Chest physical therapy (CPT), postural drainage, and percussion are airway clearance techniques used to remove mucus and secretions from the lungs.
These techniques are often used in patients with chronic respiratory conditions such as cystic fibrosis, chronic obstructive pulmonary disease (COPD), and bronchiectasis.
In this article, we will delve deeper into the science behind chest physical therapy (CPT) and percussion and provide a comprehensive overview of the different postural drainage positions.
We’ll also explore the indications, benefits, and conditions they are most commonly used to treat. We will also discuss the role of respiratory therapists in administering these essential types of airway clearance therapy.
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Chest Physical Therapy (CPT)
Chest physical therapy (CPT) is an airway clearance technique that helps clear secretions, improve ventilation, and strengthen the muscles involved in breathing. It’s effective in mobilizing secretions using the following:
- Mechanical energy
The technique involves striking the patient’s chest wall with your hands, a cuff, or an automatic percussor to loosen secretions from the airway walls. Then they are easier to remove by coughing or suctioning.
- Copious secretions
- Retained secretions
- Ineffective cough
- Cystic fibrosis
- Ciliary dyskinetic syndromes
- Head, neck, or spinal cord injury
- Hemodynamic instability
- Active hemorrhage
- Recent surgery
- Intracranial pressure (ICP) > 20 mmHg
- Active hemoptysis
- Bronchopleural fistula
- Pulmonary edema
- Congestive heart failure
- Uncontrolled coughing
- High levels of anxiety
- Pulmonary embolism
- Subcutaneous emphysema
- Flail chest
- Large pleural effusion
- Uncontrolled hypertension
- Suspected tuberculosis
- Complaint of angina
- High risk of aspiration
Postural drainage involves placing the patient in various positions to drain secretions from specific lung segments into the central airways. The technique uses gravity to mobilize secretions for removal by coughing or suctioning.
Postural drainage works by placing the target segmental bronchus in a more vertical position, allowing gravity to work its magic.
A specific position is typically held for 3–15 minutes or longer in severe cases. The length of therapy depends on the patient’s condition and ability to tolerate the body positioning.
Complications of Postural Drainage
While postural drainage is an effective airway clearance technique for patients with chronic respiratory conditions, it is not without its potential hazards and complications. Some examples include:
- Increased intracranial pressure
- Acute hypotension
- Pulmonary hemorrhage
- Injury to muscles, ribs, or spine
Postural Drainage Positions
As previously mentioned, patients may be placed in different postural drainage positions to drain secretions from a specific lung lobe or segment. This includes the following:
- Posterior basal segment
- Lateral basal segment
- Anterior basal segment
- Superior segment
Right Middle Lobe and Left Lingula
- Right lateral and medial segments
- Left superior and inferior lingula segments
- Posterior segment
- Apical segment
- Anterior segment
Percussion and Vibration
Percussion and vibration techniques involve the use of mechanical energy on the thoracic region to loosen up secretions for easier clearance. This is performed manually by hand or with a pneumatic or electrical device.
- Manual percussion: A technique performed by respiratory therapists, involves striking the patient’s chest wall with cuffed hands. Rhythmic percussions over a targetted area are performed for 3–5 minutes as the technique is performed back and forth in a circular pattern.
- Mechanical percussion: Involves a pneumatic or electrical device to deliver vibrations at a controllable frequency. This method is preferred because it reduces fatigue, decreases treatment time, and delivers consistent impact forces.
Other Types of Airway Clearance Therapy
There are several different types of airway clearance therapy, including the following:
- Chest Physical Therapy (CPT)
- Positive Expiratory Pressure (PEP) Therapy
- Autogenic Drainage
- High-Frequency Chest Wall Compression (HFCW)
- Mobilization and Physical Activity
- Active Cycle of Breathing
- Intrapulmonary Percussive Ventilation (IPV)
- Mechanical Insufflation-Exsufflation (MIE)
Each type has advantages and disadvantages and requires a different technique for delivery, but the primary goal of each type is to help clear secretions from the lungs.
What is Chest Physiotherapy?
Chest physiotherapy (CPT) is a group of airway clearance techniques that clear mucus and secretions from the lungs. This term can be used interchangeably with “chest physical therapy.”
The techniques used in CPT typically include postural drainage, percussion, and vibration, which can be performed manually or with the help of mechanical devices. CPT is commonly used to treat patients with chronic respiratory conditions that cause retained secretions.
Is Postural Drainage Used to Treat Cystic Fibrosis?
Yes, postural drainage is often used to treat patients with cystic fibrosis. Cystic fibrosis is a chronic respiratory condition that leads to the accumulation of thick and sticky mucus in the lungs, making it difficult to breathe.
By positioning the patient in various positions, postural drainage helps drain secretions from specific lung segments into the central airways, where they can be more easily removed by coughing or suctioning.
What is the Chest Physiotherapy Vest?
High-frequency chest wall oscillation is a form of airway clearance therapy that uses an inflatable vest to perform chest physical therapy. It vibrates the chest and thoracic region to help loosen and remove mucus and secretions from the lungs.
The vest fits snugly over the patient’s torso and is equipped with a motor that delivers high-frequency mechanical vibrations to the chest wall.
The vest is often used to treat patients with cystic fibrosis and can be used in conjunction with other techniques for airway clearance and secretion management.
Practice Questions About CPT and Postural Drainage:
1. What are the goals of CPT?
To prevent the accumulation of secretions, improve the mobilization of secretions, regain the most efficient breathing pattern, improve the distribution of ventilation, and improve cardiopulmonary exercise tolerance.
2. What are the techniques utilized in CPT?
Clearance techniques, exercise protocols, and breathing retraining methods.
3. What position do your hands go for manual percussion?
You should make slow rhythmic clapping with cupped hands over the appropriate lung segment for 3-5 minutes.
4. What are the diseases that benefit from CPT?
Cystic fibrosis, bronchiectasis, chronic bronchitis, aspiration pneumonia, ciliary dyskinetic syndrome, and COPD.
5. What volume of sputum produced per day indicates the need for CPT?
More than 25–30 mL per day.
6. What is postural drainage?
It is where you position the patient to remove mucus by having gravity do its job.
7. What consists of chest physical therapy?
Clearance techniques, exercise protocols, and breathing retraining methods.
8. How long should each postural drainage be held?
3–5 minutes for each position.
9. What is the procedure for performing chest wall percussion and vibration?
Percussion involves cupping over a lung segment while having the patient perform pursed-lip breathing. Vibration is done after percussion, and you should vibrate toward the carina. Be sure to have the patient inhale and then perform vibration while they are exhaling.
10. When should vibration be performed?
When the patient exhales.
11. What are the chronic conditions that may cause copious secretions?
Cystic Fibrosis, atelectasis, bronchitis, and aspiration pneumonia.
12. What is the best position to drain the anterior upper segment (upper lobes)?
Sitting up slightly with a pillow under the legs.
13. What is the best position to drain the anterior segments?
Lying supine with a pillow under the legs.
14. What is the best position to drain the left lingual (left lower)?
Raise the bed about 12 inches (on the feet) (Trendelenburg) with the left arm and back raised.
15. What is the best position to drain the posterior segments (lower lobes)?
Legs raised about 18 inches (30 degrees) (Trendelenburg). Prone with a pillow under the stomach.
16. What is the best position to drain the superior segments (middle)?
Prone with a pillow under the stomach.
17. What are the contraindications for postural drainage?
An unstable head or neck injury, hemorrhage, hemoptysis, rib fracture, flail chest, surgical wound, and a pulmonary embolism.
18. What are the contraindications for percussion and vibration?
Recent pacemaker placement, lung contusion, blood clotting, burns, wounds, osteoporosis, and chest wall pain.
19. When a patient is hooked up to an EKG, IV, or other devices, what should you do before administering CPT?
Notify the nurse and/or monitor technician.
20. What should be charted after completing CPT?
The position and time, sputum amount, tolerance, and any problems that occurred.
21. What are some adverse reactions that can occur during CPT?
Hypoxemia, increased ICP, acute hypotension, pulmonary hemorrhage, pain, vomiting, aspiration, bronchospasm, and arrhythmias.
22. What do you do if any adverse reactions occur?
Stop the treatment and put them back in the normal position; then notify the physician.
23. When is the best time to do CPT?
Before a meal or at least 1.5 to 2 hours after a meal.
24. What is the most common adverse reaction to the Trendelenburg position?
25. What are the advantages of mechanical percussion?
It’s easier for the respiratory therapist, it provides more consistent percussions, and most patients tolerate it better.
26. What are the disadvantages of mechanical percussion?
The devices are not always easy to find, and some patients don’t tolerate it as well.
27. How do you administer CPT on children or neonates?
Use only one hand or smaller cups, or use the flapper.
28. What is the most commonly affected lung segment when a patient aspirates?
The superior basal segment.
29. How do you know what location to provide CPT to?
X-rays, progress reports, and auscultation.
30. What are the signs of positive outcomes after administering CPT?
Mobilization of secretions, increased breath sounds, clearer chest x-ray, and increased oxygen saturation.
31. What are the appropriate frequency and pressure settings on the vest?
10 Hz is the most common.
32. What are the phases of autogenic drainage?
Unstick secretions, collect secretions, and evacuate secretions.
33. What can be used instead of CPT?
Insufflation/exsufflation device, flutter valve, and IPV (intrapulmonary percussive ventilation).
34. What is PEP therapy?
It stands for positive expiratory pressure and is similar to CPAP and EPAP. High-frequency oscillations are created as the patient exhales, and it helps to pop open alveoli while helping the patient cough up secretions.
35. What are the hazards and complications of PEP therapy?
Pulmonary barotrauma, increased ICP, air swallowing, vomiting, and aspiration.
36. What is the MetaNeb?
Also known as the percussionaire, it delivers continuous airway pressure and high mini bursts at rates of 100–225 cycles/minute.
37. What is the Trendelenburg position?
The head is lower than the feet (feet are raised 18 inches), and is used for drainage.
38. What is the primary reason for performing CPT?
To loosen secretions in the lungs.
39. What is an absolute contraindication of chest physiotherapy?
40. If you are draining a patient’s left lateral segment, should the patient be on their right or left side?
The patient should be on their right side (Remember: The patient is in the opposite position of the lung being drained).
41. Should the patient lie supine or prone to receive therapy to the superior segments?
42. Should the respiratory therapist coordinate therapy with the administration of pain medication?
Yes, respiratory therapists should not perform therapy on their patients who are in pain.
43. What should you do if a patient has had surgery or is experiencing pain in the area where you need to perform therapy?
You should modify the position so you can still administer the therapy the patient needs.
44. Is vibration performed on inspiration or expiration?
Vibration is performed on expiration.
45. How much mucus is considered copious for secretions?
More than 25–40 mL per day.
46. How do you know what position to put the patient in?
The physician’s order, progress notes, auscultation, and a chest x-ray can help determine the appropriate position.
47. When do you monitor a patient more aggressively while giving CPT?
If the patient has cardiac problems.
48. What does pursed-lip breathing do?
It creates back pressure, which helps to keep the alveoli open.
49. How does PEP therapy move secretions?
PEP therapy helps fill under aerated or non-aerated segments of the lungs through collateral ventilation and prevents airway collapse during expiration.
50. What is the difference between chest physical therapy and chest physiotherapy?
There is no difference; the two terms can be used interchangeably.
Chest physical therapy (CPT), which includes postural drainage, percussion, and vibration, is essential in the management of chronic respiratory conditions such as cystic fibrosis, COPD, and bronchiectasis.
Postural drainage uses gravity to mobilize and remove secretions from the airways to improve lung function and reduce the risk of infections.
Whether performed manually or with the help of mechanical devices, CPT remains an important component of comprehensive treatment plans for those with chronic respiratory conditions.
However, as with any medical procedure, it’s important to consider the risks and benefits, as there are contraindications and hazards associated with airway clearance therapy. Thanks for reading, and, as always, breathe easy, my friend.
John Landry is a registered respiratory therapist from Memphis, TN, and has a bachelor's degree in kinesiology. He enjoys using evidence-based research to help others breathe easier and live a healthier life.
- Clinical Manifestations and Assessment of Respiratory Disease. 8th ed., Mosby, 2019.
- Fink, James. “PubMed.” National Library of Medicine, July 2002, pubmed.ncbi.nlm.nih.gov/12088547.
- “POSTURAL DRAINAGE OF THE LUNGS.” PubMed Central (PMC), 8 Nov. 1934, www.ncbi.nlm.nih.gov/pmc/articles/PMC2445434.
- “Chest Physiotherapy.” PubMed Central (PMC), 4 Mar. 1989, www.ncbi.nlm.nih.gov/pmc/articles/PMC1835906.