Oxygenation: Respiratory : Chest Physiotherapy

Performing Chest Physiotherapy

Purpose

1. To perform chest physiotherapy (PT) according to the standard of care.

Assessment

• Assess the client's medical record for orders regarding activity and position restrictions, tolerance of physiotherapy, and position changes.
• Assess bilateral breath sounds, noting rate and character.
• Assess the time of last oral intake. Avoid initiating therapy until 2 hours after solid food and 1 hour after liquids.

Equipment

• Stethoscope
• Pillows or folded towels for positioning
• Tilt or postural drainage table (if available) or adjustable hospital bed
• Gloves, face shield, and gown
• Emesis basin
• Facial tissues
• Suction equipment
• Equipment for oral care
• Trash bag
• Optional: sterile specimen container, mechanical ventilator, and supplemental oxygen

Procedure

1. Verify the order.
   Rationale: Verification of order prevents potential errors.
2. Confirm the client's ID. Compare the name with the name on the client's ID bracelet using two client identifiers according to your facility's policy. Do not start the treatment if the client is not wearing an ID bracelet.
   Rationale: Checking identification ensures client safety through concept of correct procedure for correct client.
3. Provide privacy and explain the procedure to the client.
   Rationale: Explanation protects client's rights and encourages participation in care.
4. Wash your hands, don gloves, a face shield, and a gown, and follow standard precautions.
   Rationale: Handwashing and protective equipment reduce transfer of microorganisms and protect nurse.
5. Auscultate the client's lungs.
   Rationale: Auscultation determines baseline respiratory status.
6. Position the client as ordered. In generalized disease, drainage usually begins with the lower lobes, continues with the middle lobes, and ends with the upper lobes. In localized disease, drainage begins with the affected lobes and then proceeds to the other lobes to avoid spreading the disease to uninvolved areas (Fig. 1).
   Rationale: Gloves and equipment protect you from secretions.


Fig. 1: Various postural drainage positions are used to mobilize secretions
from specific lobes and segments of the lungs.

7. Instruct the client to remain in each position for 10 to 15 minutes. During this time, perform percussion and vibration, as ordered.
   Rationale: Percussion and vibration loosen secretions in target areas.
   1. To perform percussion, instruct the client to breathe slowly and deeply, using the diaphragm, to promote relaxation. Hold your hands in a cupped shape, with fingers flexed and thumbs pressed tightly against your index fingers. Percuss each segment for 1 to 2 minutes by alternating your hands against the client in a rhythmic manner. Listen for a hollow sound on percussion to verify correct performance of the technique (Fig. 2).
   2. To perform vibration, ask the client to inhale deeply and then exhale slowly through pursed lips. During exhalation, firmly press your fingers and the palms of your hands against the chest wall. Tense the muscles of your arms and shoulders in an isometric contraction to send fine vibrations through the chest wall. Vibrate during five exhalations over each chest segment (Fig. 3).


Fig. 2: With your hands held in a rigid cup position, strike the area
over the lung lobes to be drained in a rhythmic pattern



Fig. 3: Use manual compression and tremor to help loosen the
respiratory secretions

8. After postural drainage, percussion, or vibration, instruct the client to cough to remove loosened secretions. First, tell the client to inhale deeply through the nose and then exhale in three short huffs. Then, have the client inhale deeply again and cough through a slightly open mouth. Three consecutive coughs are highly effective. An effective cough sounds deep, low, and hollow; an ineffective one sounds high pitched.
   Rationale: Coughing removes secretions that have accumulated in trachea.
9. Have the client perform coughing exercises for about 1 minute and then rest for 2 minutes. Gradually progress to a 10-minute exercise period four times daily. Try to schedule the last session just before bedtime.
   Rationale: Scheduling chest physiotherapy before bed will help maximize client's oxygenation while sleeping.
10. If the client's cough is ineffective, suction the client.
    Rationale: Suction removes secretions that have accumulated in trachea.
11. Monitor the client's response to the treatment. Be alert for significant color changes, particularly if the client becomes dusky.
    Rationale: A dusky color may indicate poor oxygenation.
12. Dispose of secretions appropriately.
13. Provide oral hygiene.
    Rationale: Secretions may have a foul taste or a stale odor.
14. Auscultate the client's lungs.
    Rationale: Auscultation evaluates effectiveness of therapy.
15. Record the date and time of chest PT; which chest segments were percussed or vibrated; the color, amount, odor, and viscosity of any secretions produced and the presence of any blood; any complications and nursing actions taken; and the client's tolerance of treatment.

Sample Documentation
10/04/10	2030	Postural drainage performed with chest percussion and vibration to left lower, middle, and upper lobe. After therapy, client had a productive cough of thick yellow sputum. Client tolerated procedure well. Mouth care performed. S. Norton, RN

Special Considerations

• For optimal effectiveness and safety, modify chest PT according to the client's condition. For example, initiate or increase the flow of supplemental oxygen, if indicated. If the client tires quickly during therapy, shorten the sessions because fatigue leads to shallow respirations and increased hypoxia.
• Maintain adequate hydration in the client receiving chest PT to prevent mucus dehydration and promote easier mobilization of secretions. Avoid performing postural drainage immediately before or within 1½ hours after meals to avoid nausea, vomiting, and aspiration of food or vomitus.
• Because chest percussion can induce bronchospasm, any adjunct treatment (for example, intermittent positive-pressure breathing, aerosol, or nebulizer therapy) should precede chest PT.
• Refrain from percussing over the spine, liver, kidneys, or spleen to avoid injury to the spine or internal organs. Avoid performing percussion on bare skin or the female client's breasts. Percuss over soft clothing (but not over buttons, snaps, or zippers) or place a thin towel over the chest wall. Remember to remove jewelry that might scratch or bruise the client.
• Teach coughing and deep-breathing exercises preoperatively so that the client can practice them when pain-free and better able to concentrate.
• Postoperatively, splint the client's incision using your hands or, if possible, teach the client to splint it to minimize pain during coughing.

Complications

• During postural drainage in head-down positions, pressure on the diaphragm by abdominal contents can impair respiratory excursion and lead to hypoxia or orthostatic hypotension. The head-down position also may lead to increased intracranial pressure, which precludes the use of chest PT in a client with acute neurologic impairment.
• Vigorous percussion or vibration can cause rib fracture, especially in the client with osteoporosis. In an emphysematous client with blebs, coughing could lead to pneumothorax.