- Active cycle of breathing technique / breathing control / diaphragmic breathing / autogenic drainage / pursed-lip breathing, forced expiration technique / huff / postural drainage / glossopharyngeal breathing
- Acapella / flutter / bubblePEP / incentive spirometer / ParaPEP nebuliser
- Resting positions / fatigue management / activity pacing / education / mobilising / walking aids
- Wound bracing / chest binder
- Manual therapy / postural correction / percussions / vibrations
- Manual or machine ventilation, cough assist device, intermittent positive pressure breathing
- Nasopharyngeal, oropharyngeal, tracheal suctioning
- Respiratory muscle training, corrective dysfunctional breathing training, exercise prescription
- Superficial stroking and bouncing pressures on the chest for relaxation
- Deep stroking/frictions/trigger pointing for respiratory muscles
- Stretching of intercostal muscles to improve chest mobility
- Springing the ribs to increase depth of inspiration
- Lifting the ribs to increase ventilation and aid in secretion clearance
- Clapping percussion and course vibrations for secretion clearance
- Manually lifting the shoulder or rotating the pelvis in side-lying to increase air entry
Here are 10 Alternative Manual Chest Physiotherapy Techniques
Stretch of intercostal muscles.
Position: Supine / Side lying
Purpose: Aids expiration / Increased mobility of thorax
Technique: Applying a caudal glide to the lateral aspect of the ribs
to stretch of the intercostal muscles during a passive expiration.
The ‘intercostal stretch’ is performed
by applying a caudal glide to the lateral aspect ‘bucket-handles’ of the
ribs. When applied during a passive expiration, the intercostal muscles may
be stretched to increase the mobility of the thorax and aid expiration. If
the patient can tolerate it, the therapist may wish to briefly hold this
stretch at the end of the breath out and release before the patient breathes
in. The intercostal stretch is best performed on a patient in supine lying,
long sitting or side lying positions. Patients with a barrel chest shapes,
increased thoracic rigidity or those with a bias of accessory muscle use may
benefit most from this technique.
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Rib Springing
Position: Side lying / Long lying
Purpose: Increased depth of inspiration
Technique: Increasingly more pressure toward end-expiration with a
quick release at the beginning of inspiration.
The ‘rib springing’ technique is
performed by applying a short, low amplitude squeeze or push on the
antero-lateral aspect of the ribs to promote inhibition of expiratory muscles
and passive recoil to allow greater inspiration volume. Alternatively, the
technique can be performed by applying a long, increasingly greater pressure
toward end-expiration with a quick release on inspiration. The rib springing technique is best
performed on a patient in side-lying or long lying positions. This technique
would benefit patients with dysfunctional breathing patterns.
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Shoulder and scapular elevation
Position: Side lying, patients head in slight flexion
Purpose: Increase air entry / ventilation; Increase thoracic mobility
Technique: Lift the shoulder during inspiration. Gentle vibration to
further elevate the shoulder during the beginning of expiration.
The ‘shoulder and scapular elevation
technique’ is performed with the patient in side lying, with their head
slightly flexed. The therapist will position their hands around the scapular
and axilla, stabilising the patients arm between the therapist’s arm and
body, or with the patients arm supported at their side. The therapist
coordinates the lift of the shoulder and/or scapular with the patient’s
inspiration. This technique encourages greater mid-upper thorax mobility and
ventilation. This technique works well with vibrations during expiration.
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Rotation in side-lying
Position: Side lying
Purpose: Increase air entry / ventilation; increase thoracic
mobility.
Technique: Stabilise the shoulder with one hand, and rotate the hip
posteriorly with the other hand during inspiration, then returning to a
neutral position during expiration
The ‘rotation in side-lying technique’
is performed with the patient in side-lying. Ensure the patient is well
supported by pillows, including opening the thorax by placing pillows under
the patient’s arm. The therapist stabilises the patients shoulder with one
hand, rotating the pelvis posteriorly with the other hand during inspiration.
The therapist guides the pelvis back to a neutral position during expiration.
This technique increases mobility and ventilation to the mid-lower thorax. A
short stretch may be applied at the end of inspiration to reduce thorax
rigidity.
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Peri-oral facilitation
Position: Supine / long lying / side-lying
Purpose: Ventilation
Comment: Unconscious patient – not currently ventilated.
Technique: glide the external nasal septum downward or distract the
nasal cavity
The ‘peri-oral facilitation technique’
is performed by the therapist on a patient with a low Glasgow Coma Score and
in uncooperative with treatment to improve minute ventilation. The therapist
glides the external nasal septum inferiorly, contacting the patient
peri-orally. The glide can be held for the duration of the treatment, or more
commonly coordinated with a breath in. Similarly, a lateral glide can be
applied either side of the external nasal passage to reduce inspiratory
resistance.
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Clapping on maximal inspiration
Position: Side lying / Supine / Prone
Purpose: Loosen secretions at maximal dilation of bronchioles
Comment: Requires patient cooperation for holding of inspiration ~3s,
3-4 claps
Technique: Perform cupped percussions 3-4x during a held inspiration
for ~3s.
The ‘clapping on maximal inspiration
technique’ is performed by applying slow percussions while the patient holds
a maximal breath in. The patient is asked to hold a large breath in for ~3s
whilst the therapist performs 3-4 claps or percussion with one or both hands.
The patient is best positioned in side lying, supine or prone. The technique
is intended to loosen secretions with maximal dilation of the bronchioles.
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Course vibrations on expiration
Position: Side-lying
Purpose: Loosen secretions from distal bronchioles
Comment: Combines well with shoulder elevation technique
Technique: Course / large amplitude vibrations down chest handle or
localised.
The ‘course vibrations on expiration
technique’ is performed by applying course, large amplitude vibrations whilst
the patient breathes out. The technique can be applied locally over one
region during expiration, or the therapist may wish to vibrate progressively
inferiorly along the chest wall during a single expiration. The intention is
to assist the mobilisation of secretions. This technique is best performed
with the patient positioned in side-lying
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Costal lifting on inspiration +/- vibrations
Position: Supine / long lying
Purpose: Increased depth of inspiration / Clearing secretions
Technique: Lifting lung or chest with inspiration with vibrations /
assisted expiration
The ‘costal lifting on inspiration
technique’ is performed with the patient in supine or long lying positions.
The therapist lifts the ribs unilaterally or bilaterally during inspiration. This
technique promotes increased ventilation to the targeted segment, usually the
lower ribs. The technique allows greater ventilation to distal segments, and
can be coupled with vibrations to assist with the mobilisation of secretions.
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Manually Assisted Cough
Position: Long Lying
Purpose: Increase the end-expiratory peak cough flow
Comment: Therapists hands placed on lower ribs or inferiorly to
sternum (depending on patient preference).
Technique: The patient is asked to cough. The physiotherapist
coordinates a firm downward pressure at the moment of the forced expiration
or cough.
The ‘manually assisted cough’ is
performed by providing a compression of the lower ribs or applying a hooking compression
to upper abdominals toward the diaphragm when the patient braces to cough.
The aim is to increase the forced expiration pressure to clear secretions.
This technique is best applied on a patient in a long lying position.
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Manual facilitation of breathing techniques: autogenic drainage & diaphragmic breathing
Position: Any
Purpose: To facilitate the teaching of autogenic drainage
Comment: As per autogenic drainage technique, or to challenge the
patient to breathe deeply during diaphragmic breathing.
Technique: The therapist can position their hands on the patient’s
lower ribs, adjusting the pressure placed to restrict and encourage breathing
through the expiratory reserve lung volume. The therapist would reduce
pressure to encourage breathing at higher inspiratory volumes as per the
usual autogenic drainage technique.
The Manual facilitation of breathing
techniques are a means to train patients a better technique, here we will
demonstrate how to facilitate autogenic drainage and diaphragmic breathing.
Manual facilitation of autogenic
drainage begins with the patient in a relaxed position, either long lying or
supported sitting. The patient will have been educated about breathing
control and taught to monitor apical breathing. The therapist would then
describe autogenic drainage and how they would restrict the lungs to
illustrate and facilitate an effective technique. To facilitate the
technique, the therapist would then restrict the expansion of the lower ribs
by holding the ribs firm or applying an inferior myofascial glide. The
patient will breath in until they reach the therapists resistance, ending the
breath in when the patient began to apically breathe. The patient would
breathe out. After 3-4 breaths, the therapist would lessen their restraint
off the lower ribs. This would be repeated through to tidal breathing at
increased capacities. The therapist would assist the high volume tidal
breathing by facilitate lifting of the ribs through a myofascial glide
superiorly with their hands on either the lower and or upper chest.
Manual facilitation of diaphragmic
breathing begins with the patient placing each other their hand on the upper
and lower chest, feeling for the rise and fall of the lower chest and
consciously minimising the rise and fall of the upper hand. To facilitate and
drive the lower chest/diaphragm the therapist could place one hand on the
patients upper abdomen and ask that the patient breathe to lift the therapist's
hand when they breathe in. A mild-moderate firm pressure should be applied by
the therapist to challenge the patient.
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