Postural Drainage Positions and Chest Physiotherapy (CPT) Study Guide

Chest Physiotherapy and Postural Drainage are two common types of Airway Clearance Therapy that are performed by Respiratory Therapists. We’re going to break down the concepts of each here in this study guide, including the Postural Drainage Positions.

So if you’re ready, let’s go ahead and dive right in.

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What is Airway Clearance Therapy?

Airway Clearance Therapy uses noninvasive techniques to help mobilize and remove secretions in order to improve gas exchange.

There are several that fall into this type of therapy but this guide is specifically focused on Postural Drainage and Chest Physiotherapy.

What is Chest Physiotherapy?

It is a form of Airway Clearance Therapy that is generally performed by a Respiratory Therapist with the goal of clearing mucus from the airways and lungs. It involves striking the lungs manually with your hands, with a cuff, or with an automatic percussor.

The rhythmic strikes and vibrations help loosen secretions from the airways. Then you can help propel them forward by placing the patient in various postural drainage positions using gravity.

Chest Physiotherapy Cup

This CPT cup is used to help remove sputum. Please check with your doctor before use.

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What is Postural Drainage?

It is a form of Airway Clearance Therapy that involves placing the patient’s body in various positions in order to drain secretions from the lung segments into the central airways using gravity. From there, the secretions can be removed via cough or suctioning.

Postural Drainage Positions:

The following tables break down every Postural Drainage Position that is needed in order to drain each specific lobe or segment of the lungs.

Upper Lobes
Posterior Segment	Patient leans forward 30 degrees over the back of a chair (or in bed). Vibration and percussion can be performed over the upper portion of the back on either side, if ordered.
Apical Segment	Patient leans backward 30 degrees. Vibration and percussion can be performed between the clavicle and the top of the scapula on either side, if ordered.
Anterior Segment	Patient lies supine with a pillow under the knees, which enables the abdominal muscles to relax and makes breathing easier. Vibration and percussion can be performed between the clavicle and nipple of a male patient on either side, if ordered. It may not be possible in a female patient.

Right Middle and Left Lingual

Right Lateral and Medial Segments

Same position is used to drain both lobes.
Patient lies one-fourth turn up from the back-down position and a pillow may be placed between flexed knees.
The foot of the bed is elevated 15 degrees (14 inches).
Vibration and percussion can be performed below the right nipple area in a male patient, if ordered. It may not be possible in a female patient.

Left Superior and Inferior Lingual Segments

Same position is used to drain both lobes.
Patient lies one-fourth turn up from the back-down position and a pillow may be placed between flexed knees.
The foot of the bed is elevated 15 degrees (14 inches).
Vibration and percussion can be performed below the left nipple area in a male patient, if ordered. It may not be possible in a female patient.

Lower Lobes
Posterior Basal Segment	Patient lies face down on the bed with the pillow between hips. The foot of the bed is elevated 30 degrees (18 inches). Vibration and percussion can be performed over the appropriate lobe, if ordered.
Lateral Basal Segment	Patient lies one-fourth turn up from the face-down position on the opposite side of that which is needed to be drained. The foot of the bed is elevated 30 degrees (18 inches). Vibration and percussion can be performed over the posterolateral areas of the lower ribs, if ordered.
Anterior Basal Segment	Patient lies straight up on their opposite side of that which is needed to be drained. The foot of the bed is elevated 30 degrees (18 inches). Vibration and percussion can be performed over the lower ribs below the axilla, if ordered.
Superior Segment	Patient lies face down on the bed with a pillow beneath the hips. The bed is in the flat position. Vibration and percussion can be performed in the middle of the back below the scapula on whichever side is needed, if ordered.

Postural Drainage Positions Image:

Hopefully you can use this illustration to help make learning the Postural Drainage Positions much easier.

Postural Drainage Indications:

Postural Drainage should only be recommended for certain patients under certain conditions. Here are some examples:

To mobilize retained secretions so that they can be suctioned or expectorated
Cystic Fibrosis
Atelectasis
Bronchiectasis
Foreign body obstruction

Postural Drainage Contraindications:

There are certain situations in which Postural Drainage would not be recommended. Here are some examples:

Head, neck, or spinal injury
Hemodynamic instability
Increased intracranial pressure
Hemoptysis
Bronchopleural fistula
Pulmonary edema as a result of CHF
Pleural effusion
Flail Chest

Is Postural Drainage Used to Treat Cystic Fibrosis?

Yes, Postural Drainage is an effective method that is used to treat patients with Cystic Fibrosis.

With that said, other forms of Airway Clearance Therapy can be used as well and no one method has been proven to be more effective than others. It all depends on the patient’s preference. In general, you should select the method that will be most tolerated by the patient.

What is the Chest Physiotherapy Vest?

Using “The Vest” is also a common type of Airway Clearance Therapy for Cystic Fibrosis patients. It involves the use of an inflatable vest that produces vibrations at a very fast frequency which helps to loosen up secretions in the airways of the lungs.

After wearing the vest for a period of time, usually 5 minutes, the therapy is paused so that the patient can attempt to cough and remove mucus from the lungs.

High-Frequency Chest Wall Compression HFCW Cystic Fibrosis

Chest Physiotherapy Indications:

Chest Physiotherapy should only be recommended for certain patients under certain conditions. Here are some examples:

To mobilize retained secretions so that they can be suctioned or expectorated
Cystic Fibrosis
Atelectasis
Bronchiectasis
Foreign body obstruction
Lung abscess
Neuromuscular diseases

Chest Physiotherapy Contraindications:

There are certain situations in which Chest Physiotherapy would not be recommended. Here are some examples:

Head, neck, or spinal injury
Hemodynamic instability
Increased intracranial pressure
Hemoptysis
Rib fractures or flail chest
Vertebral fractures
Osteoporosis

More Practice Questions About Chest Physiotherapy and Postural Drainage:

1. What are the goals of CPT?
To prevent the accumulation of secretions, to improve the mobilization of secretions, to regain the most efficient breathing pattern, to improve the distribution of ventilation, and to improve the 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 a 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 is the volume of sputum produced per day that indicates the need for CPT?
More than 25–30 mL per day.

6. What is Postural drainage?
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 retaining 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 – Cupping over the lung segment. Have the patient do purse lip breathing. Vibration – is done after percussion and you should vibrate towards the carina. Be sure to have the patient inhale and then perform the vibration while they are exhaling.

10. When should vibration be performed?
When the patient exhales.

11. What are 4 chronic conditions that may cause copious secretions?
Cystic Fibrosis, atelectasis, bronchitis, and aspiration pneumonia.

12. What is the position for the anterior upper segment (upper lobes)?
Sitting up slightly with a pillow under the legs.

13. What is the position for the anterior segments?
Lying supine with a pillow under the legs.

14 What is the position for 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 position for the posterior segments (lower lobes)?
Legs raised about 18 inches (30 degrees) (Trendelenburg). Prone with a pillow under the stomach.

16. What is the position for the superior segments (middle)?
Prone with a pillow under the stomach.

17. What are the contraindications for postural drainage?
An unstabilized 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.

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19. When you have a patient is hooked up to an EKG, IV, or other device, what do 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 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 meals or at least 1.5 to 2 hours after meals.

24. What is the most common adverse reaction to the Trendelenburg position?
Hypertension.

25. What are the advantages of mechanical percussors?
They are easier on the respiratory therapist, more consistent percussion, and most patients tolerate them better.

26. What are the disadvantages of mechanical percussors?
The are not always easy to find, and some patients don’t tolerate them 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 in aspiration?
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 is the appropriate frequency and pressure settings on the vest?
10 Hz is 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. Helps to pop open the alveoli and helps 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?
It is also known as the percussionaire. It delivers both continuous airway pressure and high mini bursts. It delivers bursts of gas 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). It is used for drainage.

38. How long after a patient has had a meal is it okay to perform CPT?
Wait at least 1 Hour.

39. What is the primary reason for performing CPT?
To loosen secretions in the lungs.

40. How long is a patient generally left in a position?
3-5 minutes.

41. What type of patients is CPT most effective with?
Patients with copious secretions.

42. Is it necessary to drain parts of the lungs that do not have secretions?
No, no it is not.

43. What is an absolute contraindication of chest physiotherapy?
Untreated pneumothorax.

44. If you are draining a patient’s left lateral segment, should the patient be on their right or left side?
Right side. Remember, as we discussed in the chart above, it’s the opposite.

45. Is the patient lying supine or prone when giving therapy to the superior segments?
Prone.

46. Which of the following is the major indication for CPT?
Copious secretions.

47. Should the respiratory therapist coordinate therapy with administering pain medication?
Yes, respiratory therapists should not perform therapy on their patients if they are in pain.

48. What should you do if a patient has had surgery or bad pains where you need to perform therapy?
You should modify the position needed for the therapy so you are still able to give them the therapy that they need.

49. What should CPT include?
Postural drainage, chest percussion, and chest vibration.

50. Is vibration performed on inspiration or expiration?
Expiration.

51. How much mucus is considered copious for secretions?
More than 25–40 mL per day.

52. What are the diseases that cause copious secretions?
Cystic Fibrosis, atelectasis, bronchitis, aspiration, and pneumonia.

53. How do you know what position to put the patient is?
The physician’s order, progress notes, auscultation, and x-ray.

54. When do you monitor a patient more aggressively while giving CPT?
If the patient has cardiac problems.

55. How many minutes do you apply CPT?
3-5 minutes for each position.

56. What does pursed-lip breathing do?
It creates back pressure and therefore the alveoli opens up.

57. Where is the purpose of Chest Physiotherapy?
To help loosen up secretions in the airways and lungs so that they can be removed via cough or suctioning.

58. How does PEP therapy move secretions?
It fills under aerated or non-aerated segments through collateral ventilation and prevents airway collapse during expiration.

59. Which lobes is the apical segments located?
The upper lobes.

60. Where is the posterior basal segment located?
The lower lobes.

Final Thoughts

So there you have it. That wraps up our study guide on Chest Physiotherapy and Postural Drainage. Hopefully this information has been helpful for you and made the learning process easier.

It can be difficult to master all the different Postural Drainage Positions but with enough repetitions, I’m confident that you can do it. Thank you so much for reading and as always, breathe easy my friend.