Facebook Twitter RSS Reset

Chest physiotherapy – procedure, after care

PERFORMING PERCUSSION AND VIBRATION

To perform percussion, instruct the patient 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 patient in a rhythmic manner. Listen for a hollow sound on percussion to verify correct performance of the technique.

To perform vibration, ask the patient 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.

TEACHING PATIENT THE BREATHING EXERCISES

Pre procedure

Have the patient clear the nasal passages before beginning exercises.

During procedure

For diaphragmatic breathing

  1. Place one hand on the abdomen just below the ribs and the other hand on the middle of the sternum.
  2. Breathe in slowly and deeply through the nose, letting the abdomen protrude as far as it will. The abdomen enlarges during inspiration and decreases in size during expiration.
  3. Breathe out through pursed lips while contracting (tightening) the abdominal muscles. Press firmly inward and upward on the abdomen while breathing out. The ratio of inhalation to expiration should be 1:2. Inhale through the nose for the count of 2, exhale through pursed lips for the count of 4.
  4. The chest should not move; attention is directed at the abdomen, not the chest
  5. Repeat for 1 minute (followed by a rest period of 2 minutes). Work up to 10 minutes, four times daily.
  6. Learn to do diaphragmatic breathing while lying, then sitting, and ultimately standing and walking

Pursed-lip breathing

  1. Inhale slowly and through the nose for a count of 2.
  2. Exhale slowly and evenly against pursed lips while contracting (tightening) the abdominal muscles. Avoid exhaling forcefully. Inhalation to exhalation rate is 1:2. Pursing the lips increases intrabronchial pressure (helps maintain the bronchi in an open position) as well as intra-alveolar pressure. The pursed-lips maneuver also prolongs the expiratory phase of breathing, makes it easier to empty the air in the lungs, and promotes carbon dioxide elimination.

During procedure

  • Verify the doctor’s order.
  • Explain the procedure to the patient.
  • Provide privacy.
  • Perform hand hygiene, put on gloves, and follow standard precautions
  • Auscultate the patient’s lungs to determine baseline respiratory status.
  • Position the patient 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.
  • Instruct the patient to remain in each position for 3 to 15 minutes. During this time, perform percussion and vibration as ordered.
  • After postural drainage, percussion, or vibration, instruct the patient to cough to remove loosened secretions. First, tell him to inhale deeply through his nose and then exhale in three short huffs. Then have him 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, high-pitched.
  • Have the patient 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 to help maximize the patient’s oxygenation while he’s sleeping.
  • If the patient’s cough is ineffective, suction the patient.
  • Monitor the patient’s response to the treatment. Be alert for significant color changes, particularly if the patient becomes dusky, which may indicate poor oxygenation.
  • Dispose of secretions appropriately.
  • Provide oral hygiene because secretions may have a foul taste or a stale odor.
  • Auscultate the patient’s lungs to evaluate the effectiveness of therapy.
  • Remove and discard gloves. Perform hand hygiene.
  • Document the procedure.

 

Special consideration

  • Maintain adequate hydration in the patient 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.
  • Chest physiotherapy should be performed after nebulization therapy
  • Chest percussion should not be performed over the spine, liver, kidneys, or spleen to avoid injury to the spine or internal organs.
  • Percussion should not be performed over buttons, snaps, or zippers. A thin towel  or soft clothing can be placed over the chest wall.
  • Remember to remove jewelry that might scratch or bruise the patient.
  • Teach coughing and deep-breathing exercises preoperatively so that the patient can practice them when he’s pain-free and better able to concentrate.
  • Postoperatively, splint the patient’s incision using your hands or, if possible, teach the patient to splint it himself to minimize pain during coughing.

References:

  1. Judson, MA, Sahn, SA (1994) Mobilization of secretions in ICU patients. Respiratory Care 39,213-226
  2. Fedorovich C, Littleton MT.(1990) Chest physiotherapy: evaluating the effectiveness. Dimensions of Critical Care Nursing, Mar-Apr; 9(2): 68-74.
  3. Potter A P, Perry G A.(2006) Fundamentals of nursing.6th Edition. St.Louis: Mosby publications.

Part1|Part2|Part3