techniques used in postural drainage

postural drainage

Postural drainage is a means of mobilizing secretions in one or more lung segments to the central airways, by placing the patient in various positions, so that gravity assists in the drainage process. When secretions are moved to the larger airways, they are then cleared by coughing or endotracheal suctioning. Postural drainage therapy also includes the use of manual techniques, such as percussion and vibration, as well as voluntary coughing.

Indications

• Inability or reluctance of patient to change body position. (eg: mechanical ventilation, neuro-muscular disease, drug-induced paralysis)
• Poor oxygenation associated with position (eg: unilateral lung disease)
• Potential for or presence of atelectasis
• Presence of artificial airway
• Evidence or suggestion of difficulty with secretion clearance
• Difficulty clearing secretions with expectorated sputum production greater than 25-30 mL/day (adult)
• Presence of atelectasis caused by or suspected of being caused by mucus plugging
• Diagnosis of diseases such as cystic fibrosis, bronchiectasis, or caveating lung disease
• Presence of foreign body in airway
• External Manipulation of the Thorax

contradictions

Hemorrhage (severe hemoptysis)

• NOTE: This is different from lightly blood–streaked sputum
• Copious amounts of blood in the sputum

Untreated acute conditions

• Severe pulmonary edema
• Congestive heart failure
• Large pleural effusion
• Pulmonary embolism
• Pneumothorax

cardiovascular instability

• Cardiac arrhythmia
• Severe hypertension or hypotension
• Recent myocardial infarction

recent neurosurgery

• Head-down position may cause increased intracranial pressure.

Role of Physiotherapy

physiotherapy techniques

In addition to the use of body positioning, deep breathing and effective cough to facilitate clearance of secretions from the airways, a variety of manual techniques are used in conjunction with postural drainage to maximize the effectiveness of the mucociliary transport system. They include:

postural drainage positions

Positions are based on the anatomy of the lungs and the tracheobronchial tree.

The patient may be positioned on a:

• Postural drainage table that can be elevated at one side
• Tilt table
• Reinforced padded table with a lift
• Hospital bed

percussion

• This technique is used to further mobilize secretions by mechanically dislodging viscous or adherent mucus from the lungs.
• Percussion is performed with cupped hands over the lung segment being drained. The therapist’s cupped hands alternately strike the patient’s chest wall in a rhythmic fashion. The therapist should try to keep shoulders, elbows, and wrists loose and mobile during the maneuver. Mechanical percussion is an alternative to manual percussion techniques.
• Percussion is continued for several minutes or until the patient needs to alter position to cough.
• This procedure should not be painful or uncomfortable. To prevent irritation to sensitive skin, have the patient wear a lightweight gown or shirt. Avoid percussion over breast tissue in women and over bony prominences.

hand position of applying percussion

1. Therapist alternatively percusses over the lung segment being drained

• Relative contraindicationsPrior to implementing, percussion in a postural drainage program, the therapist must compare the potential benefits with the possible risks to the patient. In most instances, avoid the use of percussion.

• Over fractures, spinal fusion, or osteoporosis.
• Over tumor area.
• If a patient has a pulmonary embolus.
• If a patient has a condition in which hemorrhage could easily occur, such as in the presence of a low platelet count, or if a patient is receiving anticoagulation therapy.
• If a patient has unstable angina.
• If a patient has chest wall pain, for example, after thoracic surgery.

vibration

• The technique is used in conjunction with percussion in postural drainage. It is applied only during expiration as the patient is deep breathing to move the secretions to the larger airways.
• Vibration is applied by placing both hands directly on the skin and over the chest wall (or one hand on top of the other) then, gently compressing and rapidly vibrating the chest wall as the patient breathes out
• Pressure is applied in the same direction as that in which the chest is moving.
• The vibrating action is achieved by the therapist isometrically contracting (tensing) the muscles of the upper extremities from shoulders to hands.

hand placement for vibration during postural drainage

Shaking

• Shaking is a more vigorous form of vibration applied during exhalation using an intermittent bouncing maneuver coupled with wide movements of the therapist’s hands.
• Therapist’s thumbs are locked together and the open hands are placed directly on the patient’s skin and fingers are wrapped around the chest wall. The therapist simultaneously compresses and shakes the chest wall.
• Treatment procedure

General considerations

1. Time of the day
   • Never administer postural drainage immediately after meal
   • Coordinate treatment with aerosol therapy. The aerosol therapy can be applied before or after postural drainage.
   • Choose a time of day that will be beneficial for the patient. Early morning and early evening is more effective.
2. Frequency of treatment depends upon pathology of patient
   • Thick, copious mucus: two to four times per day
   • Maintenance: one to two times per day

prepare the patient

1. Loose, tight or bulky clothing
2. Have a sputum cup or tissue available
3. Sufficient amount of pillows
4. Explain the treatment procedure to the patient
5. Teach the patient deep breathing and an effective cough prior to beginning of postural drainage.
6. If the patient is producing copious amount of sputum, instruct the patient to cough a few times or have the patient suctioned prior to positioning.

treatment sequence

1. Evaluate the patient to determine which segment of the lung to be drained.
2. Position the patient in correct position of the drainage, see that he/she is as comfortable and relaxed as possible.
3. Stand in front of patient whenever possible.
4. Maintain the desired position for at least 5-10 minutes, if patient can tolerate it.
5. Have the patient breathe deeply in a relaxed manner during the drainage. Do not allow to the patient to hyperventilate or become short of breathe.
6. Apply percussion over the segment being drained while the patient is in the correct position.
7. Encourage the patient to take deep, sharp double cough whenever necessary.
8. If the patient does not cough spontaneously during positioning with percussion instruct the patient to take several deep breath and apply the vibration during expiration. This may help to elicit cough.
9. If the patient cough is not productive after 5-10 minutes, go onto the next position.
10. The duration of any one treatment should not exceed 40-45 minutes.

assess the effectiveness of the treatment

1. Note the type, color consistency and amount of secretion produced.
2. Note how the patient tolerated the treatment
3. Check the patient’s vital signs after treatment
4. Auscultate over the segments that were drained and note changes in the breath sounds.
5. Observe the patient’s breathing pattern to determine whether it is deeper, less rapid, more relaxed or less labored.
6. Check the symmetry of chest wall expansion.

when to discontinue the treatment

1. If the chest x-ray is relatively clear
2. If patient is afebrile for 24-48 hours
3. If normal or near normal breath sounds are heard with auscultation
4. If patient is on a regular home program.

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Content write and review Dr. Swati Agarwal