Clinical Pathway of Chest Physiotherapy

Phase 1: Patient Assessment

History & Interview

• Presenting complaint: productive cough, retained secretions, breathlessness, recurrent infections
• Underlying diagnosis: COPD, cystic fibrosis (CF), bronchiectasis, pneumonia, atelectasis, neuromuscular disease, post-surgical state
• Sputum characteristics: volume, viscosity, color, frequency
• Functional status and exercise tolerance
• Relevant comorbidities: osteoporosis, rib fractures, recent surgery, bleeding disorders, hemoptysis

Physical Examination

• Respiratory rate, SpO2, auscultation (wheeze, crackles, reduced air entry)
• Chest expansion, accessory muscle use
• Cough strength and efficacy
• Ability to cooperate with techniques

Risk Stratification

Phase 2: Technique Selection

A. Secretion Mobilization and Airway Clearance Techniques (ACT)

• Patient positioned so gravity assists drainage of secretions from specific lung segments toward the central airway
• Each position targets a bronchopulmonary segment
• Maintained for 5-20 minutes per position, typically 2-3 times per day
• Combined with percussion and/or vibration for maximal effect

• Rhythmic clapping over the chest wall with cupped hands over the affected segment
• Creates pressure waves transmitted through the chest wall to loosen adherent secretions
• Must be used with caution in patients with osteoporosis (risk of rib fracture)
• Not used over the spine, sternum, or surgical incisions

• Fine oscillatory pressure applied to the chest wall during exhalation
• Used after inspiration; vibratory force applied with hands flat over the segment
• Can be performed manually or mechanically
• Especially useful in bronchiectasis and CF

• Requires adequate inspiratory capacity, an intact glottis, and sufficient abdominal/diaphragmatic muscle strength
• Sequence: maximal inhalation → brief glottic closure → forceful contraction of abdominals and diaphragm → expulsive expiration
• Manually-assisted cough (abdominal thrust) is used in patients with weak cough (neuromuscular disease, spinal cord injury)

• One or two "huffs" (forced expirations with an open glottis, "haaaa") from mid-to-low lung volume
• Mobilizes peripheral secretions without the high intrapleural pressures of a cough that can cause airway collapse
• Followed by a relaxed diaphragmatic breath and rest

• A structured cycle combining:
  1. Breathing control (relaxed tidal breathing)
  2. Thoracic expansion exercises (deep breaths with 3-second inspiratory hold)
  3. Forced expiratory technique (huffing)
• Can be performed independently by patients; well-suited for bronchiectasis and CF

B. Mechanical and Oscillatory Devices

• Devices such as the Acapella, Flutter, and Aerobika
• Patient exhales against a fixed resistance, generating positive expiratory pressure (PEP)
• Prevents airway closure, promotes collateral ventilation, and mobilizes secretions
• PEP devices combined with high-frequency oscillation (vibrating PEP) are the most commonly used ACT in the US (per the U.S. Bronchiectasis Registry)
• A clinical trial of the Acapella device showed improved quality of life scores (LCQ), increased 24-hour sputum volume, and improved exercise capacity

• An external vest delivers oscillations to the thorax
• Has been associated with enhanced sputum expectoration, improved quality of life, and decreased hospitalization for exacerbations, though strong efficacy data remain limited

C. Breathing Retraining Techniques

• Inhale through the nose; exhale slowly through pursed lips (whistling/kissing position) over 4-6 seconds
• Recruits abdominal muscles during exhalation
• Increases tidal volume, slows respiratory rate, reduces end-expiratory lung volumes
• Stents collapsible airways open by creating a positive end-expiratory pressure effect
• Reduces hypoxemia and dyspnea; reduces the oxygen cost of breathing in some patients
• Particularly useful in COPD

• Inhale slowly through the nose, allowing the abdomen to move outward
• Exhale while tightening abdominal muscles, allowing them to move inward
• Note: though widely used, diaphragmatic breathing has not been conclusively shown to be beneficial and may decrease breathing efficiency in some COPD patients

• Sitting or standing while leaning forward (with or without arm bracing)
• Improves the length-tension relationship of the diaphragm, increasing maximal inspiratory pressure
• Relieves dyspnea in COPD

D. Incentive Spirometry (IS)

• Patient inhales slowly and deeply to a preset volume target, sustaining the breath for 2-3 seconds before exhaling
• Produces sustained maximal lung inflation, prevents atelectasis, preserves lung volumes
• Induces cough and loosens secretions
• Particularly indicated peri-operatively; among modalities available (IS, CPAP, PEEP, deep breathing), no single method has been proven superior

E. Pharmacologic Adjuncts

Phase 3: Application and Delivery

Indications by Clinical Scenario

Frequency and Timing

• Optimal CPT is performed 2-3 times per day
• Pharmacologic adjuncts (hypertonic saline, bronchodilators) should be administered immediately prior to physical airway clearance techniques
• Pre-operative CPT should begin before the surgical date; little improvement is seen before one month of therapy in COPD
• COPD patients with excessive sputum benefit most from CPT

Who Benefits Most

• Patients with chronic productive cough or difficulty expectorating
• Those with excessive mucus production during exacerbations
• Patients with CF, bronchiectasis, or COPD with acute exacerbations
• High-risk pre-operative patients (especially with COPD)

Phase 4: Monitoring During Treatment

• Respiratory rate, SpO2, and heart rate throughout the session
• Sputum production: volume, color, consistency
• Symptom response: dyspnea, cough, chest tightness
• Signs of adverse effects: bronchospasm, desaturation, hemoptysis, rib pain
• Stop immediately if significant desaturation, hemoptysis, or clinical deterioration occurs

Phase 5: Reassessment and Ongoing Management

• Repeat auscultation to assess secretion clearance and air entry
• Review sputum volume and character over days/weeks
• In rehabilitation settings, reassess exercise tolerance and functional status
• Spirometry to track FEV1/FVC trends (though spirometry does not typically improve with CPT alone)
• Adjust technique, position, frequency, or adjuncts based on response
• Patient education in self-directed techniques (PLB, ACBT, PEP devices) for long-term independence

Summary Table: CPT Techniques at a Glance

• Fishman's Pulmonary Diseases and Disorders - Bronchial Hygiene; Airway Clearance Techniques; Respiratory and Chest Physiotherapy Techniques
• Murray & Nadel's Textbook of Respiratory Medicine - Inspiratory Muscle Training, Breathing Training, and Chest Physical Therapy
• Goldman-Cecil Medicine - Airway Clearance
• Morgan & Mikhail's Clinical Anesthesiology - Other Respiratory Care Techniques
• Miller's Anesthesia - Physiotherapy (perioperative CPT)
• The Washington Manual of Medical Therapeutics - Pulmonary Therapy