Postural drainage and therapeutic positioning Flashcards
Postural drainage
Secretion clearance technique that uses gravitational force through the positioning of difference bronchial segments in the vertical plane to facilitate the clearance of secretions from different bronchial segments of the lungs
Indications for postural drainage
- Large amount of secretions
- Cough is insufficient to clear thick, tenacious or localized secretions
Examples include: CF, bronchiectasis, atelectasis, lung abcess, pneumonia
Postural drainage contraindications
- Raised intracranial pressure >20mm Hg
- Head and neck injuries not yet stabilized
- Aortic and cerebral aneurysm
- Cardiovascular instability
- Active hemoptysis
- Pulmonary embolus
- Tension pneumothorax
- Cardiogenic pulmonary edema
- Excessive abdominal distension
-Bronchopleural fistula hydrocephalus - Hydrocephalus
Chest percussion: clapping
What is it and how is it done?
Involves vigorous striking the chest wall alternatively with cupped hands. Should
- Produce hollow
- Sound
- Not be painful
- Be done over single layer of clothing
- Done during inspiration and expiration
Traditionally done at 3-6Hz for 1-3min
Chest percussion: Clapping
Mechanism
Transmission of energy from chest wall to the airway, loosening the secretions from bronchial walls
Chest percussion: Clapping
Contraindications
- Rib fx
- Severe hemoptysis
- Pulmonary embolus
- Untreated pneumothorax
- Recent spinal fusion
- Recent skin graft, burns, ulcers
- Osteogenesis imperfecta
- Ca of the bronchus
- Recently placed pacemaker
- Hemodynamic instability
- Coagulation
- Recent thoracic surgery
Chest percussion: Vibration
What is it and how is it done?
A gentle shaking pressure (compression and oscillation) applied to chest wall to move secretions into larger airways
- Flat hand is firm on appropriate lung segment, a rhythmic contraction is applied while relaxing the arm and shoulder muscles over patients chest
- Provide vibration as patient is exhaling
- 10-15Hz frequency
- Encourage cough afterwards
Clapping treatment parameters
10 minutes, 2-3 minutes per position
2-3 times a day
Benefits of therapeutic positioning
- Improves lung volume and optimize V/Q matching causing improvement in gas exchange
- Minimize WOB and improve efficiency of the muscles of breathing –> reduce dyspnea
- Assist with secretion clearance. –> reduction in secretion retention
Ventilation in dependent vs non dependent lung (standing)
- Lower regions of the lungs (dependent regions) receive more ventilation than upper (non-dependent)
- Dependent lungs are more compliant and receive most of tidal ventilation
- Non dependent lung has more negative intrapleural pressure
Does the affected or unaffected side go up and why?
More negative intrapleural pressure in the upper region can aid with the opening of closed alveoli in atelectasis when breathing exercises are done with affected region positioned up
V/Q benefits of upright/sitting
- Good perfusion to the bases
- Good ventilation to the bases & mid lung
- Optimal V/Q around mid lung
- Upright positioning increases FRC globally, minimizes the development of atelectasis and improves ventilation
Perfusion in dependent vs non dependent lung
Dependent lung is more perfused because distended alveloi compress blood vessels in non dependent zone
What is the ideal V/Q matching and why is it important
For adequate gas exchange, ventilation needs to be matched to perfusion in alveoli (V/Q should = ~1)
○ This happens in mid lung
More blood flow than ventilation in dependent lung
○ 5/4 = ~0.8
In apex, decreased blood flow but also poor ventilation (low density alveoli and distended compressing vessels)
V/Q benefits of side lying
Good perfusion to lower/dependent lung
○ Good lungs go down
○ If lung with atelectasis is down it wont be open and get good ventilation but high blood flow –> high V/Q mismatch
○ If bad lung is up, it will encourage the alveoli to open up due to negative intrapleural pressire
Abdominal contents push the lower diaphragm higher into chest –> increasing the mechanical efficiency of diaphragm
V/Q matching in prone
Alveolar density is greater posteriorly than anteriorly
Compression forces from heart, mediastinum and diaphragm are eliminated
Alveoli in upper gravitational field(non dependent) have greater area to expand
Greater ventilation in prone vs supine and improved V/Q matching
V/Q matching in supine
Abdominal contents fall back and restrict diaphragm movement
Dorsal lung is compressed
Heart falls backwards and compresses the lungs
Ventilation is severely impaired
How does positioning reduce dyspnea
Providing Mx advantage to the diaphragm (a more domed position of diaphragm) (forward leaned position)
Improving efficiency of accessory muscles of breathing by fixation of arms/forearm (forearm support position)
Instructions when a patient is experiencing SOB
- Keep calm
- Remove yourself from the trigger
- Stop and rest in a comfortable position (see above)
- Don’t gasp for air
- Breathe in slowly through the nose
- Breath out slowly through pursed lips
- Breathe out twice as long as the inhale
- Resume activity
