Pulmonary- Manual Secretion Removal Techniques

Question 1

What is postural drainage

Answer 1

placing pt. in varying positions for optimal gravity drainage of secretions and increased expansion of the involved segment

Question 2

indications for postural drainage

Answer 2

• increased pulmonary secretions
• aspiration
• atelectasis or collapse

Question 3

Basic procedure for postural drainage

Answer 3

• explain procedure to pt.
• place pt. in appropriate postural drainage position
• observe for signs of intolerance
• duration can be up to 20 min per position

Question 4

What is percussion

Answer 4

• a force rhythmically applied w/ PT’s cupped hands to a specific area of the chest wall that corresponds to the involved lung segment
• used to increase the amount of secretions cleared from the tracheobronchial tree
• used in conjunction w/ postural drainage

Question 5

Indications for use of percussion and shaking (vibration)

Answer 5

• excessive pulmonary secretions
• aspiration
• atelectasis or collapse due to mucous plugging obstructing the airways

Question 6

Considerations before using percussion or shaking: general guidelines

Answer 6

pain made worse by using technique

Question 7

Considerations before using percussion or shaking: circulatory system

Answer 7

• aneurysm precautions

- hemoptysis

Question 8

Considerations before using percussion or shaking: MSK

Answer 8

• fractured rib
• flail chest
• degenerative bone disease
• bone metastases

Question 9

Considerations before using percussion or shaking: coagulation disorders

Answer 9

• increased PTT
• increased pro-thrombin time (PT)
• decreased platelet count (<50,000)
• meds interfering w/ coagulation

Question 10

Considerations prior to using postural drainage in Trendelenburg position: circulatory system

Answer 10

• PE
• CHF
• HTN

Question 11

Considerations prior to using postural drainage in Trendelenburg position: abdominal problems

Answer 11

• obesity
• ascites
• pregnancy
• hiatal hernia
• nasea and vomitting
• recent food consumption

Question 12

Considerations prior to using postural drainage in Trendelenburg position: neurologic

Answer 12

• recent neurosurgery
• increased intracranial pressure
• aneurysm precautions

Question 13

Considerations prior to using postural drainage in Trendelenburg position: pulmonary

Answer 13

SOB

Question 14

Procedure for percussion

Answer 14

• explain procedure to pt.
• place pt. in appropriate postural drainage position
• cover area to be percussed with light weight cloth to prevent erythema
• Percuss. duration depends on needs and pt. tolerance. 3-5 min of percussion per postural drainage position w/ clinically assessed improvement is a guideline
• force of percussion causes the pt.’s voice to quiver

Question 15

What is shaking aka vibration

Answer 15

• following a deep inhalation, a bouncing maneuver is applied to the rib cage throughout exhalation
• used to hasten the removal of secretions from the tracheo-bronchial tree
• commonly used following percussion in appropriate postural drainage position
• modification may be required depending on pt. tolerance

Question 16

Procedure for shaking

Answer 16

• explain procedure to pt.
• place pt. in appropriate postural position
• perform percussion first if appropriate
• as pt. inhales deeply, PT’s hands are placed w/ fingers parallel to ribs
• as pt. exhales, PT hands provide a jarring bouncing motion to the rib cage below
• duration depends on pt. needs and tolerance and clinical improvement. 5-10 deep inhalations with shaking technique is generally acceptable practice
• ***more than 10 would risk hyperventilation and less than 5 would be ineffective

Question 17

List of airway clearance techniques

Answer 17

• cough
• huffing
• assisted cough
• tracheal stimulation
• endotrachial suctioning

Question 18

Huffing

Answer 18

• more effective in pt. w/ collapsible airways (chronic obstructive diseases)
• prevents high intrathoracic pressure that causes premature airway closure

Question 19

Procedure for assisted cough

Answer 19

• position pt. against solid surface (trendelnburg, reclined supine, sitting, ect..)
• PT’s hand is is placed below pt.’s subcostal angle
• pt. inhales deeply
• as pt. attempts to cough, Pt’s hands push inward and upward assisting rapid exhalation of air
• any secretions raised should be removed

Question 20

type of pt. assisted cough is intended for

Answer 20

anyone w/ weak abdominal muscle that are unable to generate an effective cough, such as SCI pt.

Question 21

What is tracheal stimulation

Answer 21

• used w/ pts. who are unable to cough on command such as infants, TBI, CVA
• Procedure: PT’s thumb or finger is placed just above the suprasternal notch, and a quick inward and downward pressure on the trachea elicits the cough reflex

Question 22

when to use endotrachial suctioning

Answer 22

only when other less invasive techniques fail to adequately remove secretions.

Question 23

Complications with endotrachial suctioning

Answer 23

• hypoxemia
• bradycardia or tachycardia
• hypotension or hypertension
• increased intracranial pressure
• atelectasis
• tracheal damage
• infections

Question 24

Positions for postural drainage: Upper Lobes- Apical segments

Answer 24

• bed or drainage table is flat
• pt. leans back (basically in sitting position) on pillow at 30 degree angle against PT
• PT claps w/ markedly cupped hands over area between clavicle and top of scapula on each side

Question 25

Positions for postural drainage: Upper Lobes- Posterior Segments

Answer 25

- bed or drainage table is flat - pt. leans over (pt. in seated position) folded pillow at 30 degree angle - PT stands behind and claps over upper back on both sides

Question 26

Positions for postural drainage: Upper Lobes- Anterior Segments

Answer 26

- bed or drainage table is flat - pt. supine w/ pillow under knees - PT claps between clavicle and nipple on each side

Question 27

Positions for postural drainage: R Middle lobe

Answer 27

- foot of table or bed elevated 12 inches - pt. lies supine and rotates 1/4 turn backward on L side (sort of between side lying and supine) - pillow may be placed behind shoulder to hip and knees flexed - PT claps over R nipple area. - In females, PT may use cupped hand w/ heel of hand under armpit and fingers extending forward under breast

Question 28

Positions for postural drainage: L Upper Lobe (lingular segments)

Answer 28

- foot of table or bed elevated 12 inches - pt. lies supine on R side and rotates 1/4 turn (sort of between side lying and supine) - pillow may be placed behind shoulder to hip and knees flexed - PT claps over L nipple area. - In females, PT may use cupped hand w/ heel of hand under armpit and fingers extending forward under breast

Question 29

Positions for postural drainage: Lower Lobe- Anterior Basal Segments

Answer 29

- foot of table or bed elevated 18 inches - pt. lies on R side w/ pillow under knees - PT claps over over L lower ribs. - To drain R anterior basal segments, pt. is L sidelying and clap over R lower ribs

Question 30

Positions for postural drainage: Lower Lobes- Lateral Basal segments

Answer 30

- foot of table or bed elevated 18 inches - pt. prone, then rotates 1/4 turn upward (sort of L sidelying-ish) - upper leg is flexed over pillow for support - Pt claps over upper most portion of lower ribs - if draining L side, position pt. into the R side-lying-ish position

Question 31

Positions for postural drainage: Lower Lobes- Posterior Basal segments

Answer 31

- foot of table or bed elevated 18 inches - pt. prone w/ pillow under hips - PT claps over lower ribs close to spine on each side

Question 32

Positions for postural drainage: Lower Lobes- Superior segments

Answer 32

- bed or drainage table is flat - pt. prone w/ 2 pillows under hips - PT claps over middle of back at tip of scapula on each side of the spine