Chest Physiotherapy: Postural Drainage, Percussion & Vibration Guide

Chest Physiotherapy (CPT) is a group of therapies used to improve respiratory efficiency, promote expansion of the lungs, and strengthen respiratory muscles. Its primary goal is Airway Clearance: removing excess secretions (sputum) that can cause infection or obstruction. This guide covers the classic manual techniques: Postural Drainage (PD), Percussion, and Vibration, along with critical contraindications.

1. Indications & Safety (When NOT to do it)

CPT is vital for conditions like Cystic Fibrosis, Bronchiectasis, and Pneumonia. However, placing a patient in head-down positions carries risks.

⚠️ CONTRAINDICATIONS for Head-Down Positioning (Trendelenburg):
• Increased Intracranial Pressure (ICP > 20 mmHg).
• Uncontrolled Hypertension.
• Distended Abdomen / Recent abdominal surgery.
• Risk of Aspiration / Severe GERD (Reflux).
• Hemoptysis (Coughing up blood).

2. Postural Drainage: Gravity is Your Friend

The principle is simple: position the patient so the bronchus of the affected lung segment is perpendicular to the floor, allowing gravity to drain secretions into the main airways.

Lobe / Segment	Patient Position	Bed Position
Upper Lobes (Apical)	Sitting upright, leaning back slightly against pillows.	Flat
Upper Lobes (Anterior)	Supine (Lying on back) with pillow under knees.	Flat
Upper Lobes (Posterior)	Sitting, leaning forward over a pillow/table.	Flat
Right Middle Lobe	Lying on LEFT side, rotated 1/4 turn backward. Pillow behind back.	Foot of bed elevated (12-14 inches / 15°)
Lingula (Left Upper Lobe)	Lying on RIGHT side, rotated 1/4 turn backward.	Foot of bed elevated (12-14 inches / 15°)
Lower Lobes (Anterior Basal)	Supine with pillow under knees.	Foot of bed elevated (18-20 inches / 30°)
Lower Lobes (Posterior Basal)	Prone (Face down) with pillow under hips.	Foot of bed elevated (18-20 inches / 30°)
Lower Lobes (Lateral Basal)	Side-lying on the unaffected side.	Foot of bed elevated (18-20 inches / 30°)

3. Manual Techniques: Percussion & Vibration

These are used during postural drainage to loosen sticky secretions.

A. Percussion (Clapping)

• Technique: Rhythmic striking of the chest wall with cupped hands.
• Sound: Should be a hollow, popping sound ("Clop-Clop"), not a slapping sound.
• Mechanism: Creates an energy wave transmitted through the chest wall to loosen mucus from bronchial walls.
• Caution: Do NOT percuss over the spine, sternum, kidneys, or female breast tissue. Avoid if ribs are fractured (Flail Chest) or osteoporosis is severe.

B. Vibration & Shaking

• Technique: Applied ONLY during exhalation. The therapist places hands over the segment and applies a fine oscillating movement while compressing the chest.
• Goal: Helps move the loosened secretions into larger airways to be coughed out.

4. The Modern Adjunct: ACBT

Active Cycle of Breathing Technique (ACBT) allows the patient to clear secretions independently without relying purely on passive treatment.

The ACBT Cycle:
1. Breathing Control: Gentle diaphragmatic breathing (Relaxation).
2. Thoracic Expansion Exercises (TEE): Deep breath in, hold for 3s, passive sigh out. (Gets air behind sputum).
3. Forced Expiratory Technique (FET/Huff): "Huffing" (fogging a mirror) instead of coughing to prevent airway collapse.

5. Revision Notes for Students

Rule of Thumb: "Bad lung UP" improves V/Q matching (oxygenation), but for DRAINAGE, put the "Bad segment UP" so gravity pulls fluid down.
Trendelenburg (Head Down): Contraindicated for high ICP, uncontrolled HTN, reflux.
Percussion: Always use cupped hands. Hollow sound. Never on bare skin (use a towel/shirt).
Middle Lobe vs. Lingula: Middle is on Right (lie on Left side). Lingula is on Left (lie on Right side). Both require 1/4 turn backward.
Huff vs. Cough: Huffing is safer for COPD/Asthma as it prevents dynamic airway compression.

6. FAQs

Q1. How long should each position be held?

Ideally 5 to 10 minutes per position if tolerated, or until secretions are cleared. The entire session typically lasts 20-30 minutes.

Q2. Can I do CPT right after eating?

No. Wait at least 1-2 hours after meals to prevent vomiting and aspiration, especially for head-down positions.

Q3. Is CPT effective for Pneumonia?

It depends. For lobar pneumonia (consolidated), CPT doesn't help much. For bronchopneumonia with loose secretions, it is very effective. Hydration is also key.

7. 10 Practice MCQs

Q1. To drain the Right Middle Lobe, the patient should be positioned:

Answer: B) Right side up to drain it; 1/4 turn back exposes the medial aspect.

Q2. Which condition is an absolute contraindication for head-down (Trendelenburg) positioning?

Answer: B) Gravity increases venous return to the head, dangerously raising ICP.

Q3. Chest percussion should be performed with:

Answer: C) Cupping creates an air cushion for safe energy transmission.

Q4. Vibration techniques are applied during which phase of breathing?

Answer: B) Vibration assists the natural flow of air out of the lungs to move secretions.

Q5. The "Lingula" is part of which lung lobe?

Answer: C) It is the left-sided equivalent of the Right Middle Lobe.

Q6. To drain the Posterior Basal segments of the lower lobes, the patient lies:

Answer: A) Prone exposes the posterior segments to gravity.

Q7. Why is "Huffing" (FET) preferred over coughing in COPD?

Answer: B) Forceful coughing increases intrathoracic pressure, collapsing unstable airways. Huffing keeps them open.

Q8. How long should you wait after a meal before performing Postural Drainage?

Answer: C) To prevent Gastroesophageal Reflux (GERD) and aspiration.

Q9. Percussion is contraindicated over which area?

Answer: B) Direct trauma to bone (spine) or organs (kidneys) must be avoided.

Q10. The Apical segments of the Upper Lobes are drained in which position?

Answer: A) Since the apices are at the top, being upright uses gravity effectively.

References

• Pryor, J. A., & Prasad, S. A. (2008). Physiotherapy for Respiratory and Cardiac Problems. Elsevier.
• Frownfelter, D., & Dean, E. (2012). Cardiovascular and Pulmonary Physical Therapy: Evidence to Practice. Mosby.
• AARC Clinical Practice Guidelines. (2013). Postural Drainage Therapy.