Chest physiotherapy

Chest physiotherapy also called chest physical therapy or chest PT, is an airway clearance technique to drain the lungs, and may include percussion (clapping), vibration, deep breathing, and huffing or coughing. With chest physiotherapy or chest physical therapy, the person gets in different positions to use gravity to drain mucus (postural drainage) from the five lobes of the lungs. Each position is designed so that a major part of the lung is facing downward. When combined with percussion, it may be known as postural drainage and percussion. This is where a caregiver or partner can clap and or vibrate the person’s chest to further dislodge and move the mucus to the larger airways where it can be coughed or huffed out of the body.

Chest physiotherapy is easy to do. For a child with Cystic Fibrosis (CF), chest physiotherapy can be done by anyone, including parents, siblings, and friends. It can also be done by physical therapists, respiratory therapists, or nurses during care center visits or in the hospital.

Cystic Fibrosis (CF) is an autosomal recessive genetic disease that is the most common genetic disorder of Caucasian individuals with a prevalence of about 1 in 3000 individuals of European descent and is estimated to affect 30,000 individuals in the United States ¹. The disease is due to a defect in the cystic fibrosis transmembrane conductance regulator (CFTR) ². While the lungs and pancreas are the pathognomonic target organs in cystic fibrosis with 85% of the mortality due to lung disease ³, many other organs are affected. These include, but are not limited to, the sweat gland, small and large intestine, vas deferens, sinuses, biliary tree and liver. Cystic fibrosis (CF) lung disease begins early in life with inflammation and impaired mucociliary clearance and consequent chronic infection of the airways ⁴. There is progressive decline of lung function with episodes of acute worsening of respiratory symptoms, often referred to as ‘pulmonary exacerbations’. The lungs of people with cystic fibrosis produce excess mucus. This leads to repeated infection and tissue damage in the lungs. It is important to clear the mucus using drugs and chest physiotherapy. Chest physiotherapy is frequently administered to people with cystic fibrosis to assist with clearing mucus from the airways ⁵. Physiotherapy clears mucus by different techniques or by using mechanical devices or both. The results of this 2015 Cochrane review show that airway clearance techniques have short‐term effects in the terms of increasing mucus transport. No evidence was found on which to draw conclusions concerning the long‐term effects ⁵.

How long does chest physiotherapy take?

Generally, each treatment session can last between 20 to 40 minutes. chest physiotherapy is best done before meals or one-and-a-half to two hours after eating, to decrease the chance of vomiting. Early morning and bedtimes are usually recommended. The length of chest physiotherapy and the number of times a day it is done may need to be increased if the person is more congested or getting sick. Your cystic fibrosis doctor or respiratory therapist can recommend what positions, how often and how long chest physiotherapy should be done.

Lungs anatomy

Learning more about the respiratory system and its relationship to other organs in the body can help you to understand why postural drainage and percussion treatments are effective.

The goal of postural drainage and percussion is to clear mucus from each of the five lobes of the lungs by moving mucus into the larger airways so that it can be coughed out. The right lung is composed of three lobes: the upper lobe, the middle lobe and the lower lobe. The left lung is made up of only two lobes: the upper lobe and the lower lobe.

The lobes are divided into smaller sections called segments. The upper lobes on the left and right sides are each made up of three segments: top (apical), back (posterior) and front (anterior).

Segments of lobes are made up of a network of airways, air sacs and blood vessels. These sacs allow for the exchange of oxygen and carbon dioxide between the blood and air. During postural drainage and percussion, it is these segments that are being drained.

Note the position of each lung segment in Figure 1 below.

Figure 1. Lung segments

Chest percussion and postural drainage

Postural drainage uses gravity to help move mucus from the lungs up to the throat. With postural drainage, the person lies or sits in various positions so the part of the lung to be drained is as high as possible. That part of the lung is then drained using percussion, vibration and gravity. Your cystic fibrosis care team may tailor these positions to your or your child’s needs.

When the person with cystic fibrosis is in one of the positions, the caregiver can clap on the person’s chest wall. This is usually done for three to five minutes and is sometimes followed by vibration over the same area for approximately 15 seconds (or during five exhalations). The person is then encouraged to cough or huff forcefully to get the mucus out of the lungs.

Percussion or clapping by the caregiver on the chest wall over the part of the lung to be drained helps move the mucus into the larger airways. The hand is cupped as if to hold water but with the palm facing down (as shown in the Figure 2 below). The cupped hand curves to the chest wall and traps a cushion of air to soften the clapping.

Chest percussion therapy is done forcefully and with a steady beat. Each beat should have a hollow sound. Most of the movement is in the wrist with the arm relaxed, making percussion less tiring to do. If the hand is cupped properly, percussion should not be painful or sting.

Special attention must be taken to not clap over the:

• Spine
• Breastbone
• Stomach
• Lower ribs or back (to prevent injury to the spleen on the left, the liver on the right and the kidneys in the lower back)

Different devices may be used in place of the traditional cupped palm method for percussion. Ask your cystic fibrosis doctor or respiratory therapist to recommend one that may work best for you.

Figure 2. Percussion hand technique

Deep breathing moves the loosened mucus and may lead to coughing. Breathing with the diaphragm, belly breathing or lower chest breathing is used to help the person take deeper breaths and get the air into the lower lungs. The belly moves outward when the person breathes in and sinks in when he or she breathes out. Your respiratory or physical therapist on your cystic fibrosis care team can help you learn more about this type of breathing.

Doing chest physiotherapy comfortably and carefully

Both the person with cystic fibrosis and the caregiver should be comfortable during chest physiotherapy. Before starting, the person should remove tight clothing, jewelry, buttons, and zippers around the neck, chest and waist. Light, soft clothing, such as a T-shirt, may be worn. Do not do chest physiotherapy on bare skin. The caregiver should remove rings and other bulky jewelry, such as watches or bracelets. Keep a supply of tissues or a place to cough out the mucus nearby.

The caregiver should not lean forward when doing percussion, but should remain in an upright position to protect his or her back. The surface that the person with CF lies on should be at a comfortable height for the caregiver.

Many families find it helpful to use pillows, sofa cushions, or bundles of newspapers under pillows for support, as well as cribs with adjustable mattress heights/tilts, foam wedges, or bean bag chairs while doing chest physiotherapy. Infants can be positioned with or without pillows in the caregiver’s lap.

To make chest physiotherapy more fun, consider one of the following:

• Schedule chest physiotherapy around a favorite TV show.
• Play favorite songs or recorded stories.
• Spend time playing, talking, or singing before, during, and after chest physiotherapy.
• For kids, encourage blowing or coughing games during chest physiotherapy, such as blowing pinwheels or coughing the deepest cough.
• Ask willing and capable relatives, friends, brothers, and sisters to do chest physiotherapy. This can provide a welcome break from the daily routine.
• Minimize interruptions. Finding ways that make chest physiotherapy more enjoyable can help you keep a regular routine and get maximum health benefits.

Performing postural drainage and percussion

Postural drainage and percussion involves a combination of techniques, including multiple positions to drain the lungs, percussion, vibration, deep breathing and coughing.

When the person with cystic fibrosis is in one of the positions, the caregiver can clap on the person’s chest wall. This is usually done for three to five minutes and is sometimes followed by vibration over the same area for approximately 15 seconds (or during five exhalations). The person is then encouraged to cough or huff forcefully to get the mucus out of the lungs.

Timing of postural drainage and percussion

Generally, each treatment session can last for 20 to 40 minutes. postural drainage and percussion is best done before meals or one and a half to two hours after eating, to decrease the chance of vomiting. Early morning and bedtimes are usually recommended. The length of postural drainage and percussion and the number of times of day it is done may need to be increased if the person is more congested or getting sick. Your CF doctor or therapist will help you know what positions, how often and how long postural drainage and percussion should be done.

Enhancing postural drainage and percussion

Both the person with cystic fibrosis and the caregiver should be comfortable during postural drainage and percussion. Before starting, the person should remove tight clothing, jewelry, buttons and zippers around the neck, chest and waist. Light, soft clothing, such as a T-shirt, may be worn. Do not do postural drainage and percussion on bare skin. The caregiver should remove rings and other bulky jewelry such as watches or bracelets. Keep a supply of tissues or a place to cough out the mucus nearby.

Doing postural drainage and percussion comfortably and carefully

The caregiver should not lean forward when doing percussion, but should remain in an upright position to protect his or her back. The table on which the person with cystic fibrosis lies should be at a comfortable height for the caregiver.

Making postural drainage and percussion more enjoyable

To enhance the quality of the time you spend doing postural drainage and percussion, do one of the following:

• Schedule postural drainage and percussion around a favorite TV show.
• Play favorite songs or recorded stories.
• Spend time playing, talking or singing before, during and after postural drainage and percussion.
• For kids, encourage blowing or coughing games during postural drainage and percussion, such as blowing pinwheels or coughing the deepest cough.
• Ask willing and capable relatives, friends, brothers and sisters to do postural drainage and percussion. This can provide a welcome break from the daily routine.
• Minimize interruptions. Finding ways that make postural drainage and percussion more enjoyable can help you keep a regular routine and get maximum health benefits.

Postural drainage

Postural drainage is done by positioning your body so that your head is lower than your chest. This allows mucus to drain better from the bottom of your lungs. Postural drainage is one way to help treat breathing problems due to swelling and too much mucus in the airways of the lungs. Chest physical therapy or postural drainage and percussion, uses gravity and percussion (clapping on the chest and/or back) to loosen the thick, sticky mucus in the lungs so it can be removed by coughing. Unclogging the airways is key to keeping your lungs healthy.

For the child with cystic fibrosis, postural drainage and percussion (clapping on the chest and/or back) can be done by physical therapists, respiratory therapists, nurses, parents, siblings and even friends. People with cystic fibrosis sometimes use other types of treatments, such as inhaled bronchodilators and antibiotics to keep their lungs healthy. If ordered, bronchodilators should be taken before postural drainage and percussion to open the airways, and inhaled antibiotics should be taken after postural drainage and percussion so that the medicine gets to the infection better. Your doctor or therapist will help you figure out a routine that will work best for you or your child.

Postural drainage treatments

The best time to do postural drainage is either before a meal or an hour and a half after a meal, when your stomach is emptiest.

Use one of the following positions:

• Sitting
• Lying on your back, stomach, or side
• Sitting or lying with your head flat, up, or down

Stay in the position for as long as your provider instructed (at least 5 minutes). Wear comfortable clothes and use pillows to get as comfortable as possible. Repeat the position as often as instructed.

Breathe in slowly through your nose, and then out through your mouth. Breathing out should take about twice as long as breathing in.

Postural drainage positions

There are 6 to 12 positions a person with pulmonary disease may take to drain mucus from a certain part of the lungs. Another person may tap in certain areas to help loosen the mucus and allow it to be coughed out. Other ways to relieve the lung congestion of cystic fibrosis or bronchiectasis include percussion vests and inhaled aerosols.

With postural drainage, you get into a position that helps drain fluid out of your lungs. It may help:

• Treat or prevent an infection
• Make breathing easier
• Prevent more problems with the lungs

A respiratory therapist, nurse, or doctor will show you the best position for postural drainage.

Postural drainage and percussion

Your doctor or chest physical therapist may also recommend doing percussion or vibration.

Percussion helps break up thick fluids in your lungs. Either you or someone else claps a hand on your ribs while you are lying down. You can do this with or without clothing on your chest:

• Form a cup shape with your hand and wrist.
• Clap your hand and wrist against your chest (or have someone clap your back, if your doctor tells you to).
• You should hear a hollow or popping sound, not a slapping sound.
• DO NOT clap so hard that it hurts.

Vibration is like percussion, but with a flat hand that gently shakes your ribs.

• Take a deep breath, then blow out hard.
• With a flat hand, gently shake your ribs.

Your doctor or chest physical therapist will show you how to do this the right way.

Do percussion or vibration for 5 to 7 minutes in each area of the chest. Do this on all of the areas of your chest or back that your doctor tells you to. When you finish, take a deep breath and cough. This helps bring up any phlegm, which you can then spit out.

Purchasing equipment

Equipment such as drainage tables, electrical and nonelectrical palm percussors and vibrators may be helpful. These can be purchased from medical equipment stores. Older children and adults may find percussors useful when doing their own postural drainage and percussion. Talk to your doctor or therapist at your cystic fibrosis care center about equipment for postural drainage and percussion.

Many families find it helpful to use pillows, sofa cushions, bundles of newspapers under pillows for support, cribs with adjustable mattress heights/tilts, foam wedges or bean bag chairs while doing postural drainage and percussion. Infants can be positioned with or without pillows in the caregiver’s lap.

Postural drainage techniques

Postural drainage and percussion is easy to do. For a child with cystic fibrosis, postural drainage and percussion can be done by anyone, such as parents, siblings and even friends. It can also be done by the physical therapists, respiratory therapists or nurses during care center visits or in the hospital.

People with cystic fibrosis sometimes use other types of treatments, such as inhaled bronchodilators and antibiotics to keep their lungs healthy. If ordered, bronchodilators should be taken before postural drainage and percussion to open the airways, and inhaled antibiotics should be taken after postural drainage & P so that the medicine gets deep into the lungs to better fight off infections. Your care team will help you figure out a routine that will work best for you or your child.

Postural drainage procedure

The following diagrams describe the positions for postural drainage and percussion. In the diagrams, shaded areas show where the chest should be percussed or clapped.

Pillows may be used for added comfort. If the person tires easily, the order of the positions can be varied, but all areas of the chest should be percussed or clapped.

Please remember to percuss and vibrate only over the ribs. Avoid percussing and vibrating over the spine, breastbone, stomach and lower ribs or back to prevent trauma to the spleen on the left, the liver on the right and the kidneys in the lower back. Do not percuss or vibrate on bare skin.

Self-Percussion of Upper Lobes

Your child should sit upright and reach across his or her chest to clap on front of chest over the muscular area between the collarbone and the top of the shoulder blade. Repeat on the opposite site. Your child can also clap his or her own upper back if able to reach it.

Figure 4. Self-Percussion of Upper Lobes

Upper Front Chest of Upper Lobes

Have your child sit upright. Clap on both sides of the upper front chest over the muscular area between the collarbone and the top of the shoulder blade.

Figure 5. Upper Front Chest of Upper Lobes

Upper Back Chest of Upper Lobes

Have your child sit up and lean forward on a pillow over the back of a sofa or soft chair at a 30-degree angle. Stand or sit behind your child and clap both sides of the upper back. Take care not to clap on your child’s backbone.

Figure 6. Upper Back Chest of Upper Lobes

Upper Front Chest of Upper Lobes

Have your child lie on his or her back with arms to sides. Stand behind your child’s head. Clap both sides of your child’s chest between the collarbone and nipple.

Figure 7. Upper Front Chest of Upper Lobes

Left Side Front Chest

Have your child lie with left side up and raise his or her left arm overhead. Clap over the lower ribs just below the nipple area on the front side of left chest. Do not clap on your child’s stomach.

Figure 8. Left Side Front Chest

Right Side Front Chest

Have your child lie with right side up and raise his or her right arm overhead. Clap over the lower chest just below the nipple area on the front side of right chest. Do not clap your child’s lower ribcage.

Figure 9. Right Side Front Chest

Lower Back Chest of Lower Lobes

Have your child lie on his or her stomach. Clap both sides at the bottom of his or her chest just above the bottom edge of the ribcage. Do not clap the lower ribcage or over the backbone.

Figure 10. Lower Back Chest of Lower Lobes

Left Lower Side Back Chest of Lower Lobe

Have your child lie with left side up and roll toward you a quarter turn so you can reach your child’s back. Clap on the lower left side of his or her chest just above the bottom edge of the ribcage.

Figure 11. Left Lower Side Back Chest of Lower Lobe

Right Lower Side Back of Lower Lobe

Have your child lie with right side up and roll toward you a quarter turn so you can reach your child’s back. Clap on the lower right side of his or her chest just above the bottom edge of the ribcage.

Figure 12. Right Lower Side Back of Lower Lobe

Chest physiotherapy for infants

Performing chest physiotherapy for infants

• Your child is placed into different positions so that mucus can be more easily moved (see pictures below).
• Different areas of the chest wall are percussed to help loosen and move the mucus toward the center of the chest.
• Percussion is performed for two minutes in each different position.
• Perform two to three huff coughs between each position, if your child is old enough.
• Repeat until all different positions are complete.

Tips for percussion

1. Put a thin layer of clothing, such a T- shirt, on your child’s chest.
2. Use a cupped hand or percussor cup. If done right, you will hear a popping sound. Percussion should not cause red marks on your child.
3. Do not percuss over the backbone, breastbone, or lower two ribs.
4. Do chest physiotherapy before meals or 30 minutes after meals.
5. Percuss on both the right and left sides.
6. Your child should get two treatments daily and increase to three to four when sick.

Lung apical segment

With the infant leaning slightly back, percuss over the area from the nipple line to the shoulder on both sides. Percuss over each area for two minutes.

Figure 13. Chest physiotherapy for infants – Lung apical segment

Lung posterior segment

With the infant leaning forward, percuss over and above each shoulder blade on both sides. Percuss over each area for two minutes.

Figure 14. Chest physiotherapy for infants – Lung posterior segment

Lung middle lobe and lingula segment

Lay infant flat on his or her side. Roll back one quarter turn with arm extended, as illustrated. Percuss over nipple area. Repeat on opposite side. Percuss over each area for two minutes

Figure 15. Chest physiotherapy for infants – Lung middle lobe and lingula segment

Lung lateral basal segment

Place infant in a flat position on his/her side, with arm extended. Percuss over side of ribcage, below armpit. Percuss over each area for two minutes.

Figure 16. Chest physiotherapy for infants – Lung lateral basal segment

Lung anterior basal segment

Place infant in a flat position, facing up. Percuss above margin of the ribs on both sides. Do not percuss on the stomach! Percuss for two minutes.

Figure 17. Chest physiotherapy for infants – Lung anterior basal segment

Lung posterior basal segment

Place infant in a flat position facing down. Percuss above the lower margin of the ribs on both sides. Percuss over each area for two minutes.

Figure 18. Chest physiotherapy for infants – Lung posterior basal segment

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