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Bronchial Hygiene and Chest Physiotherapy

1. Bronchopulmonary segmental anatomy (visual reference)

  • Each lung is divided into bronchopulmonary segments, mapped as above (1
    –10), which supports targeted airway clearance techniques.

  • Figures in standard texts show anterior, lateral, posterior, and mediastinal views illustrating the segmental divisions and fissures.

2. Physiology of airway clearance

  • Normal airway clearance requires:-

    • Patent airway

    • Functional mucociliary escalator

    • Effective cough to move mucus from lower to upper airway

  • Purpose of airway clearance techniques (ACT/CPT): mobilize secretions, prevent/reverse atelectasis, enhance respiratory muscle function

3. Four phases of a normal cough

  • Four phases (HACK!):-

    • Irritation – stimuli trigger cough receptors

    • Inspiration – deep inhalation

    • Compression – glottis closes, intrathoracic pressure builds

    • Expulsion – glottis opens, rapid expiratory flow expels mucus

  • Typical sequence illustrated as: Irritation
    → Inspiration
    → Compression
    → Expulsion

  • The cough is a reflex arc and can be voluntarily modulated in some cases

4. Cough reflex and neural pathway

  • Cough receptors are located mainly on:-

    • Posterior wall of the trachea, pharynx, and carina

  • Afferent pathway:-

    • Stimuli activate receptors; impulses travel via the internal laryngeal nerve (branch of the superior laryngeal nerve, from the vagus) to the medulla (Cough Centre)

  • Efferent pathway:-

    • Impulses travel to glottis, external intercostals, diaphragm, and other expiratory/inspiratory muscles to generate inspiration, compression, and expulsion

  • Result: coordinated respiratory muscle activity to produce a productive cough

5. Irritation and initial response (stimuli and localization)

  • Stimuli that provoke coughing include:-

    • Inflammation or infection

    • Mechanical: foreign body

    • Chemical irritants: irritant gases, smoke

    • Thermal: cold air

  • Receptors are mainly located in the trachea and larger airways

  • Reflex arc integrates signals in the medulla and returns efferent commands to respiratory muscles

6. Inspiration phase details

  • After stimulation, a deep inspiration is triggered

  • Primary muscles: diaphragm and external intercostals contract

  • Creates negative intrapleural pressure, drawing air into the lungs

  • Adult average inspiration volume: approximately 1-2\;\mathrm{L}

7. Compression phase details

  • Glottis closes; vocal cords contract to seal the larynx

  • Expiratory muscles contract, markedly increasing pleural and alveolar pressures (often > 100\ \mathrm{mmHg})

  • Compression duration is typically about t_c \approx 0.2\ \mathrm{s}

  • This phase can be reduced or inhibited by muscle weakness

8. Expulsion phase details

  • Glottis opens, creating a large pressure gradient between alveoli and airway opening

  • Continued expiratory muscle contraction drives a rapid expulsive flow

  • Peak velocities can reach up to v \approx 100\ \mathrm{mph} \approx 44.7\ \mathrm{m/s}

  • Purpose: move mucus and foreign material from lower to upper airways for expectoration or swallowing

9. Abnormal airway clearance and retention of secretions

  • Abnormal clearance occurs when any of the following are impaired:-

    • Airway patency

    • Mucociliary function

    • Strength of inspiratory/expiratory muscles

    • Thickness/viscosity of secretions

    • Effectiveness of cough reflex

  • Consequences: impaired clearance and retained secretions

10. Retention of secretions: consequences of obstruction

  • Full obstruction (mucus plugging) can cause:-

    • Impaired oxygenation due to V/Q mismatch (perfusion without ventilation)

    • Atelectasis

  • Partial obstruction can cause:-

    • Increased work of breathing (WOB)

    • Air trapping and partial overdistention

    • V/Q abnormalities

11. Mechanisms that impair cough reflex

  • Irritation: anesthesia, CNS depression, narcotics

  • Inspiration: pain, neuromuscular dysfunction, restriction

  • Compression: laryngeal nerve damage, artificial airway, abdominal surgery or abdominal muscle weakness

  • Expulsion: airway compression/obstruction, abdominal muscle weakness, poor lung recoil (e.g., emphysema)

12. Impaired mucociliary clearance in intubated patients

  • Causes include:-

    • Endotracheal or tracheostomy tube

    • Tracheobronchial suctioning

    • Inadequate humidification

    • High FiO2 values

    • Drugs: general anesthetics, opiates/narcotics

    • Underlying pulmonary disease

13. Goals and indications for bronchial hygiene

  • Primary goals:-

    • Mobilize and remove retained secretions

    • Improve gas exchange

    • Decrease work of breathing (WOB)

  • Indications:-

    • Acute conditions with copious secretions

    • Acute respiratory failure with retained secretions

    • Acute lobar atelectasis due to mucus plugging

    • V/Q abnormalities from infiltrates or consolidation

    • Chronic conditions: cystic fibrosis (CF), bronchiectasis, chronic bronchitis, ciliary diskinetic syndromes

14. Airway clearance therapy (ACT) to prevent retained secretions

  • Components include:-

    • Body positioning and patient mobilization

    • Chest physical therapy (CPT) combined with physical activity

    • Often used with suctioning, small-volume nebulization (SVN), and mucolytic/expectorant medications

  • Techniques include: Postural Drainage (PD), Percussion, Vibration, Cough Assistance, Breathing and Conditioning Exercises

15. Initial assessment of need for airway clearance therapy

  • History and context:-

    • History of pulmonary problems with increased secretions

    • Recent upper abdominal or thoracic surgery

    • Considerations: age, COPD history, obesity, nature/duration of procedure, artificial airway

  • Investigations and observations:-

    • Chest X-ray (CXR) findings: atelectasis or infiltrates

    • Pulmonary Function Tests (PFTs)

    • Posture and muscle tone

    • Effectiveness of cough

    • Sputum production, breathing pattern

    • Vital signs and ECG if available

16. Indications that a patient is retaining secretions

  • Key signs include:-

    • Unproductive or ineffective cough (lack of sputum production but retained secretions)

    • Labored breathing

    • Fever

    • Increased crackles and rhonchi; wheezing or diminished breath sounds

17. Chest physiotherapy (CPT) components and scope

  • CPT encompasses a diverse set of techniques to improve respiratory efficiency by:-

    • Mobilizing secretions

    • Preventing or reversing atelectasis

    • Enhancing respiratory muscle performance

  • Usually performed with other treatments:-

    • Suctioning, SVN, Expectorant drugs

  • CPT components include:-

    • Postural Drainage (PD)

    • Percussion and Vibration

    • Cough Assistance

    • Breathing and Conditioning Exercises

  • Applicable to all ages

18. Goals of CPT and mechanisms to achieve them

  • To move secretions to central airways via:-

    • Gravity (PD)

    • External chest manipulation (percussion and vibration)

  • To eliminate secretions by cough or suction

  • Outcomes include:-

    • Improved ventilation-perfusion (V/Q) matching

    • Normalization of functional residual capacity (FRC)

    • Note: FRC may decrease if atelectasis is present

  • Key targets: mobilize secretions, improve airway drainage

19. Indications for CPT: turning, PD, and percussion/vibration

  • Turning (position changes):-

    • Inability or reluctance to change body position

    • Poor oxygenation associated with position changes

    • Presence or risk of atelectasis

    • Presence of artificial airway

  • Postural Drainage (PD):-

    • Evidence or suggestion of difficult airway clearance

    • Secretions > 25-30\;\mathrm{mL/day} (adult)

    • Atelectasis caused by mucus plugging

    • Diseases producing large volumes of sputum

    • Presence of foreign body in the airway

  • Percussion/Vibration (external thoracic manipulation):-

    • Indicated if sputum volume or consistency suggests additional manipulation is helpful

20. Contraindications to CPT

  • Absolute contraindications (global list):-

    • Head/neck injury until stabilized

    • Active hemorrhage with hemodynamic instability

    • Intracranial pressure (ICP) > 20\ \mathrm{mmHg}

    • Recent spinal surgery or injury

    • Active hemoptysis

    • Empyema, bronchopleural fistula

    • Cardiogenic pulmonary edema

    • Inability to tolerate positions (too anxious/aging/confused)

    • Pulmonary embolism

    • Rib fractures (with or without flail chest)

    • Surgical wound or healing tissue over thorax

    • Large pleural effusion

  • Trendelenburg contraindications (head-down) include:-

    • Recent gross hemoptysis related to lung cancer treated surgically or with radiation

    • ICP > 20\ \mathrm{mmHg}

    • Uncontrolled hypertension

    • Distended abdomen

    • Conditions where increased ICP is to be avoided (e.g., neurosurgery, aneurysm, eye surgery)

    • Uncontrolled aspiration risk (e.g., tube feeding or recent meals)

  • Reverse Trendelenburg contraindications (head-up):-

    • Hypotension or use of vasoactive medications

  • External manipulation contraindications (PD, percussion, vibration) additional to the above:-

    • Subcutaneous emphysema

    • Recent spinal anesthesia or epidural

    • Recent pacemaker

    • Lung contusion

    • Recent skin grafts or wounds on thorax

    • Suspected pulmonary tuberculosis

    • Bronchospasm

    • Osteoporosis or osteomyelitis of ribs

    • Chest-wall pain

21. Hazards and complications of CPT

  • Potential adverse effects:-

    • Hypoxemia

    • Increased intracranial pressure (ICP)

    • Acute hypotension during procedure

    • Pulmonary hemorrhage

    • Pain or injury to muscles, ribs, or spine

    • Vomiting and aspiration

    • Bronchospasm

    • Dysrhythmias

  • Immediate responses: stop therapy, return to upright position, contact physician if complications arise

22. Assessment of need and outcome measures

  • Assessment of need (PD therapy):-

    • Excessive sputum production

    • Effectiveness of cough

    • History of pulmonary problems treated with PD

    • Decreased breath sounds, crackles, rhonchi

    • Change in vital signs or abnormal CXR consistent with atelectasis, mucus plugging, or infiltrates

    • Deterioration in arterial blood gases (ABG) or O2 saturation

  • Assessment of outcome indicators after CPT:-

    • Change in sputum production (e.g., if )

23. Monitoring during CPT

  • Monitor: subjective response (pain, dyspnea), vital signs (pulse, BP, rhythm), respiratory rate, chest expansion, sputum production, breath sounds, SpO2, mental status, skin color

  • ICP monitoring if applicable

24. Guidelines for performing CPT

  • Timing and safety:-

    • Schedule CPT before or at least 1.5–2 hours after meals or tube feeds

    • Administer pain medication if needed

    • Explain procedure to patient; loosen clothing around waist/neck

    • Check all lines and tubes for function and mobility

    • Position patient comfortably; maintain indicated position for 3–15 minutes per segment

    • Total treatment time typically 30–40 minutes

    • If patient experiences vigorous coughing, have them sit up until coughing subsides

  • Post-treatment assessment: vitals, SpO2, breath sounds

25. Postural Drainage (PD): concepts and main points

  • PD uses gravity to mobilize secretions from various lung segments

  • Can be used alone or with percussion/vibration (mechanical energy)

  • Positions are segment-specific and held for 3–15 minutes per position

  • Most effective when sputum production is > 25-30\;\mathrm{mL/day}

  • For maximum effect, head-down angle should exceed 25 degrees below horizontal (i.e., head-down tilt)

  • Adequate systemic hydration and airway hydration are necessary for effectiveness

  • Absolute contraindications include: unstable head/neck, active hemorrhage, ICP > 20 mmHg, etc. (as listed above)

26. Postural drainage technique: segment-specific positioning (illustrative concepts)

  • Lung segments are drained by placing the patient in positions that align with the segment to be drained

  • Common practices include elevating or lowering the trunk or limbs to optimize bronchial drainage

  • Typical segment elevations shown in teaching materials: various segments are drained with head-down (below horizontal) or head-up positions, sometimes requiring elevation (e.g., 12 inches or 18 inches) to optimize drainage of dependent segments

  • Example segment drainage concepts (not exhaustive):-

    • Superior segments of the lower lobes: prone with head-down tilt to recruit posterior segments

    • Anterior and lateral basal segments: varying degrees of head-down tilt and lateral positioning

    • Lingular segments: lateral decubitus or semi-Fowler positions

  • The exact sequence and duration per segment depend on the patient’s location of secretions, segment involvement, and tolerance

27. Case study overview (example interpretation)

  • Patient with COPD, two days of thick yellow sputum, weakening cough, patchy infiltrates on CXR, decreased breath sounds in lower lobes, rhonchi/wheezing in upper airways, HR from 75 to 85 bpm, SpO2 from 94% to 91%

  • Possible therapeutic recommendations:-

    • Begin CPT focused on mobilizing secretions in lower lobes with Postural Drainage and Percussion/Vibration for segments likely involved (e.g., lower lobes with head-down positioning, posterior basal segments)

    • Use cough assistance to improve cough efficacy and mucus clearance

    • Consider bronchodilator therapy or mucolytics or SVN as adjuncts to improve secretion clearance

    • Optimize hydration and consider oxygen therapy to maintain adequate oxygenation during CPT

    • Monitor vitals, SpO2, and tolerance; reassess sputum production and breath sounds after therapy

28. Assessment of outcome and follow-up

  • Key metrics after CPT:-

    • Reduction in retained secretions (sputum quantity and quality)

    • Improvement in breath sounds in drained regions

    • Patient-reported relief of dyspnea or improved ease of expectoration

    • Stabilization or improvement in vital signs and oxygenation (SpO2/ABG)

    • Improvement in radiographic findings over time (atelectasis resolution)

    • Continued assessment and adjustment of CPT plan based on response

29. Summary of practical considerations

  • CPT is part of a broader airway clearance strategy that includes PD, percussion, vibration, cough assistance, and breathing/conditioning exercises

  • Indications are driven by secretion burden, atelectasis risk, and gas exchange needs

  • Contraindications and hazards require careful screening before initiating CPT

  • Execution should be patient-centered, timed