Chest physiotherapy (CPT) includes postural drainage, chest percussion and vibration, and breathing exercises/breathing re-training. In addition, teaching the patient effective coughing technique is an important part of chest physiotherapy. The goals of chest physiotherapy are to remove bronchial secretions, im-prove ventilation, and increase the efficiency of the respiratory muscles.
Postural drainage uses specific positions that allow the force of gravity to assist in the removal of bronchial secretions. The se-cretions drain from the affected bronchioles into the bronchi and trachea and are removed by coughing or suctioning. Postural drainage is used to prevent or relieve bronchial obstruction caused by accumulation of secretions.
Because the patient usually sits in an upright position, secre-tions are likely to accumulate in the lower parts of the lungs. With postural drainage, different positions (Fig. 25-3) are used so that the force of gravity helps to move secretions from the smaller bronchial airways to the main bronchi and trachea. The secre-tions then are removed by coughing. The nurse should instruct the patient to inhale bronchodilators and mucolytic agents, if pre-scribed, before postural drainage because these medications im-prove bronchial tree drainage.
Postural drainage exercises can be directed at any of the seg-ments of the lungs. The lower and middle lobe bronchi drain more effectively when the head is down; the upper lobe bronchi drain more effectively when the head is up. Frequently, five po-sitions are used, one for drainage of each lobe: head down, prone, right and left lateral, and sitting upright.
The nurse should be aware of the patient’s diagnosis as well as the lung lobes or segments involved, the cardiac status, and any struc-tural deformities of the chest wall and spine. Auscultating the chest before and after the procedure helps to identify the areas needing drainage and to assess the effectiveness of treatment. The nurse teaches family members who will be assisting the patient at home to evaluate breath sounds before and after treatment. The nurse explores strategies that will enable the patient to assume the in-dicated positions at home. This may require the creative use of objects readily available at home, such as pillows, cushions, or card-board boxes.
Postural drainage is usually performed two to four times daily, before meals (to prevent nausea, vomiting, and aspiration) and at bedtime. Prescribed bronchodilators, water, or saline may be neb-ulized and inhaled before postural drainage to dilate the bron-chioles, reduce bronchospasm, decrease the thickness of mucus and sputum, and combat edema of the bronchial walls. The rec-ommended sequence of positioning is as follows: positions to drain the lower lobes first, then positions to drain the upper lobes.
The nurse makes the patient as comfortable as possible in each position and provides an emesis basin, sputum cup, and paper tis-sues. The nurse instructs the patient to remain in each position for 10 to 15 minutes and to breathe in slowly through the nose and then breathe out slowly through pursed lips to help keep the air-ways open so that secretions can drain while in each position. If a position cannot be tolerated, the nurse helps the patient to assume a modified position. When the patient changes position, the nurse explains how to cough and remove secretions (Chart 25-5).
If the patient cannot cough, the nurse may need to suction the secretions mechanically. It also may be necessary to use chest per-cussion and vibration to loosen bronchial secretions and mucus plugs that adhere to the bronchioles and bronchi and to propel sputum in the direction of gravity drainage (see “Chest Percus-sion and Vibration,” below). If suctioning is required at home, the nurse instructs caregivers in safe suctioning technique and care of the suctioning equipment.
After the procedure, the nurse notes the amount, color, vis-cosity, and character of the expelled sputum. It is important to evaluate the patient’s skin color and pulse the first few times the procedure is performed. It may be necessary to administer oxy-gen during postural drainage.
If the sputum is foul-smelling, it is important to perform pos-tural drainage in a room away from other patients and/or family members and to use deodorizers unless contraindicated. Deodor-izers delivered in aerosol sprays can cause bronchospasm and irri-tation to the patient with a respiratory disorder and should be used cautiously (Zang & Allender, 1999). After the procedure, the pa-tient may find it refreshing to brush the teeth and use a mouth-wash before resting.
Thick secretions that are difficult to cough up may be loosened by tapping (percussing) and vibrating the chest. Chest percussion and vibration help to dislodge mucus adhering to the bronchioles and bronchi.
Percussion is carried out by cupping the hands and lightly strik-ing the chest wall in a rhythmic fashion over the lung segment to be drained. The wrists are alternately flexed and extended so that the chest is cupped or clapped in a painless manner (Fig. 25-4). A soft cloth or towel may be placed over the segment of the chest that is being cupped to prevent skin irritation and redness from direct contact. Percussion, alternating with vibration, is performed for 3 to 5 minutes for each position. The patient uses diaphrag-matic breathing during this procedure to promote relaxation (see “Breathing Retraining,” below). As a precaution, percussion over chest drainage tubes, the sternum, spine, liver, kidneys, spleen, or breasts (in women) is avoided. Percussion is performed cautiously in the elderly because of their increased incidence of osteoporo-sis and risk of rib fracture.
Vibration is the technique of applying manual compression and tremor to the chest wall during the exhalation phase of res-piration (see Fig. 25-4). This helps to increase the velocity of the air expired from the small airways, thus freeing the mucus. After three or four vibrations, the patient is encouraged to cough, using the abdominal muscles. (Contracting the abdominal muscles in-creases the effectiveness of the cough.)
A scheduled program of coughing and clearing sputum, to-gether with hydration, reduces the amount of sputum in most pa-tients. The number of times the percussion and vibration cycle is repeated depends on the patient’s tolerance and clinical response. It is important to evaluate breath sounds before and after the procedures.
When performing chest physiotherapy, the nurse ensures that the patient is comfortable, is not wearing restrictive clothing, and has not just eaten. The uppermost areas of the lung are treated first. The nurse gives medication for pain, as prescribed, before per-cussion and vibration and splints any incision and provides pil-lows for support as needed. The positions are varied, but focus is placed on the affected areas. On completion of the treatment, the nurse assists the patient to assume a comfortable position.
The nurse must stop treatment if any of the following occur: increased pain, increased shortness of breath, weakness, light-headedness, or hemoptysis. Therapy is indicated until the patient has normal respirations, can mobilize secretions, and has normal breath sounds, and when the chest x-ray findings are normal.
Chest physiotherapy is frequentlyindicated at home for patients with COPD, bronchiectasis, and cystic fibrosis. The techniques are the same as described above, but gravity drainage is achieved by placing the hips over a box, a stack of magazines, or pillows (unless a hospital bed is available). The nurse instructs the patient and family in the positions and techniques of percussion and vibration so that therapy can be continued in the home. In addition, the nurse instructs the pa-tient to maintain an adequate fluid intake and air humidity to prevent secretions from becoming thick and tenacious. It also is important to teach the patient to recognize early signs of infec-tion, such as fever and a change in the color or character of spu-tum. Resting 5 to 10 minutes in each postural drainage position before chest physiotherapy maximizes the amount of secretions obtained.
Chest physical therapy may be carried out dur-ing visits by a home care nurse. The nurse also assesses the pa-tient’s physical status, understanding of the treatment plan, and compliance with recommended therapy, as well as the effective-ness of therapy. It is important to reinforce patient and family teaching during these visits. The nurse reports to the patient’s physician any deterioration in the patient’s physical status and in-ability to clear secretions.
Breathing retraining consists of exercises and breathing practices designed to achieve more efficient and controlled ventilation and to decrease the work of breathing. Breathing retraining is espe-cially indicated in patients with COPD and dyspnea. These ex-ercises promote maximal alveolar inflation and muscle relaxation, relieve anxiety, eliminate ineffective, uncoordinated patterns of respiratory muscle activity, slow the respiratory rate, and decrease the work of breathing. Slow, relaxed, and rhythmic breathing also helps to control the anxiety that occurs with dyspnea. Specific breathing exercises include diaphragmatic and pursed-lip breath-ing (see Chart 25-3).
The goal of diaphragmatic breathing is to use and strengthen the diaphragm during breathing. Diaphragmatic breathing can become automatic with sufficient practice and concentration. Pursed-lip breathing, which improves oxygen transport, helps to induce a slow, deep breathing pattern and assists the patient to control breathing, even during periods of stress. This type of breathing helps prevent airway collapse secondary to loss of lung elasticity in emphysema. The goal of pursed-lip breathing is to train the muscles of expiration to prolong exhalation and increase airway pressure during expiration, thus lessening the amount of airway trapping and resistance. The nurse instructs the patient in diaphragmatic breathing and pursed-lip breathing, as described earlier in Chart 25-3. Breathing exercises may be practiced in sev-eral positions because air distribution and pulmonary circulation vary with the position of the chest. Many patients require addi-tional oxygen, using a low-flow method, while performing breath-ing exercises. Emphysema-like changes in the lung occur as part of the natural aging process of the lung; therefore, breathing ex-ercises are appropriate for all elderly patients who are hospitalized and elderly patients in any setting who are sedentary, even with-out primary lung disease.
The nurse instructs the patient tobreathe slowly and rhythmically in a relaxed manner and to ex-hale completely to empty the lungs. The patient is instructed always to inhale through the nose because this filters, humidifies, and warms the air. If short of breath, the patient should concen-trate on breathing slowly and rhythmically. To avoid initiating a cycle of increasing shortness of breath and panic, it is often help-ful to instruct the patient to concentrate on prolonging the length of exhalation rather than merely slowing the rate of breathing. Minimizing the amount of dust or particles in the air and pro-viding adequate humidification may also make it easier for the pa-tient to breathe. Strategies to decrease dust or particles in the air include removing drapes or upholstered furniture, using air fil-ters, and washing floors and dusting and vacuuming frequently.
The nurse instructs the patient that an adequate dietary intake promotes gas exchange and increases energy levels. It is important to provide adequate nutrition without overfeeding patients. Nurses should teach patients to consume small, frequent meals and snacks. Having ready-prepared meals and favorite foods available helps encourage nutrient consumption. Gas-producing foods such as beans, legumes, broccoli, cabbage, and Brussels sprouts should be avoided to prevent gastric distress. Because many of these patients
lack the energy to eat, they should be taught to rest before and after meals to conserve energy (Lutz & Przytulski, 2001).
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