watch?v=LJU_zVMnF3o