“Chest Physiotherapy,” by Susan Hamilton, MS, RN, for OPENPediatrics
14
September

By Adem Lewis / in , , , , , , , , , , , , , , /


Chest Physiotherapy, by Susan Hamilton. Health care workers in all health care settings
should always adhere to the latest World Health Organization guidelines on hand hygiene and
barrier precautions before and after contact with the patient, bodily fluids, or patient
surroundings. For more information, please watch our video entitled Hand Hygiene. Introduction. Hi, I’m Sue Hamilton. I’m a nurse educator
at Children’s Hospital Boston. I’m here to talk to you today about some techniques of
chest physical therapy that include percussion, vibration and postural drainage.Indications.
Chest physiotherapy is used to help improve a patient’s pulmonary function, including
gas exchange and lung compliance. This is accomplished through mobilizing secretions,
which are present in the artificial airways and/or lungs of a critically-ill child. You
would want to perform this procedure in order to stimulate a productive cough and improve
aeration in patients with disorders that result in mucus production. These disorders include,
but are not limited to, pneumonia, acute atelectasis, bronchiolitis, cystic fibrosis. Contraindications. Some health care providers
would refrain from performing this procedure in patients with active hemoptysis or coagulopathy,
which is characterized by a platelet count of less than 50,000. You should also exercise
caution in patients with rib fractures or metastases, an active pulmonary embolism,
an untreated pneumothorax, a bone density deficiency, or recent spinal injury or surgery. Equipment. You will need the following equipment
to perform the procedure. Suction catheter, connection tubing, suction source with a receptacle,
oxygen source, manual ventilation bag and mask with manometer, stethoscope, personal
protective equipment, clean gloves. Pre-Procedure Assessment and Monitoring. Before starting, you should do an assessment
of the patient’s lungs and listen for wheezing or crackles or aeration that is not equal
on either side. I’m just going to listen to this baby now. Also, assess the patient’s ability to be placed
into the different postural drainage positions. If the patient has lines, tubes, IVs, that
may keep you from doing that, or if the patient happens to lower their oxygen level in one
particular position, you would want to know that prior to starting. Get a set of baseline vital signs and a baseline
pain score and make sure that the patient doesn’t have any causes of pain in the chest
area that would keep you from doing this procedure. Also, make sure to explain the procedure to
the patient and family. As I said, parents can sometimes be a little bit concerned when
they hear the noise of percussion and think that it may be hurting their child. Procedure. I’m going to start first by just
talking about postural drainage. I’m going to talk about each of the techniques, and
then I’m going to demonstrate them on this baby. So first would be postural drainage.
And that just means the positioning of the patient to allow gravity to help to mobilize
secretions. This is done in conjunction with the percussion and vibration. And if a patient can’t tolerate all of the
position changes that may be involved, modification certainly can be made, or the patient can
be kept either in a flat or elevated position through the entire. There are generally six
positions or basic positions that you can use, and I’m going to demonstrate those after
the end of this talk. Now I’m going to talk about percussion. Percussion
is a painless, rhythmic clapping with a cupped hand over an area of the chest. You basically
want to take your hand and make almost a C with it. And you want to have a loose wrist.
And the way to percuss is to go over an area of the chest and getting the full– the C–
against the chest so that there is a pocket of air there that creates a nice seal for
doing the percussion. You would perform percussion for 1-2 minutes
in each of the given areas, and that is done to help assist mobilization of secretions.
Following that, you can go ahead and do vibration, which is basically a sustained downward vibrating
motion with the flat part of the palm. It’s important to only do the vibration piece of
this when the patient is exhaling. It also helps with mobilization of secretions. So after you’re done percussing, you can put
your hand flat. You can use your other hand to help you. And when the patient has an exhalation,
you can just vibrate very gently. I find that most babies actually are very
soothed by this procedure. Some people, because you can end up making a loud clapping noise,
patient or parents can be afraid that children are being hurt. But they’re not being hurt.
And as I said, most babies actually find this to be very soothing. When doing the actual procedure, you want
to continue to look at the patient’s vital signs, how they’re oxygenation is doing, the
patient’s tolerance to the different position changes, the tolerance to the actual percussion
and vibration, how strong the patient’s cough is, their ability to cough and mobilize secretions,
and how their overall comfort is. I’m going to go ahead and start to get ready to do the
actual procedure by putting on my personal protective equipment. Now that I’ve assessed my patient and prepared
the family and the patient for the procedure, I’m going to go ahead and start. I’m going
to do six different positions on the patient. As I mentioned before, you would normally
go for 1-2 minutes in each position. For the sake of this video, I’m not going to do the
full 1-2 minutes, but that would be expected of what you would do. I’m going to start with the anterior segments
of the upper lobes. The patient should start out supine in a flat position. And I’m going
to start with percussing above, between the nipple line and the clavicle line, first,
on the right for 1-2 minutes and then on the left for 1-2 minutes. So I would start on the right. I would do
percussion. I’d be noting how the patient is tolerating it, be looking for any color
changes or oxygenation changes in the patient. I would continue that for 1-2 minutes. And
then I would follow that with some vibrations. I would wait for the patient to exhale and
vibrate. You’d do that three or four times and see if you’re starting to get any productive
secretions from the patient. Then you would move on to the left side and continue to do
that for 1-2 minutes as well. After finishing the anterior upper lobes,
you want to move on to the posterior segments of the upper lobes as well. If you start with
using the right side, you can keep the patient flat. But when you come over to the left side,
you want to elevate the head of the bed some and go ahead and percuss basically between
the spine and the axilla, and again, using that cupping motion for 1-2 minutes as such. And at the end, you want to wait for the patient
to exhale and give a few good vibrations. If the patient needs any suctioning, you could
go ahead and do this at this point and before you move on to the next position. Point of clarification. Please note that we
will now show the appropriate patient positioning for the four remaining positions. It is expected
that you would continue to perform percussion and vibration for 1-2 minutes on each side
in each position as previously demonstrated. The next position that you’ll do is the anterior
mid-lung. For this position, you’d preferably want to have the patient in about a 10 degree
slope downwards as long as the patient can tolerate that. I’m using a pillow to help
position my patient, and I have one little pillow under her head for comfort. I have
her hand up over her head, but whatever is most comfortable for your patient. And once you have the patient in a good position
and the patient’s on their side, you want to percuss this over the nipple line that
is most adjacent to you. So again, you want to do one to two minutes of percussion followed
by some vibration. The next position, you’ll just move the patient back supine, keeping
her head down the 10 degrees if at all possible. I’m going to remove her pillow now to help
get a better position. And now I’m going to try to do the chest PT in the anterior bases
of the lower lobes. I’m going to percuss below the axilla over the lower ribs followed by
some upward vibration and repeat on the left side. Now you’ll go ahead and work on the lateral
bases of both sides. Again, get the patient in the head dependent position of about 10
degrees as long as the patient is comfortable. And you want to first do percussion on the
lower ribs along the side. So this is going for the lateral bases of the lower lobes followed
by vibrations on exhalation. Then you would turn the patient to the other
side and do the other side. And then the last position would be the posterior bases. So
if the patient can tolerate, you can bring the patient a little bit more prone. If the
patient doesn’t tolerate a full turn, you can do a modified turn. And again, you’re
going to do the cupping on the backside– be careful not to overlie the spine or to
go near the kidneys– followed by vibration. Once you’re all done with all of the positions–
the six positions that I showed you– you want to bring the patient back supine and
make an assessment of the baby and decide whether the patient needs to be suctioned
or to help the patient with their cough. Post-Procedure Assessment and Monitoring. After placing the patient back in a supine
position, you want to do another overall assessment of how the patient tolerated the procedure
and also suction any secretions that may have come up during the percussion and vibration. My patient sounds as though she has some secretions
in the back of her throat. She has a productive cough, but I’m going to go ahead and suction
her nose to see if we can get some of those secretions up. As I suction her, I’m going to note the color,
the consistency, and if there’s any odor from the secretions that I do get up. This patient
actually has very few secretions. If she will tolerate it, I will just suction the inside
of her mouth and make sure that there’s no further secretions there. Once I’m done suctioning and I’m sure that
the patient looks well, I will do another assessment of lung sounds and see if there’s
any change from the beginning of the procedure. It is important to monitor the patient’s vital
signs, including oxygen saturation, heart rate, blood pressure, and respiratory rate
and effort. You will also want to assess the patient’s lungs, which includes listening
for the presence of any wheezing, crackles, and whether or not aeration is equal on both
sides. And the ability to place the patient in different positions. Finally, you will want to monitor the patient’s
oxygenation, tolerance of position, cough, and comfort during the procedure. Complications. The complications that you
may observe include oxygen desaturations, pain or injury to the patient’s ribs, muscles,
or spine, vomiting, aspiration of oral secretions into the lungs, increased intracranial pressure,
hypotension, bleeding in the lungs. Documentation. Following chest physiotherapy,
you should document the following information in the patient’s medical record. The indication
for the procedure, the date and time of the procedure, The characteristics of any secretions
including amount, color, consistency, and odor. The strength and productiveness of the patient’s
cough. The vital signs before, during, and after the procedure. The resolution or persistence
of the indication for the procedure, the patient’s comfort during the procedure, and any adverse
outcomes. Please help us improve the content by providing
us with some feedback.


15 thoughts on ““Chest Physiotherapy,” by Susan Hamilton, MS, RN, for OPENPediatrics

  1. clarification! if there is a need to suction after the procedure, do you suction the nose first or the mouth first?

  2. VERY informative, the switch to the black background with the section titles was a little distracting for me, but the content was easy to follow and helpful

  3. Thanks for this info, which I modified somewhat for my per rat. She's doing better. I just wondered – would Ventolin would help or hinder the process? Thanks in advance.

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