Introduction
Chest physiotherapy (CPT) refers to a group of techniques designed to improve lung function, enhance airway clearance, and prevent respiratory complications in critically ill patients. It plays a vital role in mechanically ventilated patients, those with respiratory failure, and conditions such as pneumonia, atelectasis, and neuromuscular diseases.
Goals of Chest Physiotherapy
Mobilization and clearance of airway secretions.
Prevention and treatment of atelectasis.
Improvement of ventilation-perfusion (V/Q) matching.
Reduction of work of breathing.
Enhancement of lung expansion and compliance.
Indications for Chest Physiotherapy
1. Respiratory Conditions
Excessive Secretions: COPD, bronchiectasis, cystic fibrosis.
Atelectasis: Postoperative patients, prolonged immobilization, mechanical ventilation.
Pneumonia: Especially in patients with poor cough effort.
Acute Respiratory Distress Syndrome (ARDS): Helps recruit alveoli in selective cases.
Aspiration Pneumonitis: Helps clear secretions.
2. Neuromuscular and Critical Care Conditions
Guillain-Barré Syndrome, Myasthenia Gravis: Ineffective cough and secretion clearance.
Spinal Cord Injury: Reduced diaphragmatic function.
Postoperative Patients: Prevents pulmonary complications.
Prolonged Mechanical Ventilation: Helps with secretion clearance and weaning.
3. Contraindications
Unstable hemodynamics: Hypotension, arrhythmias.
Severe bronchospasm: Acute asthma exacerbation.
Recent pneumothorax without chest tube.
Massive hemoptysis: Risk of worsening bleeding.
Rib fractures, flail chest: Risk of worsening pain and instability.
Techniques of Chest Physiotherapy
1. Postural Drainage
Uses gravity to drain secretions from different lung segments.
Patient is positioned to allow secretions to move towards central airways for easier clearance.
Performed 2–4 times a day, depending on secretion burden.
2. Percussion and Vibration
Percussion (Clapping/Tapping):
Rhythmic striking of the chest wall with cupped hands.
Helps loosen mucus in the peripheral airways.
Vibration:
Performed during exhalation by placing hands on the chest and applying gentle oscillatory pressure.
Facilitates movement of secretions to larger airways.
3. Incentive Spirometry
Encourages deep breathing and lung expansion.
Prevents postoperative atelectasis.
Patient inhales through the device, maintaining a target volume to improve lung recruitment.
4. Active Cycle of Breathing (ACBT)
A series of breathing exercises that include:
Breathing control: Normal tidal breathing.
Thoracic expansion exercises: Deep breathing with breath holds.
Forced expiratory technique (FET): Huffing to clear secretions.
5. Autogenic Drainage
Self-drainage technique where the patient modifies breathing depth and airflow to mobilize secretions without coughing.
Used in bronchiectasis, cystic fibrosis.
6. Positive Expiratory Pressure (PEP) Therapy
Patient exhales against resistance, creating positive airway pressure.
Keeps airways open, preventing collapse and aiding secretion clearance.
Examples: PEP masks, flutter devices, Acapella.
7. Mechanical Insufflation-Exsufflation (Cough Assist Device)
Simulates a cough by applying positive pressure followed by rapid negative pressure.
Used in neuromuscular disorders with weak cough reflex.
8. High-Frequency Chest Wall Oscillation (HFCWO)
Vest therapy: Uses air pulses to generate vibrations.
Improves mucus mobilization in patients with cystic fibrosis, chronic bronchitis.
9. Manual Hyperinflation (Bag Squeezing)
Used in mechanically ventilated patients to recruit collapsed alveoli and aid secretion clearance.
Can be combined with suctioning to remove secretions.
10. Suctioning
Indicated in patients with impaired cough (e.g., intubated, tracheostomy patients).
Helps clear airway secretions when non-invasive methods fail.
Can be oropharyngeal, nasopharyngeal, or endotracheal.
Role of Chest Physiotherapy in Critical Care Medicine
1. In Mechanically Ventilated Patients
Prevents ventilator-associated pneumonia (VAP).
Reduces atelectasis.
Helps in early weaning by improving secretion clearance.
2. In Postoperative and ICU Patients
Prevents pulmonary complications.
Reduces the risk of hypoxemia and pneumonia.
Promotes early mobilization and lung recruitment.
3. In ARDS and Severe Respiratory Failure
Selective use in prone positioning for secretion clearance.
Not routinely recommended unless airway clearance is impaired.
4. In Neuromuscular Disorders
Essential for secretion management due to weak cough reflex.
Prevents recurrent infections and respiratory failure.
Monitoring and Complications of Chest Physiotherapy
1. Parameters to Monitor
Respiratory rate, oxygenation (SpO₂, ABG).
Sputum volume and consistency.
Hemodynamic stability (HR, BP).
Patient comfort and tolerance.
2. Potential Complications
Hypoxia: Due to excessive suctioning or airway collapse.
Bronchospasm: Worsening airway obstruction.
Hemoptysis: Trauma from aggressive suctioning or infection.
Rib fractures: In osteoporotic patients with excessive percussion.
Vagal stimulation: Bradycardia due to excessive airway manipulation.