Basics of Postural Drainage Techniques and Percussion

Chest physical therapy (CPT), or postural drainage and percussion (PD & P), uses gravity and percussion (clapping on the chest and/or back) to loosen the thick, sticky mucus in the lungs so it can be removed by coughing. Unclogging the airways is key to keeping lungs healthy.

PD & P is easy to do. For a child with CF, PD & P can be done by anyone, such as parents, siblings and even friends. It can also be done by the physical therapists, respiratory therapists or nurses during care center visits or in the hospital. 

Postural Drainage Techniques

People with CF sometimes use other types of treatments, such as inhaled bronchodilators and antibiotics to keep their lungs healthy. If ordered, bronchodilators should be taken before PD & P to open the airways, and inhaled antibiotics should be taken after PD & P so that the medicine gets deep into the lungs to better fight off infections. Your care team will help you figure out a routine that will work best for you or your child

Know Your Lungs  

Learning more about the respiratory system and its relationship to other organs in the body can help you to understand why PD & P treatments are effective.

The goal of PD & P is to clear mucus from each of the five lobes of the lungs by moving mucus into the larger airways so that it can be coughed out. The right lung is composed of three lobes: the upper lobe, the middle lobe and the lower lobe. The left lung is made up of only two lobes: the upper lobe and the lower lobe.

The lobes are divided into smaller sections called segments. The upper lobes on the left and right sides are each made up of three segments: top (apical), back (posterior) and front (anterior).

Segments of lobes are made up of a network of airways, air sacs and blood vessels. These sacs allow for the exchange of oxygen and carbon dioxide between the blood and air. During PD & P, it is these segments that are being drained. 

lung-anatomy-illustration


Performing PD & P  

PD & P involves a combination of techniques, including multiple positions to drain the lungs, percussion, vibration, deep breathing and coughing.

When the person with CF is in one of the positions, the caregiver can clap on the person's chest wall. This is usually done for three to five minutes and is sometimes followed by vibration over the same area for approximately 15 seconds (or during five exhalations). The person is then encouraged to cough or huff forcefully to get the mucus out of the lungs.

Description of PD & P Techniques

Postural drainage uses gravity to help move mucus from the lungs up to the throat. The person lies or sits in various positions so the part of the lung to be drained is as high as possible. That part of the lung is then drained using percussion, vibration and gravity. Your CF care team may tailor these positions to your or your child's needs.

Percussion or clapping by the caregiver on the chest wall over the part of the lung to be drained helps move the mucus into the larger airways. The hand is cupped as if to hold water but with the palm facing down (as shown in the figure below). The cupped hand curves to the chest wall and traps a cushion of air to soften the clapping.

cupped-hand-illustration


Percussion is done forcefully and with a steady beat. Each percussion also should have a hollow sound. Most of the movement is in the wrist with the arm relaxed, making percussion less tiring to do. If the hand is cupped properly, percussion should not be painful or sting.

Special attention must be taken to not clap over the spine, breastbone, stomach and lower ribs or back to prevent injury to the spleen on the left, the liver on the right and the kidneys in the lower back.

Different devices may be used in place of the traditional cupped palm method for percussion. Ask your doctor or therapist for which one may work best for you.

Vibration gently shakes the mucus into the larger airways. The caregiver places a hand firmly on the chest wall over the part of the lung being drained and tenses the muscles of the arm and shoulder to create a fine shaking motion. Then, the caregiver applies a light pressure over the area being vibrated. (The caregiver also may place one hand over the other, then press the top and bottom hand into each other to vibrate.) 

Vibration is done with the flattened hand, not the cupped hand (see the figure below). Exhalation should be as slow and as complete as possible.

flat-hand-illustration


 

 

Deep breathing moves the loosened mucus and may lead to coughing. Breathing with the diaphragm, belly breathing or lower chest breathing is used to help the person take deeper breaths and get the air into the lower lungs. The belly moves outward when the person breathes in and sinks in when he or she breathes out. Your respiratory or physical therapist on your CF care team can help you learn more about this type of breathing. 

Timing of PD & P

Generally, each treatment session can last for 20 to 40 minutes. PD & P is best done before meals or one and a half to two hours after eating, to decrease the chance of vomiting. Early morning and bedtimes are usually recommended. The length of PD & P and the number of times of day it is done may need to be increased if the person is more congested or getting sick. Your CF doctor or therapist will help you know what positions, how often and how long PD & P should be done.

Enhancing PD & P For the Person and Caregiver 

Both the person with CF and the caregiver should be comfortable during PD & P. Before starting, the person should remove tight clothing, jewelry, buttons and zippers around the neck, chest and waist. Light, soft clothing, such as a T-shirt, may be worn. Do not do PD & P on bare skin. The caregiver should remove rings and other bulky jewelry such as watches or bracelets. Keep a supply of tissues or a place to cough out the mucus nearby.

Doing PD & P Comfortably and Carefully

The caregiver should not lean forward when doing percussion, but should remain in an upright position to protect his or her back. The table on which the person with CF lies should be at a comfortable height for the caregiver.

Purchasing Equipment  

Equipment such as drainage tables, electrical and nonelectrical palm percussors and vibrators may be helpful. These can be purchased from medical equipment stores. Older children and adults may find percussors useful when doing their own PD & P. Talk to your doctor or therapist at your CF care center about equipment for PD & P.

Many families find it helpful to use pillows, sofa cushions, bundles of newspapers under pillows for support, cribs with adjustable mattress heights/tilts, foam wedges or bean bag chairs while doing PD & P. Infants can be positioned with or without pillows in the caregiver's lap.

Making PD & P More Enjoyable 

To enhance the quality of the time you spend doing PD & P, do one of the following: 

  • Schedule PD & P around a favorite TV show. 
  • Play favorite songs or recorded stories. 
  • Spend time playing, talking or singing before, during and after PD & P. 
  • For kids, encourage blowing or coughing games during PD & P, such as blowing pinwheels or coughing the deepest cough.
  • Ask willing and capable relatives, friends, brothers and sisters to do PD & P. This can provide a welcome break from the daily routine. 
  • Minimize interruptions. Finding ways that make PD & P more enjoyable can help you keep a regular routine and get maximum health benefits.

Instructions for PD & P 

The following diagrams describe the positions for PD & P. In the diagrams, shaded areas show where the chest should be percussed or clapped. 

Pillows may be used for added comfort. If the person tires easily, the order of the positions can be varied, but all areas of the chest should be percussed or clapped. 

Please remember to percuss and vibrate only over the ribs. Avoid percussing and vibrating over the spine, breastbone, stomach and lower ribs or back to prevent trauma to the spleen on the left, the liver on the right and the kidneys in the lower back. Do not percuss or vibrate on bare skin.

self-percussion-upper-lobes

Self-Percussion -- Upper Lobes 

Your child should sit upright and reach across his or her chest to clap on front of chest over the muscular area between the collarbone and the top of the shoulder blade. Repeat on the opposite site. Your child can also clap his or her own upper back if able to reach it. 

upper-front-chest-upper-lobes

Upper Front Chest -- Upper Lobes

Have your child sit upright. Clap on both sides of the upper front chest over the muscular area between the collarbone and the top of the shoulder blade.

upper-back-chest-upper-lobes-illustration

Upper Back Chest -- Upper Lobes 

Have your child sit up and lean forward on a pillow over the back of a sofa or soft chair at a 30-degree angle. Stand or sit behind your child and clap both sides of the upper back. Take care not to clap on your child's backbone. 

upper-front-chest-upper-lobes-2

Upper Front Chest -- Upper Lobes 

Have your child lie on his or her back with arms to sides. Stand behind your child's head. Clap both sides of your child's chest between the collarbone and nipple.

left-side-front-chest-3

Left Side Front Chest 

Have your child lie with left side up and raise his or her left arm overhead. Clap over the lower ribs just below the nipple area on the front side of left chest. Do not clap on your child's stomach.

right-side-front-chest-3

Right Side Front Chest 

Have your child lie with right side up and raise his or her right arm overhead. Clap over the lower chest just below the nipple area on the front side of right chest. Do not clap your child's lower ribcage. 

lower-back-chest-lower-lobes-illustration

Lower Back Chest -- Lower Lobes 

Have your child lie on his or her stomach. Clap both sides at the bottom of his or her chest just above the bottom edge of the ribcage. Do not clap the lower ribcage or over the backbone. 

left-lower-side-back-chest-lower-lobes-illustration

Left Lower Side Back Chest -- Lower Lobe 

Have your child lie with left side up and roll toward you a quarter turn so you can reach your child's back. Clap on the lower left side of his or her chest just above the bottom edge of the ribcage. 

right-lower-side-back-lower-lobe-illustration

Right Lower Side Back -- Lower Lobe 

Have your child lie with right side up and roll toward you a quarter turn so you can reach your child's back. Clap on the lower right side of his or her chest just above the bottom edge of the ribcage. 

 

*Children shown without shirts to better demonstrate the PD&P technique in illustrations. Images are from the CF Family Education Program. 

 

Dr Rohit Bhaskar, Physio
Dr Rohit Bhaskar, Physio Dr. Rohit Bhaskar, Physio is Founder of Bhaskar Health and Physiotherapy and is also a consulting physiotherapist. He completed his Graduation in Physiotherapy from Uttar Pradesh University of Medical Sciences. His clinical interests are in Chest Physiotherapy, stroke rehab, parkinson’s and head injury rehab. Bhaskar Health is dedicated to readers, doctors, physiotherapists, nurses, paramedics, pharmacists and other healthcare professionals. Bhaskar Health audience is the reason I feel so passionate about this project, so thanks for reading and sharing Bhaskar Health.

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