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Priming the Pump
Monday May 12, 2008

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Chest physical therapy (CPT), also know as bronchopulmonary hygiene, is a common intervention for patients with airway diseases. Conventional CPT, which consists of forced expirations (directed cough or huff), postural drainage, percussion, and shaking, facilitates secretion transport and thus decreases retention of secretions in the airways. Physical therapists, as well as respiratory therapists and nurses, should be trained in these techniques.

“Patients with pneumonias and chronic lung conditions, including chronic obstructive pulmonary disease with bronchitis or emphysema, bronchiectasis, and cystic fibrosis, benefit from this type of therapy,” explains Konrad J. Dias, PT, DPT, CCS, assistant professor of the physical therapy program at Maryville University of St. Louis.

Secretions in the patient’s lungs and airways can build up after prolonged bed rest due to illness or injury, or with thoracic pain after surgery. “It is painful to take breaths or cough, so the secretions we naturally produce don’t move; instead, they build up and can lead to other problems, like pneumonia,” explains Tamara Gravano, PT, DPT, GCS, senior physical therapist, CCCE, and residency program coordinator at St. Catherine’s Rehab Hospital and Villa Maria Nursing Center in North Miami, Fla.

Rusty skills

But some PTs are no longer performing this useful therapy. “I have noticed that in physical therapy, we have really stepped away from doing bronchopulmonary hygiene in most of the country, other than the Northeast and in some major hospitals,” says Dias, who conducts continuing education courses across the country.

“I think the reason this is happening is because physicians believe respiratory therapists are supposed to do this. As a team, PTs, respiratory therapists, and nurses should all be doing these techniques,” Dias says.

Julie Ronnebaum, MSPT, instructor in the DPT program at Des Moines University in Iowa, explains that it often depends on the region of the country and the particular facility as to which specialist does which techniques. “For example, in our region, respiratory therapy does the formal chest percussion and vibration. As far as PTs, we should always be performing postural drainage and positioning,” she says.

One of the biggest benefits of PTs performing CPT is to promote an increase in patients’ aerobic capacity and endurance. “If when I evaluate the patient I find out that the patient is unable to ambulate 100 feet, I listen to the lungs and I find that they really need to be cleaned. I know I need to improve the patient’s ability to clear his or her airway,” Dias says.

Going with the flow

“Chest percussion [mechanical or manual] is a commonly used technique. It consists of ‘clapping’ cupped hands over the affected lung segments,” Gravano says, who notes that it sounds like a horse slowly trotting, at about 100 to 300 bpm. “This is easy to learn and to train caregivers to perform.”

Vibration can be performed mechanically or manually by placing the palms of the hands on the affected segments and gently vibrating the body from the end of inspiration though the end of expiration. “It is useful in patients where chest percussion is too painful,” she says.

“Postural drainage is when specific body positioning is used to move secretions from the lung segments. PTs can use pillows or hospital bed positions to aid positioning. It is maintained for 5 to 10 minutes, if able, and then you move to the next segment,” Gravano explains. In addition, postural drainage can be combined with other techniques, including vibration and percussion.

She points out that for directed cough (also called huff), the patient must take a larger than normal breath, close the glottis, contract the trunk muscles, and then forcefully open the glottis and push air, and any loose secretions, out of the lungs.

Benefits of directed cough are that it is easy to perform, no equipment is necessary, it is easy to train patients to do independently, and it requires less energy than percussion or vibration. “The typical treatment progression for directed cough is lower lobes to upper lobes, usually, or most affected to least affected segments, until secretions are gone, goals are met, or patient/caregiver can perform independently,” Gravano says.

A recent study from the Netherlands concluded that directed cough is the most effective and important part of conventional CPT, but not all experts agree. Dias notes that postural drainage, percussions, vibrations, and rib springing all can be very effective. He says that devices such as the Vest® airway clearance system, the Flutter® mucous clearance device, and the Acapella™ device also can aid with percussions. “These are good devices that can be used if a patient is [in] need of frequent [every two or three hours] bouts of chest PT,” he says, adding that a therapist can utilize manual techniques in addition to the devices to help benefit the patient.

“The good part of chest physical therapy is that the results are instantaneous,” Dias notes. Directly following the techniques, the patient coughs, the airway is cleared, and the patient is able to participate better with rehab, he explains.

Practice makes perfect

Caregivers can use CPT to improve patient quality of life. The ultimate goal of caregiver training is to provide the knowledge and skills to perform techniques using the appropriate equipment in a safe way, Ronnebaum explains.

This requires meeting with the family and the patient to go over proper techniques, standard precautions, and contraindications. “In some facilities, it can take an hour a day for one to two weeks, and for others, it may be an hour a day for a couple of days,” she says. This training may include getting the family set up with the proper vendor for any needed equipment. “If the patient is on a ventilator, they will need to have a home assessment done, as well as a line up of additional caregivers in case they can’t be with the patient 24 hours a day,” Ronnebaum adds.

“The most important part of any caregiver training is to have them demonstrate to you exactly what they will do once they are with the patient. You need to see their skills at performing the technique so you can give them feedback,” Gravano says.

Handouts with pictures of positions and written instructions are important. “These are given in case they need it, or they need to train other caregivers. Rarely do you get to train the 24-hour exclusive caregiver; most work in shifts because everyone needs a break,” Gravano says.

Resource

• van der Schans, C. P. 2007. Conventional chest physical therapy for obstructive lung disease. Respir Care 52(9): 1,198-206.



Lisa B. Samalonis is a medical writer for the Gannett Healthcare Group. To comment on this story, send e-mail to pteditor@gannetthg.com.


Monday May 12, 2008
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