Chest physiotherapy plays a vital role to play not only in medical or surgical chest conditions but also in surgical procedures involving spine. Pelvis, extremities, and abdomen.
Chest physiotherapy plays a significant role in the prevention of the common postoperative complications or, in reducing the degree of severity when these complications occur. It is also instrumental in early returns of a patient to his preoperative status.
OBJECTIVE OF CHEST PHYSIOTHERAPY
1. To help remove secretion
Percussion: Cupped hands rhythmically applied to the thorax. Precaution include: Rib fracture, costo condritis. Hemoptysis, blood coagulation problems, dysrthymias, pain, severe dyspnea, pneumothorax and increased bronchospasm.
Shaking: Following inspiration, a bouncing of the rib cage.
Vibration: Isometric co- contraction of the arms applied to the thorax, usually used in conjunctions with shaking, percussion and postural drainage positioning.
2. To help clear the airway
Cough: Forcefully expelling air following a deep inhalation and closing of the glottis to expel mucus.
Forced expiration technique: One or two forced expirations with relatively low lung volumes, the glottis in not closed. Ideal for patients used with COPD.
Huffing: Similar to a cough with an open glottis. Patient may say HA, Ha during expiration.
Assisted coughing: Similar to a Heimlich maneuver done during expiration.
3. To improve gas exchange and increase lung volume:
Three breathing exercises technique are useful:
- Diaphragmatic breathing
- Segmental breathing
- Pursed lip breathing.
The approach of a physiotherapist should be basically be problem oriented to prevent or minimize the expected complications following surgery.
Early identification of the patients who are at the risk of developing complications is of primary importance. This is done by preoperative observations and assessment of various parameters in relation to the patient’s condition, planned surgical procedure and the patient’s physical work requirements for the job as well as for the hobbies.
In subjective assessment evaluation it is important to know the duration, severity, pattern, and the factors associated with the following when present:
- Dyspnoea or breathlessness
- Orthopnea or breathlessness while lying flat
- Paroxysmal or nocturnal dyspnoea
- Sputum and haemoptysis
- Types of chest pain, pleuritic, tracheitic, musculoskeletal, angina or pericarditis.
- The chief disturbing factors as expressed by the patient.
It is vital to record other relevant information about the symptoms, past and present, medical history, clinical and laboratory, investigations and also physiotherapeutic evaluation.
- Respiratory rate : normal adult 12-16 b/min)
- Chest expansion: normal adult 3.5 cm
- Breath sound
- Auscultation with stethoscope during inspiration is useful in detecting the sputum retention the opening of the alveoli and small airways during inspiration produces a sharp crackling sound or continuous musical sound. These added breath sounds indicate the alveolar narrowing and mucus retention. Its detachment and elimination. It can be correlated with the other signs of retention.
- Forced vital capacity
- Forced expiratory volume in one second: Measurement of FVC and FEV1 can be done by spirometry. The ratio of FEV1 and FVC provides a direct measure of the degree of airway obstruction. The ratio of less than 75% is graded as mild less than 60% graded as moderate and less than 40% is graded as severe.
- Peak expiratory flow
- Values of arterial blood gases
Normal adult values
PaO2= 80-100 mmHg
PaCO2= 35-45 mm Hg
HCO3 = 22-26 mmHg
Base excess = -2 to + 2
- Flow volume curves
- Chest radiograph
- Strength and endurance of the muscles of respiration
- Pattern of respiration including the efficiency of diaphragm or the degree of substitution by the accessory muscles of respiration
- Range of body temperature ( normal adult 36.5-37.5 f)
- Heart rate
- Blood pressure
- Body weight
- Exercise tolerance tested by 6 minute walk test
Besides this observation of finger tips for clubbing, color of eyes, cyanosis, jugular venous pressure and peripheral edema provides important clues.
After assessment the physiotherapy has two basic functions:
- Preoperative guidance and training
- Postoperative management.
- Preoperative guidance and training: After evaluation and planning of a type of surgical procedure the physiotherapist must apprise the patient about the detrimental effects of general anesthesia. The patient should be made aware of the process to minimize the ensuing complications, during immediate and late postoperative phases. Ideally sessions on the sequentially progressive postsurgical therapeutic regime should be taught during this preoperative period.
- Post operative physiotherapy management: The basic function of physiotherapy is firstly to improve breathing control by training of normal tidal breathing, making it relaxed and least exerting and secondly the elimination of the postsurgical secretions. This is achieved by:
- Positioning of the patient
To increase functional residual capacity as well as preventing lung collapse, upright erect posture should be assumed as early as feasible. Whenever possible ambulation should be resumed at the earliest possible opportunity. It could be assisted and well supported.
- Teaching and practicing active cycles of breathing technique: The basic technique of the chest physiotherapy also known as active cycles of breathing technique (ACBT).
Components of ACBT
- Breathing control or normal relaxed breathing
- Thoracic expansion technique or inspiratory control technique
- Forced expiration technique or expiratory control technique.
Breathing control technique: It is a technique of relaxed smooth, normal tidal breathing, primarily using the lower chest. Former known as diaphragmatic breathing technique, it is actually accomplished by coordinated activity of the abdominals, external and internal oblique muscles, the scalene muscles and the diaphragm.
- Improves inspiratory control
- Minimize the work of breathing
- Helps to relieve breathlessness at rest and on exertion
- Facilitates return of the normal patterns of breathing
- Improves ventilation of the bases of the lungs preventing collapse, hyperventilation and fatigue.
The patient is positioned in a relaxed sitting with back head and shoulder fully supported and the abdominal wall fully relaxed. It can be given even in the high side lying position. Hands are placed on the anterior costal margins. The patient is taught to breathe out as quietly as possible sinking down the lower ribs and the abdomen without any force. It must be remembered that forced or prolonged expiration will increase work of breathing and may even increase air flow obstruction. Passage of air through the nose allows the air to be warm, humidified and filtered before it reaches the upper airway. During this phase of inspiration the abdomen should bulge out to its fullest extent. A careful watch is needed to ensure that the upper chest and the accessory muscles are not over used as this may result in early fatigue due to increased oxygen consumption due to the excessive work of the accessory muscles of respiration.
THROCIC EXPANSION TECHNIQUE OR INSPIRATORY CONTROL TECHNIQUE
It is a technique of deep breathing with efforts and emphasis on active inspiration as against relaxed effortless technique of breathing control.
- Assists in loosening of excessive bronchial secretion
- Facilitates the movements of secretions
- Assists in the re- expansion of the lung tissue
- Improves lung volume and mobilize the thoracic cage, promoting air flow through the collateral ventilator channels, thus getting air exactly behind bronchial secretions
- Prevents collapse of the lung tissues
After deep inspiration with maximum expansion of the thoracic cage, air is held for 3 seconds like in pranayama. This is followed by relaxed passive expiration. As it is followed by relaxed passive expiration. As it is a tiring procedure, there should be a pause for relaxation after 4 to 5 breaths.
The patient may feel dizzy owing to hyperventilation. Ideally every 4 to 5 expansion exercises should be followed by a pause for relaxation by repeating breathing control technique.
This technique is given in half lying position with the knees slightly flexed over a pillow or in the sitting on an upright chair or stool.
The technique is especially important during early postoperative phase to [prevent lung collapse, facilitate mobilization of secretions and decrease atelectasis.
The maneuvers of chest clapping, shaki8ng and vibrations are contraindicated or done very carefully in patients with-
- Osteoporosis of ribs
- Metastatic deposits affecting the ribs or vertebral column
- Acute pleuritic pain
- A active pulmonary infections e.g. tuberculosis
CONTRAINDICATION OF POSTURAL DRAINAGE
- Recent severe haemptysis
- Cerebral oedema
- Aortic and cerebral aneurysms
- Acute asthma emphysema or dysponea
THE FORCED EXPIRATION TECHNIQUE OR EXPIRATORY CONTROL TECHNIQUE
The excessive bronchial secretion is eliminated by this technique of forceful expiration. It is a combination of one or two forceful expiration followed by intermittent periods of breathing control to prevent possible occurrence or sudden increase in the bronchial spasm. The important part of the clearance mechanism by huff or cough is the airways towards the mouth.
To mobilize the secretion huffing or coughing is initiated from the mid lung volume i.e. following a medium size inspiration. Air is squeezed out forcefully by using abdominals and the chest wall with mouth open. A rapid flow of the secretions results when a forced expiratory effort is made with coughing against a closed glottis which raises intrathoracic pressure. Then when the glottis opens abruptly there occurs a large pressure gradient between the alveolar pressure and the upper tracheal pressure, resulting in a rapid flow of secretions.
To produce effective elimination of secretion by huff or cough, it is mandatory to take a deep breath before coughing. Strong contractions in the abdominal muscles are needed to produce effective cough. A continuous huff down the same lung volume or a series of huff and cough without intermittent inspirations could be used.
ACBT done in gravity assisted positions is also an alternative method of clearing secretions
If the cause of reduced lung volume happens to be atelectasis or lobar collapse due to retained secretions a patient may fail to respond ACBT technique. it may be necessary to adopt measures like antibiotic, oxygen therapy or mechanical adjustments like periodic continuous positive airway pressure (PCPAP) , intermittent positive pressure breathing (IIPB), positive expiratory pressure mask (PEP). Incentive spirometry may be considered along with the ACBT in gravity assisted positions.