Chest Physical Therapy and Lung Expansion Therapy

Overview of Chest Physical Therapy (CPT)

Chest Physical Therapy (CPT) encompasses a single or combination of procedures performed to maintain bronchial hygiene and pulmonary toilet. A comprehensive chest physical therapy regimen typically consists of anatomical positioning aimed at achieving maximum gravitational drainage of secretions. In order for CPT to be effective, a respiratory therapist needs to possess a solid understanding of pulmonary anatomy and physiology. This expertise allows for the effective implementation of techniques that facilitate secretion clearance from the airways.

Contraindications of CPT

There are certain situations where CPT should not be performed due to potential risks:

Increased Intracranial Pressure (ICP): CPT could exacerbate intracranial issues.
Active Hemorrhage with Hemodynamic Instability: The risk of further bleeding and instability may increase.
Hemoptysis: The presence of blood in sputum necessitates caution.
Recent Spinal Injury or Surgery: Any procedures that could further complicate spinal injuries should be avoided.
Empyema: The accumulation of pus in the pleural cavity poses severe risks if CPT is applied.
Broncho-pleural Fistula: Direct communication between the bronchi and pleura can lead to further complications.
Rib Fracture: Movement during CPT may worsen pain or cause further injury.
Flail Chest: Instability of the chest wall can hinder proper therapy.
Uncontrolled Hypertension: Increased blood pressure can pose additional risks.

Cautions When Performing CPT

Certain precautions should be taken during the performance of CPT to minimize risks:

Osteoporosis: Fragile bones may be easily fractured.
Surgical Incisions: Care is needed to avoid affecting healing incisions.
Indwelling Catheters: Movement may dislodge catheters, leading to complications.
Chest Tubes: Any therapy should not disturb chest tube placements.
Subcutaneous Empyema: This condition may worsen with mechanical disturbance.
Cardiac Instability: Sudden changes in thoracic pressure can harm the heart.
Traction: Active traction must be considered when selecting postural positions.
Ventilatory and Monitoring Circuitry: Any interference may disrupt critical monitoring while performing CPT.

Hazards of CPT

CPT can lead to various complications, which include:

Dyspnea: Patients may experience difficulty in breathing.
Aspiration: There's a risk of inhaling secretions.
Increased Intracranial Pressure: Risk associated particularly in certain patient populations.
Hypotension: Drops in blood pressure can occur.
Broncho-pleural Fistula: Already mentioned, but emphasizes the risk of worsening this condition.
Extra-pleural Hematomas: Areas of bleeding outside of the pleura may emerge.
Heparin Infusion Risks: Specific care to monitor while patients are on anticoagulation therapy.
Empyema Risks: Continued monitoring necessary to prevent further complications.

Postural Drainage Techniques

Postural drainage is a method used to mobilize secretions from the lungs by positioning the patient to utilize gravity. This method is indicated under circumstances such as excessive accumulation of secretions, retained secretions, and prophylactic care for pre-operative patients with a history of pulmonary problems. Positioning is critical in allowing gravity to help drain secretions into larger airways where they can be either coughed out or suctioned.

Percussion Technique

Percussion is a rhythmical tapping technique using cupped hands to loosen secretions in lungs beneath the percussion site. This is carried out ideally for periods of 30 to 45 seconds and can be repeated for 4-6 minutes during each postural drainage position. To minimize transmission, percussion should be conducted over bare skin, with a focus on wrist movement and minimal arm motion to alleviate fatigue in the therapist.

Indications and Precautions for Percussion

The indications for percussion overlap with those for postural drainage. Precautionary measures include:

Malignancy with Metastatic Changes: Risk increases when pressure is applied to tumors.
Anticoagulant Therapy: Increases bleeding risks.
Tuberculosis: Care must be taken as this is a contagious disease.
Petechiae: Presence of small bleeding spots under the skin can signify fragile vessels.
Osteoporotic Changes: Can lead to fractures with pressure.
Empyema and Pulmonary Embolus: Similar risks to those noted above must be considered.
Untreated Tension Pneumothorax: This condition could worsen with any physical pressure exerted.
Flail Chest Risk: Would need special consideration regarding rib stabilization.

Vibrations Technique

Vibrations are performed by placing one hand over the other on the affected area and tensing the shoulders while applying vibration from shoulder to hand. Oscillation is done for about 5 to 10 seconds and should coincide with exhalations to assist in secretion clearance. Coughing during each vibrations cycle will enhance the mobilization of secretions.

Cough Assist Techniques

Cough assistance is indicated for those who cannot develop a forceful cough on their own. The therapist places hands on the rib cage's sides and exerts inward and downward pressure during forced exhalations. The normal cough reflex involves engaging the glottis, contracting abdominal muscles to build intrapulmonary pressure before a forceful exhalation, stimulated by the presence of secretions.

Huff Coughing Technique

Huffing is beneficial for patients with ineffective coughs, particularly those with large functional residual capacities or neurological impairments. The technique involves encouraging patients to perform short, successive coughs of small volumes to aid in secretion clearance.

Breathing Retraining Techniques

These techniques are aimed at patients with muscular weakness, post-operative pain, or chronic pulmonary disease. The key goals include:

Improvement and increase in ventilation.
Strengthening of respiratory musculature.
Prevention of atelectasis development.
Decrease in the work of breathing.

Diaphragmatic Exercise

Patients are trained to abandon inefficient breathing methods and utilize the diaphragm effectively. This involves slow and completely purposeful exhalation, with possible assistance from the therapist applying slight pressure below the xiphoid process.

Pursed Lip Breathing Technique

This technique has been discovered to help COPD patients. Patients inhale slowly and then exhale through pursed lips. This method generates back pressure via resistance to airflow, thereby preventing premature collapse of the airways and aiding patients in controlling the rate and depth of their breathing.

Segmental Breathing Technique

Utilized to direct airflow to specific lung areas. The therapist applies firm pressure over targeted areas of the lungs, encouraging the patient to inhale actively against this pressure. Treatment focuses on areas such as the lung apices, middle lobes, and the lateral and posterior basal segments.

Lung Expansion Therapy

Lung expansion therapy consists of various medical treatment modalities aimed at preventing and treating pulmonary atelectasis (collapse of air sacs) and associated complications. This is especially relevant post-thoracic or abdominal surgeries, heavy sedation, and in neuromuscular diseases.

Intermittent Positive Pressure Breathing Therapy (IPPB)

IPPB is defined as the therapeutic application of inspiratory positive pressure applied to the airway of a spontaneously breathing patient, either intermittently or for short term. Treatments typically last between 15-20 minutes and can be administered several times a day or for extended periods overnight,

Goals of IPPB Therapy

Preventing or correcting atelectasis by increasing alveolar ventilation.
Improving and promoting effective cough mechanisms through deep inspirations.
Reducing the work of breathing, effectively allowing patients to rest while remaining ventilated.
Delivering medication via aerosol effectively due to larger volume of inspired gas under pressure.

Indications of IPPB

Common indications include:

Patients unable to take deep breaths.
Reduction of pulmonary edema.
Decreasing the work of breathing and accessory muscle use, particularly in COPD.
Mechanical bronchodilation and improved aerosol distribution for medications.
Enhancing collateral ventilation and cough mechanisms.

Complications of IPPB Therapy

While beneficial, IPPB comes with risks:

Hyperventilation: Can lead to alkalosis due to excess ventilation beyond metabolic needs, lowering CO2 in the blood.
Barotrauma: Injury to lung tissue due to excessive pressure, particularly in patients with COPD.
Oxygen-Induced Hypoventilation: Particularly concerning for COPD patients with loss of CO2 sensitivity.
Gastric Distention: May occur if air is swallowed or if patients are unresponsive.
Hemoptysis: Possible result of bronchial venous bleeding during efforts to cough.
Bronchospasm: Could arise from the sudden application of high flow rates.

Incentive Spirometry (IS)

IS is acknowledged as an economical, convenient, and effective method of lung expansion therapy. It emphasizes patient orientation rather than equipment and stands as a primary lung expansion therapy since the introduction of IS technology.

Goals of Incentive Spirometry

The overarching goals of IS include:

Preventing or minimizing atelectasis in post-surgical patients.
Optimizing lung inflation.
Improving cough mechanisms for better pulmonary resilience.
Early detection of acute pulmonary diseases.

Efficacy and Effectiveness of IS

IS aims to restore normal pre-operative pulmonary function in post-surgical patients by enabling them to take deep breaths while seeing their progress, which acts as an incentive. It encourages sustained maximal inspiration, helping to expand lungs and thereby decrease postoperative micro-atelectasis. The inspired volume goal is often defined based on predicted values or initial performance observations by a respiratory care professional.

Types of Incentive Spirometry

Volume-Based: Patient inspires until a preset volume of gas is inhaled. Common targets include 2000-4000 mL, displayed on a gauge.
Flow-Based: Patient’s inspiratory flow rate raises a ball or indicator within the device, allowing for real-time feedback on breathing efforts.

Factors Influencing IS Effectiveness

To maximize effectiveness, the patient should inhale a sufficient air volume to inflate alveoli adequately, recommended to be at least twice the patient's normal tidal volume. Effectiveness is further enhanced by holding the breath for 2-3 seconds at the peak of inspiration to maintain hyperinflation. IS devices encourage deep breathing and sustained inhalation, challenging patients to meet specific goals, thereby promoting better pulmonary function.

Conclusion

The detailed strategies and methodologies surrounding chest physical therapy and lung expansion techniques are vital in achieving effective pulmonary hygiene and improving overall respiratory health, particularly in patients with chronic conditions or post-operative risks. These techniques, when applied by trained professionals, can significantly enhance patient outcomes in respiratory care.