Postural drainage for lower lobes university exam answer practical
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postural drainage lower lobes positions techniques university practical exam
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Postural Drainage for Lower Lobes - University Practical Exam Answer
Definition
Postural drainage is a chest physiotherapy technique in which the patient is placed in specific body positions that use gravity to facilitate the drainage of mucus/secretions from particular bronchopulmonary segments into the larger central airways, where they can be cleared by coughing or suctioning.
Aim / Purpose
- Mobilize and clear retained bronchial secretions
- Improve airway patency and ventilation
- Reduce risk of respiratory infection
- Improve lung function
- Used alongside percussion and vibration for maximum efficacy
Principle
Each bronchopulmonary segment has a specific bronchus that opens at a particular anatomical angle. By tilting the patient so the affected segment is uppermost and its draining bronchus points vertically downward, gravity draws secretions centrally. The lower lobe bronchi require a head-down (Trendelenburg) tilt of 20-30 degrees to achieve effective drainage.
Lower Lobe Segments and Specific Positions
The lower lobes (right and left) each have 5 segments:
| Segment | Position | Percussion Area |
|---|---|---|
| 1. Apical (Superior) Segment | Prone lying with a pillow under the abdomen (no head-down tilt needed) | Over the middle of the back bilaterally, below the scapula |
| 2. Anterior Basal Segment | Supine (lying on back) with hips elevated / foot of bed raised ~18-20 inches (30°), knees flexed | Over the lower anterior chest wall / lower ribs anteriorly |
| 3. Posterior Basal Segment | Prone with hips raised / foot of bed raised ~18-20 inches (30°), pillow under the hips | Over the lower posterior chest wall on the affected side |
| 4. Lateral Basal Segment (Right) | Left lateral decubitus (lying on left side) with foot of bed raised ~18-20 inches (30°) | Over the lower right lateral chest wall |
| 4. Lateral Basal Segment (Left) | Right lateral decubitus (lying on right side) with foot of bed raised ~18-20 inches (30°) | Over the lower left lateral chest wall |
| 5. Medial Basal (Cardiac) Segment (right lower lobe only) | Right lateral decubitus (lying on right side) with foot of bed raised ~20° | Over the lower right lateral/anterior chest wall |
Key rule for lower lobes: Foot of bed (or drainage table) raised approximately 18-20 inches (30 degrees) for all basal segments. The apical (superior) segment of the lower lobe is an exception - it drains with the patient prone and flat (no head-down tilt).
Step-by-Step Procedure
1. Pre-procedure Assessment
- Check medical history and contraindications
- Auscultate chest to identify affected segments
- Explain procedure to patient; obtain consent
- Schedule 1-2 hours after meals (to prevent aspiration/nausea)
- Administer prescribed bronchodilators 15-20 min before if ordered
2. Equipment Needed
- Tilting drainage bed / wedge pillows
- Pillow supports
- Tissues / sputum cup
- Gloves, percussion device (optional)
- Stethoscope
3. Positioning the Patient (Lower Lobe Specific)
- Position the patient as per the target segment (table above)
- Foot of bed raised 18-20 inches (30°) for all basal segments
- Support with pillows for comfort
- Ensure airway is accessible
4. Percussion (Clapping)
- Cup the hands (fingers together, thumb tucked)
- Clap rhythmically over the affected segment for 1-2 minutes
- Never percuss over: spine, sternum, clavicles, kidneys, or bare skin
- Rate: approximately 100-480 claps per minute
5. Vibration
- Place both hands flat over the chest wall
- Apply fine trembling pressure during expiration only
- Performed for 3-5 breaths after percussion
6. Breathing and Coughing
- Ask the patient to take 3 slow deep breaths
- Instruct to huff cough (forced expiration technique) or cough to expectorate secretions
- Provide sputum container
7. Duration per Position
- Each position: 5-15 minutes (or as tolerated)
- Total session: up to 30-45 minutes
- Frequency: 2-4 times/day depending on clinical condition
8. Post-procedure
- Return patient to comfortable position
- Auscultate to assess improvement
- Document: amount, color, consistency of sputum
- Oral hygiene for patient
Indications
- Bronchiectasis
- Cystic fibrosis
- Lung abscess
- COPD with excessive secretions
- Post-operative (especially thoracic/abdominal surgery)
- Aspiration pneumonia
- Neuromuscular disorders impairing cough
Contraindications
| Absolute | Relative |
|---|---|
| Raised intracranial pressure | Active haemoptysis |
| Unstable cardiovascular status | Recent surgery / rib fractures |
| Severe haemoptysis | Pulmonary oedema |
| Undrained tension pneumothorax | Severe osteoporosis |
| Recent spinal injury | GERD (head-down positions) |
Complications / Precautions
- Gastro-oesophageal reflux (GERD): Head-down positions can worsen reflux - modified flat positions may be used
- Hypoxaemia: Monitor SpO2 throughout
- Arrhythmia: Monitor cardiac patients
- Increased ICP: Avoid Trendelenburg in head injury patients
- Aspiration: Never perform immediately after feeding
Modified Postural Drainage
Current evidence (Cecins et al., 1999) supports modified positions without head-down tilt (e.g., side-lying) as equally effective as classic head-down positions for secretion clearance, with fewer adverse effects. Modified positions are now preferred in many centres, especially for patients with GERD, cardiac instability, or raised ICP.
Summary Mnemonic for Lower Lobe Positions
"A-P-A-L-L" (Apical-Posterior-Anterior-Lateral-Lateral):
| Segment | Lie |
|---|---|
| Apical (superior) | Prone, flat |
| Posterior basal | Prone, head DOWN |
| Anterior basal | Supine, head DOWN |
| Lateral basal (R) | Left side, head DOWN |
| Lateral basal (L) | Right side, head DOWN |
Key Points to Emphasize in Exam
- Gravity is the driving force - the affected segment must be uppermost, bronchus pointing downward
- Lower lobe basal segments require 30° head-down (Trendelenburg) tilt except the apical/superior segment
- Always combine with percussion + vibration + huffing/coughing for best results
- The apical (superior) segment of the lower lobe is drained prone and flat - a common exam trick question
- Duration: 5-15 min per position, frequency 2-4x/day
- Contraindicated in raised ICP, unstable haemodynamics, undrained pneumothorax
- Modified (flat/side-lying) positions are now often preferred over classic Trendelenburg to avoid GERD
Sources: Fishman's Pulmonary Diseases and Disorders (Bronchial Hygiene section); Barash Clinical Anesthesia (Hydration and Removal of Bronchial Secretions); StatPearls - Postural Drainage and Vibration; Bronchiectasis Toolbox - Gravity Assisted Drainage (Pryor & Prasad, Physiotherapy for Respiratory and Cardiac Problems, 4th ed., Churchill Livingstone, 2008)
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