(1) Percussion:

 Force rhythmically applied with therapist cupped hands to specific area of chest.
o The aim of this technique is to remove mucus from the airways.
o Place patient in the appropriate postural drainage position.
o Cover the area to be percussed with a lightweight cloth to avoid erythema.
o Percuss over area of thorax which corresponds to the involved lung segment.
o The technique is administered for 3 to 5 minutes over involved lung segment.
(2) Shaking (Vibration):
 Bouncing maneuver applied to the ribcage Performed during exhalation only.
 Helps the removal of secretions from the tracheobronchial tree.
 Used following percussion in the appropriate postural drainage position.
 When patient inhales, the therapist's hands placed fingers are parallel to the ribs.
 When patient exhales, the therapist's hands apply vibration to the ribcage below.
 5 to10-minute treatments are applied to each affected region.
(3) Coughing:
 Cough: is reflex controlled primarily by afferent stimulation of the vagus nerve.
 Double cough: After a deep inspiration, the patient performs two coughs in one breath
the second is usually more forceful than the first
 Huffing: The patient takes a deep inspiration and then air is forcefully exhaled as in
coughing except that the mouth is kept.
 Manual-Assisted Cough use if a patient has abdominal weakness manual pressure on
the abdominal area assists for a more forceful cough.
o Pt. in a supine position, the Th places the heel of one hand on the epigastric area just
distal to the xiphoid process. The other hand is placed on top of the first,
keeping the fingers open or interlocking them. After the patient inhales deeply the Th
manually with compressed inward and upward force, which pushes the diaphragm
upward to cause a more forceful and effective cough.
(4) Bronchial/Postural Drainage (PD):-
 Positioning the patient to promote gravity-assisted drainage of retained secretions.
 The head-down position is contraindicated in patients with pulmonary edema,
increased intracranial pressure, hemoptysis, large pleural effusion, and in any patient
who becomes anxious during treatment. Caution is indicated when positioning patients
who are recovering from orthopedic surgery, such as THR.
 The procedures involved in positioning patients for bronchial drainage include the
following steps:
o Explain the treatment to the patient and ask him to loosen tight clothing.
o Observe any tubes or other equipment connected to the patient.
o Check the patient’s vital signs and breath sounds.
o If the Pt has excessive secretions, have cough or suctioning before positioning.
o Place the patient in the proper position, with assistance if necessary.
o Maintain position for 5 to 20 minutes, depending on secretions and Pt tolerance.
o Have Pt breathe deeply during drainage but not hyperventilate or become dyspnea.
o Have the patient cough or perform suctioning before changing positions.
o Always treat the most critical areas first.
o Pts. should never be left in the head-down position unsupervised unless they are
alert and independent in functional mobility.
o Percussion and vibration, usually applied to facilitate the movement of secretions.
(5) Breathing Exercises and Ventilatory Training:
 Pursed-lip breathing: involves lightly pursing the lips together during controlled
exhalation. Have the Pt in comfortable position. Have the Pt breathe deeply
through the nose and then breathe out gently through lightly pursed.
 Positive expiratory pressure: a resistance to airflow is applied during
exhalation, Pt in an upright position seated with the elbows resting on a table. The
patient inhales, holds the inspiration for 2 to 3 seconds, and then exhales,
repeating the sequence for approximately 10 to 15 cycles. The patient takes
several coughs to clear the mobilized secretions from the airways.
 Inspiratory resistance training: using pressure devices to provide resistance to
airflow to improve the strength and endurance of the muscles of inspiration. The
patient inhales through a resistive training device placed in the mouth for a
specified period of time several times each day. The time is gradually increased
to 20 to 30 minutes at each session to increase inspiratory muscle endurance.
 Incentive Respiratory spirometry: sustained maximum inspirations. The
patient inhales deeply through a small, handheld spirometer that provides
feedback about whether a target maximum inspiration was reached. The purpose
of incentive spirometry is to increase the volume of air inspired.
(6) Chest mobilization exercises:
 (A) Chest mobilization during inspiration and expiration.
 (B) Chest expansion is increased with the arms overhead during inspiration.
Expiration is then reinforced by reaching the arms toward the floor.
 (C) A stretch is of the pectoralis muscles during inspiration, and expiration.

(A) (B) (C)