CardioPulm Exam 2 - Pulmonary Interventions and Auscultation

Postural Drainage

• Aka bronchial drainage
• Uses gravity-assisted body positioning to help mobilize & remove secretions from lungs
• Especially useful in pts w/ mucus retention

Postural Drainage - Gravity-Assisted Clearance

• Bronchial segment to be drained perpendicular to floor
• Gravity helps move secretions from smaller airways toward larger central airways
• Must understand tracheobronchial tree
• Ventilation Influence
  → Gravity affects regional lung ventilation, which can enhance drainage effectiveness

Postural Drainage is Beneficial for patients with

• Cystic Fibrosis
• Bronchiectasis
• COPD
• Pneumonia w/ retained secretions
• NM disorders affecting cough strength

Postural Drainage - Clinical Settings (ICU)

• Ensure slack in all tubes & lines to allow safe repositioning
• Monitor vital signs & O₂ saturation throughout treatment

Postural Drainage - Home Settings

• Use pillows or foam wedges for positioning
• Administer nebulized bronchodilators or mucolytics beforehand to loosen mucus
• Have tissues, specimen cups, & suction equipment ready

Postural Drainage - Positioning

• Use adjustable bed & support devices
  → Pillows, blanket rolls
• Modify positions for pts w/ contraindications
  → Avoid Trendelenburg in pts subject to reflux
• Always keep pt's face visible to monitor tolerance

Postural Drainage - Duration

• PD alone: maintain each position for 5-10 min
  → Longer if tolerated
• PD w/ percussion/vibration: 3-5 min per position

Postural Drainage - Technique Integration

• Percussion: rhythmic clapping over lung segments to loosen mucus
• Vibration: gentle shaking during exhalation to mobilize secretions
• Active Cycle of Breathing: breathing exercises to enhance clearance

Steps for Performing Postural Drainage

1) Assess lung segments via auscultation or imaging
2) Position pt appropriately
3) Apply percussion/vibration if indicated
4) Encourage deep breathing & coughing between positions
5) Suction if needed
6) Monitor for delayed secretion mobility

• Up to 1-hr post-treatment

Postural Drainage - Advantages

• Low cost & min equipment
• Flexible
  → Can be done in various settings
• Effective for secretion mobilization
• Can be taught to caregivers & pts

Postural Drainage - Challenges

• Time-intensive
  → Esp for children
• Requires cooperation
  → Pediatric pts may need distraction or role-play
• Caregiver burden
  → Especially in chronic conditions

Postural Drainage Contraindications

• Intracranial pressure (ICP) > 20 mm Hg
• Head & neck injury until stabilized
• Active hemorrhage w/ hemodynamic instability
• Recent spinal surgery or acute spinal injury
• Active hemoptysis
• Empyema
• Bronchopleural fistula
• Pulmonary edema associated w/ heart failure
• Large pleural effusions
• Pulmonary embolism
• Older, confused, or anxious pts
• Rib fx, w/ or w/out flail chest
• Surgical wound or healing tissue

Postural Drainage Signs of Intolerance

• SOB
• Anxiety
• Nausea
• Dizziness
• HTN
• Bronchospasm

Postural Drainage Clinical Recommendations

• Treat most affected lobes 1st
• Not all segments need treatment in every session
• Encourage deep breathing & coughing after each position
• Use upright or forward-leaning positions post-treatment to enhance cough effectiveness

Postural Drainage - Positions Diagram

Percussion

• Also known as chest clapping
  → Used to mobilize bronchial secretions to be removed by coughing or suctioning
• Often combined w/:
  → Postural drainage
  → Active cycle of breathing techniques
• Types of Percussion
  → Manual
  → Mechanical

Manual Percussion

• Performed by individual using cupped hands
• Rhythmically clap over affected lung segments
• Air trapped between hand & chest creates hollow thumping sound
  → Not slapping
• Should be done during inspiration & expiration

Proper technique for Mechanical Percussion

• Relaxed wrists, arms, & shoulders
• Equal force from both hands
• Avoid bony prominences
• Use thin towel or gown
  → Protect skin

Devices for Mechanical Percussion

Useful for:

• Self-administration by pts
• Reducing caregiver fatigue
• Treating posterior lung fields
  Studies show mixed results:
• Mechanical percussion equally effective as manual percussion
• Less effective when combined w/ postural drainage

Percussion Guidelines

• Ensure proper body mechanics to avoid fatigue or injury
• Adjust bed height for ergonomic positioning
• Used appropriate postural drainage positions
• Maintain steady rhythm
  → 100-480 claps/min
• Adapt force to pt comfort

Percussion - Advantages

• Enhances secretion clearance
• Can shorten treatment time
• Often soothing for infants & young children
• Mechanical devices offer independence

Percussion - Disavantages

• Not well tolerated postoperatively w/out p! control
• May cause:
  → Oxygen desaturation
  → Mitigated w/ breathing exercises
  → Caregiver injury from repetition
• Consistent caregiver availability

Shaking (Vibration)

• Manual or mechanical techniques used to mobilize secretions from lungs
• May be used in conjunction w/ postural drainage
• Vibration
  → Gentle, high-frequency oscillatory force applied to chest wall
• Shaking
  → Vigorous, rhythmic bouncing that applies compressive force to chest wall

Shaking (Vibration) Techniques - Both

• Begin at peak inspiration & continue through expiration
• Performed only during expiratory phase of breathing
• Require caregiver assistance
  → Mechanical devices can be used for vibration

Shaking (Vibration) Action

Techniques

• Enhance mucociliary transport, moving secretions from peripheral lung fields to central airways
  Shaking
• Causes more chest wall displacement & may stretch respiratory muscles
• Encouraging deeper inspiration & ↑ lung volume
  Vibration
• Leads to ↑ tidal expiration, promoting deeper subsequent breath & more effective cough

Shaking (Vibration) Preparation Guidelines

• Manual techniques require only caregiver's hands
• Mechanical vibrators
  → Can reduce caregiver fatigue & allow limited self-treatment
• Place pt in appropriate postural drainage position or modified
• Cover chest w/ towel or gown to avoid discomfort
• Ensure proper caregiver body mechanics to prevent fatigue or injury

Shaking (Vibration) Treatment Technique - Vibration

• Hands placed side-by-side or overlapping on chest wall
• Being at peak inspiration, apply gentle pressure, & oscillate through expiration
• Can be coordinated w/ ventilator-controlled exhalation in pts on mechanical ventilation

Shaking (Vibration) Treatment Technique - Shaking

• Hands placed over target lung lobe
• At peak inspiration, apply slow, rhythmic bouncing pressure
• Continue through expiration
• May need to be applied every other exhalation if pt has rapid RR

Shaking (Vibration) Special Considerations

• Mobile chest wall necessary for effective & comfortable application
• Vibration better tolerated than shaking in pts w/ limited chest wall compliance or postoperative p!
• Mechanical vibrators may not effectively reach posterior lung segments

Shaking (Vibration) - Advantages

• Enhances secretion mobilization when combined w/ postural drainage
• May be better tolerated than percussion (especially post-surgery)
• Encourages deeper inspiration & more effecting coughing

Shaking (Vibration) - Disadvantages and Limitations

• Requires caregiver assistance
• Mechanical devices may be hard to synchronize w/ breathing
• Contraindications:
  → Osteoporosis
  → Coagulopathy
  → Chest wall discomfort

Cough

• Critical mechanism for clearing secretions from lungs
• Effective cough follows 4-stage process

1. Inspiration (Breathing In)
2. Glottal Closure
3. Pressure Build-Up
4. Glottal Opening & Expulsion

Cough (Inspiration)

• Pt must inhale volume greater than tidal volume
• Signs of adequate inspiration include:
  → Trunk extension
  → Upward eye gaze
  → Use of arms to assist inhalation
• Strong inspiration allows for multiple coughs per breath
• Cascade effect

Cough (Glottal Closure)

• Glottis (vocal folds) closes at peak of inspiration
• Traps air & builds pressure
• If glottis doesn't close properly, pt may produce huff instead of cough

Causes of poor glottal closure

• Vocal fold paralysis or hemiparesis
• Edema from prolonged intubation
• Brain injury affecting coordination

Cough (Pressure Build-Up)

• Abdominal & intercostal muscles contract
• Creates positive intrathoracic & intraabdominal pressure
• Trunk moves into flexion
• Strong cough sounds low & resonant
• Weak cough may sound high-pitched or throaty

Cough (Glottal Opening and Expulsion)

• Glottis opens suddenly
• Air forcefully expelled, carrying mucus up through trachea
• Timing is crucial
• Poor coordination can lead to gagging or breath-holding
• Neurological impairments or bronchospasms may interfere w/ this stage

Evaluating Cough Effectiveness

Prep pt

• Ask pt to assume preferred coughing posture
• Avoid supine positions
  Demonstrate functional cough
• Ask pt to cough as if had mucus to clear
• Observe for:
  → Deep inspiration w/ trunk ext
  → Breath hold
  → Strong expirations w/ trunk flex
  Analyze each stage
• Look for deficiencies in any of 4 stages
• Ineffective cough can lead to:
  → Retained secretions
  → Atelectasis
  → Hypoxemia
  → Pneumonia
  → Respiratory failure

Huffing

• Modified form of forced expiration that avoids glottal closure
• Useful for:
  → Postop pts who find coughing painful
  → Pts w/ chest wall discomfort or fatigue

How Huffing Works

• Sit upright in stable position
• Take deep breath in & hold it briefly
• Forcefully exhale in 2-3 short bursts w/out closing glottis
  → Creates "hu-ff" sound, like fogging up mirror
  → Stomach muscles contract to help push air out
• Why it's effective
  → Breath hold allows air to move behind mucus & separate from lung walls
  → Short huffs clear larger airways
  → Long huffs clear smaller airways

Coughing vs. Huffing Chart

Manually Assisted Cough

Used to help pts who cannot generate effective cough on own due to:

• Weakness
• Paralysis
• Neurological impairment
• Post-surgical limitations

Five manually assisted cough techniques

• Costophrenic Assist
• Heimlich-Type (Abdominal Thrust) Assist
• Combined Costophrenic & Heimlich-Type Assist
• Anterior Chest Compression Assist
• Counter-Rotation Assist

Manually Assist Cough Costophrenic Assist - Purpose

• Enhances diaphragmatic & intercostal ms contraction during inhalation & supports forceful expiration

Manually Assist Cough Costophrenic Assist - Technique

• Can be performed in any posture, most commonly sitting or side-lying
• PT places hands on costophrenic angles of rib cage
• At end of exhalation, quick stretch down & inward toward navel applied to stimulate stronger inhalation
• During inspiration, PNF techniques may be used to max lung expansion
• Just before cough; PT applies strong pressure down & in to assist w/ pressure build-up & expulsion

Manually Assist Cough Costophrenic Assist - Best for:

• Pts w/ weak or paralyzed abdominal/intercostal muscles

Manually Assist Cough (Abdominal Thrust) - Purpose

• Forcefully expels air to simulate cough, similar to Heimlich maneuver

Manually Assist Cough (Abdominal Thrust) - Technique

• PT places heel of hand just above navel (avoiding lower ribs)
• Pt instructed to inhale deeply & hold
• As pt coughs; PT pushes up & in under diaphragm

Manually Assist Cough (Abdominal Thrust) - Considerations

• Very effective, but can be uncomfortable
• Use only when other techniques fail & strong cough is urgently needed

Manually Assist Cough (Combined) - Purpose

• Targets unilateral or thorax conditions or hemiplegia

Manually Assist Cough (Combined) - Technique

• Performed in side-lying position
• One hand performs Heimlich assist, while other performs unilateral costophrenic assist
• Compresses all 3 planes of ventilation in lower chest

Manually Assist Cough (Combined) - Benefit

• Allows targeted treatment of 1 side of chest, enhancing effectiveness

Manually Assist Cough (Anterior Chest Compression Assist) - Purpose

• Compresses both upper & lower anterior chest to support all stages of cough

Manually Assist Cough (Anterior Chest Compression Assist) - Technique

• 1 arm across pectoralis region (upper chest), other on lower chest or abdomen
• PTs facilitates inspiration & breath hold
• During expulsion, PT applies force
• Down & back on upper chest
• Up & back on lower chest
• Arms form V-shape during compression

Manually Assist Cough (Anterior Chest Compression Assist) - Best for

• Pts w/ weak chest wall muscles

Manually Assist Cough (Anterior Chest Compression Assist) - Positioning

• Most effecting in side-lying or 3/4 supine

Manually Assist Cough (Counter-Rotation Assist) - Purpose

• Most effective for pts w/ neurological disorders or low cognitive function

Manually Assist Cough (Counter-Rotation Assist) - Technique

• Performed in side-lying
• PT places hands on shoulder & pelvis, assisting w/ inhalation & exhalation for 3-5 cycles
• During tcough
  → Pt takes deep breath & holds
  → PT applies forceful compression during flexion phase
  → Compression must follow diagonal plane to prevent air shifting & ensure expulsion

Active Cycle Breathing

• Method developed to aid in clearance of bronchial secretions
  → Asthma, cystic fibrosis (CF), & other pulmonary diseases
• Integrates 3 ventilatory phases:
  → Breathing control
  → Thoracic expansion exercises
  → Forced expiration technique (FET)

Active Cycle Breathing - Breathing Control

• Purpose: prevent bronchospasm & allow relaxation
• Method: gentle, relaxed breathing at normal TV
• Focus: relaxation of upper chest & shoulders; activation of lower chest & abdomen
• Duration: typically, 5-10 sec, or longer if needed
  → Up to 20 sec in pts w/ bronchospasm

Active Cycle Breathing - Thoracic Expansion Exercises

• Purpose: loosen secretions & promote collateral ventilation
• Method: deep inhalation to inspiratory reserve volume, followed by passive, relaxed exhalation
• Enhancements:
  → Percussion, shaking, or vibration during exhalation
  → Breath hold or sniff at end of inspiration for collapsed lung segments
  → Hand placement over thorax to facilitate chest wall movement
• Repetition: typically repeated 3-4x per cycle

Active Cycle Breathing - Forced Expiration Technique (FET)

• Purpose: mobilize & clear secretions from peripheral & central airways
• Method: 1 or 2 huffs (rapid, forced exhalations w/ open glottis)
  → Medium-sized inspiration huff: longer, quieter; mobilizes peripheral secretions
  → Deep inspiration huff: shorter, louder; clears proximal secretions
• Key Points:
  → Glottis remains open (unlike coughing)
  → Abdominal muscles contract to ↑ expiratory force
  → Breathing control follows each huff to prevent airway obstruction

Active Cycle Breathing Preparation - Equipment

• Only hands needed for manual percussion or vibration
• Mechanical percussors/vibrators may be used

Active Cycle Breathing Preparation - Positioning

• Preferable in postural drainage position to aid drainage
• Upright sitting also acceptable

Active Cycle Breathing Preparation - Duration

• Min of 10 min in productive position for moderate sessions
• Adjust based on pt condition & fatigue level

Active Cycle Breathing Treatment Protocol

1. Breathing control: 5-10 sec
2. Thoracic expansion: deep inhalation, passive exhalation
3. Breathing control: 5-10 sec
4. Repeat thoracic expansion: 3-4x
5. Breathing control: 5-10 sec
6. FET: 1-2 huffs w/ abdominal contraction
7. Breathing control: 5-10 sec

• Adaptations
  → Longer breathing control for bronchospasm
  → Additional thoracic expansion cycles for tenacious secretions
• Termination
  → When 2 consecutive huffs from medium inspiration dry & nonproductive

Active Cycle Breathing - Advantages

• Encourages active pt participation
• Effective in children as young as 3-4 y.o.
• Min oxygen desaturation compared to PD w/ percussion
• Adaptable for pts w/ GERD, bronchospasm, or acute exacerbation

Active Cycle Breathing - Disadvantages

• May require caregiver assistance in young children or severely ill adults
• Hyperactive airways may be irritated by deep breathing & huffing

Autogenic Drainage

• Program to sense peripheral secretions & clear them w/out tracheobronchial irritation from coughing
• Used for: infants & pts unable to actively participate
• Technique: gentle manual pressure on chest during inspiration
  → None during exhalation
• 3 phases:
  → Unsticking phase
  → Collecting phase
  → Evacuating phase

Autogenic Drainage - Unsticking Phase

• Goal: mobilize secretions from peripheral lung regions
• Method:
  → Begin w/ normal inspiration
  → Hold breath briefly to allow collateral ventilation
  → Deep exhalation into expiratory reserve volume (ERV)
  → Lowers TV below functional residual capacity, compressing peripheral alveolar ducts & loosening mucus

Autogenic Drainage - Collecting Phase

• Goal: move mucus from peripheral to central airways
• Method:
  → Gradually ↑ TV from ERV to inspiratory reserve volume (IRV)
  → Adjust airflow to max mucus movement w/out collapsing airways
  → Flow-volume curves show AD achieves higher, longer-duration airflow than other techniques

Autogenic Drainage - Evacuating Phase

• Goal: expel mucus from central airways
• Method:
  → Deep inspiration into IRV
  → Use huffing (forced exhalation) to evacuate mucus
  → Avoid uncontrolled coughing to prevent airway collapse

Autogenic Drainage Preparation

• No equipment required
• Caregiver should:
  → Use tactile & auditory cues to guide pt
  → Sit beside & slightly behind pt
  → Place 1 hand on abdomen & 1 on upper chest
• Environment:
  → Pt seated upright in supportive chair
  → Quiet, distraction-free setting
  → Clear upper airways before starting

Autogenic Drainage Treatment Procedure

General Guidelines

• Inhale slowly though nose using diaphragm
• Hold breath for 2-3 sec to allow air behind secretions
• Exhale actively w/ mouth & glottis open
• Listen & feel for mucus movement
  Treatment duration: 30-45 min

Autogenic Drainage - Advantages

• Can be performed independently by pts over 12 y.o.
• No equipment or PD positions needed
• Suitable for:
  → Adolescents/adults preferring independence
  → Pts w/ gastroesophageal reflux
  → Pts w/ airway hyperreactivity

Autogenic Drainage - Disadvantages

• Requires high concentration, discipline, & practice
• Not ideal for:
  → Unmotivated or uncooperative pts
  → Small children

Positive Expiratory Pressure

Respiratory technique involves breathing out against resistance to:

• Keep airways open
• Mobilize & clear mucus
• Improve lung function & gas exchange
  2 types:
• Low-pressure PEP (approved in U.S.)
• High-pressure PEP (used elsewhere)

PEP devices use…

• 1-way valve & expiratory resistor to create back pressure during exhalation
• Pressure helps:
  → Stent airways open
  → Reinflate collapsed alveoli
  → Redistribute air through collateral channels
  → Mobilize secretions toward larger airways
• Oscillatory PEP adds vibration to:
  → Loosen mucus
  → Mimic ciliary movement
  → Accelerate expiratory flow

Positive Expiratory Pressure Benefits

• Improves airway clearance
  → Esp in cystic fibrosis & postop atelectasis
• Enhances ventilation & gas exchange
• Can be combined w/ nebulized meds & supplement oxygen
• Reduces hospital stays
• Promotes pt independence & adherence

Common PEP Devices

• TheraPEP
• Acapella
• Flutter VRP1
• Quake
• Aerobika, RC-Cornet

Preparation for PEP Therapy

Device Familiarity

• PTs must know how to use & instruct pts
  Mouthpiece vs. Mask
• Masks may help maintain lung volume better
  Manometer Use
• Helps monitor & adjust resistance to achieve 10-20 cm H20
  Medication Delivery
• Nebulizers & oxygen can be used inline
  Bubble PEP
• Child-friendly version using tubing & water to generate pressure (

Performing PEP Therapy - Position & Breathing Technique

Position:

• Sit upright; elbows on table
  Breathing technique:
• Inhale using lower chest
• Hold breath for 2-3 sec
• Exhale actively (not forcefully) into device

Performing PEP Therapy - Cycle

• 10-15 breaths → remove device → huff/cough
• Repeat cycle 4-6 cycles
• Total time: 15-20 min, 2x/day or as needed

Performing PEP Therapy - Monitoring

• Used manometer initially
• Adjust resistance to maintain 10-20 cm H20
• Reassess periodically

Positive Expiratory Pressure - Advantages

• Easy to learn & use
• Portable & inexpensive
• Encourage independence & compliance
• Some musical instruments mimic PEP effects
  → Trumpet, clarinet
• Suitable for children (age >4) & adults

Positive Expiratory Pressure - Disadvantages

• Acute sinusitis
• Ear infections
• Nosebleeds
• Recent facial/oral surgery

High-Frequency Chest Wall Oscillation

• Mechanical airway clearance technique designed to mobilize mucus in pts w/ obstructive lung disease
• Uses inflatable vest connected to an air-pulse generator to deliver rapid compressions to chest wall

High-Frequency Chest Wall Oscillation - Mechanism of Action

→ Created differential airflow: expiratory flow > inspiratory flow
→ Mobilizes mucus from peripheral to central airways
→ Reduces mucus viscosity & ↑ shear forces to move secretions
→ Mimics airflow pulse of cough

Scientific Support and Effectiveness of HFCWO - Mechanisms Proposed

• Oscillatory airflow reduces mucus viscoelasticity
• Shear forces from airflow differences mobilize mucus

Scientific Support and Effectiveness of HFCWO - Clinical Findings

• Comparable or superior to manual percussion & postural drainage
• ↑ sputum production
• Improved pulmonary function in pts w/ CF
• Safe for long-term use, including in ventilated pts
• No significant adverse effects reported

Performing HFCWO - Position, Set-up, & Pressure Settings

• Position: pt seated upright
• Setup:
  → Connect tubing to air-pulse generator
  → Start aerosol therapy before activating vest
• Pressure Settings:
  → Adjust to highest comfortable pressure

Performing HFCWO - Frequency Progression: & Secretion Clearance

Frequency Progression:

• Low (7-10 Hz): ↑ lung volume
• Medium (10-14 Hz)
• High (14-20 Hz): ↑ flow rate
• Spend 10 min at each frequency
• Adjust based on tolerance & secretion amount
  Secretion Clearance:
• After each frequency cycle, instruct pt to huff or cough

Diaphragmatic Breathing

Therapeutic breathing technique aimed at:

• Reducing dyspnea
• Preventing or resolving atelectasis
• Improving oxygenation
• Promoting relaxation & efficient breathing
  Emphasizes abdominal wall movement during inspiration while min upper chest motion, encouraging use of diaphragm

Diaphragmatic Breathing - Positioning

• Use posterior pelvic tilt to promote diaphragm use
• In acute care, place towel roll under ischial tuberosities
• Use side-lying or semi-Fowler positions to reduce gravity's effect

Diaphragmatic Breathing - Relaxation and Cueing

• Use verbal & tactile cues to relax accessory muscles
• Apply contract-relax techniques to promote diaphragm engagement

Diaphragmatic Breathing - Sniffing Technique

• Pt sniffs 3x, then exhales slowly
• PT observes abdominal vs. chest movement
• Progression:
  → 3 sniff → 2 bigger sniffs → 1 slow sniff
  → Goal: relaxed, quiet breathing

Diaphragmatic Scoop Technique

• Position pt (side-lying or semi-Fowler) w/ posterior pelvic tilt
• PT hand on abdomen
• After exhalation, scoop hand under ant thorax
• Instruct: "Breathe into my hand"
• Repeat w/ each breath
• Progress to:
  → Supine → Sitting → Standing → Activity
  → Remove hand as pt gains proficiency

Segmental Breathing

Targeted breathing technique designed to:

• Improve ventilation in underused or hypo-ventilated lung segments
• Enhance regional gas distribution
• Maintain or restore functional residual capacity
• Improve chest wall mobility
• Prevent pulmonary complications such as atelectasis

Segmental Breathing - Useful for patients who:

• Have pleuritic pain, surgical incisions, or trauma that limits chest wall movement
• At risk of developing atelectasis due to shallow breathing or immobility

Segmental Breathing - Red Flag

• Contraindicated in pts w/ intractable hypoventilation until their medical condition is stabilized