Activities to increase pulmonary function in the absence of disease

• Pacing
  • Rationale: breathing technique used to spread the metabolic demands of an activity to improve performance
    • Example: An individual running on a treadmill attempting not to become short of breath with the activity
  • How to perform:
    • Break the activity into manageable components
    • Inhale at rest or at concentric activation
    • Exhale through pursed lips (to slow breathing) during eccentric activation
    • Repeat until the activity is complete
• Energy conservation
  • Rationale: strategic planning of normal activities during the day to allow for decreased fatigue and improve pulmonary function. This can be used with those in the presence of a pulmonary disorder and those without.
  • How to perform:
    • Recognize activities that are performed with ease and those with increased difficulty
    • Organize the day from easy to hard to allow for the completion of all activities

Breathing exercises for pulmonary function

Breathing exercises assist with improving ventilation through the facilitation of the muscles of respiration.

• Diaphragmatic breathing
  • Rationale for use: increased ventilation, decreased work of breathing, and increased relaxation
  • Patient population: individuals with restrictive or obstructive lung disease, postoperative patients
  • How to perform:
    • Position the patient in semi-Fowler’s position
    • Place a hand on the subcostal angle of the thorax
    • Apply pressure with the hand during exhalation
    • Increased pressure with the hand at the end of inhalation
    • Each cycle increased pressure with the hand to allow for firm resistance, specifically during inhalation
    • Can be progressed to be performed in sitting upright and standing
• Segmental breathing
  • Rationale: increased ventilation to a segment of hyperventilated lung, maintain or improve functional residual capacity, or prevent pulmonary compromise
  • Patient population: individuals with immobility of part of the thorax, such as from rib fractures, thorax incisions, or partial lung removal
  • How to perform:
    • Position the individual to provide access to the lung segment, such as postural drainage positions (see later in this chapter)
    • Apply pressure with the hand over the thorax at the identified segment during exhalation
    • Increase pressure during inhalation
    • Allow for full pressure to be applied to allow for full inhalation
• Pursed lip breathing
  • Rationale: provide pressure support to allow for bronchioles to remain dilated during exhalation, decrease respiratory rate, and improve gas exchange for those with COPD
  • Patient population: primarily used with individuals with obstructive lung disease
  • How to perform:
    • Inhale through the nose
    • Exhale slowly through pursed lips

Airway clearance techniques

The goal of airway clearance techniques is to remove secretions from the pulmonary system to allow for adequate oxygenation. Can be performed independently or with assistance.

• Cough
  • Rationale: remove secretions from all the major and central airways
    • Performed independently by the patient
• Assisted cough
  • Rationale: used when the patient’s abdominal muscles can not generate sufficient pressure to aid in effective cough
  • How to perform:
    • Individual positioned supine or semi-fowler with hand placement at the subcostal angle
    • Individual inhales
    • During exhalation, the hand is forcefully pushed up and in to aid in rapid exhalation, thus causing a cough
• Huffing
  • Rationale: effective to provide support for individuals with collapsed airways
  • How to perform:
    • The individual inhales deeply
    • Upon exhalation, the individual then says “ha ha” to allow the airways to remain open and remove secretions
• Endotracheal suctioning
  • Rationale: typically utilized when a patient is unable to perform an independent cough, an assisted cough, or huffing to provide airway clearance. Likely to perform when the patient is on mechanical ventilation
  • How to perform: A suctioning catheter is used to remove secretions either through an artificial airway, oral airway, or nares for 10-15 seconds

Independent secretion removal techniques

The goal of independent secretion removal techniques is to remove secretions from the pulmonary system for those diagnosed with chronic pulmonary diseases. These techniques are all performed independently by the patient.

• Active cycle of breathing technique
  • Rationale: removal of peripheral sections for those in which a combination of techniques must be utilized to remove secretions
  • Patient population: Obstructive lung disease
  • How to perform:
    • An individual performs diaphragmatic breathing
    • Followed by thoracic expansion exercises
    • Lastly, forced expiration with a series of huffing
    • Repeat cycle until the airway is clear
• Autogenic drainage
  • Rationale: used to remove peripheral secretions by controlling the rate, depth, and location of respiration due to increased irritability from coughing
  • How to perform:
    • Unstick phase: quiet breathing with a 2-3 second hold at the end of inhalation, moving into a deep expiration to allow for mucus to loosen and move into the airway. Breathing is occurring with a small flow of air (low vital capacity)
    • Collect phase: performance of increasing respiratory reserve volume (deep breath in) until secretions move to the central airways and are ready to be expelled. Breathing is occurring at a mid-high amount of air flow (mid-high vital capacity)
    • Evacuation phase: performance cycles between normal inspiration and deep inspiration (respiratory reserve volume) until secretions move into the central airways. Breathing is occurring at a mid-high amount of air flow (mid-high vital capacity). No coughing occurs during this phase.
    • Repeat these cycles until all secretions are removed
• Flutter or an a acapella device
  • Rationale: used to provide intermittent positive airway support to allow for adequate secretion clearance
  • How to perform:
    • Inhale through the nose or around the device
    • Exhale through the device
    • Perform huffing or coughing as appropriate
    • Repeat until all secretions are removed
• Low-pressure positive expiratory pressure mask
  • Rationale: prevent lung collapse by providing a low amount of pressure to allow for adequate secretion removal in diagnoses of COPD, cystic fibrosis, or bronchiectasis
  • How to perform:
    • Seated or supine, a mask is placed over the face with inspiration hold for 2-3 seconds before expiration (~10 breaths)
    • Remove the mask for coughing or huffing
    • Repeat until all secretions are removed
• High-pressure positive expiratory pressure mask
  • Rationale: prevent lung airway collapse by providing a high amount of pressure to allow for adequate secretion removal in diagnoses of acute respiratory failure, pulmonary edema, or pneumonia
  • How to perform:
    • Seated or supine with normal breathing performed with a mask in place (~10 breaths)
    • Huffing is performed with a mask in place
    • Repeat until all secretions are removed

Manual secretions removal techniques

The goal of manual secretion removal techniques is to remove secretions from the pulmonary system for those diagnosed with acute pulmonary disease, from mucus plugs, respiratory failure, and on mechanical ventilation, weakness of the respiratory system without neurological origin, or acute exacerbations of cystic fibrosis.

• Postural bronchial drainage
  • Rationale: provides removal of secretions by positioning the lung (i.e., lung segments) to be assisted by gravity to remove secretions
  • How to perform:
    • Specific to the lung segment

• Shaking (vibration)
  • Rationale: used in conjunction with postural drainage positions to aid in the removal of secretions from the tracheobronchial tree
  • How to perform:
    • Place in appropriate postural drainage position
    • The individual inhales, and the therapist’s hands are placed over the appropriate segment parallel to the ribs
    • At exhalation, the therapist provides a fast, rhythmic bouncing motion to the ribcage at the frequency and duration of the patient’s pulmonary needs
• Percussion
  • Rationale: Rationale: used in conjunction with postural drainage positions to loosen and mobilize secretions by loosening secretions in the lungs.
    • Percussion is typically performed at a rate of 100 to 480 beats per minute (BPM). A common frequency is 150 to 200 BPM, which translates to about 2 to 3 claps per second.
  • How to perform:
    • Place in appropriate postural drainage position
    • Place a barrier between the hand and the segment that will be percussed
    • Percuss over the identified segment with a cupped hand by the therapist at a rhythmic rate. Percussion is applied during inhalation and exhalation at the frequency determined by the patient’s pulmonary needs.

Definitions

Trendelenburg: The Trendelenburg position, where a patient lies head-down, is used in postural drainage to help clear secretions from the lower parts of the lungs using gravity.

Precautions for postural drainage positions

• Placement in Trendelenburg position
  • Pulmonary edema
  • Congestive heart failure
  • Obesity
  • Recent food consumption
  • Recent neurosurgery
  • Increased intracranial pressure <20 mmHg
  • Shortness of breath
  • Esophageal surgery
  • General discomfort from the position
• Placement in side-lying
  • Axillo-femoral graft
  • Humeral fractures
  • Arthritis
  • Shoulder or hip bursitis
  • General discomfort from the position

Contraindications for all postural drainage positions

• Active hemorrhage
• intracranial pressure >20 mmHg
• Embolism
• Large pleural effusion
• Emphysema
• Recent spinal surgery
• Non-stabilized head or neck injury

Considerations for initiating percussion or shaking

• Pain increased with the techniques
• Decreased platelet count
• Increased clotting time- on anti-coagulation medication
• Fractured rib
• Degenerative bone disease
• Bone metastases

Pulmonary medications

• Bronchiodilators
  • Mechanism of action: medications that assist with improving ventilation by providing relaxation of bronchioles (bronchodilation) in either short-acting or long acting
  • Appropriate diagnoses: asthma, chronic obstructive pulmonary disease
  • Physical therapy considerations: trembling, palpitations, headache, muscle cramps
  • Common name: Theophylline
• Expectorants
  • Mechanism of action: thinning mucus, increasing secretions, increasing mucus production by cough, and reducing the viscosity of secretions
  • Appropriate diagnoses: pneumonia, flu, cold, cystic fibrosis, and any other diagnoses that produce increased mucus
  • Physical therapy considerations: rash, difficulty breathing, dizziness
  • Common name: Guaifenesin
• Corticosteroids
  • Mechanism of action: an anti-inflammatory that reduces the inflammation that is present in the bronchial lining
  • Appropriate diagnoses: chronic obstructive pulmonary disease (COPD), asthma, interstitial lung disease (ILD), sarcoidosis, and severe acute respiratory illness.
  • Physical therapy considerations: typically, long-term use can cause osteoporosis, increased blood sugar, increased risk for infections, and development of glaucoma or cataract
  • Common name: prednisone