Postural Drainage

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Role of physiotherapy Before ,during and after postural drainage

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Presentation Transcript

Postural drainage : 

Postural drainage Dr.K.V.Haribabu Assistant Professor Physiotherapy Department M.Y.Govt Hospital & M.G.Medical college Indore,M.P

Postural Drainage (Bronchial Hygiene Therapy) : 

Postural Drainage (Bronchial Hygiene Therapy) It consist of positioning the patient to allow gravity to assist the drainage of secretions from specific areas of the lungs

General considerations : 

General considerations Aerosol therapy with humidification prior to PD Aerosol therapy after PD Time of treatment Worst area should be drained first On average 15-20 mins is spend in each position

Slide 4: 

Segments receiving drainage should be uppermost PD is less effective without cuff or huff In certain condition positions are modified Should never be carried out immediately before or after meal Treat the lower lobe segments first and upper lobe last

Slide 5: 

Check the patients vital signs… Breath sounds should be evaluated Stand in front of patient If patient does not cough during positioning with percussion instruct to take deep breathing and vibrate during expiration

Thinks to remember.. : 

Thinks to remember.. Before postural drainage During postural drainage After postural drainage

Before postural drainage : 

Before postural drainage Instructions to the patient About the treatment Explain the breathing pattern Co operation during treatment Other instruction Identification of segments to be treated

Cont.. : 

Cont.. Bronchodilator Indication and contraindications Absolute contraindications Relative contraindications Relaxed Diaphragmatic breathing Teaching the patient Huffing and Cuffing

Different segments of right and left lobes : 

Different segments of right and left lobes

Upper lobe-apical segments (bilateral) : 

Upper lobe-apical segments (bilateral) Half lying

Upper lobe-posterior segment-rightleft side lying 45 degree turn towards face side : 

Upper lobe-posterior segment-rightleft side lying 45 degree turn towards face side

Upper lobe-posterior segment-Left : 

Upper lobe-posterior segment-Left Right side lying45 degree turn towards face side Three pillow

Upper lobe-Anterior segments-Bilateral Supine lying : 

Upper lobe-Anterior segments-Bilateral Supine lying

Middle lobe –lateral and medial segments right From supine 45 degree turn towards leftpillow from shoulder to hipfoot end raised 14” : 

Middle lobe –lateral and medial segments right From supine 45 degree turn towards leftpillow from shoulder to hipfoot end raised 14” 14”

Left Lingula –superior and inferior segmentsFrom supine 45 degree turn towards rightpillow from shoulder to hipfoot end raised 14” : 

Left Lingula –superior and inferior segmentsFrom supine 45 degree turn towards rightpillow from shoulder to hipfoot end raised 14” 14”

Lower lobe-apical segments(bilateral)Prone lying pillow under hip : 

Lower lobe-apical segments(bilateral)Prone lying pillow under hip

Lower lobe-anterior basal segments(bilateral)supine lying pillow under hipfoot end elevated to 18” : 

Lower lobe-anterior basal segments(bilateral)supine lying pillow under hipfoot end elevated to 18” 18”

Lower lobe-posterior basal segments(bilateral)prone lying pillow under hip foot end elevated 18 inches : 

Lower lobe-posterior basal segments(bilateral)prone lying pillow under hip foot end elevated 18 inches 18”

Lower lobe- Medial basal of right& lateral basal of leftRight Side lying pillow under hipfoot end elevated 18” : 

Lower lobe- Medial basal of right& lateral basal of leftRight Side lying pillow under hipfoot end elevated 18” 18”

Lower lobe-lateral basal segment-rightLeft side lying pillow : 

Lower lobe-lateral basal segment-rightLeft side lying pillow 18”

Modified PD Position : 

Modified PD Position

PD for upper lobes in child : 

PD for upper lobes in child

During postural drainage : 

During postural drainage Chest manipulations like (Vibration, clapping, shaking )-Tappotment massage are performed in postural drainage position Should be done in order Vibrations and clapping first Shaking next

vibrations : 

vibrations Palmar aspect of the hand are in full contact with patients chest wall or one hand may be partially or fully overlapping the other At the end of deep inspiration therapist exerts pressure on the patients chest wall and gently oscillates it through the end of expiration

Cont.. : 

Cont.. Vibration frequency should be 12-20 Hz Vibration is alternative for percussion in ill patients with chest wall discomfort or pain It causes some volume of air to be expired greater than tidal breathing and encourage deeper than tidal inspiration

Percussion (clapping) : 

Percussion (clapping) Can be performed manually or with mechanical device Consist of rhythmical clapping with cupped hands over affected area Thin clothing should be placed over the area to be treated Principal –compression and rarefaction

Cont.. : 

Cont.. Electrically (or) pneumatically powered percussion devices Rhythm is between 100-480 times /sec Amount of force should be adjusted to promote patient comfort Bony prominence and surgical incisions should be avoided

Precautions(for clapping) : 

Precautions(for clapping) Uncontrolled Broncho spasm Osteoporosis Rib fracture Tumor obstructions of airway

Relative contraindications(for clapping) : 

Relative contraindications(for clapping) Hemoptysis Untreated tension pneumothrax Open wounds and burns Low platelets Recent skin grafts or flaps on thorax

Shaking : 

Shaking Should be performed only during expiratory phase Anterior and posterior chest wall is grasped and shaked towards main bronchus Should be combined with relaxed breathing to prevent airway closure and bronchospasm

After postural drainage : 

After postural drainage Active or passive removal of the secretions from main bronchus Active by cuffing or by huffing Passive by suctioning apparatus

Phases of cough : 

Phases of cough

Techniques to improve cuff : 

Techniques to improve cuff Positioning for cough Forced expiration stimulates cough Pressure over extra thoracic trachea (supra sternal notch) elicit reflex cuff

Cont.. : 

Cont.. Nuero muscular facilitation –intermittent application of ice over paraspinal muscle 3-5 sec of thoracic spine Reflex cuff are stronger than voluntarily produced

Cont.. : 

Cont.. Therapist should determine the phase or phases of cuffing are reducing its effectiveness ,when inspiration is too shallow, deep breathing or lateral costal expansion exercise is taught to patient

Suctioning : 

Suctioning Before and after postural drainage if patient cant cough

Active cycle of breathing : 

Active cycle of breathing It consist of a cycle of huff from mid to low lung volume with deep breathing and relaxed abdominal breathing

Mechanism : 

Mechanism During huffing or forced expiration the pleural pressure becomes positive and equals the alveolar pressure at a point along the airway called Equal pressure Point(EPP)

Slide 39: 

Towards the mouth from this point the transmural pressure gradient is reversed so that pressure outside the airway is higher than inside thus squeezing the air way by the process called Dynamic compression Squeezing of airways mouthwards from this point mobilizes secretions

Cont.. : 

Cont.. At high lung volume the EPP is more proximal because pleural pressure decreases and alveolar elastic recoil increases

Location of EPP : 

Location of EPP Forced expiratory maneuver (huff or cuff)at low lung volume mobilizes secretions from alveoli Forced expiratory maneuver at mid lung volume mobilizes secretion from lobar and segmental bronchi Forced expiratory maneuver at high lung volume mobilizes secretions from larger airways ( trachea and main bronchi)

FEM in Low lung volume : 

FEM in Low lung volume EPP ++ + + Alveoli Upper respiratory way + + + + +

FEM in Mid lung volume : 

FEM in Mid lung volume EPP Alveoli + + + + + + + + + Upper respiratory way

FEM in High lung volume : 

FEM in High lung volume + + + + + + + + + EPP Alveoli Upper respiratory way

Mechanical Percussors : 

Mechanical Percussors

Slide 46: 

Theory: Shock waves transmit through chest loosening secretions in the airways—often dependant on positioning to drain mucus into upper airways Technique: Patient is positioned for optimal drainage of lobe to be percussed with each area being treated for 2-5 minutes

Positive Expiratory Pressure : 

Positive Expiratory Pressure

Slide 49: 

Theory: Prolonged exhalation with positive pressure stabilizes smaller airways open allowing inhaled air to pass and then on exhalation move secretions into larger airways Technique: Patient exhales through flow restrictor via mask or mouth piece and then performs “huff” cough—typical treatment last about 15-20 minutes

Flutter Valve : 

Flutter Valve

Flutter Valve Therapy : 

Flutter Valve Therapy

Flutter Valve Therapy : 

Flutter Valve Therapy Vibrations applied to the airway facilitate the loosening of secretions The increase in bronchial pressure helps avoid air trapping Expiratory air flows are accelerated and facilitate the upward movement of mucus

Slide 53: 

Theory: Intermittent positive pressure breaths with airway oscillation vibrates the airway walls and loosens secretions—accelerated expiratory flow rates move secretions to larger airways Technique: Patient exhales through the device causing the steel ball to oscillate rapidly for 5-6 breaths than coughs and repeats for a minimum of 15 minutes—the position/angle of the device determines intensity of vibration

Concluding treatment : 

Concluding treatment Watch for signs of postural hypotension If cough is not productive after treatment it may be productive after some time Auscultate (over the segments that were drained) Observe the breathing pattern Check symmetry of the chest wall expansion

Discontinue PD : 

Discontinue PD If chest X-Rays are relatively clear If near normal breath sounds are heard with auscultation If patient is on regular home program

How do we know that this worked? : 

How do we know that this worked? Increased sputum production Improved breath sounds Improved chest x-ray Improved arterial blood gases Improved oxygenation Patient subjective response

Slide 57: 

THANK YOU

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