Lecture 4: Pulmonary Rehabilitation Airway Clearance Techniques (Coughing and Postural Drainage)

What is a Restrictive Lung Disease?

a condition that makes it hard to fully expand the lungs during inhalation (hard to get air in)

What is an Obstructive Lung Disease?

a condition where exhalation is slower and air gets trapped in the lungs (hard to get air out)

What are examples of Restrictive Lung Diseases?

pulmonary fibrosis, scoliosis, obesity, sarcoidosis

What are examples of Obstructive Lung Diseases?

Asthma, COPD (emphysema and chronic bronchitis), cystic fibrosis

What is COPD?

chronic pulmonary conditions that obstruct airflow in the respiratory tract

What is a major risk factor for COPD?

cigarette smoking

What happens to the airways in COPD?

chronic inflammation and narrowing of the airways

What structural damage happens in COPD?

destruction of alveolar and bronchial walls

How is mucus affected in COPD?

increased production and retention of mucus

What happens to lung elasticity in COPD?

loss of normal elastic recoil of the lungs

How is ciliary function impacted in COPD?

decrease in ciliary function, making it harder to clear mucus

How does COPD affect breathing rate?

it causes increased shortness of breath (SOB) and respiratory rate (RR)

How does COPD impact lung volumes?

it leads to decreased vital capacity

What muscles are increasingly used in COPD?

accessory muscles

How does COPD affect the chest wall?

causes progressive chest wall stiffness

How does COPD impact exercise?

decreases exercise tolerance

What symptom becomes more frequent with COPD?

frequent episodes of dyspnea

How does COPD affect walking ability?

decreased walking speed and distance

How does COPD impact daily activities?

decreased ability to perform activities of daily living (ADLs)

What is the PTA’s role in smoking cessation?

patient education

What is the PT’s role in managing COPD?

leading a pulmonary rehabilitation program

What types of exercises are included in COPD management?

breathing exercises and airway clearance techniques

What kind of exercise program is important for COPD patients?

a graded exercise program including aerobic conditioning

What types of strength training are recommended for COPD patients?

upper extremity (UE) and lower extremity (LE) strength training

What is Restrictive Pulmonary Disease?

inability of the lungs to fully expand due to extra-pulmonary or pulmonary restriction

What is the most common cause of restrictive lung disease?

idiopathic pulmonary fibrosis (IPF)

How can chest wall injury cause restrictive pulmonary disease?

trauma can prevent the chest wall from expanding fully, limiting lung expansion

How does surgery contribute to restrictive lung disease?

chest wall stiffness or pain after surgery can restrict lung expansion

How does respiratory muscle weakness cause restrictive lung disease?

diseases like SCI, CP, and Parkinson’s weaken respiratory muscles, limiting the ability to breathe deeply

How do postural deformities contribute to restrictive pulmonary disease?

kyphosis and scoliosis distort the chest cavity, restricting lung expansion

How does pleural disease lead to restrictive lung problems?

can stiffen or scar the lining around the lungs, limiting lung movement

What causes decreased pulmonary expansion in restrictive lung disease?

inflammation limits the lungs’ ability to expand

How does chest wall mobility change with restrictive pulmonary disease?

chest wall mobility decreases, making deep breaths harder

What happens to arterial blood gases in restrictive lung disease?

decreased arterial blood gases, leading to hypoxia

What do pulmonary function tests show in restrictive lung disease?

abnormal pulmonary function tests indicating reduced lung capacity

How is coughing affected in restrictive pulmonary disease?

decreased ability to cough and the cough is nonproductive (no mucus)

An increased respiratory rate is commonly seen in which type of pulmonary disease?

Both — restrictive and obstructive

Bronchitis and emphysema are classified as which type of pulmonary disease?

obstructive

A patient recovering from thoracic surgery is most likely to exhibit symptoms of which type of pulmonary disease?

restrictive

A productive cough is most characteristic of which type of pulmonary disease?

obstructive

Kyphosis leading to difficulty with lung expansion is associated with which type of pulmonary disease?

restrictive

What is the main function of coughing?

to remove respiratory obstructions

Why is coughing important for patient with respiratory conditions?

helps clear the airways, especially in acute or chronic respiratory conditions

Can a cough be both reflexive and voluntary?

yes

Should patients with respiratory issues be encouraged to cough?

yes, patients need to cough to maintain clear airways

What is the most effective and painless way to expel secretions?

coughing

In which types of patients is coughing equally important?

both medical and surgical chest patients

Why is coughing more difficult for surgical chest patients?

due to incisional pain after surgery

How often should surgical chest patients cough post-op?

every ½ hour for first 48 hours after surgery

What is the first step of the cough mechanism?

deep inspiration

What happens to the glottis and vocal cords during the cough mechanism?

they close and tighten

What muscles contract to increase intra-thoracic and abdominal pressure during coughing?

abdominal muscles contract and the diaphragm elevates

What happens after the pressure builds up during the cough mechanism?

the epiglottis is forced open

What is the final action in the cough mechanism?

a strong, forced, explosive exhalation

What causes inadequate inspiration leading to ineffective coughing?

pain, muscle weakness, and medications

What causes inadequate forceful exhalation leading to ineffective coughing?

muscle weakness, fatigue, pain, and tracheotomy

What can cause decreased action of cilia and impair coughing?

anesthesia, COPD, and smoking

What conditions can lead to an increased amount of mucus that must be cleared, making coughing less effective?

cystic fibrosis, bronchitis, pneumonia, dehydration, and intubation

What should a PTA assess about a patient’s cough?

whether the cough is weak, dry, or otherwise ineffective

How should a patient be positioned for effective coughing?

relaxed and leaning forward

What breathing technique should be practiced to maximize inhalation?

deep breathing

After inhaling deeply, what should the patient do before coughing?

perform a breath hold

What pressures should be maximized to help a strong cough?

Intra-abdominal and intrathoracic pressures

Which muscles must the patient contract to generate an effective cough?

abdominal muscles

What is the final action sequence to perform an effective cough?

breathe in, then perform two sharp, forced coughs (forced exhalation)

What is the first step when teaching a patient to cough?

assess the patient’s cough (ex: weak, dry, productive)

How should the patient be positioned for an effective cough?

relaxed and leaning slightly forward

How can you help the patient maximize inhalation before coughing?

practice deep breathing

What should the patient do after taking a deep breath?

perform a breath hold

What pressures need to be encouraged to assist coughing?

maximal intra-thoracic and intra-abdominal pressures

Which muscle group must the patient engage to produce a strong cough?

abdominal muscles

What final action completes the coughing technique?

breathe in, then produce 2 sharp, forced coughs (forced exhalation)

What is a Manual-Assisted Cough?

a therapist-assisted or self assisted technique to help a patient cough more effectively

Where is manual pressure applied during a manual-assisted cough?

on the abdominal area

When is manual-assisted coughing especially used?

when there is abdominal weakness to stimulate a stronger cough

When is “splinting” during a cough used?

when there is chest wall pain from surgery

What does “splinting” involve during coughing?

pressing on or supporting the incision site to reduce pain while coughing

What are some asides that can be used for successful splinting?

hands, arms (bear-hug fashion), pillow, towel, or folded sheet

When is humidification particularly helpful for patients?

when the patient’s secretions are thick

When should you work with the patient if they have thick secretions?

after respiratory therapy

What treatments help thin secretions before working with the patient?

after using an ultrasonic nebulizer (USN) or after humidification therapy

What is endotracheal suctioning?

a method to clear the airway when coughing is ineffective or impossible

Who requires suctioning?

all patients with artificial airways

What parts of the respiratory system does suctioning clear?

the trachea and mainstream bronchi only

Why should excessive suctioning be avoided?

it can be harmful to the patient

What is required to perform suctioning properly?

training in proper suctioning techniques

What position should the patient be in for huffing?

sitting position, if possible

How is huffing performed?

patient blows 3 short breaths out, followed by a deep inspiration through the nose

When is huffing especially useful?

for patients who have trouble with expiration

What simple actions can help stimulate a productive cough?

have the patient turn, change position, or sit up

What therapies should be performed before asking the patient to cough?

breathing exercises, postural drainage, and vibration

How can fluids help stimulate a cough?

sips of fluids, especially warm ones, before coughing attempts can help

What is the order of performing a cough?

1.) deep inspiration

2.) glottis and vocal cords close

3.) contract abdominals, diaphragm elevates

4.) glottis opens

5.) strong/forced/explosive exhalation

What is postural drainage?

a physical therapy intervention for airway — to clear mucus from the lungs

What is the first step in the Postural Drainage process and what is its purpose?

positioning — position the client so that the lung fields needing clearance are gravity dependent

What is the second step in the PD process and its purpose?

Percussion — mechanically jars and loosens accumulated secretions

What is the third step in the PD process?

Vibration — moves mucus toward larger airways

How is “shaking” different from vibration in PD?

shaking is more vigorous form of vibration to help move mucus

What is the purpose of postural drainage?

to mobilize secretions in the lungs by placing the patient in positions where gravity assists in the drainage process

What is a key goal of postural drainage for patients with pulmonary diseases or prolonged bed rest?

to prevent accumulation of secretions in the lungs