Cardiopulmonary Physiotherapy

HPI: History of Presenting Illness (or History of Presenting Complaint)

LMO: Local Medical Officer (a general practitioner or primary doctor)

Ix: Investigations (such as blood tests or scans)

Bx: Biopsy

Ca: Cancer or Carcinoma (or Calcium, depending on context)

AMI: Acute Myocardial Infarction (a heart attack)

1992 - CABG x3: In 1992, the patient had a Coronary Artery Bypass Graft procedure involving 3 bypass vessels (triple bypass open-heart surgery)

ETOH: Ethanol / Alcohol intake

JVPNR: Jugular Venous Pressure Not Raised (a normal neck vein finding suggesting no right-sided heart failure)

CXR: Chest X-ray

ECG: Electrocardiogram (heart tracing test)

NBM: Nil By Mouth (nothing to eat or drink)

Mane: Morning (Noct is night)

FBC G+H: Full Blood Count (FBC) to measure blood cells and a Group and Hold (G+H) to determine your blood type and screen for antibodies in case you need a transfusion

HB: Haemoglobin

PLT: Platelet Count

WCC: White Blood Cell Count

GA: General Anaesthetic

R/O: Removal of

RTW: Return to Ward

NGT: Nasogastric Tube

Look encompasses their general appearance:
• Level of consciousness: Awake / asleep / drowsy / unconscious
• Mental state and alertness
• Comfort level: Comfortable / restless / distressed
• Speaking in full sentences
• Physical attributes: Body size – obese / cachectic
• Requires assistance for tasks e.g. bed mobility
• Visible wounds / scars

Position and posture
• Bed vs chair
• Sitting / slumped / supine
• Leaning forward
• Bracing with arms

Colour
• Tone and colouration
• Cyanosis: bluish colour of skin / Mucous membranes
• Peripheral: extremities
• Central: lips / tongue / mucous membranes

Breathing Patterns:
• Observe (and palpate (FEEL)) activity of accessory muscles during breathing – resting (quiet) and deep breathing
• Pursed lip breathing  Adopted spontaneously by some patients
• Paradoxical rib movement – flail chest  where a section of rib cage moves in on inspiration
• Breath Rate 12-16 breaths / min
• Are their shoulders relaxed
• Outward movement of lower chest on inspiration
• Outward movement of abdomen with inspiration
• Symmetrical breathing patterns

You need to differentiate the thoracic pain to assess whether it might be cardiac related.

- When did this begin presenting? Was it trauma-induced, sudden onset or gradual/progressive over time
- Where do you feel the pain?
- What type of Pain is it? Dull, Aching, Heavy, Sharp? VAS score of Pain
- What are the aggravating factors? What eases the pain (NSAIDs, rest, etc)? Taking any medication?
- Have you had any other symptoms? (Nausea, Dyspnoea etc)

Soft tissues
Accessory muscles
Trachea
Chest expansion

1) We are to auscultate one full breath (isnpiration and expiration) at each of the 20 lung regions.

2) Beginning at the first point slightly above the clavicle, auscultate one side of the lung before progressign to the same placement but on the opposite lung.

3) Then move downwards and repeat across the five anterior auscultation points

4) Repeat for the 5 posterior auscultation points to assess the lower lobes

• Normal and abnormal Added sounds
• Crackles
• Wheeze
• Pleural rub
• Extrapulmonary noise
• Bronchial breath sounds (BBS)  These are harsh tubular sounds which are normal over large airways, but abnormal when heard over peripheral lung tissue. Caused by Consolidation and/or Fibrosis

• Crackles: Caused by changes in the elastic properties of the lung so that airways and alveoli suddenly open or close

• Wheezing: Mechanism not well understood but probably due to abnormal vibration or oscillation of narrowed airways

• Pleural rub: The noise made when the two surfaces of the pleura are inflamed and rub together

• Pericardial rub: Causes similar to pleural rub, the sound is frequently compared to a “creaking gate”

We palpate much of the same structures, including soft tissues, accessory muscles, trachea and chest function during respiratory processes such as inspiration. Generally, it is normal for us to palpate:
- The SCM and scalenes (neck accessory muscles) anteriorly
- The pectoralis / breast tissue
- The rib cage and intercostal muscles

Positive expiratory pressure (PEP) therapy is a breathing treatment that uses handheld devices or masks that create resistance when you breathe out to help clear trapped mucus from your lungs.

How PEP Works
• Breathing in: Air flows freely and easily into your lungs.
• Breathing out: You exhale hard against a resistor or small opening. This makes exhalation take longer than inhalation.
• Airway support: The back pressure "splints" or holds your airways open, preventing them from closing too early.
• Mucus clearance: Air gets behind the sticky mucus and helps push it up from smaller airways into the larger central airways where you can cough it out.

Common Uses
• Cystic Fibrosis
• Bronchiectasis
• Chronic Obstructive Pulmonary Disease (COPD)
• Pneumonia or other conditions with retained secretion

1) Increases functional residual capacity (FRC) and Lung Volume (LV) and reduced residual volume (air trapping)
- PEP maintains more air in the lungs at the end of expiration. This helps recruit atelectatic lung units and improve alveolar ventilation.

2) Promoters Collateral Ventilation
- Air travels through alternate pathways when the normal airway is obstructed. This allows air to get behind retained sections, helping move them towards larger airways. Was initially used to post-op to reinflate areas of the lung (AV trechnique) collapsed by using collateral ventilation but was later used to mobilise secretions

3) Splints the airways open during expiration
- Positive pressure prevents premature or dynamic airway collapse. This maintains expiratory airflow and allows more time for secretion clearance

ABGs are a medical blood test which measures the levels of oxygen and carbon dioxide, as well as the acid-base (pH) balance, by taking a small blood sample from an artery and analyzing it with an automated blood gas machine.

Blood is usually drawn from the radial artery at the wrist. The femoral artery in the groin or brachial artery in the arm can also be used. A heparinized syringe with a small needle is used to collect pulsating arterial blood.

An automated blood gas analyser uses electrodes and sensors to measure direct values and calculate others within 10 to 15 minutes.

• Directly Measured: pH (acidity), partial pressure of oxygen (PaO₂), and partial pressure of carbon dioxide (PaCO₂).
• Calculated Values: Bicarbonate (HCO₃⁻) and oxygen saturation (SaO₂) are often derived from the primary measurements

The Acid Base essential for body homeostasis. The shape of enzymes, essential for all body
processes is determined by pH, where a substantial change in pH can result in serious
problems e.g. coma or seizures.

To be clear, we must define key definitions first:

Acid = a substance that releases H+

Base = a substance that absorbs / accepts H+

pH = a reflection of the H+ ions in the blood

Base excess (BE) = amount of a strong acid required to return the pH to normal (can be added or removed)

pH: 7.38 - 7.42

PaCO2: 38-42 mmHg

PaO2: >80 mmHg

SaO2: 95-100%

HCO3-: 22 - 26 mEq / l (milliequivalents per liter)

BE: -3 --> 3 mEq / l

TV: 5 to 8 mL/kg (about 350 to 500 mL)

respiratory rate (RR0: 12 to 20 breaths per minute

pH < 7.38 is acidosis

pH > 7.42 is alkalosis

PaO2 < 90 but > 75 is mild hypoxia

PaO2 <75 mmHg is severe hypoxia

PaCO2 <38mmHg is alkalosis

PaCO2 > 42 mmHg is acidosis

HCO3 <22 mEq / l is acidosis

HCO3 > 26 mEq / l is alkalosis

↓ pH + ↑ CO₂ = Respiratory acidosis
- Casues include COPD, hypoventilation, respiratory fatigue, CNS depression

↑ pH + ↓ CO₂ = Respiratory alkalosis
Causes include anxiety, PE, early hypoxaemia, pain

↓ pH + ↓ HCO₃⁻ = Metabolic acidosis
-Causes include sepsis, shock, renal failure, DKA

↑ pH + ↑ HCO₃⁻ = Metabolic alkalosis
- Causes include vomiting, diuretics

↓ PaO₂ + normal/↓ CO₂ = Type 1 respiratory failure
- Causes include pneumonia, pulmonary oedema, PE, ARDS

↓ PaO₂ + ↑ CO₂ = Type 2 respiratory failure
- Causes include COPD, severe asthma, neuromuscular weakness, hypoventilation

An uncompensated arterial blood gas (ABG) has an abnormal pH with only one abnormal system value (PaCO2 or HCO3-), while a compensated ABG has a normal pH because the unaffected system has shifted out of range to balance it.

Uncompensated ABG
• pH: Abnormal (< 7.38 or > 7.42).
• Primary Cause: Abnormal (either PaCO2 for respiratory or HCO3- for metabolic).
• The Other System: Normal reference range (no attempt to fix yet).
• Clinical Meaning: Usually indicates a fresh or acute problem where the body has not yet had time to respond.

Compensated ABG (Fully Compensated)
• pH: Returned to normal range (7.38–7.42).
• Primary Cause: Abnormal.
• The Other System: Abnormal (shifted in the same or opposite direction to push pH back to normal).

The fraction of inspired oxygen, which is the concentration or percentage of oxygen a person inhales. Normal room air contains 21% oxygen, which is written as a decimal value of 0.21.

The Alveolar-arterial (A-a) gradient measures the difference between alveolar oxygen (PAO₂) and arterial oxygen (PaO₂). It is crucial for determining the cause of hypoxemia (abnormally low level of oxygen in the blood, specifically in the arteries.). Therefore the A-a gradient formula is PAO2 - PaO2

Normal A-a gradient is < 10mmHg

PA02 = (FiO2 x 713) - (PaCO2 / 0.8)

V/Q where V = Ventilation (air getting to alveoli) and Q = Perfusion (air entering bloodas exchange) The ideal V/Q is 0.8 (ventilation slightly less than perfusion) In a healthy individual the following V/Q ratios are observed:
- V/Q in middle of the lung = 1 (ventilation matches perfusion)
- V/Q in base of lung = 0.3 = Greater perfusion
- V/Q in apex (top) of lung = 2.1 = Greater ventilation

- Normal Ratio: A healthy lung has an ideal V/Q ratio of about 0.8, meaning ventilation is roughly 4 L/min and perfusion is 5 L/min.
- High V/Q (Dead Space): Ventilation exceeds perfusion. Air gets into the alveoli, but blood flow is blocked or reduced (e.g., from a pulmonary embolism).
- Low V/Q (Shunt-like): Perfusion exceeds ventilation. Blood flows past the alveoli, but air cannot get in due to an obstruction or fluid (e.g., from pneumonia, asthma, or COPD)

PaO2 is low

Look at PaCO₂ :
- Low or Normal PaCO₂ = Gas Exchange Issue causing Low PaO2
- High PaCO₂ = AV issue causing both PaO2 and PaCO₂

Why?
In a gas exchange issue (V / Q mismatch, pneumonia, atelctasis, lung cosnolidation etc) the patients oxygen transfer is impaired as the affected alveoli have little air, so less oxygen can enter the blood. However because CO₂ is 20x more readily dissolvable across the alveolar-capillary membrane, the unaffected areas of the lung can often continue removing CO₂ effectively. As a compensatory mechanism the patient may also breathe faster and deeper (hyperventilation), increasing ventilation in functioning parts of the lung and helping remove CO₂.

In a AV issue (Severe COPD, neuromuscular weakness, respiratory depression - sedatives / opiods) the patients oxygen transfer is impaired because not enough fresh air is reaching and entering the alveoli (Hypoventilation). Our cells continue producing CO₂, and blood continues delivering it to the lungs. However, the patient is not bringing enough fresh air into the alveoli or breathing enough air out to remove that CO₂, so therefore CO₂ accumulates in the blood, causing PaCO₂ to rise.

Essentially:
Gas exchange: Oxygen is not getting into the blood adequately but CO₂ is getting removed by functioning lung regions and hyperventilation
Alveolar ventilation: Not enough fresh air is reaching the alveoli to remove CO₂ adequately (hypoventilation - too slow and shallow breathing)

ABG outcome: Uncompensated Respiratory Alkalosis with hyperoxemia (excessive oxygen in blood --> Due to FiO2 and hyperventilation)

A-a Gradient:
PAO2 = [0.60 x 713] - [31/0.8]
PAO2 = 389.05 - 286 (PaO2)
= 103.05 which is abnormal as normal A-a gradient is <10mmHg

To test whether it is ventilation or perfusion ask these general questions:
- Is PaO2 within expected limits? No
- Is PaCo2 high, low or normal? Low (Hypocapnia) indicating Gas exchange and a V / Q mismatch
- A widened (elevated) A-a gradient is the hallmark sign that oxygen is failing to move properly across the alveolar-capillary membrane, pointing directly to a V/Q mismatch, diffusion defect, or shunt (gas exchange issue)

NOTE: Even though the patient's arterial oxygen tension (PaO2 = 286mmHg) is high, this is purely a result of providing a high concentration of inspired oxygen (FiO2 = 60%).

1. Check details
• Correct patient?
• Date and time?
• Compare with previous imaging if available.

2. Assess technical quality
• Projection
• Rotation
• Inspiration (chest X-rays should be taken during maximal inspiration)
• Exposure
• Image coverage

3. Assess systematically
A → Airway
B → Breathing/lungs and pleura
C → Cardiac/mediastinum
D → Diaphragm
E → Everything else
F → Foreign bodies: lines, tubes and drains

4. Describe the abnormality
A useful descriptive framework is:
• Where is it?
• What is its density/appearance?
• What structures are affected?
• Is there volume loss or expansion?
• Is there mediastinal shift?
• What is the likely pathology?

The two common projections are: PA & AP

PA — Posteroanterior
The X-ray beam travels: Posterior → anterior

The patient is usually upright with the anterior chest against the detector.

Important consideration:
A PA film generally provides a more accurate representation of heart size because the heart is closer to the detector.
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AP — Anteroposterior
The X-ray beam travels: Anterior → posterior

AP films are commonly performed:
• At the bedside
• In ICU
• In patients unable to stand

Important consideration:
An AP film can artificially magnify the cardiac silhouette (make the heart look bigger)
Therefore, apparent cardiomegaly should be interpreted cautiously on a portable AP film.

Rotation can distort the appearance of the:
• Mediastinum
• Heart
• Lungs/diaphragm

Assess rotation by comparing the distance between the medial ends of the clavicles and the spinous processes.

In a non-rotated film:
The medial clavicles should be approximately equidistant from the thoracic spinous processes.

Significant rotation can create a false appearance of:
• Mediastinal shift
• Unequal lung density
• Altered heart position

Exposure refers to whether an appropriate amount of X-ray radiation has passed through the chest.

Adequate penetration
The thoracic vertebral bodies should be Faintly visible through the cardiac silhouette / Should be able to see the spinous process of T4
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Underpenetrated / underexposed film
Too little radiation has passed through the patient.
The film may appear:
• Too white
• Dense

This can make the lungs appear falsely opaque and may obscure pathology.
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Overpenetrated / overexposed film
Too much radiation has passed through the patient.
The film may appear:
• Too dark

This can make subtle pulmonary abnormalities more difficult to identify.

• Standard View: Chest X-rays should be taken during maximal inspiration (the inspiratory phase of breathing).

• Prevents False Alarms: Poor inspiration (expiratory phase) crowds lung markings, makes the heart look bigger, and widens the upper mediastinum, which can falsely look like heart failure, fluid in the lungs, or collaps

The trachea should generally be midline but tracheal deviation may occur like:
Deviation away from the affected side:
• Tension pneumothorax
• Large pleural effusion
• Large mass

Deviation toward the affected side:
• Lung collapse
• Significant volume loss
• Post-pneumonectomy changes

The carina is usually visible around the level of T4–T5

For the Diaphragm, you must e able to recognise the:
• Right and left hemidiaphragms
• Costophrenic angles
• Cardiophrenic angles

Normal findings:
• The right hemidiaphragm is usually: Slightly higher than the left. (6th rib anteriorly and 9th rib posteriorly)
• Both costophrenic angles should normally be: Sharp and well defined.

Airspace Disease occurs when alveolar air is replaced or when there is a loss of aerated lung. Two important examples are:
- Collapse (Atelectasis)
- Consolidation

Atelectasis is: Loss of aeration of part or all of the lung associated with loss of lung volume.

Possible causes include:
• Mucus plugging
• Airway obstruction
• Tumour
• Postoperative hypoventilation
• External compression
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Key radiographic features (look for)
The major concept is Opacity + volume loss
• Increased opacity
• Displacement of interlobar fissures towards area of collapse
• Crowding of ribs (the ribs on the affected side are closer together than normal because of a loss of lung volume)
• Mediastinal or tracheal shift towards the affected side
• Compensatory hyperinflation of remaining lung
• Elevation of a ipsilateral hemidiaphragm

Physiological relevance
Collapse reduces the available area for ventilation and may contribute to:
• V/Q mismatch
• Shunt
• Hypoxaemia
• Reduced lung compliance

Definition
Consolidation occurs when air within the alveoli is replaced by material such as:
• Inflammatory exudate
• Pus
• Fluid
• Blood
• Cells
A common cause is Pneumonia
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Radiographic features (look for)
• Homogeneous Opacification: An area of increased whiteness (density) in the lung fields that obscures the normal lung tissue and the normal lung borders such as the hemidiaphragm
• Air Bronchograms: This is a hallmark sign. Normally bronhci are difficult to distinguish from the sourrounding air-filled lung, however in consolidation, as the alveoli fill with fluid (white), the air-filled bronchi running through them remain dark, creating a visible "branching tree" effect.

Infiltrates are abnormal substances, such as fluid, pus, or cells, that fills the lung tissue and shows up as bright white areas where dark air should normally be. There are three types of infiltrates to know and recognise.

Three types include:
1) Interstitial
2) Pleural
3) Alveolar

• Location: Found in the interstitium, which is the supportive framework or walls surrounding the air sacs. LOOK FOR CLOUDING CENTRALLY

• Appearance: Looks like fine lines, small dots, a mesh, or a "cobweb" pattern.

• Common Causes: Viral infections, early swelling, or chronic scarring diseases

• Location: Found in the pleural space, which is the narrow gap between the outside of the lung and the inside of the chest wall. LOOK FOR CLOUDING DISTALLY

• Appearance: Looks like a smooth white layer at the base of the chest, hiding the sharp normal edges of the diaphragm.

• Common Causes: Heart failure, infection (possie exudate), or fluid leaking from the body into the chest cavity (transudate)

Exudate = protein and cell-rich fluid that leaks out of blood vessels due to local inflammation or tissue damage

Transudate = clear, watery fluid pushed out by systemic pressure imbalances where vessel walls remain intact.

Same signs seen in consolidation

• Location: Found directly inside the alveoli (the tiny air sacs where oxygen enters the blood).

• Appearance: Looks fluffy, dense, and cloud-like, often blending together into solid white patches (consolidation). Air Bronchodiagrams will show Dark, branching air-filled bronchi stand out clearly against the bright, fluid-filled opacified lung background. LOOK FOR DARK RIVERS (air bronchodiagrams)

• Common Causes: Bacterial pneumonia, severe fluid overload, or lung trauma

An electrocardiogram is a recording of the electrical activity of the heart on the skins surface. An ECG involves 10 electrodes, with one on each limb (limb leads) and the remaining 6 in an arc around the heart (chest leads).

P wave = atrial depolarisation

PR Interval = SA node to AV node impulse

QRS = Ventricular depolarisation

ST segment = Plateau phase in ventricle

T wave = ventricular repolarisation

A cardiac dysrhythmia (arrhythmia) is an abnormal heart rhythm where the heart beats too fast (tachycardia), too slow (bradycardia), or irregularly, resulting from faults in the heart’s electrical system. Arrythmias can be sinus node abnormalities, atrial and ventricular conduction abnormalities.

These are all SA node abnormalities:

Bradycardia (<60 beats / minute)
– regular but slow heartrate
– results from vagal nerve/PNS stimulation

Tachycardia (100-160 beats / minute)
– regular but rapid heartrate
– normal response to SNS stimulation
– compensation for decreased blood volume

Sick sinus syndrome (HR irregularity)
– marked by altering bradycardia and tachycardia and often requires mechanical pacemaker
• Causes: damage to SA node from heart surgery, drugs, heart disease

Atrial flutter is a type of atrial conduction abnormality
– Atrial heart rate of 160 to 350beats/min. Rapid and organised flutter of the heart
• AV node delays conduction – ventricular rate is slower (2:1 ratio)
• ↓stroke volume
• 'Saw-tooth' ECG
•Causes: Coronary heart disease, heart failure, mitral valve disease

Atrial fibrillation is a type of atrial conduction abnormality
- No distinct P waves but normal QRS under an Irregularly irregular rhythm
• leads to pooling of blood in the atria increasing thrombus risk
• Causes: Coronary heart disease, heart failure, mitral valve disease, hypertension, congenital heart defect

Ventricular tachycardia
• Normal contractions but very fast
• Wide QRS (3 small boxes or > 0.12 seconds)
• Rapid rate
Danger: ultimately reduces CO and may deteriorate into ventricular fibrillation

Self limiting VT is one that starts and stops on its own in less than 30 seconds

Ventricular fibrillation
• Chaotic waveform with very little or no contraction. Life-threatening
• No effective filling or ejection of the ventricle
• No cardiac output leading to cardiac arrest
• No P, QRS or T waves, just eratic waveforms

ECG: PR interval >0.20 (over one big box) seconds but every P wave is still followed by a QRS.

So conduction is: Slow, but all impulses get through.

Some atrial impulses Fail to conduct to the ventricles.

There are two major patterns: One is Mobitz I / Wenckebach

Mobitz I / Wenckebach is a progressive PR prolongation (gets longer each QRS) → dropped QRS
Then the cycle repeats.

Mobitz II is where a PR intervals remain relatively constant then suddenly a QRS is dropped.

This is more concerning because it can progress to a Complete heart block.

There is a Complete dissociation between atrial and ventricular activity.

P waves occur independently of QRS complexes.

The atria follow the SA node, while the ventricles are driven by an escape rhythm.

ECG
• P waves occur regularly
• QRS complexes occur regularly
• But there is no consistent relationship between them

Right Bundle Branch Block (MaRRoW)

- M sign will appear between V1 and V4
- RR means right bundle branch block
- W sign will appear in v 6

Left Bundle Branch Block (WiLLaM)

- W sign will appear between V1 and V4
- LL means left bundle branch
- M sign will appear in V6

Spirometry measures airflow and the volume of air that a person can move in and out of their lungs whereby the patient breathes through a mouthpiece connected to a spirometer. It involves the measurement of forced expiration from TLC.

Spirometry is the most commonly performed test of lung function and is often performed by physiotherapists. Patients readings are compared to age and height matched normative values. Perform at least 3 to get their best effort.

Forced Expiratory Volume in 1 Second (FEV₁)
FEV₁ = the volume of air forcibly exhaled during the first second of the FVC manoeuvre

FEV₁ is particularly useful for identifying airflow obstruction as FEV₁ may be dreduced by narrowing of airways.

Normal FEV₁
Approximately 80–120% of predicted is often used as a rough reference, although LLNeference equations are preferred clinically.

Forced Vital Capacity (FVC)
FVC = the maximum volume of air that can be forcibly exhaled after taking a maximal inspiration.

A person takes the deepest breath possible and then exhales as hard and as completely as possible. The total volume exhaled = FVC.

Normal FVC
FVC is generally around 80–120% of predicted, although interpretation should use the appropriate reference equations and lower limit of normal (LLN) rather than relying solely on a fixed percentage.


FEV₁/FVC Ratio
The FEV₁/FVC ratio tells us what proportion of the person's total forced exhaled volume comes out during the first second.

Normal
Approximately ≥0.70, but clinically the LLN is preferred because the normal ratio decreases with age.

A spirometer can produce a volume-time curve and a flow-volume loop.

Obstructive Spirometry on a volume-time curve = Exhalation is slower and takes longer to reach the plateau, ⬇️ FEV₁ / FVC ratio <75%

Restrictive Spirometry on a volume-time curve = The total volume is reduced, but the curve can retain a relatively normal shape.


Flow- volume Loops provide a graphic representation of changes in flow rate during inspiration and expiration. A normal flow volume looks like a triangle sitting on top of a semi circle.

Obstructive spirometry on a flow-volume loop = scooped-out or caved-in expiratory (concave) curve due to trapped air

Restrictive spirometry on a flow-volume loop = The curve looks tall and narrow, resembling a miniature normal loop.

1) Compare Actual and predicted values for FEV₁ and FVC

2) Look at the FEV₁ / FVC ratio
- < predicted = obstructive pattern
- > or = predicted = restrictive pattern

3) HLCO < predicted means decreased diffusion capacity for carbon monoxide, < 100% of predicted = increased

4) Static Lung Function (TLC, RV, FRC, VC)
- TLC < predicted = Restricitve
- TLC > predicted (>120%) = Hyperinflation
- RV > predicted = air trapping

An Obstructive and Restrictive Pattern:
- FEV₁, FVC and FEV₁ / FVC ratio (<0.70) all decreased = Obstructive and restrictive
- TLC < predicted = restrictive further confirmation

Peak Expiratory Flow (PEF) is the maximum flow rate achieved during a forceful expiration after maximal inspiration.

It is usually measured in: L/min

A peak flow meter is a small, portable device.

The patient:
1. Takes a maximal inspiration
2. Seals lips around the mouthpiece
3. Blows out as hard and as fast as possible
4. Records the highest value

Usually several attempts are performed and the best effort is recorded.

PEF is commonly used for monitoring asthma, assessing response to bronchodilators and the home monitoring of respiratory conditions

• Tidal Volume (TV): The amount of air you breathe in or out during a normal, quiet breath (about 500 milliliters).

• Inspiratory Reserve Volume (IRV): The extra air you can force yourself to breathe in after a normal inhalation (about 3,000 milliliters).

• Expiratory Reserve Volume (ERV): The extra air you can force yourself to breathe out after a normal exhalation (about 1,200 milliliters).

• Residual Volume (RV): The air that stays in your lungs even after you breathe out as hard as you can (about 1,200 milliliters).

Lung capacities are combinations of two or more lung volumes:

• Inspiratory Capacity (IC): Tidal Volume plus Inspiratory Reserve Volume (VT + IRV)

• Vital Capacity (VC): Total amount of air you can exhale after taking your biggest breath in. IRV + VT + ERV

• Functional Residual Capacity (FRC): Air left in the lungs after a normal, quiet breath out. ERV + RV

• Total Lung Capacity (TLC): The maximum amount of air your lungs can hold, averaging about 6 liters in adult males. IRV + VT + ERV + RV

1) Alveolar Ventilation (Not enough fresh air reaching alveoli)

2) Secretion Clearance (Cannot effectively clear mucus)

3) Gas Exchange (O₂ / CO₂ transfer impaired)

4) Increased Work Of Breathing (WOB) (Too much effort required to breathe)

Alveolar ventilation = the amount of fresh air reaching the alveoli per minute and available for gas exchange

Physical observation
The patient may present with:
• Shortness of breath / dyspnoea
• Quick Onset (eg; post op)
• Increased respiratory rate or abnormally slow breathing
• Shallow breathing
• Reduced tidal volume
• Poor chest expansion
• Accessory muscle use if respiratory effort is increased
• Fatigue
• Reduced level of alertness in severe hypercapnia
• Headache, confusion or drowsiness with significant CO₂ retention
• Cyanosis may occur with significant hypoxaemia

Auscultation
• There isn't one characteristic auscultation finding for impaired AV but you may hear
• Reduced/quiet breath sounds → low ventilation (VERY COMMON)
• Diminished air entry
• Wheeze if airway obstruction is contributing
• Can just be normal

CXR
• There is no specific CXR appearance of hypoventilation itself.
• May be normal; possible atelectasisnderlying disease

ABG
This is the definitive diagnostic tool. You will see
• Elevated PaCO₂ (Hypercapnia), typically >45 mmHg (↓ AV → ↑ PaCO₂ )
• Decreased pH (<7.35) in acute cases

Spirometry (may show depending on cause)
• Reduced FVC/FEV₁ in neuromuscular weakness
• Obstructive pattern if airway disease is responsible
• Restrictive pattern if reduced respiratory muscle/chest wall function is responsible

Secretion Clearance = the patient has excessive or retained respiratory secretions that they cannot effectively clear.

Common causes:
• Pneumonia
• Bronchiectasis
• COPD
• Cystic fibrosis

Physical observation
• Weak but productive / wet cough
• Coarse breathing sounds may sometimes be audible without a stethoscope
• Reduced chest expansion in affected areas
• Frequent coughing
• Difficulty clearing sputum
• Audible secretions
• Sputum production
• Increased respiratory rate (tachypaenia)
• Dyspnoea

Auscultation (classic findings include)
• Presence of coarse crackles = secretions in larger airways which may clear or change after coughing
• Rhonchi = Low-pitched/coarse sounds associated with airflow through larger airways containing secretions. They may also change following coughing.
• Wheezes = mucus causes airway narrowing
• Diminished or absent breath sounds indicating mucus plugging (obstructed airwas)

CXR
• Infiltrates indicating retained secretions (interstital, pleural or alveolar)
• Consolidation = Airspace opacity ± air bronchograms
• Atelectasis = opacification, volume loss / crowding of lungs, elevate hemidiaphragm

ABG (V/Q mismatching caused by plugged airways or alveolar hypoventilation)
• Hypoxemia (PaO₂ < 80 mmHg): The most common finding due to mucus plugging, which blocks airflow to perfused alveoli.

Spirometry
• A reduced FEV₁ and a decreased FEV₁ / FVC ratio (< 70%) due to physical airway narrowing by mucus
• Obstructive presentation ⬆️⬆️

The respiratory system is unable to adequately Get O₂ into the blood and/or remove CO₂. The main mechanisms causing impaired gas exchange are:
• V/Q mismatch
• Shunt
• Diffusion limitation
• Low inspired oxygen
• Hypoventilation

Physical observation
• Dyspnoea (shortness of breath)
• Tachypnoea (respiratory rate >20 breaths / min)
• Increased WOB
• Accessory muscle use
• Cyanosis in significant hypoxaemia
• Restlessness/anxiety
• Fatigue

Auscultation
There is no single sound that means "gas exchange problem." Depending on the pathology:
• Wheezes: High-pitched, musical sounds indicating bronchoconstriction or airway narrowing (common in asthma or COPD).
• Crackles: Discontinuous popping sounds indicating fluid in the alveoli or small airways (common in pneumonia, pulmonary edema, or heart failure).
• Decreased or Absent Breath Sounds: Suggests a pneumothorax, severe pleural effusion, or atelectasis where air is not entering the lung space.

CXR
CXR findings will depend on the cause, but most commonly you will see:
• Pneumonia → Consolidation
• Pulmonary oedema → Bilateral interstitial/alveolar opacities
• Infilitrates imparing gas exchange

ABG (gold standard for detecting a gas exchange problem at the alveolar-capillary membrane)
• Hypoxemia (Type 1 Respiratory Failure): Characterized by a low partial pressure of oxygen (PaO₂ < 60mmHg) but PaCO₂ may be Normal,↓ due to hyperventilation or ↑ in severe fatigue/hypoventilation

• Hypercapnia (Type 2 Respiratory Failure): Characterized by a high partial pressure of carbon dioxide (PaCO₂ > 45mmHg) typically accompanied by hypoxemia. 

• ↓ SpO₂ (especially during exercise or activity)

Work of breathing pathology occurs when the respiratory muscles must generate more force/pressure to move air. This can occur because of:

Increased resistive load (The friction and resistance encountered by air flowing through the airways)
• COPD
• Asthma
• Secretions
• Airway oedema
• Bronchospasm

Increased elastic load (The stiffness and recoil forces of the lungs and chest wall that resist being stretched)
• Pulmonary fibrosis
• Pulmonary oedema
• Pneumonia
• ARDS
• Atelectasis

Increased threshold load (A set amount of pressure that must be reached before any airflow can begin)
• Intrinsic PEEP/auto-PEEP
• COPD
• Dynamic hyperinflation

Physical observation (where it is most obvious, look for)
• Increased Respiratory rate and Accessory muscle use (Sternocleidomastoid, Scalenes, Pectoralis minor / major)
•Increased respiratory effort (Visible increased effort with inspiration/expiration)
• Increased chest movement
• Reduced chest expansion
• Rapid shallow breathing
• Irregular breathing
• Prolonged expiration
• Upright or Forward-leaning/tripod position posture
• Nasal flaring
• Intercostal recession
• Sweating
• Anxiety/agitation
• Cyanosis
• Fatigue
• Reduced ability to speak in full sentences

Auscultation (depends on the cause of WOB)
• Obstructive Disease will present as reduced breath sounds, prolonged expiratory phase or wheeze
• Pulmonary Oedema = fine inspiratory crackles
• Pneumonia and SC = coarse crackles

CXR = WOB itself doesn't have a specific radiographic appearance,

ABG
•↑ ventilation (compensatory hyperventilation) → ↓ PaCO₂, → ↑ pH
• However, if respiratory muscles fatigue:↓ alveolar ventilation will lead to↑ PaCO₂ and thus pH ↓
• This transition from: Low CO₂ → rising CO₂ can be clinically important in severe respiratory disease

Spirometry = Depends on the cause (is it obstrucitve or restricitve pathology)

1) Dysponea, reduced breath sounds on auscultation, increased PaCO₂, increased RR or abnormally slow breathing

2) Productive / wet cough, coarse crackles / bronchi on auscultation, consolidation or atelectasis on CXR, Obstructive spirometer pattern

3) Shortness of breath, tachypnoea and increased RR, possible cyanosis, hypoxemia (decreased PaO₂),↓ SpO₂ and a widened alveolar-arterial oxygen gradient

4) Physically observavable charachterisitcs like: Increased repsiratory rate and effort, increased accessory muscle use, forward leaning posture, prolonged expiration

Performing Technique:
1) Get the patient to shuffle up the bed as far as possible by bringing their knees up and getting them to lift their bottom up and push up the bed.

2) After patient has shuffled up, ask them to bring their head up while you raise the head rest height

3) With the bed at 45 ask the patient to bring their knees up and little bit to prepare for comfortability. Continue to raise the bed using the chair function or just by bending at the knee and bringing the seat to 90 until upright

4) Reposition pillows, ask for patient comfort and inform them that they are to stay here to maximise benefits

Breathing exercises include lateral base expansion (LBE) and Inspiratory Hold (IH) and these:
1) Allows for collateral ventilation – When you hold your breath at full inspiration, the sustained high pressure forces air through these alternative pathways into neighbouring, under-ventilated, or collapsed alveoli (atelectasis). ALTERNATIVE PATHWAYS FOR AIR

2) Interdependence – adjacent alveoli share their walls and mechanical forces thus when alveoli expand this exerts traction on neighbouring alveoli helping them to remain open. Previously collapsed alveoli will fill due to the surrounding healthy alveoli filling. This relies on a slow time constant (deep sustained breathing to allow alveoli to fill) ALVEOLI HELP PULL EACH OTHER OPEN

3) Slow time constants – A slow, deep and sustained inspiration gives more time for the aor to each poorly ventilated areas of the lung. MORE TIME FOR AIR TO GET IN

1) Ask patient to take some deep breaths in through their nose and out through their nose (if they can) while counting to three in and out as they go.

2) Palpate chest / thorax and guide the breathwork counting for the patient eg: “In for three, 1…2….3 and out for three, 1…. 2…. 3”.

3) Explain palpation observations to patient such as “I can feel that your left side of lung is moving a little more than your right side, could you try direct some more of your airflow to that right side?’

4) Repeat 3 second breathwork while continuing to palpate

5) Ask patient to now add a ‘hold’ at the top for two seconds while continuing to breath in and out 3 seconds at a time.

6) After so many reps give the patient a break and ask them to perform another set of three this time without the PTs feedback and counting. Observe to ensure they are doing it correctly

Dosage: 2-3x daily, during acute exarcabation of symptoms or just included as part of the 10-20 minute ACBT session.

Absolute Contraindications:
• Untreated or undrained pneumothorax.

Relative Contraindications & Precautions (Modify or Postpone):
• Rib or sternum fractures, or flail chest: Manual pressure or deep expansion over unstable bones causes extreme pain and risks bone displacement.
• Severe chest wall pain or muscle guarding: Post-operative patients must have adequate analgesia and manual incision support before attempting expansion.
• Severe osteoporosis: Extreme care or avoidance is required to prevent pathological rib fractures from manual compression.
• Severe bronchospasm or acute asthma: Forcing deep segment expansion during acute airway narrowing can worsen air trapping and respiratory distress

This incentive spirometer is called a tri-flow and its going to give you some feedback when your doing your breathing exercises. There are three chambers which will train you to inhale at a steady, slow and controlled rate as each of the three chambers contains a coloured ball and is calibrated with a specific minimum flow requirement. That is different balls will raise at different breath strengths.

Intro) “Hey ___ Im just going to go through prescribing and using a incentive spirometer with you, is that okay?” [Explain Incentive spirometer]

1) 'I’m going to get you to breath in nice, slowly and deeply so that only the ball in the first chamber rises'

2) 'You’ll wrap your lips around that and with your lips sealed around you’ll breath in nice, deeply and slowly.'

3) 'See if you can hold the first ball at the top of the chamber for three seconds' – PT counts for patient

4) Encourage the patient to breath all the way in and all the way out, being repetitive in your wording of deep, slow and steady breath control.

• Uncooperative or Noncompliant Patients: Patients who cannot or will not follow instructions.
• Cognitive Impairment or Severe Confusion: Patients with dementia, delirium, or severe developmental delay who cannot be properly instructed or supervised.
• Inability to Generate Deep Breath: Patients who are heavily sedated, comatose, or exhausted

Mobilisation will increase pulmonary ventilation, lung expansion and improve physical mobility. However we want to reinforce that we want them breathing deeply and not quickly.

Bed → sitting → standing → walking
↓
↑Increase tidal volume
↓
↑ Increase ventilation
↓
Improved lung expansion
↓
Improved secretion clearance
↓
Improved V/Q matching
↓
Improved functional capacity

- These consist of two small prongs that fit into the nostrils, and they are connected directly to the oxygen source

- These deliver supplemental oxygen at a flow rate of up to 4L/min to patients. 1 L of additional oxygen by nasal prongs multiplies the FiO2 by 3% as it is delivered directly up the nares. Therefore, FiO2 for a patient receiving 2L/min by nasal prongs has an FiO2 of 21% + 6% = 27%

- Best for: Mild hypoxia or stable patients

- It covers the nose, mouth and is securely held in place by an elastic strap
- These are used for delivering supplemental oxygen at flow rates between 5-10L/min to patients

- Minute ventilation requirement is 10ml per kg eg; 60kg = 6L/min or 5 to 8 liters per minute for a normal adult

- Patients entrain room air to mix with oxygen delivered by the mask in order to meet their MV

- Best for: Moderate hypoxia or patients who breathe heavily through their mouths

- A nebuliser mask is used to administer inhaled medications to patients with respiratory issues. It flows at a minimum flow rate of 10L/min

- Connected to a nebuliser machine is wall oxygen or air (on the diagram) that converts liquid medications into fine mist particles that are easily inhaled (eg; bronchodilators). Room air may be suitable over oxygen for patients with COPD as this may cause their breathing to stop. You can use a nebuliser mask with nasal prongs connected to O2

- The mask will ensure effective medication delivery to the lungs rather than deposition into the mouth or URT

- Best for: Pediatric patients (typically aged 5–6 years or younger) who lack the coordination or ability to seal their lips properly around a mouthpiece. Patients experiencing acute respiratory distress, severe asthma, or a COPD exacerbation who find it too difficult or exhausting to use a mouthpiece

- A NRBM is a low-flow mask used to provide high concentrations of oxygen to patients with a minimum flow rate of 15L/min to ensure the reservoir bag stays inflated

- It covers the nose and mouth featuring a one way valve that prevents exhaled air from entering the mask

- With reservoir bags and adjustable flow rates it ensures maximum oxygen delivery up to an FIO2 of approximately 0.70 (the concentration of oxygen in a patient’s gas mixture)

- Used for delivering supplemental oxygen at high flow rates to patients who need significant or precise assistance with breathing

- It features an adjustable system of valves/dials and adaptors that mix oxygen with room air ensuring accurate and controlled oxygen therapy. You can choose the FiO2 and the mask will tell you the flow rate to put on the wall

- It can deliver oxygen at specific FiO2 values from 21% to 50%

The less room air you include – the higher the fio2.
- Mixing 21% room air with pure supplemental oxygen lowers the overall percentage of oxygen you actually breathe.

- Limiting or eliminating room air entrainment—such as by using a high-flow device or a sealed non-rebreather mask—keeps the oxygen concentrated, raising the FiO₂ closer to 100%

Bedrest can cause ↓ Lung volumes as prolonged lying, particularly supine positioning, can cause:
• ↓ FRC
• ↓ tidal volume
• ↓ inspiratory capacity
↓
Decreased Ventilation of dependent lung regions
↓
V/Q mismatch
↓
Hypoxaemia

Reduced lung volumes + poor ventilation can cause: Small airway closure → alveolar collapse (atelectasis)

One of the major effects is cardiovascular deconditioning, this includes reduced Venous return and orthostatic intolerance

When standing and walking: Muscle pump → venous return → cardiac output

With bed rest: ↓ muscle pump activity →↓ venous return


Orthostatic intolerance - After prolonged bed rest:
Standing
↓
Blood pools in lower limbs
↓
Decreased venous return
↓
Decreased cardiac output / cerebral perfusion
↓
Dizziness, light-headedness, hypotension. This is orthostatic hypotension/intolerance.

ATROPHY + MUSCLE WEAKNESS
Disuse
↓
↓ muscle protein synthesis
↓
Muscle atrophy
↓
↓ strength (drops 1-1.5% per day with postural muscles affected quickly and the lower body suffers greater atrophy than the upper body)
________________________________________
LOSS OF FUNCTIONAL CAPACITY
Difficulty with:
• Bed mobility
• Transfers
• Standing
• Walking
• Stairs
• Muscle endurance (eg; 15-20% reduction in knee extension after 4 weeks of bed rest)

CONTRACTURES, JOINT STIFFNESS & REDUCED ROM

REDUCED BONE DENSITY & INCREASED FRACTURE RISK
Prolonged unloading
↓
Decreased mechanical loading (bones need mechanical stress to maintain density)
↓
Increased bone resorption
↓
Reduced bone density (loss of calcium from bone)
↓
Increased fracture risk over time

Secretion Clearance starts with the subjective assessment as the patient can report:
- excessive secretions
- the amount of sputum
- characteristics like colour and thickness
- ease of clearance
- how they have cleared it (if they have)
- what position it manifests
- any shortness of breath (SOB)

O / E may let us find:
- Fever, temperature and HR
- Cough Characteristics: Strong or weak, dry or moist, productive or non-productive
- Breathwork: Noisy, quick, shallow etc
- Auscultation: Wheeze, coarse crackles or rhonchi (Indicative of SC), URTN’s, reduced breath sounds
- Chest expansion: Normal, LBE

The results of the O/E and S/E will let us know whether we need to inquire into further investigations. This may mean:

+ve ABG = redcued Pa02 or increased PaC02

+ve CXR = signs of collapse or consolidation, Infiltrates

+ve PFTs = reduced FEV1 due to obstruction of airflow, however not always used clinically

+ve Lab Tests = sputum culture

Mobilisation Techniques
Airway Clearance Techniques (ACTs)
Postural Drainage
Devices (Flutter, PEP, Acapella, cough assist)

- Mobilisation (moving, walking, or changing body positions) improves secretion clearance by using gravity, increasing airflow behind mucus, and stimulating deeper breathing

- Exercise and movement will increase Myocardial Cardiac Cost (MCC), volume and Exploration Fonctionnelle Respiratoire (Respiratory Function Test or Pulmonary Function Test)

- It is a non-specific technique with no specific research

- PD uses gravity to assist the clearance of secretions from lung segments as the segment to be drained is placed non-dependant with the orientation of the bronchus such that secretions will be drained towards the man airways for clearance via ACT. Usually included with other techniques

- Indications for PD include: excessive secretions, difficulty clearing secretions, globalegional problem

- Historically this was a mainstay of cystic Fibrosis management, not many reasons to perform head-down-tip (HDT) on adults therefore not really used

- Contraindications / precautions: High ICP, recent neuro failure, CVS instability, hypertension, pulmonary oedema/heart failure, respiratory distress (extreme SOB), upper GIT, eye, head and neck surgery, severe abdominal distension, obesity, late in pregnancy

Huff & Cough

Forced Expiratory Technique (FET)

Active Cycles of Breathing Technique (ACBT)

Percussion

Vibrations

Positive Expiratory Pressure Mask (PEP)

Cough Assist Device

Oscillating Positive Expiratory Pressure (OPEP) - Flutter device

Percs x Vibes x ACBT

• Sit upright: Keep your posture straight with your chin tilted slightly up and your mouth open.

• Inhale slowly: Take a deep breath to fill your lungs about three-quarters full.

• Inspiratory Hold: Pause for 2 to 3 seconds to let air get behind the mucus.

• Exhale actively: Push the air out forcefully but smoothly, making a "huff" sound as if fogging up a mirror or window.

• Clear the mucus: Repeat the huff manoeuvre two or three times, then finish with one strong cough to expel the loosened mucus

An Assisted Coughing technique helps people with weak abdominal or chest muscles (due to injury or a medical condition) clear lung secretions.

• Abdominal / Heimlich-style assist: A caregiver places hands on your upper abdomen, pressing inward and upward under the patients xiphoid process as they cough. Ensure a towel or padding is placed between mobilisation and patient

• Costophrenic assist: A caregiver firmly squeezes and pushes down on the lower rib cage as you exhale or cough. Ensure a towel or padding is placed between mobilisation and patient

Wound support or "splinting" protects a surgical incision or chest/abdominal injury during a cough. To perform:
• Hold a pillow: Press a firm pillow tightly against your incision or wound using your hands or arms before you cough or huff.

• Bend knees: If lying down, bend your knees to relax your abdominal muscles and lessen strain on your stitches.

• Breathe and press: Take a deep breath in and apply firm, steady pressure to the pillow as you cough to minimize pain

DISTAL:
To move mucus out of the small, distant airways at the bottom of the lungs, you must focus on low lung volumes and gentle force as his keeps the smaller airways open for longer, preventing them from collapsing and trapping the mucus.

• Thoracic Expansion Exercises (TEE) in ACBT: You take deep, slow inspirations, holding your breath for 3 seconds at the top. This utilizes collateral ventilation, allowing air to get behind the mucus in peripheral airways and push it forward.

• Low-Volume Huffing in FET: Taking a small-to-medium breath in and performing a long, gentle, sustained "huff" (forced expiration) targets the distal airways.

PROXIMAL:
Once mucus has traveled up into the larger airways (bronchi and trachea), the goal changes to generating high airflow velocity to clear it out.

• FET - you cannot target proximal secretions using FET unless you take a deep breath in, thus its better suited to ACBT which is essntially FET with a deep breath

• High-Volume Huffing in ACBT: Taking a deep breath in and performing a short, fast, and forceful "huff" targets the proximal airways. Because the lungs are full, the airways are wider, and the high-velocity air shears mucus off the walls of the larger airways.

1. Sit comfortably: Maintain a relaxed, upright posture with good support.

2. Breathe in: Take a breath in at a relaxed rate (low volume for deep mucus, or a larger breath for mucus higher up - which makes it more ACBT).

3. Keep the throat open: Keep your mouth and throat wide open in an "O" shape. Do not tighten your throat or close your vocal cords for maximum benefit

4. Exhale (Huff): Push the air out actively and smoothly using your stomach muscles, making a "huff" sound like fogging glass. Do this for 1 to 2 huffs.

5. Recover: Return to gentle, relaxed breathing (breathing control) to rest your airways before repeating or attempting a final clear cough.

NOTE: BC can be any relaxed breathing technique you like eg; box breathing, candlestick breathing etc

Three Phases of ACBT:
• Breathing Control: Relaxed, gentle tidal breathing using the lower chest and abdomen while keeping the upper chest and shoulders loose. Breathe in softly through your nose and out through your mouth. Use this phase to recover between more active exercises.

• Thoracic Expansion (Deep Breathing): Slow, deep breaths taken in through the nose, filling the lungs completely. Hold the air in for 2 to 3 seconds before breathing out gently and passively through the mouth. Repeat this 3 to 5 times (TEE)

• Forced Expiratory Technique (FET): Exhaling forcefully through an open mouth—similar to fogging up a mirror—using your stomach muscles to move mucus upward from the smaller airways to the larger ones. Start with a small, long huff, followed by a big, short huff, ending with a productive cough only if mucus has reached the upper airways

1) Teach patient TEE and FET in Isolation

2) Combine TEE with the FET technique, instructing the patient to take 3-5 slow deep breaths filling the lungs completely before returning to BC

3) BC ➡️ 3-5 TEE ➡️ BC ➡️ 3-5 TEE ➡️ 1-2 Huffs ➡️ BC ➡️ REPEAT

4) Understand which secretions you are trying to clear, i.e are they local? If so distal or proximal? Adjust huff accordingly (slow gentle huff for distal and quick rapid huff for proximal)

Dosage: 10-20 minute repetitions, 2-3x daily

Chest percussion is performed with cupped hands by trapping air between the patient's thorax and caregiver's hand in an alternating rhythmic manner over the lung segments in which the secretions are to be drained. This loosens the thick, sticky secretions from the walls of the lung allowing them to move more freely into the larger airways, especially when used with associated gravity positioning. It is performed during both phases of breathing, the inspiratory and the expiratory phase

1) Lay the patients most affected side up towards you in a gravity assisted position in sidelined to facilitate to secretion drainage and clearance to larger airways.

2) The technique should be applied over a thin towel to ensure it doesn’t not feel uncomfortable, too thick of padding will absorb the mechanical percussion and be of no benefit to the patient

3) Making a cupping action with your hands and with the bed level at a reasonable height, keeping your shoulders, elbows and wrist relaxed during the maneuverer, perform a fast and rhythmic cupping movement (100-480 times/min)

4) The sound heard must be hollow and not a slap, must be equal force applied each time, must not be performed on any bony prominences and not over breast tissue

4) Duration: Several minutes or until the patient needs to alter the position to cough

Sample Physiotherapy Script:
“Hey ____ I’m going to go through a technique called percussion now which is meant to help get some of the phlegm out of your lungs, does that sound okay? Im going to get you to lay on your side with your affected side facing up and im going to make a cupping action with my hands on your chest to make a mechanical energy that’s going to help move those secretions to larger airways so that when you cough you can get rid of it. Its going to be pretty firm but it shouldn’t be painful in any way so do let me know if does at any time”

Vibration is a technique that consists of an oscillatory (shaking) and a compression component to the thorax for the transmission of mechanical energy to increase the sheer force of expiratory flow to move secretions to larger airways for airway clearance techniques (ACTs). It is often used alongside Percussion and other ACTs

1) Again, laying them in sidelined with their affected side in a postural drainage position (ask if they need assistance rolling over - dependant on patient ability)

2) Make sure their comfortable and adjust the bed for the clinician’s mechanical advantage

3) Patient takes a deep breath in and a big breath out, while breathing out the hands are placed firmly on the chest wall over the affected lung segment. Apply a gentle, rapid shaking or co-contraction movement directed inward and downward, following the natural movement of the ribs during exhalation.

4) Typically repeated for 3 to 5 consecutive exhalations, followed by a huff or cough to clear the loosened mucus

Sample Physiotherapy Script:
I’m going to take you through secretion clearance technique called vibrations now, is that cool? Okay so let’s go over why we want to use this, this technique will create a shaking force that helps to sheer off some of the phlegm sitting on your airway walls and push them towards larger airways so you can remove them easier. So what’s going to happen is your going to lie on your side (1) and this technique is going to work when you breathe out I;m going to apply the vibration (3)”

Contraindications and precautions include
- thoracic pain or injury such as rib #s or surgical wounds ➡️ absolute contraindications may be tension pneumothroax, flail ribs, pulmonary haemmorhage)
- bronchospasms
- severe osteoporosis (# risk)
- low platelets (<150) ➡️ more of a precaution as some patient presentations will still require percussion despite low platelet levels such as cystic fibrosis
- raised ICP
- haemodynamic instability
- frank haemoptysis (coughing up bright red unmixed blood or blood-streaked mucus)

This is a mechanical device that increases resistance to airflow by generating positive pressure in airways during expiration

• Application is via a face mask or mouthpiece with a small valve fitted nto the mask to reduce the expiratory diamater. Positive pressure is measured with a manometer

• Inhalation: Air flows in freely through a one-way valve.

• Exhalation: You breathe out against a selected colored resistor, creating back-pressure (right resistance = breathing out for 3-5 seconds and manometer reading of 10 to 20 cm H2O).

• Benefit: This resistance keeps your airways open longer and lets air slip behind sticky mucus, pushing it upward toward the larger airways so you can cough it out.

1. Setup: Sit up straight. Place the mask tightly over your nose and mouth to form a secure seal without leaking.

2. Breathing: Take a slightly deeper breath than normal (not completely full).

3. Exhaling: Breathe out steadily and completely through the mask, making sure your exhalation lasts about three to five times longer than your inhalation (1:3-5).

4. Clearing: Repeat this breathing cycle for 5-10 breaths for 15-20 minutes, then remove the mask and perform two to three "huff" coughs (breathing out sharply with an open mouth) to clear loosened mucus

5. Patient comfort: Ensure patient is not SOB or experiencing faintness or dizziness.

Sample Physiotherapy script:
“So this mask is going to help you improve the amount of phlegm you can get out of your lungs by creating more air to get behind your phlegm and in your lungs so that its easier and more effective to remove the phlegm, any questions? In a moment your going to hold the mask on your face and there’s these series of resistors which will change the difficulty of how hard it is to breathe out against the mask. I will just need to monitor the positive pressure that is measured with this manometer so we can find the right resistance and youll just breathe a slightyl deepr than normal breath in and breath out at a rate a little harder than normal for 3-5 seconds”

The cough assist device is a mechanical insufflator and exsufflator used to improve flow rate especially expiratory flow rate to increase the patients ability to clear secretions in the absence of an affective cough / huff

- Most used in patients with neuromuscular disease, spinal cord injury, brain injury but can be used in any patients with SC problems and a non-producive cough

- Works to clears mucus from the lungs by first applying positive air pressure to fill the lungs, then rapidly shifting to negative pressure to pull secretions out and simulate a natural cough. Most effective when patient synchronises breathing and coughing with the machine

1. Setup: Sit up straight. Place the mask tightly over your nose and mouth to form a secure seal without leaking. Set the right pressure for the patient

2. Breathing: Breathe in with the machine and when the machine begins to suck air out forcefully, you cough

3. Repeat three times

Sample Physiotherapy Script:
“This cough assist device is used to improve the strength of your cough by pushing air into your lungs and then assisting to suck it out of your lungs. I’m going to set the machine up so it’s the right pressure for you to have a go. The machine works best when you synchronise your breathing and coughing with it so all you’ll need to do is breathe in with the machine when you feel it pushing air in, and as the machine sucks air out I would like you to try and cough with it. We are going to try 5 breaths in and out”

These devices use resistance and vibrations during exhalation to create a positive expiratory pressure that loosens and clears trapped mucus from the lungs + improves gas-liquid interaction

- The “Flutter’ Device is an example that applies that variable resistance to expiratory airflow. The Flutter devices oscillation is angle dependant and can be adjusted to create the highest frequency (ranges from 8-26Hz)

- Acapella, which is similar to flutter but allows variable resistance by changing the dial on the back of the device. It is better because it can be used at any angle (because of its plastic no ball bearing composition). Dosage is the same as the flutter.

A Flutter device is a small, handheld respiratory tool that helps clear excess mucus from the lungs using positive expiratory pressure and high-frequency vibrations. It is commonly used by people with chronic conditions like chronic obstructive pulmonary disease (COPD), bronchiectasis, or cystic fibrosis

• Sit upright with a straight back and your head tilted slightly upward.

• Take a slow, deep breath in (filling your lungs, but not completely to maximum capacity), then hold your breath for 2 to 3 seconds.

• Place the mouthpiece in your mouth, forming a tight seal with your lips

• Exhale steadily and reasonably fast through the device—not forcefully, but longer than a normal breath—while feeling the vibrations in your chest.

• Repeat the breathing cycle 5 to 10 times, finish with a strong cough or "huff" manoeuvre to expel loosened mucus, and clean the device daily with warm soapy water.

High ICP

Hypertension

Pulmonary oedema / heart failure

Respiratory distress (extreme SOB)

Upper GIT, eye, head and neck surgery

Obesity

Late in pregnancy

Key Principle to think about is 'bad side up'. The lung segment or lobe that needs draining must be up in a gravity assisted drainage position

L & R Anterior Apical: Supine on upwards incline (seated essentially) whilst L& R Posterior Apical: hunched over seated

L & R Anterior Basal: Supine on downwards incline (head towards the floor) whilst L & R Posterior Basal: Prone on downwards Incline (head towards the floor)

R Middle Lobe: Slight sidelined (semilateral) position with right lung up towards you

Left Lingular: Slight sidelined (semilateral) position with left lung up towards you