Chest Physiotherapy

Chest Physiotherapy (CPT) is a therapeutic approach used in nursing care to enhance respiratory function by mobilizing secretions, promoting lung expansion, and clearing airways. CPT is particularly beneficial for patients with respiratory conditions that impair natural airway clearance, such as chronic obstructive pulmonary disease (COPD), pneumonia, or cystic fibrosis. By mobilizing secretions using various techniques, CPT supports optimal gas exchange, improves oxygenation, and reduces the risk of respiratory complications.

What is Chest Physiotherapy?

Chest physiotherapy includes various mechanical techniques to enhance lung function by improving lung volumes and aiding in the clearance of airway secretions. Key techniques include percussion, vibration, postural drainage, active cycle of breathing, thoracic expansion exercises, and positive expiratory pressure (PEP) therapy. Intermittent positive pressure ventilation (IPPV) and structured walking programs may also be used to improve lung expansion and endurance.

Goals of Chest Physiotherapy

Chest physiotherapy aims to clear airway secretions, improve lung function, enhance oxygenation, and prevent respiratory complications like atelectasis and pneumonia, particularly in vulnerable patients.

To mobilize and expel secretions from the airways. Clearing secretions reduces infection risk and respiratory complications, improving airflow and respiratory function, especially in patients with compromised lung function.
To improve lung ventilation and perfusion. Chest physiotherapy aids lung expansion and airflow, promoting balanced air and blood distribution in the lungs for optimal respiratory efficiency.
To enhance oxygenation by improving gas exchange. Chest physiotherapy supports efficient gas exchange by improving ventilation and secretion clearance, aiding oxygen delivery and carbon dioxide removal.
To prevent or treat respiratory complications like atelectasis and pneumonia, particularly in immobile patients or those with compromised respiratory function. Chest physiotherapy minimizes the risk of atelectasis and pneumonia by expanding the lungs, mobilizing secretions, and preventing mucus buildup in at-risk patients.

Indications for Chest Physiotherapy

Chest physiotherapy is essential for improving lung function and aiding mucus clearance in various respiratory conditions:

Chronic respiratory conditions such as COPD, bronchitis, cystic fibrosis
Infectious respiratory conditions such as Pneumonia, bronchiectasis
Postoperative patients, particularly thoracic or abdominal surgeries to prevent atelectasis
Neuromuscular conditions that impair effective cough, such as muscular dystrophy or spinal cord injuries
Prolonged bed rest or immobility due to the high risk of secretion buildup and atelectasis in immobile patients

Contraindications of Chest Physiotherapy

Certain medical conditions may limit the use of chest physiotherapy to ensure patient safety. Assessing for contraindications is important to avoid complications and tailor care appropriately.

Recent thoracic or abdominal surgery without physician approval
Severe osteoporosis or rib fractures
Uncontrolled hypertension or cardiovascular instability
Increased intracranial pressure or recent head trauma
Severe anxiety or cognitive impairment hindering cooperation

Techniques of Chest Physiotherapy

These techniques, either individually or in combination, form a comprehensive approach to chest physiotherapy, helping manage respiratory conditions, maintain lung health, and improve patient outcomes.

Percussion (Clapping)

Percussion involves rhythmically clapping the chest wall with cupped hands over specific lung segments to loosen mucus. The vibration from the clapping helps dislodge secretions from the bronchial walls, making it easier for the patient to cough up or clear secretions with other techniques.
This technique is often performed for 3-5 minutes on each targeted lung segment and is commonly combined with postural drainage for more effective secretion clearance.

Vibration

Vibration involves placing the flat hands on the chest and applying a fine, shaking pressure during exhalation. This technique helps move mucus up the airways by vibrating it loose from the walls of the bronchial passages.
Nurses use vibration immediately after percussion or on its own, coordinating with the patient’s breathing to enhance mucus mobilization, typically during exhalation.

Postural Drainage

Postural drainage uses gravity to assist in draining mucus from different parts of the lungs. Patients are positioned in specific ways (such as Trendelenburg or lying on one side) so that mucus drains from smaller airways to the larger ones, where it can be coughed up.
This technique is especially beneficial for patients with conditions like cystic fibrosis or bronchiectasis, where mucus buildup is a concern. Each position is generally held for 5-15 minutes to allow maximum drainage.
Lung segments with their recommended positions for chest physiotherapy (postural drainage):

Lung Segment	Recommended Position
Upper Lobe:
Apical Segments (Right & Left Upper Lobes)	Patient sits upright, leaning slightly forward with pillows under the arms.
Posterior Segments (Right & Left Upper Lobes)	Patient leans forward while sitting, with the nurse clapping over the upper back.
Anterior Segments (Right & Left Upper Lobes)	Patient lies flat on their back with a pillow under the knees for support.
Right Middle Lobe:
Lateral and Medial Segments	Patient lies on the left side with the head down (Trendelenburg position), and a pillow supports their back for a slight tilt backward.
Left Lingula (Part of Left Upper Lobe):
Superior and Inferior Segments	Patient lies on the right side with the head down, with a pillow behind the back for a slight backward tilt.
Lower Lobes:
Superior Segments (Right & Left Lower Lobes)	Patient lies on the abdomen (prone position) with a pillow under the hips.
Anterior Basal Segments (Right & Left Lower Lobes)	Patient lies on their side with the head down (Trendelenburg position).
Lateral Basal Segments (Right & Left Lower Lobes)	Patient lies on the opposite side of the segment to be drained with the head down.
Posterior Basal Segments (Right & Left Lower Lobes)	Patient lies on the abdomen with the head down, and a pillow supports the hips.

Active Cycle of Breathing Technique (ACBT)

Active Cycle of Breathing Technique (ACBT) is a structured series of breathing exercises designed to clear secretions while maintaining lung expansion. It includes three phases: breathing control, thoracic expansion exercises, and forced expiration or huffing.
- The Active Cycle of Breathing Technique (ACBT) consists of three main phases:
  - Breathing Control—Gentle, relaxed breathing keeps the airways calm and prevents hyperventilation. It is used between more active phases for recovery and relaxation.
  - Thoracic Expansion Exercises (TEE)- Deep breaths to expand the chest, improve ventilation, and loosen secretions. Often includes a brief breath hold to enhance air distribution.
  - Forced Expiratory Technique (FET)- Controlled exhalations, or “huffs,” to mobilize secretions from the smaller to larger airways without coughing.
This technique improves breathing patterns, mobilizes secretions, and minimizes airway collapse. It’s particularly useful for patients who need to self-manage chronic respiratory conditions, as it requires no equipment and can be performed independently.

Positive Expiratory Pressure (PEP) Therapy

Positive Expiratory Pressure (PEP) Therapy uses a device to create resistance during exhalation. This helps keep airways open, improves airflow to obstructed areas, and aids mucus clearance. The device requires the patient to breathe out through a mouthpiece or mask that applies back pressure.
This technique is beneficial for patients with obstructive lung disease. It’s typically performed in cycles of 10-15 breaths, followed by coughing or huffing to clear loosened secretions.

Oscillating Positive Expiratory Pressure (Oscillating PEP)

Oscillating PEP combines positive expiratory pressure with oscillations or vibrations to help break up mucus and mobilize. Devices like the Flutter or Acapella create rapid air oscillations, which shake mucus loose as the patient exhales against resistance.
Ideal for patients with thick or difficult-to-clear mucus, oscillating PEP is performed similarly to standard PEP but with the added benefit of oscillations to enhance mucus clearance.

Autogenic Drainage

Autogenic drainage is a self-administered technique where patients learn to control their breathing to move mucus from small airways to larger airways. It has three phases: unsticking (slow breaths), collecting (deeper breaths), and evacuating (deep breaths with forced exhalation).
This method is often taught to patients with chronic respiratory conditions who need a technique they can perform independently. It promotes effective self-management of mucus clearance.

Nursing Procedure for Chest Physiotherapy

Chest physiotherapy (CPT), often administered by a nurse or respiratory therapist and teachable to family members, focuses on enhancing lung function by loosening and mobilizing secretions, which are then cleared through coughing or drainage.

Preparation for Chest Physiotherapy

1. Review patient history and assess respiratory status before and after CPT, noting any changes in breath sounds, respiratory rate, oxygen saturation, and cough effectiveness.
Baseline and post-treatment assessments allow evaluation of CPT effectiveness and identify any adverse effects such as respiratory distress.

2. Identify contraindications, such as recent surgeries, cardiovascular instability, rib fractures, or increased intracranial pressure, which may limit or modify CPT techniques.
Recognizing contraindications helps ensure CPT is safe and suitable, reducing the risk of complications from inappropriate techniques.

2. Explain the procedure to the patient and answer any questions.
Clear communication reduces anxiety, encourages active participation, and enhances the effectiveness of CPT.

3. Gather the following necessary equipment and provide privacy.
Organizing equipment in advance streamlines the procedure and respects patient dignity.

Pillows for positioning
Cupped hands or percussion cups
Vibration device
Suction device
Handheld flutter or PEP device (optional, depending on patient condition)
Incentive spirometer for deep breathing exercises
Pulse oximeter
Stethoscope

4. Position the patient comfortably and use pillows for support as needed. Adjust positions according to specific lung areas being targeted.
Proper positioning maximizes secretion drainage from target lung areas and supports patient comfort during the procedure.

Percussion Technique

1. Position the patient with the area to be treated facing up or slightly elevated if possible.
Facilitates drainage from specific lung segments.

2. Cup hands with fingers and thumb close and rhythmically clap on the chest wall over the targeted lung segments. (Use mechanical percussor or neonatal percussor on premature infants).
Loosens mucus by creating vibrations that help dislodge secretions from bronchial walls.

3. Perform percussion on each lung area for 3-5 minutes, avoiding areas over bony prominences, breast tissue, and surgical sites.
Targeted duration and avoiding sensitive areas prevent patient discomfort and injury.

4. Monitor the patient’s response throughout, checking for signs of discomfort, hypoxia, or respiratory distress.
Ensures patient tolerance and allows for immediate intervention if adverse reactions occur.

Vibration Technique

1. Position the patient with the area of treatment elevated or angled.
Promotes gravity-assisted drainage from specific lung areas.

2. Place one hand over the area, using the other hand on top for support, then apply gentle pressure and create a vibrating motion during the patient’s exhalation.
Assists in loosening and moving mucus toward the larger airways during exhalation for easier expulsion.

3. Repeat vibrations on each exhalation for 3-5 breaths, then allow the patient a break with relaxed breathing.
Short, repeated vibrations minimize fatigue and allow the patient to recover, preventing respiratory distress.

4. Reassess the patient’s respiratory status after each set of vibrations.
Monitoring post-technique provides feedback on effectiveness and patient response.

Postural Drainage Technique

1. Position the patient in different positions to drain specific lung segments (e.g., semi-Fowler’s for upper lobes or Trendelenburg for lower lobes).
Utilizes gravity to assist in mobilizing secretions from specific lung areas toward larger airways.

2. Maintain each position for 5-10 minutes, ensuring the patient is comfortable and can tolerate the position.
Adequate time in each position allows for effective drainage while monitoring for discomfort or respiratory distress.

3. Administer nebulization or bronchodilator medications if needed prior CPT.
This improves the effectiveness of chest physiotherapy by enhancing airflow and facilitating secretion clearance.

4. Encourage relaxed breathing while in each position, using breathing control techniques.
Helps prevent hyperventilation and keeps the airways relaxed for effective drainage.

5. Monitor the patient’s oxygen saturation and vital signs throughout, especially if in head-down positions.
Certain positions can impact oxygen levels or increase intracranial pressure, so continuous monitoring is essential.

Forced Expiratory Technique (Huff Cough)

1. Instruct the patient to take a deep breath in and then exhale forcefully in a “huff” manner.
Helps mobilize secretions from smaller to larger airways without causing airway collapse as a normal cough might.

2. Repeat 2-3 times, allowing the patient a moment of relaxed breathing in between.
Prevents fatigue and hyperventilation while maintaining effective secretion movement.

3. Encourage the patient to expectorate any mucus brought up by the huff.
Clears mobilized secretions, reducing airway obstruction and improving oxygenation.

Post-CPT Monitoring and Documentation

1. Reassess respiratory status, including breath sounds, oxygen saturation, respiratory rate, and cough effectiveness.
Evaluate CPT effectiveness and ensure patient safety after the procedure.

2. Document the procedure, including techniques used, duration, patient response, and any secretion characteristics.
Provides a record of the patient’s tolerance, the effectiveness of CPT, and any need for adjustments in future sessions.

Complications of Chest Physiotherapy

During CPT, nurses are responsible for closely monitoring the patient for any signs of complications, promptly addressing any issues that arise, and adjusting the therapy as needed to ensure safety. This involves assessing tolerance levels and providing interventions to prevent discomfort or harm. Here are potential adverse reactions to chest physiotherapy (CPT)

Pain or Discomfort. CPT, particularly percussion, can be physically uncomfortable or even painful, especially for patients with recent surgery, rib fractures, or inflammation in the chest wall.
Vomiting or Nausea. Postural drainage positions, especially those with the head down, may cause nausea or vomiting, particularly if CPT is performed soon after eating. This reaction can be uncomfortable and increase the risk of aspiration.
Increased Work of Breathing. Some patients may experience shortness of breath or labored breathing due to the physical exertion of CPT, especially if they have compromised lung function. This can increase respiratory fatigue and discomfort.
Hemoptysis. CPT can sometimes irritate airway linings, leading to minor bleeding. Patients with fragile capillaries, infections, or other underlying lung conditions are at higher risk of hemoptysis.
Hypoxia. During CPT, secretions can temporarily block airways, reducing oxygen exchange. This can lead to lower oxygen saturation levels, particularly if the patient has difficulty coughing or clearing secretions.
Arrhythmias (Irregular Heartbeat). For some patients, CPT can stimulate the vagus nerve or place stress on the cardiovascular system, occasionally leading to irregular heart rhythms. Patients with heart conditions should be closely monitored.
Bronchospasm. In some cases, CPT can trigger bronchospasm, a sudden narrowing of the airways, making breathing difficult. Patients with reactive airway disease, like asthma, are more susceptible to this response.
Dizziness or Postural Hypotension. Changing positions quickly during CPT, especially in postural drainage, can lead to a sudden drop in blood pressure or dizziness, particularly in patients on blood pressure medications or those who are dehydrated.

Nursing Considerations

During CPT, nurses should prioritize patient comfort, monitor for any adverse reactions, and adjust the approach based on individual tolerance and medical conditions. Timing and hydration are also managed to support optimal secretion clearance and patient safety.

1. Assess respiratory status before and after CPT.
Observe breath sounds, respiratory rate, and oxygen saturation to gauge the effectiveness of the intervention.

2. Monitor for signs of hypoxia and distress.
Ensure the patient does not experience cyanosis, labored breathing, or significant discomfort, which may necessitate stopping the procedure.

3. Provide adequate rest periods
Offer rest breaks between different CPT techniques, especially for frail or fatigued patients, to prevent exhaustion.

4. Avoid CPT after meals
Schedule CPT at least 1–2 hours after meals to prevent nausea or vomiting during the procedure.

5. Encourage adequate hydration
Hydration helps thin secretions, making them easier to mobilize and expel.

6. Instruct the patient in proper breathing techniques such as “huffing” and
effective cough.
Teach controlled, deep coughing to help expel secretions effectively and improve airway clearance.

7. Instruct on using an incentive spirometer
Guide patients in regular spirometer use to expand lung capacity and promote recovery, especially postoperatively.

8. When performing postural drainage, monitor patients on diuretics, antihypertensives, sedatives, vasodilators, or opioids.
These medications affect fluid balance, blood pressure, and respiratory function, making patients more susceptible to dizziness, hypotension, or compromised breathing during postural changes.

9. Avoid percussion over the rib cage, sternum, and spine.
Percussing these areas risks injury to underlying organs and bones and is ineffective for mobilizing lung secretions, as they don’t directly cover lung tissue.

Sources and References

Ahmad, A. M. (2018). Essentials of physiotherapy after thoracic surgery: What physiotherapists need to know. A narrative review. The Korean journal of thoracic and cardiovascular surgery, 51(5), 293.
Battaglini, D., Robba, C., Caiffa, S., Ball, L., Brunetti, I., Loconte, M., … & Pelosi, P. (2020). Chest physiotherapy: An important adjuvant in critically ill mechanically ventilated patients with COVID-19. Respiratory physiology & neurobiology, 282, 103529.
Chaves, G. S., Freitas, D. A., Santino, T. A., Nogueira, P. A. M., Fregonezi, G. A., & Mendonca, K. M. (2019). Chest physiotherapy for pneumonia in children. Cochrane Database of Systematic Reviews, (1).
Goñi-Viguria, R., Yoldi-Arzoz, E., Casajús-Sola, L., Aquerreta-Larraya, T., Fernández-Sangil, P., Guzmán-Unamuno, E., & Moyano-Berardo, B. M. (2018). Respiratory physiotherapy in intensive care unit: Bibliographic review. Enfermería Intensiva (English ed.), 29(4), 168-181.
Spapen, H. D., De Regt, J., & Honoré, P. M. (2017). Chest physiotherapy in mechanically ventilated patients without pneumonia—a narrative review. Journal of thoracic disease, 9(1), E44.

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