CPT Part 1: Percussion and Postural Drainage Vs High-Frequency Chest Wall Oscillation

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Seon Adams
Seon Adams

Registered Respiratory Therapist with a diverse background in healthcare but a keen interest in trauma intensive care. Additional interests are ventilators, new innovations in healthcare, and traveling

The Pre-brief

Chest physiotherapy is a modality that is commonly used by RT’s. Most of the time it is utilized in patients in whom the chest x-ray reveals some sort of focal lung opacity, evidence of retained secretions, and/or ineffective cough. This can be performed in quite a number of ways dependent upon the patient, the lobe that requires the therapy, and any contraindication that can prevent a certain method of therapy. Like most modalities, Chest Physiotherapy is not only dependent on the practitioner performing it but the patient’s willingness to have it done and work with the practitioner.

This week we will focus on two forms of Chest physiotherapy: Postural Drainage/Percussion Vibration and High-Frequency Chest Wall Oscillation Therapy commonly known as Vest therapy.

What is Chest Physiotherapy?

Chest physical therapy (CPT or Chest PT) is an airway clearance technique (ACT) to drain the lungs and may include percussion (clapping), vibration, deep breathing, and huffing or coughing.

When is Chest Physiotherapy indicated?

CPT  therapy is indicated in any patient whose cough alone cannot provide adequate lung clearance or the mucociliary escalator malfunctions. This is particularly true of patients with voluminous secretions, thick tenacious secretions, and patients with neuromuscular disorders. 

Percussion (and Vibration)

Percussion and vibration involves the application of mechanical energy to the chest wall by the use of either hands or various electric or pneumatic devices like a percussor. Percussion and Vibration combined with other physiotherapy techniques helps to move secretions to where they can easily be coughed up and cleared. This in turn allows air to reenter areas of lung tissue previously blocked by mucus further re-opening the lungs. Cystic fibrosis, COPD, asthma, lung disease with secretory problems, and patients with atelectasis are some of the typical patients that would benefit from Percussion and Vibration.

If the RT chooses to perform Percussion and vibration by hand the RT must be aware of the patient at all times. If possible it is best to have the patient facing the practitioner as to notice any changes in the patients’ condition. Care should be taken to avoid any tender sites or areas of recent surgery or pain. This is a skill the RT must master in order to perform correctly, but to avoid fatigue it is advised that the RT use the pneumatic percussor instead of by hand.

Cupping of the hand will create vibrations through the thoracic cavity.

A flat hand will not create vibrations and will hurt!

Postural drainage

Postural drainage involves the use of gravity and mechanical energy to help mobilize secretions. This drainage is accomplished by simply placing the segmental bronchus to be drained in a more vertical position, permitting gravity to assist in the process.  A good acronym to remember when performing postural drainage is BLU (Bad Lung Up). When using postural drainage it should be noted that the patient should have an adequate cough therefore making it easier to clear secretions. 

Postural drainage is not likely to succeed until adequate systemic and airway hydration is ensured.

Contraindications for percussion and postural drainage include:

  • Head and neck injury until stabilized
  • Active hemorrhage with hemodynamic instability
  • Recent spinal injury/surgery
  • Active hemoptysis
  • Pulmonary Embolism
  • Large Pleural effusions
  • ICP greater than 20 mmHg 
  • Uncontrolled hypertension
  • Uncontrolled risk of aspiration
  • Subcutaneous emphysema
  • Lung contusion
  • Bronchospasm

High-Frequency Chest Wall Oscillation

This modality is commonly referred to as Vest therapy where a variable air pulse generator and an inflatable vest covers the patient’s chest while small volumes of gas are injected at a fast rate creating an oscillatory effect against the patient’s chest. The objective of this modality is to create microscopic “coughs” in the patient’s alveoli releasing mucus from blocked airways and moving them into larger airways to be coughed out or suctioned. RT’s perform 10-30 minute therapy sessions at frequencies between 5 Hertz and 25 Hertz.

Contraindications for high-frequency chest wall oscillation include:

  • Unstable head or neck trauma 
  • Active hemorrhage with hemodynamic instability 
  • Subcutaneous emphysema 
  • Recent epidural
  • Spinal fusion
  • Recent skin grafts 
  • Burns
  • Open wounds
  • Recently place transvenous pacemaker or subcutaneous pacemaker 
  • Bronchospasm

Conclusion

With the therapies noted, as well as the ones to come in the next coming weeks,  the RT must be aware of the hazards and complications of the therapies chosen and able to recommend another adjunct therapy if not sufficient. There must also be an assessment of need, assessment, and monitoring during the therapy and assessment of outcome after the therapy is performed. Proper documentation must be noted to have an accurate record of each outcome.

Debrief 

  • Chest physical therapy (CPT or Chest PT) is an airway clearance technique (ACT) to drain the lungs and may include percussion (clapping), vibration, deep breathing, and huffing or coughing.
  • Postural drainage involves the use of gravity and mechanical energy to help mobilize secretions.
  • High-frequency Chest Wall oscillation creates microscopic “coughs” in the patient’s alveoli releasing mucus from blocked airways and moving them into larger airways to be coughed out or suctioned. 

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