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870 POSTURAL DRAINAGE

P R E C A U T I O N : Only individuals who have been taught

proper suctioning technique should use this alternative
means of clearing the airways. Suctioning, if performed
incorrectly, can introduce an infection into the airways or
damage the delicate mucosal lining of the trachea and
bronchi. Improper suctioning also can cause hypoxemia, an
abnormal heart rate, and atelectasis. A complete description
of the proper endotracheal suctioning technique may be
found in other resources.29,60

POSTURAL DRAINAGE
Postural drainage (bronchial drainage), another interven-
tion for airway clearance, is a means of mobilizing secre-
tions in one or more lung segments to the central airways
by placing the patient in various positions so gravity assists
FIGURE 25.22 Splinting over an anterior surgical incision. in the drainage process.4,11,25,51,60 When secretions are
moved from the smaller to the larger airways, they are then
cleared by coughing or endotracheal suctioning. Postural
drainage therapy also includes the use of manual tech-
niques, such as percussion, shaking, and vibration, coupled
with voluntary coughing.
Goals and indications for postural drainage are noted
in Box 25.9, and relative contraindications are summarized
in Box 25.10.4,11,25,51,60 Despite the risks, postural drainage
may be necessary in the unstable patient. Modified posi-
tioning to avoid head-down or fully horizontal positions
typically is necessary for most high-risk patients.

Manual Techniques Used with

Postural Drainage Therapy
In addition to the use of body positioning, deep breathing,
and an effective cough to facilitate airway clearance, a
variety of manual techniques are used in conjunction with
postural drainage to maximize the effectiveness of the
FIGURE 25.23 Splinting over a posterior lateral incision.

BOX 25.9 Goals and Indications

of which enhance the mucociliary transport system and for Postural Drainage
facilitate a productive cough.66
Tracheal Stimulation Prevent Accumulation of Secretions in Patients at
Tracheal stimulation, sometimes called a tracheal tickle, Risk for Pulmonary Complications
may be used with infants or disoriented patients who can- • Patients with pulmonary diseases that are associated with
not cooperate during treatment.66 Tracheal stimulation is a increased production or viscosity of mucus, such as
somewhat uncomfortable maneuver, performed to elicit a chronic bronchitis and cystic fibrosis
reflexive cough. The therapist places two fingers at the • Patients who are on prolonged bed rest
sternal notch and applies a circular motion with pressure • Patients who have received general anesthesia and who
downward into the trachea to facilitate a reflexive cough. may have painful incisions that restrict deep breathing
and coughing postoperatively
• Any patient who is on a ventilator if he or she is stable
Suctioning: Alternative to Coughing
enough to tolerate the treatment
Endotracheal suctioning may be the only means of clear- Remove Accumulated Secretions from the Lungs
ing the airways in patients who are unable to cough or huff • Patients with acute or chronic lung disease, such as
voluntarily or after reflex stimulation of the cough mecha- pneumonia, atelectasis, acute lung infections, COPD
nism.29,60 Suctioning is indicated in all patients with artifi- • Patients who are generally very weak or are elderly
cial airways. The suctioning procedure clears only the • Patients with artificial airways
trachea and the mainstem bronchi.
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C H A P T E R 2 5 Management of Pulmonary Conditions 871

BOX 25.10 Relative Contraindications drained.25,67 The therapist’s cupped hands strike the
patient’s chest wall in an alternating, rhythmic manner
to Postural Drainage
(Fig. 25.24B). The therapist should try to keep shoulders,
elbows, and wrists loose and mobile during the maneuver.
• Severe hemoptysis
Mechanical percussion is an alternative to manual percus-
• Untreated acute conditions
sion techniques.
• Severe pulmonary edema
Percussion is continued for several minutes or until the
• Congestive heart failure
• Large pleural effusion
patient needs to alter position to cough. This procedure
• Pulmonary embolism should not be painful or uncomfortable.
• Pneumothorax P R E C A U T I O N S : To prevent irritation to sensitive skin,
• Cardiovascular instability
have the patient wear a lightweight gown or shirt. Avoid
• Cardiac arrhythmia
percussion over breast tissue in women and over bony
• Severe hypertension or hypotension
prominences.
• Recent myocardial infarction
• Unstable angina Relative Contraindications to Percussion
• Recent neurosurgery
Prior to using percussion in a postural drainage program, a
• Head-down positioning may cause increased intracra-
therapist must weigh the potential benefits versus potential
nial pressure; if PD is required, modified positions can
risks. In most instances, it is prudent to avoid the use of
be used
percussion.25,67

Over fractures, spinal fusion, or osteoporotic bone

mucociliary transport system.11,25,51,60,66,72 They include Over tumor area
percussion, vibration, shaking, and rib springing. Findings If a patient has a pulmonary embolus
from studies that have been implemented to evaluate the If the patient has a condition in which hemorrhage could
efficacy of these manual techniques as adjuncts to postural easily occur, such as in the presence of a low platelet
drainage are inconclusive.66 count, or if the patient is receiving anticoagulation therapy
Percussion If the patient has unstable angina
Percussion is used to augment mobilization of secretions If the patient has chest wall pain, for example after tho-
by mechanically dislodging viscous or adherent mucus racic surgery or trauma
from the airways. Percussion is performed with cupped
Vibration
hands (Fig. 25.24A) over the lung segment being
Vibration, another manual technique, often is used in con-
junction with percussion to help move secretions to larger
airways. It is applied only during the expiratory phase as
the patient is deep-breathing.25,51,72 Vibration is applied
by placing both hands directly on the skin and over the
chest wall (or one hand on top of the other) and gently
compressing and rapidly vibrating the chest wall as the
patient breathes out (Fig. 25.25). Pressure is applied in the
same direction as the chest is moving. The vibrating action
is achieved by the therapist isometrically contracting (tens-
ing) the muscles of the upper extremities from shoulders to
hands.

FIGURE 25.24 (A) Hand position for applying percussion. (B) The therapist
alternately percusses over the lung segment being drained. FIGURE 25.25 Hand placement for vibration during postural drainage.
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872 POSTURAL DRAINAGE

Shaking Postural Drainage Positions

Shaking is a more vigorous form of vibration applied dur-
ing exhalation using an intermittent bouncing maneuver Positions for postural drainage are based on the anatomy of
coupled with wide movements of the therapist’s hands. The the lungs and the tracheobronchial tree (see Figs. 25.2 and
therapist’s thumbs are locked together, the open hands are 25.4). Each segment of each lobe is drained using the posi-
placed directly on the patient’s skin, and fingers are tions depicted in Figures 25.26 through 25.37. The shaded
wrapped around the chest wall. The therapist simultaneous- area in each illustration indicates the area of the chest wall
ly compresses and shakes the chest wall.25,51,72 where percussion or vibration is applied.

RIGHT AND LEFT UPPER LOBES

Anterior apical segments

FIGURE 25.27 Percussion is applied above the scapulae. Your fingers curve
FIGURE 25.26 Percussion is applied directly under the clavicle. over the top of the shoulders.

FIGURE 25.28 Percussion is applied bilaterally, directly over the nipple or

just above the breast.

FIGURE 25.29 Patient lies one-quarter turn from prone and rests on the
right side. Head and shoulders are elevated 45! or approximately 18 inches FIGURE 25.30 Patient lies flat and one-quarter turn from prone on the left
if pillows are used. Percussion is applied directly over the left scapula. side. Percussion is applied directly over the right scapula.
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C H A P T E R 2 5 Management of Pulmonary Conditions 873

LINGULA MIDDLE LOBE

FIGURE 25.31 Patient lies one-quarter turn from supine on the right side, FIGURE 25.32 Patient lies one-quarter turn from supine on the left side,
supported with pillows and in a 30! head-down position. Percussion is supported with pillows behind the back, and in a 30! head-down position.
applied just under the left breast. Percussion is applied under the right breast.

RIGHT AND LEFT LOWER LOBES

FIGURE 25.34 Patient lies prone with a pillow under the abdomen in a 45!
FIGURE 25.33 Patient lies supine, pillows under knees, in a 45! head-down head-down position. Percussion is applied bilaterally over the lower portion
position. Percussion is applied bilaterally over the lower portion of the ribs. of the ribs.

FIGURE 25.35 Patient lies on the right side in a 45! head-down position. FIGURE 25.36 Patient lies on the left side in a 45! head-down position
Percussion is applied over the lower lateral aspect of the left rib cage. Percussion is applied over the lower lateral aspect of the right rib cage.

FIGURE 25.37 Patient lies prone with a pillow under the abdomen to flatten the
back. Percussion is applied bilaterally, directly below the scapulae.
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874 MANAGEMENT OF PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE

The patient may be positioned on a postural drainage Check the patient’s vital signs and breath sounds.
table that can be elevated at one end, a tilt table, a rein- Position the patient in the correct position for drainage.
forced padded table with a lift, or a hospital bed. A small See that he or she is as comfortable and relaxed as pos-
child can be positioned on a therapist’s or parent’s lap. sible.
Stand in front of the patient, whenever possible, to
observe his or her color.
Guidelines for Implementing Maintain each position for 5 to 10 minutes if the patient
Postural Drainage can tolerate it or as long as the position is productive.
General Considerations Have the patient breathe deeply during drainage but do
not allow the patient to hyperventilate or become short
Time of day. Consider the following when scheduling pos- of breath. Pursed-lip breathing during expiration is
tural drainage into a patient’s day. sometimes used.
Never administer postural drainage directly after a meal. Apply percussion over the segment being drained while
Coordinate treatment with aerosol therapy. Some thera- the patient is in the correct position.
pists believe that aerosol therapy combined with humidi- Encourage the patient to take a deep, sharp, double
fication prior to postural drainage helps loosen secretions cough whenever necessary. It may be more comfortable
and increases the likelihood of productivity. Others for the patient to momentarily assume a semiupright
believe that aerosol therapy is best after postural position (resting on one elbow) and then cough.
drainage when the patient’s lungs are clearer and maxi- If the patient does not cough spontaneously during posi-
mal benefit can be gained from medication administered tioning with percussion, instruct the patient to take sev-
through aerosol therapy. eral deep breaths or huff several times in succession as
Choose a time (or times) of day likely to be of most ben- you apply vibration during expiration. This may help
efit to the patient. A patient’s cough tends to be highly elicit a cough.
productive in the early morning because of accumulation If the patient’s cough is not productive after 5 to 10 min-
of secretions from the night before. Postural drainage in utes of positioning, go on to the next position. Secretions
the early evening clears the lungs prior to sleeping and that have been mobilized during a treatment may not be
helps the patient rest more easily. coughed up by the patient until 30 minutes to 1 hour
after treatment.
Frequency of treatments. The frequency of postural The duration of any one treatment should not exceed 45
drainage each day or during the week depends on the type to 60 minutes, as the procedure is quite fatiguing for the
and severity of a patient’s pathology. If secretions are thick patient.
and copious, two to four times per day may be necessary
until the lungs are clear. If a patient is on a maintenance Concluding a Treatment
program, the frequency is less, perhaps once a day or only Have the patient sit up slowly and rest for a short while
a few days a week. after the treatment. Watch for signs of postural hypoten-
sion when the patient rises from a supine position or
Preparation for Postural Drainage from a head-down position to sitting.
Loosen tight or bulky clothing. It is not necessary to Advise the patient that even if the cough was not produc-
expose the skin. The patient may wear a lightweight tive during treatment it may be productive a short while
shirt or gown. after treatment.
Have a sputum cup or tissues available. Evaluate the effectiveness of the treatment by reassess-
Have sufficient pillows for positioning and comfort. ing breath sounds.
Explain the treatment procedure to the patient. Note the type, color, consistency, and amount of secre-
Teach the patient deep breathing and an effective cough tions produced.
prior to beginning postural drainage. Check the patient’s vital signs after treatment and note
If the patient is producing copious amounts of sputum, how the patient tolerated the treatment.
instruct the patient to cough a few times or have the Criteria for Discontinuing Postural Drainage
patient suctioned prior to positioning.
Make any adjustments of tubes and wires, such as chest If the chest radiograph is relatively clear
tubes, electrocardiography wires, or catheters, so they If the patient is afebrile for 24 to 48 hours
remain clear during positioning. If normal or near-normal breath sounds are heard with
auscultation
Postural Drainage Sequence If the patient is on a regular home program
Determine which segments of the lungs should be
drained. Some patients with chronic lung diseases, such
as cystic fibrosis, need to be drained in all positions.
Modified Postural Drainage
Other patients may require drainage of only a few seg- Some patients who require postural drainage cannot
ments in which secretions have accumulated. assume or cannot tolerate the positions optimal for postural
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C H A P T E R 2 5 Management of Pulmonary Conditions 875

drainage. For example, a patient with congestive heart fail-

ure may exhibit indications of orthopnea (shortness of
breath while lying flat). After neurosurgery a patient may
not be allowed to assume a head-down (Trendelenburg)
position because this position causes increased intracranial
pressure. After thoracic surgery a patient may have chest
tubes and monitoring wires that limit positioning. Under
these circumstances and others, positioning during postural
drainage must be modified.25,51,60,66 The positions in which
postural drainage is undertaken are modified consistent
with the patient’s medical or surgical problems. This com-
promise, although not ideal, is better than not administer-
ing postural drainage at all.

Home Program of Postural Drainage

Postural drainage may have to be carried out on a regular
basis at home for patients with chronic lung disease.
Patients need to be shown how to position themselves using
inexpensive aids. An adult may place pillows over a hard
wedge or stacks of newspapers to achieve the desired head-
down positions in bed. A patient also can lean the chest
FIGURE 25.38 Normal lung volumes and capacities compared with abnor-
over the edge of a bed, resting with the arms on a chair mal lung volumes and capacities found in patients with obstructive pul-
or stool. A child can be positioned on an ironing board monary disease. (From Rothstein, J, Roy, A, Wolf, SL: The Rehabilitation Specialist’s
propped up against a sofa or heavy chair. A family member Handbook, ed. 3. FA Davis, Philadelphia, 2005, p 428, with permission.)
often must be taught proper positioning, percussion or
shaking techniques, and precautions to assist the patient.
Pathological Changes in
the Pulmonary System
MANAGEMENT OF PATIENTS Changes in chronic bronchitis and emphysema that occur
WITH CHRONIC OBSTRUCTIVE over time are inflammation of the mucous membranes of
PULMONARY DISEASE the airways; increased production and retention of mucus;
narrowing and destruction of airways; and destruction of
alveolar and bronchial walls.6,30,67 These structural changes
Chronic obstructive pulmonary disease is a broad term are reflected in pulmonary function tests depicted in Figure
encompassing a number of chronic pulmonary conditions, 25.38. These changes in the patient’s pulmonary status pre-
all of which obstruct the flow of air in the conducting air- dispose the patient to frequent acute respiratory infections.
ways of the lower respiratory tract and alter ventilation and
gas exchange.6,30,67 Although a variety of pulmonary dis-
eases are classified as obstructive in nature, each disease Impairments and Impact on Function
has its unique features and clinical manifestations and is As a result of the pathophysiology of COPD, many physi-
distinguished by the cause of the obstruction of airflow, the cal impairments develop over time. Patients typically have
onset of the disease, the location of the obstruction, and the a chronic, productive cough and are often short of breath.
reversibility of the obstruction. The characteristic impact of COPD on the pulmonary sys-
tem is the inability to remove air from the lungs effectively,
which in turn affects the ability of the respiratory system to
Types of Obstructive Pulmonary Disorders
transport oxygen into the lungs.
Typically, peripheral airway disease, chronic bronchitis, Consequently, functional limitations and eventually
and emphysema are classified as COPD; but other obstruc- disability occur consistent with the disablement process.42
tive pulmonary diseases that are chronic in nature, such as Impairments such as increased respiratory rate, decreased
asthma, bronchiectasis, cystic fibrosis, and bronchopul- vital capacity and forced expiratory volume, increased use
monary dysplasia, also may be included under this broad of accessory muscles of inspiration, and progressive chest
descriptor. The focus of discussion and guidelines for wall stiffness are associated with decreased tolerance to
management presented in this section of the chapter is on exercise, frequent episodes of dyspnea, decreased walking
chronic bronchitis and emphysema because patients with speed and distance, and eventual inability to perform activ-
these diseases commonly are seen in pulmonary rehabilita- ities of daily living at home or in the workplace or to
tion programs.6,7,12,37,67 remain an active participant in the community.
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876 MANAGEMENT OF PATIENTS WITH RESTRICTIVE PULMONARY DISORDERS

Management Guidelines: COPD Extrapulmonary Causes

Lifelong management includes appropriate medical man- Chest wall pain secondary to trauma or surgery
agement to lessen disabling symptoms and prevent infec- Chest wall stiffness associated with extrapulmonary
tion, smoking cessation, and participation in a disease (e.g., scleroderma, ankylosing spondylitis)
comprehensive pulmonary rehabilitation program. Impor- Postural deformities (scoliosis, kyphosis)
tant aspects of management include breathing exercises, Ventilatory muscle weakness of neuropathic or myo-
ongoing, airway clearance, and participation in an indi- pathic origin (e.g., spinal cord injury, cerebral palsy,
vidually designed, graded exercise program that includes Parkinson’s disease, muscular dystrophy)
upper and lower extremity strength training and aerobic Pleural disease
conditioning.6,7,11,12,37,55,67,70 Common impairments and Insufficient diaphragmatic excursion because of ascites
guidelines for management are described in Box 25.11. or obesity

Focus on Evidence Pathological Changes in

Patients with COPD who appear to benefit most from pul- the Pulmonary System
monary rehabilitation are those with only moderate-level Pulmonary function may be altered as a result of pul-
disease and without a substantial number of co-morbidities. monary or extrapulmonary conditions. These alterations in
A combination of upper and lower extremity exercises have lung volumes and capacities are depicted in Figure 25.39.
been shown to improve functional status more effectively Cardiopulmonary factors contributing to these changes are
than either upper or lower extremity exercise alone.6 decreased pulmonary compliance caused by inflammation
Systematic reviews of the literature of pulmonary reha- or fibrosis (thickening of the alveoli, bronchioles, or pleu-
bilitation programs have demonstrated that the effects of a ra), pulmonary congestion, and decreased arterial blood
program of breathing exercises (diaphragmatic and pursed- gases (hypoxemia).
lip breathing) on respiratory function13 and the effects of
inspiratory resistance training on exercise capacity50 are Management Guidelines:
equivocal. However, peripheral muscle strengthening pro- Post-Thoracic Surgery
grams improve physical functioning.55
Although any number of acute or chronic disorders can be
the underlying cause(s) of restrictive lung dysfunction,
only management after thoracic surgery is addressed in this
MANAGEMENT OF section. Patients with cardiac or pulmonary conditions that
require surgical interventions are at high risk for restrictive
PATIENTS WITH RESTRICTIVE pulmonary complications after surgery. Thoracotomy, an
PULMONARY DISORDERS incision into the chest wall, is necessary during many types
of pulmonary surgery including lobectomy (removal of a
Restrictive pulmonary disorders are characterized by lobe of a lung), pneumonectomy (removal of a lung), or
the inability of the lungs to expand fully as a result of segmental resection (removal of a segment of a lobe of a
extrapulmonary and/or pulmonary disease or restriction.11,17 lung).17,23,36,40
In other words, the patient has difficulty taking in a deep Cardiac surgeries, such as coronary artery bypass graft
breath. surgery, replacement of one or more valves of the heart,
repair of septal defects, or heart transplantation also require
thoracotomy.17,23,36,40
Acute and Chronic Causes of N O T E : Patients who undergo upper abdominal surgery
Restrictive Pulmonary Disorders also have a high risk of developing postoperative pulmonary
complications. Postoperative pain is often greater after
There are a variety of acute or chronic disorders directly upper abdominal surgery than after thoracic surgery.73 This
involving structures of the pulmonary system or extrapul- results in hypoventilation (55% decreased vital capacity for
monary disorders that can cause restrictive pulmonary the first 24 to 48 hours after surgery) and an ineffective
dysfunction.11,17 cough, which place the patient at risk for developing pneu-
Pulmonary Causes monia or atelectasis.17,40 A systematic review of the litera-
Diseases of the lung parenchyma such as tumor, intersti- ture revealed that postoperative programs of
tial pulmonary fibrosis (e.g., pneumonia, tuberculosis, cardiopulmonary physical therapy have beneficial effects
asbestosis), and atelectasis after upper abdominal surgery.73
Disorders of cardiovascular/pulmonary origin, such as Factors That Increase the Risk of Pulmonary
pulmonary edema or pulmonary embolism Complications and Restrictive Lung Dysfunction
Inadequate or abnormal pulmonary development (bron- After Thoracic Surgery
chopulmonary dysplasia) The post-thoracotomy patient experiences considerable
Advanced age chest pain, which leads to chest wall immobility, poor lung
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C H A P T E R 2 5 Management of Pulmonary Conditions 877

BOX 25.11
MANAGEMENT GUIDELINES—Chronic Obstructive Pulmonary Disease (COPD)
Impairments
An increase in the amount and viscosity of mucus production
A chronic, often productive cough
Frequent episodes of dyspnea
A labored breathing pattern that results in:
• Increased respiratory rate (tachypnea)
• Use of accessory muscles of inspiration and decreased diaphragmatic excursion
• Upper chest breathing
Inadequate exchange of air in the lower lobes
Most difficulty during expiration; use of pursed-lip breathing
Changes in pulmonary function
• Increased residual volume
• Decreased vital capacity
• Decreased expiratory flow rates
Decreased mobility of the chest wall; a barrel chest deformity develops
Abnormal posture: forward-head and rounded and elevated shoulders
Decreased general endurance during functional activities

Plan of Care Interventions

1. Decrease the amount and viscosity of secre- 1. Administration of bronchodilators, antibiotics, and humidification
tions and prevent respiratory infections. therapy.
If patient smokes, he or she should be strongly encouraged to stop.
2. Remove or prevent the accumulation of 2. Deep and effective cough.
secretions. (This is important if emphyse- Postural drainage to areas where secretions are identified.
ma is associated with chronic bronchitis or N O T E : Drainage positions may need to be modified if the patient is
if there is an acute respiratory infection.) dyspneic in the head-down position.
3. Promote relaxation of the accessory mus- 3. Positioning for relaxation.
cles of inspiration to decrease reliance on • Relaxed head-up position in bed: trunk, arms, and head are well
upper chest breathing and to decrease supported.
muscle tension associated with dyspnea. • Sitting: leaning forward, resting forearms on thighs or on a table.
• Standing: leaning forward on an object, with hands on the thighs
or leaning backward against a wall.
Relaxation exercises for shoulder musculature: active shoulder
shrugging followed by relaxation; shoulder and arm circles; hori-
zontal abduction and adduction of the shoulders.
4. Improve the patient’s breathing pattern 4. Breathing exercises: controlled diaphragmatic breathing with mini-
and ventilation. mal upper chest movement; lateral costal breathing; pursed-lip
Emphasize diaphragmatic and lateral costal breathing (careful to avoid forced expiration).
breathing and relaxed expiration; decrease the Practice controlled breathing during standing, walking, climbing
work of breathing, rate of respiration, and use stairs, and other functional activities.
of accessory muscles. Carry over controlled
breathing exercises to functional activities.
5. Minimize or prevent episodes of dyspnea. 5. Have a patient assume a comfortable position so the upper chest is
relaxed and the lower chest is as mobile as possible.
Emphasize controlled diaphragmatic breathing.
Have the patient breathe out as rapidly as possible without forcing
expiration.
N O T E : Initially, the rate of ventilation is rapid and shallow. As the
patient gets control of breathing, he or she slows the rate.
Administer supplemental oxygen during a severe episode, if needed.
6. Improve the mobility of the lower thorax. 6. Exercises for chest mobility, emphasizing movement of the lower
rib cage during deep breathing.
7. Improve posture. 7. Exercises and postural training to decrease forward-head and
rounded shoulders.
8. Increase exercise tolerance. 8. Graded endurance and conditioning exercises (see Chapter 4).
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878 MANAGEMENT OF PATIENTS WITH RESTRICTIVE PULMONARY DISORDERS

Depresses the respiratory center of the central

nervous system
Decreases the normal ciliary action in the bronchial tree
General Inactivity, Postoperative
Weakness and Fatigue
Pooling of secretions, particularly in the posterior basilar
segments of the lower lobes, because of inactivity
Decreased effectiveness of the cough pump because
of postoperative weakness and fatigue
Other risk factors not directly related to the surgery
Patient’s age (" age 50)
History of smoking
History of COPD or restrictive pulmonary disorder
because of neuromuscular weakness
Obesity
Poor mentation and orientation
FIGURE 25.39 Normal lung volumes and capacities compared with abnor-
mal lung volumes and capacities found in patients with restrictive pulmonary Thoracic Surgery: Operative and Postoperative
disorders. (From Rothstein, J, Roy, A, Wolf, SL: The Rehabilitation Specialist’s Handbook, Considerations during Management
ed. 3. FA Davis, Philadelphia, 2005, p 428, with permission.) Many factors contribute to a patient’s postoperative impair-
ments, any one of which influences postoperative manage-
ment.17,23 A patient who has undergone thoracotomy for a
expansion, and an ineffective cough. In addition, pul- pulmonary or cardiac condition typically is hospitalized for
monary secretions are greater than normal after surgery. a week or less. Postoperative impairments and guidelines
Therefore, the patient is more likely to accumulate pul- for management of a patient who has undergone thoracic
monary secretions and develop secondary pneumonia surgery are summarized in Box 25.12.16,17,23,36,40,41,71 Thera-
or atelectasis. Factors that increase the risk of postopera- peutic interventions begin on the first postoperative day
tive pulmonary complications are noted in the following and include breathing and coughing exercises, shoulder
sections.17,40 ROM, posture awareness training, and a graded aerobic
conditioning program.16,23,36,40,41,71
General Anesthesia Co-morbidities and Related Dysfunction
Decreases the normal ciliary action of the tracheo- In addition to the primary pulmonary or cardiac pathology
bronchial tree (e.g., a malignant tumor, lung abscess, coronary artery dis-
Depresses the respiratory center of the central nervous ease) the patient also may have related cardiopulmonary
system, which causes a shallow respiratory pattern conditions, such as angina, congestive heart disease, chronic
(decreased tidal volume and vital capacity) bronchitis, or emphysema. The patient with a long history
Depresses the cough reflex of cardiac disease may have preoperative pulmonary dys-
function such as hypoxemia, dyspnea on exertion, orthop-
Intubation (Insertion of an Endotracheal Tube)
nea, or pulmonary congestion. Such co-morbidities and
Causes muscle spasm and immobility of the chest related pulmonary or cardiac dysfunction can complicate
Irritates the mucosal lining of the tracheobronchial tree, postoperative rehabilitation.
which causes increased production of mucus Surgical Approach
Decreases the normal action of the cilia in the tracheo- Pulmonary surgery typically involves a large posterolateral,
bronchial tree, which leads to pooling of secretions lateral, or anterolateral chest incision. A standard postero-
lateral approach (Fig. 25.40), for example, is performed by
Incisional Pain incising the chest wall along the intercostal space that cor-
Causes muscle splinting and decreases chest wall com- responds to the location of the lung lesion. The incision
pliance, which in turn causes a shallow breathing pat- divides the trapezius and rhomboid muscles posteriorly
tern. Consequently, lung expansion is restricted and and the serratus anterior, latissimus dorsi, and external and
secretions are not adequately mobilized. internal intercostals laterally.
Restricts a deep and effective cough. The patient usually Postoperatively, the incision is painful, and the poten-
has a weak, shallow cough that does not effectively tial for pulmonary complications is significant. Many
mobilize and clear secretions. patients, quite understandably, complain of a great deal of
shoulder soreness on the operated side. Loss of range of
Pain Medication shoulder motion and postural deviations are possible
Although pain medication administered postoperatively because of the disturbance of the large arm and trunk mus-
diminishes incisional pain, it also: culature during surgery.
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C H A P T E R 2 5 Management of Pulmonary Conditions 879

BOX 25.12
MANAGEMENT GUIDELINES—Post-Thoracic Surgery
Impairments
Reduced lung expansion or an inability to take a deep inspiration because of incisional pain
Decreased effectiveness of the cough because of incisional pain and irritation of the throat from intubation
Possible accumulation of pulmonary secretions either preoperatively or postoperatively
Decreased chest wall and upper extremity mobility
Poor postural alignment because of incisional pain or chest tubes
Increased risk of deep vein thrombosis and pulmonary embolism
General weakness, fatigue, and disorientation

Plan of Care Interventions

1. Ascertain the status of the patient 1. Evaluate orientation, color, respiratory rate, heart rate, breath sounds, sputum
before each treatment. drainage into chest tubes.
2. Promote relaxation and reduce 2. Position the patient in a semi-Fowler’s position (head of bed elevated to 30!
postoperative pain. and hips and knees slightly flexed). This position reduces traction on the tho-
racic incision.
Coordinate treatment with administration of pain medication.
3. Optimize ventilation and re-expand 3. Begin deep-breathing exercises on the day of surgery as soon as the patient
lung tissue to prevent atelectasis is conscious; diaphragmatic breathing; segmental expansion.
and pneumonia. Add incentive spirometry or inspiratory resistance exercises to improve inspi-
ratory capacity.
Emphasize a deep inhalation followed by a 3- to 5-second hold and then
relaxed exhalation.
Continue deep-breathing exercises postoperatively, with six to ten consecu-
tive deep breaths per hour until the patient is ambulatory.
4. Assist in the removal of secretions. 4. Begin deep, effective coughing as soon as the patient is alert and can
cooperate.
Implement early functional mobility (getting up to a chair, early ambulation).
Institute modified postural drainage only if secretions accumulate.
5. Maintain adequate circulation in 5. Begin active exercises of the lower extremities, with emphasis on ankle
the lower extremities to prevent pumping exercises on the first day after surgery.
deep vein thrombosis and pul- Continue leg exercises until the patient is allowed out of bed and is
monary embolism. ambulatory.
6. Regain ROM in the shoulders. 6. Begin relaxation exercises for the shoulder area on the first postoperative
day. These can include shoulder shrugging or shoulder circles.
Initiate active-assistive ROM of the shoulders, being careful not to cause pain.
Reassure the patient that gentle movements will not disturb the incision.
Progress to active shoulder exercises on the succeeding postoperative days to
the patient’s tolerance until full active ROM has been achieved.
7. Prevent postural impairments. 7. Reinforce symmetrical alignment and positioning of the trunk on the first
postoperative day when the patient is in bed.
N O T E : The patient will tend to lean toward the side of the incision.
Instruct the patient in symmetrical sitting posture when he or she is allowed
to sit up in a chair or at the side of the bed.
8. Increase exercise tolerance. 8. Begin a progressive and graded ambulation or stationary cycling program as
soon as the chest tubes are removed and the patient is allowed out of bed.
Precautions
Monitor vital signs throughout treatment.
Be certain to show the patient how to splint over the incision to minimize incisional pain during coughing.
Avoid placing traction on chest tubes when moving the patient.
To prevent dislodging a chest tube for the patient who has a lateral incision, limit shoulder flexion to 90! on the operated
side for several days until the chest tube is removed.
If postural drainage must be implemented, modify positioning to avoid a head-down position.
Do not use percussion over the incision.
When turning a patient, use a logroll technique to minimize traction on the incision.
25Kisner (F)-25 3/9/07 12:55 PM Page 880

880 MANAGEMENT OF PATIENTS WITH RESTRICTIVE PULMONARY DISORDERS

chest cavity can be exposed. After completion of the surgi-

cal procedure, the sternum is closed with stainless steel
sutures. Postoperatively, there is less incisional pain after a
median sternotomy than after a posterolateral thoracotomy,
but deep breathing and coughing are still painful. After a
median sternotomy, a patient tends to exhibit rounded
shoulders and is at risk for developing shortened pectoralis
muscles bilaterally.
Additional Considerations
After any type of thoracotomy one or two chest drainage
tubes are put in place at the time of the surgery to pre-
vent a pneumothorax or a hemothorax. While these
tubes are in place, crimping, clamping, or traction on
the tubes must be avoided during postoperative inter-
ventions.
FIGURE 25.40 A posterolateral approach commonly used in thoracic surgery Fatigue occurs easily during the first few postoperative
incises and divides the trapezius, rhomboids, latissimus dorsi, serratus anterior, days, so treatment sessions should be short but frequent.
and internal and external intercostal muscles. The duration of treatment sessions should be increased
gradually during the patient’s hospital stay.
Check the patient’s chart regularly to note any day-to-
The most common incision used with cardiac surgery day changes in vital signs or laboratory test results. Always
is a median sternotomy. A large incision extends along the monitor vital signs such as heart rate and rhythm, respira-
anterior chest from the sternal notch to just below the tory rate, and blood pressure prior to, during, and after
xiphoid. The sternum is then split and retracted so the every treatment session.

INDEPENDENT LEARNING ACTIVITIES

● Critical Thinking and Discussion referred to your outpatient facility to begin a graded
conditioning program.
1. Describe the structure of the lower respiratory tract 2. How would you alter or change the focus of your exami-
from the trachea to the alveoli and discuss the impact nation of a patient with a traumatic brain injury who is
of pulmonary diseases on those structures and their on a ventilator or a patient who is 1 day post-coronary
functions. artery bypass graft surgery?
2. Describe the thorax and its movements during ventila- 3. Practice auscultation of breath sounds.
tion and the actions of the primary and accessory mus- 4. Practice a complete postural drainage sequence on your
cles of ventilation. laboratory partner. Include manual techniques and cough
3. Organize a presentation that compares and contrasts the instruction. Perform the activity for a minimum of 1 to 2
characteristics and management of obstructive and minutes per position to begin to appreciate the endurance
restrictive pulmonary disorders. needed by the therapist. Then have your partner perform
4. What factors contribute to placing the post-thoracic sur- the same sequence with you as the patient to appreciate
gery patient at risk for the development of postoperative how it feels from the patient’s perspective to undergo
complications? postural drainage.
5. Under what circumstances (types of impairment or 5. What methods of measurement should be used to docu-
pathology) would it be appropriate to try to change a ment improvement in a pulmonary patient’s condition as
patient’s breathing pattern? For what purpose? the result of a pulmonary rehabilitation program? Prac-
6. Analyze how ventilation and coughing are affected by a tice those techniques.
spinal cord injury at a mid-thoracic level, a C6 level, and
a C3 to C4 level. ● Case Study
CASE 1
● Laboratory Practice
T.M. is a 62-year-old man who underwent thoracic surgery
1. Perform a systematic physical examination of a patient (right lower lobe lobectomy) yesterday for bronchogenic
with a year history of chronic bronchitis who has been carcinoma. He has a posterolateral incision. Although his