POSTURAL DRAINAGE
Postural drainage (bronchial drainage), another
intervention for airway clearance, is a means of mobilizing secretions in one
or more lung segments to the central airways by placing the patient in various
positions so gravity assists in the drainage process. When secretions are moved
from the smaller to the larger airways, they are then cleared by coughing or
endotracheal suctioning. Postural drainage therapy also includes
the use of manual techniques, such as percussion, shaking, and vibration,
coupled with voluntary coughing.
Manual Techniques Used with Postural Drainage Therapy
In addition to the use of body positioning, deep breathing, and
an effective cough to facilitate airway clearance, a variety of manual
techniques are used in conjunction with postural drainage to maximize the
effectiveness of the mucociliary transport system. They include percussion,
vibration, shaking, and rib springing. Findings from studies that have been
implemented to evaluate the efficacy of these manual techniques as adjuncts to
postural drainage are inconclusive.
Percussion
Percussion is used to augment mobilization of secretions by
mechanically dislodging viscous or adherent mucus from the airways. Percussion
is performed with cupped hands over the
lung segment being drained. The therapist’s cupped hands strike the patient’s
chest wall in an alternating, rhythmic manner. The therapist should try to keep
shoulders, elbows, and wrists loose and mobile during the maneuver. Mechanical
percussion is an alternative to manual percussion techniques. Percussion is
continued for several minutes or until the patient needs to alter position to
cough. This procedure should not be painful or uncomfortable
Relative Contraindications to Percussion
Prior to using percussion in a postural drainage program, a therapist
must weigh the potential benefits versus potential risks. In most instances, it
is prudent to avoid the use of percussion. Over fractures, spinal fusion, or
osteoporotic bone Over tumor area If a patient has a pulmonary embolus If the
patient has a condition in which hemorrhage could easily occur, such as in the
presence of a low platelet count, or if the patient is receiving
anticoagulation therapy If the patient has unstable angina If the patient has
chest wall pain, for example after thoracic surgery or trauma
Vibration
Vibration, another manual technique, often is used in
conjunction with percussion to help move secretions to larger airways. It is
applied only during the expiratory phase as the patient is
deep-breathing. Vibration is applied by placing both hands directly on the skin
and over the chest wall (or one hand on top of the other) and gently compressing
and rapidly vibrating the chest wall as the patient breathes out . Pressure is
applied in the same direction as the chest is moving. The vibrating action is
achieved by the therapist isometrically contracting (tensing) the muscles of
the upper extremities from shoulders to hands.
Shaking
Shaking is a more vigorous form of vibration applied during exhalation
using an intermittent bouncing maneuver coupled with wide movements of the
therapist’s hands. The therapist’s thumbs are locked together, the open hands
are placed directly on the patient’s skin, and fingers are wrapped around the
chest wall. The therapist simultaneously compresses and shakes the chest wall.
Guidelines for Implementing Postural Drainage
General Considerations
Time of day
Consider
the following when scheduling postural drainage into a patient’s day. Never
administer postural drainage directly after a meal. Coordinate treatment with
aerosol therapy. Some therapists believe that aerosol therapy combined with
humidification prior to postural drainage helps loosen secretions and increases
the likelihood of productivity. Others believe that aerosol therapy is best
after postural drainage when the patient’s lungs are clearer and maximal benefit
can be gained from medication administered through aerosol therapy. Choose a
time (or times) of day likely to be of most benefit to the patient. A patient’s
cough tends to be highly productive in the early morning because of
accumulation of secretions from the night before. Postural drainage in the
early evening clears the lungs prior to sleeping and helps the patient rest
more easily.
Frequency of treatments
The frequency of postural drainage each day or during the
week depends on the type and severity of a patient’s pathology. If secretions
are thick and copious, two to four times per day may be necessary until the
lungs are clear. If a patient is on a maintenance program, the frequency is
less, perhaps once a day or only a few days a week.
Preparation for Postural Drainage
Loosen tight or bulky clothing. It is not necessary to expose
the skin. The patient may wear a lightweight
shirt or gown. Have a sputum cup or tissues available. Have
sufficient pillows for positioning and comfort. Explain the treatment procedure
to the patient. Teach the patient deep breathing and an effective cough prior
to beginning postural drainage. If the patient is producing copious amounts of
sputum, instruct the patient to cough a few times or have the patient suctioned
prior to positioning. Make any adjustments of tubes and wires, such as chest tubes,
electrocardiography wires, or catheters, so they remain clear during
positioning.
Postural Drainage Sequence
Determine which segments of the lungs should be drained.
Some patients with chronic lung diseases, such as cystic fibrosis, need to be
drained in all positions. Other patients may require drainage of only a few
segments in which secretions have accumulated. Check the patient’s vital signs
and breath sounds. Position the patient in the correct position for drainage. See
that he or she is as comfortable and relaxed as possible. Stand in front of the
patient, whenever possible, to observe his or her color. Maintain each position
for 5 to 10 minutes if the patient can tolerate it or as long as the position
is productive. Have the patient breathe deeply during drainage but do not allow
the patient to hyperventilate or become short of breath. Pursed-lip breathing
during expiration is sometimes used.
Apply percussion over the segment being drained while the
patient is in the correct position. Encourage the patient to take a deep,
sharp, double cough whenever necessary. It may be more comfortable for the
patient to momentarily assume a semiupright position (resting on one elbow) and
then cough. If the patient does not cough spontaneously during positioning with
percussion, instruct the patient to take several deep breaths or huff several
times in succession as you apply vibration during expiration. This may help elicit
a cough. If the patient’s cough is not
productive after 5 to 10 minutes of positioning, go on to the next position.
Secretions that have been mobilized during a treatment may not be coughed up by
the patient until 30 minutes to 1 hour after treatment. The duration of any one
treatment should not exceed 45 to 60 minutes, as the procedure is quite
fatiguing for the patient.
Concluding a Treatment
Have the patient sit up slowly and rest for a short while after
the treatment. Watch for signs of postural hypotension when the patient rises
from a supine position or from a head-down position to sitting. Advise the
patient that even if the cough was not productive during treatment it may be
productive a short while after treatment. Evaluate the effectiveness of the
treatment by reassessing breath sounds. Note the type, color, consistency, and
amount of secretions produced. Check the patient’s vital signs after treatment
and note how the patient tolerated the treatment.
Criteria for Discontinuing Postural Drainage
If the chest radiograph is relatively clear If the patient
is afebrile for 24 to 48 hours If normal or near-normal breath sounds are heard
with auscultation If the patient is on a regular home program.
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