What is the procedure for performing chest physiotherapy?

How Chest Physiotherapy is Performed

Chest physiotherapy combines postural drainage (gravity-assisted positioning), percussion (manual or mechanical chest clapping), vibration/shaking of the chest wall, and directed coughing techniques, typically performed in 20-minute sessions twice consecutively for maximum effectiveness. 1

Core Components and Technique

Postural Drainage

• Position the patient head-down with appropriate tilt to target specific bronchopulmonary segments based on CT imaging findings to use gravity for draining lower and middle lung lobes 2
• The head-down tilt is the standard positioning approach recommended for effective drainage 2
• Sessions should last 20 minutes and be performed twice consecutively (total 40 minutes) for cumulative effect, particularly for clearing viscous secretions 2

Percussion (Clapping)

• Apply rhythmic striking to the chest wall with cupped hands over the affected lung segments during postural drainage 1
• Mechanical percussion devices can substitute for manual percussion with equivalent effectiveness, reducing dependency on caregivers 3, 4
• Percussion should only be used during active postural drainage sessions, not as a standalone technique 2

Vibration and Shaking

• Apply rapid vibratory movements or shaking to the chest wall during the expiratory phase of breathing 1
• These manual techniques augment secretion mobilization but show minimal benefit when added to postural drainage alone 1

Directed Coughing

• Coughing is the most effective and important component of conventional chest physiotherapy 5
• Instruct patients to perform controlled coughs after positioning and percussion to expectorate loosened secretions 1

Disease-Specific Modifications

Cystic Fibrosis and Bronchiectasis

• Combine postural drainage with huffing (forced expiratory technique) instead of vigorous coughing 1, 2
• Huffing consists of one or two forced expirations without glottic closure, starting from mid-lung to low-lung volume, followed by relaxed breathing 1
• This technique minimizes airway collapse that occurs with traditional coughing in patients with compliant airways 1

COPD Patients

• Use huffing exclusively and avoid vigorous coughing to prevent airway collapse 2
• Never use manually assisted cough in COPD patients, as it decreases peak expiratory flow by 144 L/min and worsens outcomes 1, 2

Neuromuscular Weakness

• Apply manually assisted cough by placing both hands on the upper abdomen and applying pressure following an inspiratory effort and glottic closure 1
• This technique improves peak cough expiratory flow by 14-100% in patients with expiratory muscle weakness 1

Treatment Sequencing

Administer treatments in this specific order for optimal effectiveness: 6

1. Bronchodilator first to open airways
2. Mucoactive agents (if prescribed) to thin secretions
3. Postural drainage with percussion for 20 minutes
4. Repeat for second 20-minute session
5. Directed coughing or huffing to expectorate mobilized secretions

Contraindications and Precautions

Avoid or Modify in These Situations:

• Gastroesophageal reflux disease (GERD) is a theoretical concern with head-down positions, though unproven in bronchiectasis patients 2
• Use modified postural drainage without head-down tilt when GERD or breathlessness is problematic, though effectiveness is unproven compared to traditional positioning 2
• Avoid manually assisted cough in patients with stiff chest walls (severe scoliosis), osteoporosis, recent abdominal surgery, or intraabdominal catheters 1

Common Pitfalls

• Single 20-minute sessions are insufficient for clearing viscous secretions; two consecutive sessions are required 2
• Percussion and vibration add minimal benefit when used alone without postural drainage and should not be performed independently 2
• In COPD, manually assisted cough is detrimental and should never be used 1, 2
• The technique is time-consuming and may require caregiver assistance, which affects long-term compliance 1

Evidence Limitations

While chest physiotherapy increases expectorated sputum volume and enhances short-term mucus clearance in cystic fibrosis patients, long-term benefits on pulmonary function, hospitalization rates, quality of life, and mortality remain unproven 1. The therapy is most beneficial in patients producing >20-30 mL of mucus daily 1. For other conditions beyond cystic fibrosis, evidence is insufficient to recommend routine use 1.