WHAT IS CHEST PHYSIOTHERAPY(CPT)?
The procedure of chest physical therapy involves re-expanding the non-ventilated lung as well as clearing secretions from the large and small airways.
WHAT ARE THE OBJECTIVES OF CHEST PHYSIOTHERAPY?
The objectives of chest physiotherapy are:
to achieve results that are equally as good as those of bronchoscopy while avoiding the procedure’s invasiveness, trauma, risk of hypoxemia, complications that involve doctors, and expense.
especially to enhance ventilation in regions where local lung obstruction occurs.
An increase in local lung expansion and a concomitant rise in perfusion to the affected region should happen if the goals of the chest physical therapy are met. Airway resistance and obstruction should diminish if secretions are removed from larger airways.Lung compliance should be increased by improved small airway airflow and secretion clearance. It is reasonable to assume that the work of breathing and oxygen intake should decrease, and gas exchange should improve, if clearance of secretions from both large and small airways occurs.
The incidence of postoperative respiratory infections, morbidity, and hospital stays for people with acute and chronic lung illnesses should also decrease if these goals are met.
TECHNIQUES USED UNDER CHEST PHYSIOTHERAPY
There are numerous ways to practise breathing and use ventilation methods. The following techniques are included when the phrase “chest physiotherapy” is used.
Segmental breathing: lateral costal expansion and posterior basal expansion
Pursed lip breathing
Additionally, whenever feasible, patient mobilisation is used.
Ventilation is successful and muscle oxygen consumption is very low during quiet, relaxed breathing when the diaphragm is performing as it should in its position as the main muscle of inspiration. The effort required for breathing rises when a patient uses their accessory muscles of inspiration.Although breathing is involuntarily controlled by the diaphragm, a patient with a primary pulmonary illness like chronic obstructive pulmonary disease
By making the best use of the diaphragm and relaxing the accessory muscles, (COPD) can be taught to regulate its breathing. When emphasising diaphragmatic breathing, controlled breathing methods are intended to increase diaphragmatic excursion, reduce work required to breathe, and improve gas exchange and oxygenation. During postural evacuation, this method is also used to move lung secretions.
An purposeful movement towards maximum inspiration is required for incentive spirometry. In this type of ventilation exercise, continuous maximum inspiration is emphasised. As the patient inhales as thoroughly as possible, a spirometer that offers visual or auditory feedback monitors the patient’s progress.
Lateral costal expansion:
One can breathe in one direction or the other when using this technique. It is believed that encouraging deep breathing while concentrating on the movement of this area of the lower rib cage will help with diaphragmatic extension. Patients with a stiff lower rib cage, like those who suffer from chronic bronchitis, emphysema, or asthma, can benefit the most from this method.
Posterior nasal breathing:
For the postsurgical patient who is confined to bed in a semi-relining position for a prolonged period of time, this type of segmental breathing is crucial. Frequently, secretions build up in the lower lobes’ posterior section.
When there is a significant weakness of the inspiration muscles, it is a method of increasing the patient’s inspiratory capacity. Patients who have trouble taking a deep breath, say before coughing, are instructed how to do it. Most frequently given to people with severe spinal cord injuries who are prone to breathing problems.
Pursed lip breathing:
A helpful technique is gentle pursed-lip breathing with regulated expiration. By exerting backpressure on the airways, it is believed to maintain the airways open. With chronic obstructive pulmonary disease (COPD), it is taught to patients to assist them manage episodes of dyspnea. Reduced respiratory rate, increased tidal volume, and improved exercise endurance are all benefits of pursed lip breathing.
By positioning the patient in different ways so that gravity helps with the draining process, postural drainage, also known as bronchial drainage, is a technique for mobilising secretions from one or more lung segments to the central airways. Coughing or endotracheal suctioning are then used to remove the secretions after they have been transferred to the large airways. Other physical methods used in postural drainage treatment include vibration, percussion, and coughing on command. Most high-risk patients require modified positioning to prevent a head-down or completely horizontal position.
The percussion technique involves rhythmically “clapping” over the affected lung segment with cupped palms. Instead of a slapping sound, percussion should create a hollow sound. It should emit an energy pulse that travels through the chest wall and causes the secretions on the bronchial wall to become less sticky. On impact, the hand should produce a “air cushion” that, according to theory, helps to dislodge pulmonary secretions.Both inspiration and expiration involve percussion, which shouldn’t put too much weight on the soft tissues in the chest. Manual percussion is typically done 100–480 times per minute, and it is estimated to exert 2–4 foot-pounds and 58–65 Newtons of power against the chest wall.The patient should not experience excessive discomfort during chest percussion, nor does it need to be vigorous. When percussion causes skin redness, it’s typically due to poor technique, most often slapping, or a lack of air being trapped between the palm and the chest wall. The secretions are thought to have become looser as a result of the confined air, which also produces the hollow cupping sound.
Postural drainage is used in combination with chest vibration, much like percussion. Vibration is a brief compression of the chest wall that occurs mostly during exhalation. It could start right before the expiratory phase and go all the way to the start of the inspiratory phase. This procedure should be carried out over the affected lung region during either ventilator-controlled or voluntary expiration.If a patient is inhaling on their own, chest wall vibration should come before encouraging them to make their best possible inhalation. The chest wall shakes in the same way that the ribs and soft tissues of the chest typically move during expiration after a maximal inspiration. According to a number of sources, distinct vibrations are described as “rib springing” or “chest shaking.”All of these are varying degrees of vigorous variations of the same basic technique, with “vibration” typically denoting a softer, more oscillatory course of action than the other terms. Manual vibration has been observed to occur between 12 and 20 Hz.
Mechanical vibrators and percussors:
Mechanical percussors and vibrators were created mainly to help patients with chronic pulmonary pathology with their physiotherapy at home. They are used in the intensive care unit because these mechanical devices, which some studies refer to as vibrators and others as precussors, can generate rotary or vertical movements or a combination of the two.
When normal ciliary activity is missing or foreign bodies or excessive amounts of sputum need to be removed, coughing is effective. The fastest method of secretion clearance is provided by the cough process. The treatment of individuals with acute or chronic respiratory conditions includes the clearance of the airways. A typical cough involves an attempt to inhale. The glottis shuts. Pressures in the intrathoracic and intra-abdominal cavities rise as a result of abnormal muscular contraction and diaphragm elevation. The glottis expands, causing an explosive air exhalation.
In patients who are unable to cough or huff on their own volitionally or after reflex activation of the cough mechanism, endotracheal suctioning may be the only option for clearing the airways. All individuals with artificial airways require suctioning. Only the trachea and the major bronchi are cleaned during the suctioning process.
Positive expiratory pressure (PEP):
Standard chest physical therapy is similar to PEP therapy. It is a technique for clearing the airways that involves providing mechanical pressure to the mouth. A positive pressure is produced in the airways by exhaling gently through the device’s resistance, which helps to keep the airways clear. In regions where mucus is obstructing airflow, this positive pressure enables the mucus to move towards the larger airways where it can be expectorated. Children over the age of four who are attentive and cooperative may benefit from this method.
Patients whose coughs are inadequate to clear thick localised secretions should take it.
- Chronic obstructive pulmonary disease
- Lung abscess
- Cystic fibrosis
- Patients having difficulty in breathing
- Unstable vitals (blood pressure, pulse, SPO2, etc).
- Unstable angina, cardiac arrhythmias
- Recent myocardial infarction
- Lung tumor
- Suspected or known active pulmonary tuberculosis
- Elevated intracranial pressure
- Head and neck injury
- Pulmonary embolism
- Rib fracture with or without flail chest
- Surgical wound
- Uncontrolled hypertension
- Subcutaneous emphysema
- Recent epidural anesthesia or recent epidural or intrathecal drug administration
- Recent skin grafts or flaps on the thorax
- Osteomyelitis of the thorax
- Osteoporosis of the thoracolumbar region
- Unconscious patient with an unprotected airway
- Acute abdomen (i.e., abdominal aortic aneurysm, hiatal hernia, or pregnancy)
- Recent spinal surgery (i.e., laminectomy)
- Bronchopleural fistula