Chest physical therapy
Chest physical therapy is the term for a group of treatments designed to improve respiratory efficiency, promote expansion of the lungs, strengthen respiratory muscles, and eliminate secretions from the respiratory system.
The purpose of chest physical therapy, also called chest physiotherapy, is to help patients breathe more freely and to get more oxygen into the body. Chest physical therapy includes postural drainage, chest percussion, chest vibration, turning, deep breathing exercises, and coughing. In the early 2000s, some newer devices, such as the positive expiratory pressure (PEP) valve and the flutter device, have been added to the various chest physical therapy techniques. Chest physical therapy is normally done in conjunction with other treatments to rid the airways of secretions. These other treatments include suctioning, nebulizer treatments, and the administering expectorant drugs.
Good respiratory health is not possible without efficient clearance of secretions in the airway. In a healthy person, this is normally accomplished through two mechanisms: the mucociliary clearance system (MCS) and the ability to cough . There are many diseases and disabilities in children linked with poor lung health and an impaired ability to clear secretions. These include cystic fibrosis, asthma, cerebral palsy, muscular dystrophy , and various immunodeficiency disorders. When a child is unable to clear mucus, breathing becomes hard work. He or she must expend extra effort and energy in order to get oxygen. This difficulty can lead to a vicious cycle of recurrent episodes of inflammation, respiratory infections, lung damage, increased production of excess mucus, and possibly airway obstruction. Chest physical therapy is one way to reduce the risks of an inefficient clearance of airway secretions. Depending on the specific technique and health situation, chest physical therapy may be used on children from newborns to adolescents.
Various methods of chest physical therapy have been used since the early 1900s to help manage airway clearance disorders. The techniques have been refined since that time. The procedure may be performed by a respiratory therapist, a nurse, or a trained family member. However, chest physical therapy presents some challenges and requires skill and training in order to be safely and effectively performed.
Chest physical therapy is a method of clearing the airway of excess mucus. It is based on the theory that when various areas of the chest and back are percussed, shock waves are transmitted through the chest wall, loosening the airway secretions. If the child is positioned appropriately, the loosened secretions will then drain into the upper airways, where they can then be cleared using coughing and deep breathing techniques. The following techniques are all part of chest physical therapy.
Turning from side to side permits lung expansion. The child may turn on his or her own, or be turned by a caregiver. Turning should be done at a minimum of every two hours if the child is bedridden. The head of the bed can also be elevated in order to promote drainage.
Coughing helps to break up secretions in the lungs so that the mucus can be expectorated or suctioned out if necessary. Patients sit upright and inhale deeply through the nose. They then exhale in short puffs or coughs. This procedure is repeated several times a day.
Deep breathing helps expand the lungs and forces an improved distribution of the air into all sections of the lungs. The patient either sits in a chair or sits upright in bed and inhales then pushes the abdomen out to force maximum amounts of air into the lung. The abdomen is then contracted, and the patient exhales. Deep breathing exercises are done several times each day for short periods.
Because of the mind-body awareness required to perform coughing and deep breathing exercises, they are unsuitable for most children under the age of eight.
Postural drainage uses the force of gravity to assist in effectively draining secretions from the smaller airways into the central airway where they can either be coughed up or suctioned out. The child is placed in a head- or chest-down position and is kept in this position for up to 15 minutes. To obtain the head-down positions, the use of a pillow, beanbag chair, or couch cushions can be helpful. Often, percussion and vibration are performed in conjunction with postural drainage.
Percussion involves rhythmically striking the chest wall with cupped hands. It is also called cupping or clapping. The purpose of percussion is to break up thick secretions in the lungs so they can more easily be removed. Percussion is performed on each lung segment for one to two minutes at a time. Mechanical percussors are available and may be suitable for children over two years of age. The percussor is moved over one lobe of the lung for approximately five minutes, while the patient is encouraged to performing coughing and deep breathing techniques. This process is repeated until each segment of the lung is percussed.
As with percussion, the purpose of vibration is to help break up lung secretions. Vibration can be either mechanical or manual. It is performed as the patient breathes deeply. When done manually, the person performing the vibration places his or her hands against the patient's chest and creates vibrations by quickly contracting and relaxing arm and shoulder muscles while the patient exhales. The procedure is repeated several times each day for about five exhalations.
Positive expiratory pressure (PEP)
PEP therapy has been extensively tested and is equivalent to standard chest physical therapy. It is an airway clearance method that is administered by applying a mechanical pressure device to the mouth. By breathing out with a moderate force through the resistance of the device, a positive pressure is created in the airways that helps to keep them open. This positive pressure permits airflow to reach beneath the areas of mucus obstruction and to move the mucus toward the larger airways where it can be expectorated. This technique may be suitable for alert, cooperative children over the age of four.
The flutter valve is a hand-held mucus clearance device designed to combine positive expiratory pressure (PEP) with high frequency airway oscillations. The device looks like a pipe containing an inner cone that cradles a steel ball sealed with a perforated cover. Exhalation through the device results in a vibration of the airway walls, which in turn loosens secretions. It may be a suitable technique for children aged five years and over.
A child is considered to have responded positively to chest physical therapy if some, but not necessarily all, of the following changes occur:
- increased volume of sputum secretions
- changes in breath sounds
- improved chest x ray
- increased oxygenation of the blood as measured by arterial blood gas sampling
- the child's report of increased ease in breathing
Chest physical therapy should not be performed on those children with the following:
- bleeding in the lungs
- head or neck injuries
- fractured ribs
- collapsed lungs
- acute asthma
- pulmonary embolism
- active hemorrhage
- some spinal injuries
- open wounds or burns
The child should be taught about the necessity and rationale for chest physical therapy. It may be a challenge to get children to cooperate with the procedure. Providing a toy, watching a video, or giving a reward may be ways to encourage cooperation.
Many children may wish to perform oral hygiene measures after therapy to lessen the poor taste of the secretions they have expectorated.
The risks and complications associated with chest physical therapy are dependent upon the health of the child. Although chest physical therapy normally poses few problems, in some patients it may cause the following:
- oxygen deficiency if the head is kept lowered for drainage
- increased intracranial pressure
- temporary lowering of blood pressure
- bleeding in the lungs
- pain or injury to the ribs, muscles, or spine
- inhalation of secretions into the lungs
- heart irregularities
Coughing —In chest physical therapy, coughing is used to help break up secretions in the lungs so that the mucus can be suctioned out or expectorated. Patients sit upright and inhale deeply through the nose. They then exhale in short puffs or coughs.
Deep breathing —Deep breathing helps expand the lungs and forces better distribution of the air into all sections of the lung. The patient either sits in a chair or sits upright in bed and inhales, pushing the abdomen out to force maximum amounts of air into the lung. The abdomen is then contracted, and the patient exhales.
Mucociliary escalator —The coordinated action of tiny projections on the surfaces of cells lining the respiratory tract, which moves mucus up and out of the lungs.
Percussion —An assessment method in which the surface of the body is struck with the fingertips to obtain sounds that can be heard or vibrations that can be felt. It can determine the position, size, and consistency of an internal organ. It is performed over the chest to determine the presence of normal air content in the lungs, and over the abdomen to evaluate air in the loops of the intestine.
Postural drainage —The use of positioning to drain secretions from the bronchial tubes and lungs into the trachea or windpipe where they can either be coughed up or suctioned out.
Vibration —The treatment that is applied to help break up lung secretions. Vibration can be either mechanical or manual. It is performed as the patient breathes deeply. When done manually, the person performing the vibration places his or her hands against the patient's chest and creates vibrations by quickly contracting and relaxing arm and shoulder muscles while the patient exhales. The procedure is repeated several times each day for about five exhalations.
Because chest physical therapy is often prescribed for childrven with chronic health problems, parents are often required to learn the techniques so the procedure can be performed regularly at home. Many parents are fearful they might hurt their child or may perform the procedure incorrectly. They should be reassured that thousands of parents have learned how to perform chest physical therapy and do so safely and effectively.
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Cystic Fibrosis Foundation. 6931 Arlington Road, Bethesda, MD 20814. Web site: http://www.cff.org.
"Chest Physical Therapy." Dr. Joseph F. Smith Medical Library , 2003. Available online at http://www.chclibrary.org/micromed/00042330.html (accessed December 8, 2004).
"Cystic Fibrosis Center, Airway Clearance Center." University of Wisconsin Medical School Department of Pediatrics , 2004. Available online at http://www.pediatrics.wisc.edu/patientcare/cf/acc.html (December 8, 2004).
Deanna M. Swartout-Corbeil, RN
Tish Davidson A.M.