Chest physiotherapy (CPT)

1. Postural drainage
2. Percussion (clapping)
3. Vibration or shaking
4. Directed coughing or huff coughing

Objectives

• Loosen and move secretions from smaller to larger airways.
• Improve expectoration and airway patency.
• Reduce mucus plugging and secondary atelectasis.
• Improve ventilation of affected lung areas and reduce work of breathing.
• Help prevent recurrent infection in disorders with chronic secretion retention.
• Teach patients and caregivers an independent, sustainable airway-clearance routine.

Indications

• Bronchiectasis, especially with chronic productive cough or exacerbation
• Cystic fibrosis (CF)
• Primary ciliary dyskinesia
• Mucus plugging with lobar or segmental atelectasis
• Selected patients with COPD who have troublesome retained sputum and cannot clear it with cough
• Neuromuscular weakness or impaired cough, although assisted cough techniques may be more appropriate
• Intubated or tracheostomized patients with retained secretions, usually as part of a respiratory-care plan
• Some postoperative patients with secretion retention, not routinely as prevention alone

When it is not routinely useful

Assessment before treatment

• Diagnosis, chest imaging, and location of secretions if known
• Amount, color, viscosity, and odor of sputum
• Cough strength and ability to cooperate
• Respiratory rate, work of breathing, chest expansion, breath sounds
• Pulse, blood pressure, oxygen saturation, and oxygen requirement
• Pain, recent surgery, fractures, osteoporosis, bleeding risk, reflux, nausea, and feeding status
• Presence of hemoptysis
• Ability to tolerate specific drainage positions
• Need for bronchodilator, humidification, nebulized therapy, or suctioning

Traditional components of CPT

1. Postural drainage

Principle

General rules

• Choose positions according to the suspected or imaged affected area.
• Use pillows and modify positions for comfort, oxygenation, pain, obesity, pregnancy, reflux, or recent surgery.
• Encourage slow deep breaths, then huff or cough after each position.
• Stop or alter the position if there is desaturation, severe dyspnea, dizziness, arrhythmia, pain, reflux, or distress.
• Head-down tilt is not required for all drainage. Modified gravity-assisted or upright positions are often safer.

Examples of positions

2. Percussion or clapping

Principle

Method

• The therapist cups the hand, keeping fingers and thumb together to create an air pocket.
• Clap rhythmically over the chest wall, generally during both inspiration and expiration.
• Treat one segment at a time, usually for several minutes.
• Use a gown, towel, or thin clothing layer if needed for comfort. Do not strike bare skin hard enough to cause pain or redness.
• Alternate with deep breathing and coughing/huffing.

Avoid percussion over

• Spine, sternum, clavicles, scapulae
• Kidneys or lower back
• Breasts
• Drains, wounds, lines, implanted devices, or fresh surgical sites
• Areas of trauma, rib fracture, bone metastasis, severe osteoporosis, or significant pain

3. Vibration and shaking

Principle

• Vibration: gentle, rapid oscillations through tensed hands.
• Shaking: a coarser, more forceful oscillation, used selectively by trained clinicians.

Method

1. Place both hands flat over the target lung segment.
2. Ask the patient to take a deep breath in.
3. During exhalation, apply gentle inward pressure plus rapid vibration in the direction of expiration.
4. Repeat over several breaths, then encourage huff coughing or coughing.

4. Coughing and huff coughing

Directed cough

• Sit upright if possible.
• Take a slow deep inspiration.
• Briefly hold the breath for 2 to 3 seconds.
• Lean slightly forward and cough from the abdomen, usually once or twice rather than in a prolonged exhausting coughing fit.

Huff cough or forced-expiratory technique

• Take a medium-sized breath in.
• Exhale quickly with the mouth open, saying “ha, ha.”
• Use a low-volume huff to move peripheral secretions and a larger-volume huff to clear central secretions.
• Follow with a cough if mucus reaches the throat.

Other airway-clearance methods

Active cycle of breathing technique (ACBT)

1. Breathing control: relaxed diaphragmatic breathing.
2. Thoracic expansion exercises: several deep breaths, with or without a short inspiratory hold.
3. Forced expiratory technique: one or two huffs, then return to breathing control.

Autogenic drainage

PEP and oscillating PEP devices

• A PEP mask or mouthpiece provides resistance during exhalation, helping maintain small-airway patency behind secretions.
• Oscillating PEP devices such as Flutter, Acapella, and Aerobika add airway vibrations that may loosen mucus.

High-frequency chest-wall oscillation (HFCWO)

Mechanical insufflation-exsufflation or cough assist

Exercise and early mobilization

Contraindications and precautions

Do not perform or stop treatment if there is

• Hemodynamic instability
• Severe respiratory distress requiring urgent escalation
• Untreated tension pneumothorax
• Active significant hemoptysis
• Suspected pulmonary embolism or acute unstable cardiac condition
• Acute spinal instability
• Inability to protect the airway with high aspiration risk, unless performed in a controlled setting
• Patient refusal, severe agitation, or inability to tolerate the procedure

Use caution or modify technique with

• Rib fractures, flail chest, chest trauma, severe chest-wall pain
• Severe osteoporosis, bone metastases, or fragile skin
• Recent thoracic, abdominal, spinal, or neurosurgery
• Recent eye surgery or elevated intracranial pressure
• Significant gastroesophageal reflux, hiatus hernia, pregnancy, obesity, or recent feeding
• Severe hypertension, arrhythmia, or cardiac instability
• Coagulopathy, thrombocytopenia, anticoagulant therapy
• Bullous lung disease or a history of pneumothorax
• Acute bronchospasm or marked hypoxemia
• Pleural effusion or empyema, depending on clinical circumstances

Complications and adverse effects

• Hypoxemia or desaturation
• Increased dyspnea, fatigue, or bronchospasm
• Nausea, vomiting, reflux, and aspiration
• Hemoptysis
• Musculoskeletal pain, rib injury, or bruising
• Headache, dizziness, or raised intracranial-pressure concerns with inappropriate positioning
• Arrhythmia or hemodynamic instability in susceptible patients
• Spread of infection if equipment is not cleaned properly

Stop and seek urgent clinical review for

• New or worsening chest pain
• Marked breathlessness, cyanosis, confusion, or persistent desaturation
• Fresh or increasing blood in sputum
• Fainting, severe dizziness, palpitations
• Fever or clinical deterioration with inability to clear secretions

Monitoring effectiveness

• Sputum amount and ease of expectoration
• Breath sounds and chest expansion
• Respiratory rate and work of breathing
• Heart rate, blood pressure, and oxygen saturation
• Cough effectiveness
• Patient comfort, pain, and fatigue
• Need for suctioning
• Longer-term outcomes: exacerbations, antibiotic courses, exercise tolerance, sleep, and quality of life

Key clinical points

• CPT is indicated for retained secretions, not for every cough, pneumonia, or COPD diagnosis.
• Traditional CPT is postural drainage + percussion + vibration + cough/huff.
• Modern airway clearance is individualized and may use ACBT, PEP, oscillating PEP, HFCWO, exercise, suction, or cough assist.
• The patient should be taught a technique they can perform consistently and safely.
• Avoid routine head-down drainage where reflux or aspiration risk is relevant, especially in infants.
• In CF and bronchiectasis, regular airway clearance is often central to long-term care; in uncomplicated pneumonia and routine postoperative or routine COPD care, evidence does not support automatic use.
• CPT should be prescribed and demonstrated by a respiratory physiotherapist, respiratory therapist, nurse, or physician familiar with the patient’s condition.