What is the prescription for postural drainage in a physiotherapy (physio) setting?

Postural Drainage Prescription in Physiotherapy

Prescribe two consecutive 20-minute sessions of postural drainage using gravity-assisted head-down tilt positions, combined with percussion and the forced expiration technique (huffing), performed twice daily for patients with cystic fibrosis, bronchiectasis, or excessive sputum production. 1

Core Treatment Protocol

Session Duration and Frequency

• Two consecutive 20-minute sessions are required for cumulative effect, particularly for clearing viscous secretions with poor rheological properties 1
• Single 20-minute sessions may not adequately clear viscous secretions 1
• Each position should be maintained for 3-15 minutes to achieve effective drainage 2

Positioning Technique

• Head-down tilt positions are the standard approach for postural drainage, using gravity to drain lower and middle lung lobes 1
• Review CT imaging to identify affected bronchopulmonary segments and teach appropriate postural drainage positions for specific segments 3
• A simplified sequence for intubated or complex patients: supine → 45° rotative prone with left side up → 45° rotative prone with right side up → return to supine 4

Essential Adjunctive Techniques

• Combine postural drainage with percussion and coughing/huffing - this combination clears significantly more sputum at 60 and 90 minutes compared to other techniques 1
• Manual techniques (percussion, vibration, shaking) should only be used during active postural drainage sessions, not independently 1
• Incorporate the forced expiration technique (huff) as an adjunct for all patients with cystic fibrosis and bronchiectasis 1

Disease-Specific Modifications

Cystic Fibrosis and Bronchiectasis

• Postural drainage is recommended as an effective technique to increase mucus clearance in CF patients 3
• Continue treatment for a minimum of 10 minutes up to a maximum of 30 minutes, continuing until two clear huffs/coughs are completed 5
• Consider positive expiratory pressure (PEP) devices as an alternative - they are approximately as effective, inexpensive, safe, and can be self-administered 6

COPD Patients

• Huffing should replace vigorous coughing to minimize airway collapse in COPD patients 1
• Do not use manually assisted cough as it decreases peak expiratory flow by 144 L/min and may be detrimental 1

Contraindications and Modified Approach

When to Modify Standard Postural Drainage

• Use modified postural drainage (no head-down tilt) when gastroesophageal reflux disease (GORD) or breathlessness is problematic 1
• If symptoms of gastro-oesophageal reflux increase with modified postural drainage, teach an airway clearance technique in the sitting position 3
• Consider autogenic drainage as a substitute for patients who cannot tolerate head-down positions, though it clears mucus faster without spirometry differences 1, 7

Alternative Techniques When Postural Drainage Fails

• Consider autogenic drainage, positive expiratory pressure, high frequency chest wall oscillation, or intrapulmonary percussive ventilation if postural drainage is not effective or acceptable 3
• Active cycle of breathing techniques (ACBT) plus postural drainage enhances sputum expectoration compared to ACBT in sitting position alone 3

Monitoring and Follow-up

Assessment Schedule

• Patients admitted with exacerbations should be seen daily by a respiratory physiotherapist until airway clearance is optimized 5
• Review airway clearance technique within 3 months of initial assessment 5
• Annual review should include respiratory physiotherapist assessment to optimize airway clearance regimen 5

Effectiveness Markers

• Monitor sputum volume, radioaerosol clearance, and patient tolerance 3
• The correlation between tracheobronchial clearance and radioactivity content in sputum (rs² = 0.76) and number of coughs (rs² = 0.65) is better than sputum weight alone (Rs = 0.39) 8

Critical Pitfalls to Avoid

• Do not prescribe single 20-minute sessions - two consecutive sessions are needed for viscous secretions 1
• Do not use percussion and vibration independently without active postural drainage - evidence does not support standalone use 1
• Do not apply manually assisted cough in COPD as it worsens outcomes 1, 6
• Postural drainage is time-consuming, may require caregiver assistance, and has limited long-term outcome data for quality of life, exacerbation rates, or mortality 3