What is the recommended technique for postural drainage in patients with retained secretions?

Postural Drainage Technique for Retained Secretions

Postural drainage uses gravity-assisted positioning with head-down tilt to drain the lower and middle lung lobes, and is most effective when combined with percussion and coughing for 20-minute sessions performed twice consecutively. 1

Core Positioning Technique

Traditional postural drainage involves head-down tilt positioning to utilize gravity for draining specific lung segments, particularly targeting the lower and middle lobes. 1 The technique requires:

• 3-15 minutes per position for adequate drainage time 2
• Head-down tilt positions as the standard approach 1
• Segment-specific positioning corresponding to the anatomical bronchial tree 3

Most Effective Combination Approach

For maximum secretion clearance, combine postural drainage with percussion and coughing rather than using postural drainage alone. 1 Evidence demonstrates:

• PD with percussion and coughing cleared significantly more sputum at 60 and 90 minutes compared to other techniques 1
• Two consecutive 20-minute sessions are required for cumulative effect, particularly for clearing viscous secretions with poor rheological properties 1
• PD combined with active cycle of breathing technique (ACBT) produced twice the sputum weight compared to sitting positions alone 1

Simplified Position Sequence for Intubated Patients

For patients with tracheal intubation or those requiring simplified protocols, use this anatomically-validated sequence 3:

1. Supine position
2. 45-degree rotative prone with left side up
3. 45-degree rotative prone with right side up
4. Return to supine

Optional additions: 10-degree right-side-up supine and 45-degree rotative prone with head raised 45 degrees 3

Patient-Specific Considerations

Cystic Fibrosis and Bronchiectasis

• Postural drainage is specifically indicated for patients producing large quantities of sputum 2, 4
• Combine with huffing or forced expiratory technique as an adjunct 1
• Autogenic drainage can substitute for patients who cannot tolerate head-down positions, though it clears mucus faster but without spirometry differences 1

COPD Patients

• Huffing should replace vigorous coughing to minimize airway collapse 1
• Avoid manually assisted cough as it decreases peak expiratory flow by 144 L/min and may be detrimental 1

Contraindications and Cautions

• Gastroesophageal reflux disease (GORD) is a theoretical concern with head-down positions, though no studies confirm increased reflux in bronchiectasis patients 1
• Modified postural drainage (without head-down tilt) can be used when GORD or breathlessness is problematic, though effectiveness compared to traditional PD is unproven 1
• Patient discomfort is significantly higher with head-down PD compared to sitting techniques 1

Duration and Frequency

• Minimum 3 minutes per position, with optimal drainage occurring at 3-15 minutes 2
• 20-minute sessions performed twice consecutively for maximum viscous secretion clearance 1
• Three times daily is standard for hospitalized patients 5

Adjunctive Techniques

Manual techniques (percussion, vibration, shaking) should only be used during active postural drainage sessions, not independently, as evidence does not support their standalone use. 2 These techniques help loosen secretions and reduce fatigue during the drainage process. 1

Common Pitfalls

• Insufficient drainage time (less than 3 minutes per position) reduces effectiveness 2
• Single 20-minute session may not clear viscous secretions; two consecutive sessions are needed 1
• Using percussion/vibration without postural drainage provides no benefit 2
• Applying manually assisted cough in COPD can worsen outcomes 1