Postural Drainage techniques ; and treatment

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.

POSTURAL DRAINAGE


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.

POSTURAL DRAINAGE


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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