Chapter24

Airway Clearance Dysfunction

Jan Stephen Tecklin

including airway obstruction, inflammation, infection,

CHAPTER OUTLINE
atelectasis, abnormal ventilation/perfusion relationships,
Objectives and deterioration of arterial blood gas (ABG) values.
Pathology Airway obstruction occurs in many groups of individuals
Examination and is a defining feature of chronic obstructive pulmonary
Patient History
disease (COPD) in adults and of cystic fibrosis (CF) in chil-
Systems Review
Tests and Measures
dren, adolescents, and adults.
Evaluation, Diagnosis, and Prognosis
Intervention PATHOLOGY
Coordination, Communication, and Documentation Airway clearance dysfunction occurs in many diseases
Patient/Client-Related Instruction and conditions. In reviewing the codes from the Interna-
Airway Clearance Techniques tional Classification of Diseases—Ninth revision (ICD9)1 that
Therapeutic Exercise
are listed in the Guide to Physical Therapist Practice2 for
Devices and Equipment
Case Study
preferred practice pattern 6C: Impaired ventilation, res-
Chapter Summary piration/gas exchange, and aerobic capacity/endurance
Additional Resources associated with airway clearance dysfunction, it appears
Glossary that patients in three large diagnostic groups are at risk
References for airway clearance dysfunction. One group includes
patients with disorders caused by chronic inhalation of
OBJECTIVES particulate matter, including organic (generally tobacco
smoke) and inorganic dusts; another group of patients
After reading this chapter, the reader will be able to:
have infectious disorders; and the third large group is
1. Identify four common causes of airway clearance
dysfunction.
associated with operative procedures, including cardio-
2. Describe associations between specific pathological findings vascular and orthopedic procedures and solid organ trans-
and airway clearance techniques. plantation. In addition, the nature of the pathological
3. Apply valid and reliable tests to determine whether airway process in CF, which leads to tenacious and voluminous
clearance techniques are appropriate for a particular bronchial secretions, inevitably produces airway clearance
patient. problems.
4. Design and execute safe and effective interventions for
improving airway clearance. EXAMINATION
5. Document and communicate the examination findings,
prognosis, plan of care, and reexamination findings for any
patient with airway clearance dysfunction.
PATIENT HISTORY
6. Identify when airway clearance techniques should be taught The patient history should include questions about the
to a patient’s family members. following areas:

irway clearance dysfunction is a problem common to

A individuals with a wide variety of medical and surgi-
cal diagnoses. Airway clearance dysfunction implies an
Employment/work Does the patient’s current
employment contribute to the airway dysfunction?
inability to adequately clear the airways of obstructing Is there exposure to fumes, dusts, gases or other
material such as mucus, secretions, fluid, cellular debris, particulate matter? Such exposure often causes
inflammatory exudate, or other items such as aspirated and/or exacerbates lung disease.3,4 Does the
foreign objects. Many immediate and potentially adverse physical disability limit the ability to perform work-
outcomes may result from an inability to clear the airways, related tasks?

642

Living environment Does the home or other
discharge destination provide space and resources
(including adequate electrical outlets) for necessary
respiratory support items such as oxygen, a
ventilator, and suction devices?
General health status Is the patient mobile at
home? Is the patient depressed? Depression is
common in individuals with COPD.5 Has there
been a change in community, leisure, and social
function because of the illness?
Social/health habits Is the patient a smoker and has
there been an attempt to stop smoking? It is clear
that smoking cessation, even on an intermittent
basis, can reduce the long-term decline in
pulmonary function associated with smoking.6 Can
and does the patient participate in fitness
activities? Long-term exercise for individuals with
chronic lung disease may reduce self-reported
disability and improve functional status.7
Medical/surgical history Were there recent
hospitalizations or illnesses? Are there co-
morbidities that may affect rehabilitation
participation and effort?
Current condition/chief complaint What current
concern has led to the request for rehabilitation
intervention and is this a recurrence? What are the
current therapeutic interventions? Has the patient
been performing any type of airway clearance or
exercise regimen? What are the patient’s and
family’s expectations for this episode of care?
Functional status/activity level Was the patient
previously independent at home and with activities
of daily living (ADLs)? What is the current and
recent status regarding work and community
activities?
Medications What medications is the patient taking
and can these be expected to impact the physical
therapy regimen? Patients with airway clearance
dysfunction often use aerosolized bronchodilator
and mucolytic medications. Taking these before
airway clearance and exercise interventions can
optimize benefits from such treatments.8
Clinical Tests. Available records should be reviewed.
Pulmonary function test results and ABG values can help
guide the appropriate intensity of interventions and the
need for rest during interventions.
SYSTEMS REVIEW
The systems review is used to target areas requiring further
examination and to define areas that may cause compli-
cations or indicate a need for precautions during the
examination and intervention processes. See Chapter 1 for
details of the systems review.
TESTS AND MEASURES
Musculoskeletal
Posture. Posture is commonly altered by chronic lung
disease, particularly when hyperinflation is present for a
long period of time.9 An examination of postural align-
Airway Clearance Dysfunction • CHAPTER 24 643
ment should therefore be performed on any patient with
chronic lung disease (see Chapter 4).10 Patients with long-
term hyperinflation have several typical findings, includ-
ing tight pectoral, sternocleidomastoid, scalene, and
scapular muscles and an increased anterior-posterior (AP)
diameter of the thorax. The normal ratio of the AP diam-
eter to the transverse diameter of the thorax in the absence
of hyperinflation is approximately 1 : 2. This ratio is
termed the thoracic index. In the presence of hyperinfla-
tion, the thoracic index increases and is often ≥2 : 1. This
is termed a barrel chest.11 The muscle shortening and
increase in thoracic index associated with hyperinflation
are generally accompanied by an increase in thoracic
kyphosis. Overall, the rigidity of the continually enlarged
thoracic cage reduces both thoracic excursion and spinal
flexibility. Measurement of chest circumference with a
tape measure at the level of the xiphoid process can be
used to determine thoracic expansion. Chest calipers, also
called pelvimeters, may also be used to determine the tho-
racic index and changes in thoracic index with active
efforts at chest expansion and with hyperinflation.
Range of Motion. Because of the degree of chronic
inactivity and lack of mobility in many individuals with
chronic lung disease, it is important to test range of
motion (ROM) at all major joints in this group of patients.
Shoulder girdle and thoracic spine ROM are of particular
importance to assure that chest expansion is not impeded
by soft tissue tightness or lack of joint mobility. In addi-
tion, people with chronic lung disease, who commonly
are not able to be very active, tend to spend a great deal
of time seated or supine, which often reduces ROM in the
lower extremities. Examination of ROM using classical
goniometric techniques, inclinometry, and observation of
functional ROM are all appropriate in this population.
Muscle Performance. Individuals with COPD often
have muscle weakness in their extremities, shoulder
girdle, neck, and chest that limits physical activity.12 There
is increasing evidence that peripheral muscle dysfunction
exists independent of ventilation limitations in individu-
als with COPD and CF.12 Studies indicate that chronic lung
disease results in muscle weakness and that oxidative
stress reduces muscle endurance in individuals with
COPD.13 Regardless of the cause, it is clear that the periph-
eral muscle strength deficits in this population lead to
exercise limitation and intolerance.14-16
With airway clearance dysfunction, the patient benefits
from an effective cough. The power behind a cough is
achieved by a sudden and forceful contraction of the
abdominal muscles and expiratory muscles of the thorax.
Expiratory muscle function is reflected by maximal static
expiratory pressure and peak expiratory flow (see Chapter
26).17,18 These can be measured easily and inexpensively
with an analog “bugle” dynamometer or a digital device.19
Neuromuscular
Pain. Assessment of pain—both its source and per-
ceived level—is an important part of the examination of
the patient with airway clearance difficulties. Chest wall
pain resulting from musculoskeletal problems is common.
This pain is usually nonsegmental, localized to the ante-
rior chest, and aggravated by deep breathing and has a
644 PART 3 • Cardiopulmonary System
palpable source. Chest wall pain is also usually unrelated to
exercise. In contrast, chest pain caused by cardiac ischemia
(angina pectoris) is typically a viselike, crushing midline
pain that radiates to the jaw and arm and is aggravated by
exercise. Thoracic nerve root inflammation can also cause
chest pain, but this will follow a dermatomal distribution.
If the patient has chest wall pain, a pain scale (see
Chapter 22) should be used to determine the level of pain.
A pain diary may be helpful to determine the effects of
pain on daily activity and to evaluate the effects of inter-
ventions on this symptom.
Cardiovascular/Pulmonary
Ventilation and Respiration/Gas Exchange. Two
important indicators of potential problems with respira-
tion include the rate of perceived exertion (RPE) and the
level of dyspnea, commonly quantified with the revised 10-
point Borg Scale20 and with dyspnea scales, respectively.
The Borg Scale of perceived exertion was originally a scale
with a range of scores from 6 to 20 (see Box 23-3). A score
of 6 indicated no exertion at all and 20 indicated very,
very hard exertion. The scale was later revised to a 10-
point scale from 0-10 with 0 equating to no exertion at all
and 10 indicating very, very strong exertion (Box 24-1).
This revision has been shown to be both valid and reliable
in more than 400 consecutive patients with dyspnea in an
emergency department.21 It has also been shown to be
reproducible over long time periods.22
There are numerous dyspnea scales that range from
simple and unidimensional to more complex and multi-
dimensional (see Fig. 23-3). In addition, dyspnea measures
often appear within more wide-ranging questionnaires
about respiratory diseases and their effects on the quality
of life. A visual analog scale (VAS) similar to the visual
analog scale used to quantify pain severity (see Chapter
22) can also be used to quantify dyspnea. A 10-cm hori-
zontal line is presented with end points of “not breathless
at all” to “worst breathlessness I can imagine.” The patient
indicates his or her level of breathlessness on the line.
Scoring of breathlessness on the VAS has strong concur-
rent validity with the Borg Scale23 and is reproducible at
varying levels of exercise.24
Two very commonly employed valid and reliable
disease-specific instruments that include dyspnea are the
Chronic Respiratory Questionnaire (CRQ)25 and the St.
George’s Respiratory Questionnaire (SGRQ).26 Both instru-
ments are self-report questionnaires that examine the
impact of respiratory problems on daily life. Both have
been used extensively in research and allow for ready com-
parison of results from different studies.27 (See Additional
Resources for information on obtaining copies of these
instruments.)
Many of the findings associated with impaired ventila-
tion and gas exchange have a direct bearing on procedural
intervention selection. These findings are best gathered
through the tools of a traditional chest examination,
which include inspection, auscultation, palpation, and per-
cussion.
Inspection. The inspection phase of the chest exami-
nation involves looking at the patient, specifically seeking
signs of problems with breathing. Inspection should first
focus on the patient’s general appearance. The therapist
evaluates body type as normal, obese, or cachectic and
then examines posture, taking particular note of any
spinal misalignment or unusual postures as noted previ-
ously. The therapist should look for and document the
presence of kyphosis, scoliosis, and forward bend, or pro-
fessorial posture (Fig. 24-1).
During inspection of the extremities the therapist
should look for nicotine stains on the fingers, digital
clubbing, painful swollen joints, tremor, and edema.
Nicotine stains suggest a history of heavy smoking and
are important in the evaluation of the unconscious
patient. Clubbing of the fingers or toes is associated with
cardiopulmonary and small bowel disease.28 Painful
swollen joints in certain patients with lung disease may
indicate pseudohypertrophic pulmonary osteoarthropa-
thy rather than the osteoarthritis or rheumatoid arthritis
more familiar to physical therapists (PTs).29 Bilateral pedal
edema may indicate cor pulmonale or right-sided heart
failure in those with long-standing chronic lung disease.
The therapist should also note all equipment used in
managing the patient. For example, the use of a cardiac
monitor, a Swan-Ganz catheter, or a left ventricular assist
device suggests potential or actual cardiac rhythm distur-
bances or hemodynamic or cardiac output problems,
respectively.
When inspecting the head and neck, the therapist
should check the face for signs of respiratory distress and
oxygen desaturation. Signs commonly seen in individuals
with significant respiratory distress include flaring of the
alae nasi and cyanosis of the mucous membranes.30
Inspection of the unmoving chest should include
looking for congenital defects such as pectus carinatum
(pigeon breast) and pectus excavatum (funnel chest or
hollow chest). The therapist should next inspect the rib
angles and intercostal spaces. Normally, the rib angles are
less than 90 degrees, and the ribs attach to the vertebrae
at an angle of about 45 degrees. The spaces between the
ribs are broader posteriorly than anteriorly. Widening of
the rib angles and broadening of the anterior intercostal
spaces suggests hyperinflation of the lungs. Inspection of
the musculature around the chest often reveals bilateral
trapezius and sternocleidomastoid muscle hypertrophy as
a result of overuse of these accessory muscles of ventila-
tion associated with acute respiratory distress and chronic
dyspnea. However, a prominent appearance of these
muscles is most often caused by an increase in thoracic
kyphosis and a forward-head position rather than actual
muscle hypertrophy.31 The two hemithoraces should be
compared for asymmetry such as unilateral chest wall
retraction.
Inspection of the moving chest begins with assessment
of the respiratory rate, which normally ranges from 12-20
breaths per minute (breaths/min) in adults. This normal,
or eupneic, pattern of breathing supplies one breath for
every four heartbeats. Tachypnea refers to a ventilatory
rate faster than 20 breaths/min. Bradypnea refers to a ven-
tilatory rate slower than 10 breaths/min. Fever affects ven-
tilatory rate which increases by 3-4 breaths/min for every
 Airway Clearance Dysfunction • CHAPTER 24 645

BOX 24-1 Borg CR10 Scale

Instruction. Use this rating scale to report how strong your perception is. It can be exertion, pain, or something else.
Ten (10) or “Extremely strong”—“Maximal” is a very important intensity level. It serves as a reference point on the scale.
This is the most intense perception or feeling (e.g., of exertion) you have ever had. It is, however, possible to experience
or imagine something even more intense. That is why we’ve placed “Absolute maximum” outside and further down on
the scale without any corresponding number, just a dot “•”. If your experience is stronger than “10,” you can use a
larger number.
First look at the verbal expressions. Start with them and then the numbers. If your experience or feeling is “Very
weak,” you should say “1,” if it is “Moderate,” say “3.” Note that “Moderate” is “3” and thus weaker than “Medium,”
“Mean,” or “Middle.” If the experience is “Strong” or “Heavy” (it feels “Difficult”) say “5.” Note that “Strong” is about
50 percent, or about half, of “Maximal.” If your perception is “Very strong” (“Very intense”) choose a number from 6 to
8, depending upon how intense it is. Feel free to use half-numbers like “1.5” or “3.5,” or decimals like “0.3,” “0.8,” or
“2.3.” It is very important that you report what you actually experience or feel, not what you think you should report.
Be as spontaneous and honest as possible and try to avoid under- or over-estimating. Look at the verbal descriptors and
then choose a number.
When rating perceived exertion give a number that corresponds to your feeling of exertion, that is, how hard and
strenuous you perceive the work to be and how tired you are. The perception of exertion is mainly felt as strain and
fatigue in your muscles and as breathlessness or aches in the chest. It is important that you only think about what you
feel, and not about what the actual load is.
1 Very light. As for a healthy person taking a short walk at his or her own pace.
3 Moderate is somewhat but not especially hard. It feels good and not difficult to go on.
5 The work is hard and tiring, but continuing isn’t terribly difficult. The effort and exertion are about half as intense as “Maximal.”
7 Quite strenuous. You can still go on, but you really have to push yourself you are very tired.
10 An extremely strenuous level. For most people this is the most strenuous exertion they have ever experienced.
• Is “Absolute maximum ,” for example “12” or even more.
Any questions?
0 Nothing at all
0.3
0.5 Extremely weak Just noticeable
0.7
1 Very weak
1.5
2 Weak Light
2.5
3 Moderate
4
5 Strong Heavy
6
7 Very strong
8
9
10 Extremely strong “Maximal”
11

• Absolute maximum Highest possible

Borg CR10 Scale
© Gunnar Borg 1982, 1998
“The Borg CR-10 Scale,” Borg G, 2003.

degree Fahrenheit of fever, and by even more in young
children32 (see Chapter 22 for further details of how to
measure respiratory rate). Next, the therapist inspects the
ratio of inspiratory and expiratory time (the I : E ratio).
Normally, expiration lasts twice as long as inspiration,
giving an I : E ratio of 1 : 2. In obstructive lung disease,
expiration is prolonged, commonly producing I : E ratios
of 1 : 4 or 1 : 5.
When examining the moving chest, one also examines
the sounds associated with breathing. Detection of stridor,
a crowing sound during inspiration, suggests upper airway
obstruction and may indicate laryngospasm.33 Stertor, a
snoring noise created when the tongue falls back into the
lower palate, may be heard in patients with depressed con-
sciousness. Expiratory grunting, commonly heard in
infants with respiratory distress, may be a physiological
attempt to prevent premature airway collapse. Gurgling
sounds heard during inspiration and expiration may
indicate copious secretions in the larger airways. The ther-
apist next determines the pattern of breathing to identify
646 PART 3 • Cardiopulmonary System

the rate, depth and regularity of the ventilatory cycle.
Some commonly encountered breathing patterns appear
in Table 24-1.
After inspecting the pattern and sounds of breathing,
the therapist determines the symmetry and synchrony of
breathing. The timing and relative motion of one
hemithorax to the other and to the abdomen are com-
pared during both normal tidal breathing and deep
breathing. Individuals with respiratory muscle dysfunc-
tion because of neuromuscular disease often have asym-
metrical or paradoxical thoracic motion. Paradoxical
motion occurs when the diaphragm or rib cage muscula-
FIG. 24-1 Forward-bend or professorial posture.
ture are impaired preferentially. Paradoxical motion
involves chest wall motion contradictory to the expected
inspiratory motion.34 The chronically hyperinflated
thorax and flattened diaphragm, often seen with severe
COPD, can result in a simultaneous in-drawing of the
lower ribs and expansion of the upper ribs during inspi-
ration.35 Gross observation of the respiratory muscles facil-
itates detection of accessory inspiratory or expiratory
muscle activity. Moreover, careful observation of the inter-
costal spaces may reveal inspiratory retraction associated
with decreased pulmonary compliance or expiratory
bulging associated with expiratory obstruction.36
Inspection of the chest continues with evaluation of
speech, breath, cough, and sputum. Speech patterns asso-
ciated with breathing difficulties or specific breath prob-
lems can often be recognized during casual conversation,
particularly shortness of breath that causes frequent inter-
ruptions in speech known as “dyspnea of phonation.”
This may be quantified by the number of words that can
be spoken between sequential breaths and called, for
example, “three word dyspnea” or “four word dyspnea.”
Malodorous breath detected during conversation may
indicate anaerobic infection of the mouth or respiratory
tract.37
If a patient has complaints of coughing, the clinician
next identifies characteristics of the cough, including
whether it is persistent, paroxysmal, or occasional; dry or
productive; and the circumstances associated with the
onset or cessation of coughing. Examination of voluntary
coughing can also assist in patient evaluation because
certain cough characteristics are associated with different
pathologies. For example, patients with COPD often
cough with poor inspiratory effort and negligible abdom-
inal muscle compression, making the cough ineffective for
airway clearance. Patients with COPD also often have

TABLE 24-1 Breathing Patterns Commonly Found in the Examination of Patients with Airway Clearance
Problems
Pattern of Breathing Description
Apnea Absence of ventilation
Fish-mouth Apnea with concomitant mouth opening and closing; associated with neck extension and bradypnea
Eupnea Normal rate, normal depth, regular rhythm
Bradypnea Slow rate, shallow or normal depth, regular rhythm; associated with drug overdose
Tachypnea Fast rate, shallow depth, regular rhythm; associated with restrictive lung disease
Hyperpnea Normal rate, increased depth, regular rhythm
Cheyne-Stokes respiration Increasing then decreasing depth, periods of apnea interspersed with somewhat regular rhythm; associated
(periodic) with critically ill patients
Biot’s respiration (cluster) Slow rate, shallow depth, apneic periods, irregular rhythm; associated with CNS disorders such as meningitis
Apneustic Slow rate, deep inspiration followed by apnea, irregular rhythm; associated with brainstem disorders
Prolonged expiration Fast inspiration, slow and prolonged expiration yet normal rate, depth, regular rhythm; associated with
obstructive lung disease
Orthopnea Difficulty breathing in postures other than erect
Hyperventilation Fast rate, increased depth, regular rhythm; results in decreased arterial carbon dioxide, tension; called
“Kussmaul breathing” in metabolic acidosis; also associated with CNS disorders such as encephalitis
Psychogenic dyspnea Normal rate, regular intervals of sighing; associated with anxiety
Dyspnea Rapid rate, shallow depth, regular rhythm; associated with accessory muscle activity
Doorstop Normal rate and rhythm; characterized by abrupt cessation of inspiration when restriction is encountered;
associated with pleurisy

From Irwin S, Tecklin JS: Cardiopulmonary Physical Therapy: A Guide to Practice, ed 4, Philadelphia, 2004, Elsevier Science.
CNS, Central nervous system.

much paroxysmal coughing that can be very fatiguing
because it is so frequent and ineffective.
Sputum inspection attempts to estimate or measure the
quantity of expectorate raised per day. In addition to
quantity, the color and consistency of any sputum raised
should be evaluated.
The inspection phase of the chest examination closes
with a brief examination of the abdomen to detect any-
thing that may affect diaphragmatic function. Findings
affecting diaphragm function may include morbid
obesity; previous and recent abdominal surgeries, includ-
ing colostomy; or insertion of a feeding tube. Findings
from the inspection phase of the examination may be
further elucidated and validated by the auscultation phase
of the chest examination,.
Auscultation. Auscultation provides information about
which parts of the lungs are being ventilated during
breathing and about the location and presence of secre-
tions in the lungs. Poor ventilation of an area may be
addressed by breathing retraining or positional change,
whereas accumulation of secretions may be addressed by
specific airway clearance activities. During chest ausculta-
tion the patient should breathe in and out deeply with the
mouth open.
A wide range of terminology is used to describe breath
sounds.38 Breath sounds are generated by the vibration
and turbulence of airflow into and out of the airways and
lung tissue during inspiration and expiration. Normal
breath sounds can be divided into four specific types:
Tracheal, bronchial, bronchovesicular, and vesicular. Each
of these is considered normal when heard over a specific
region of the thorax. However, when heard in a different
region, these sounds are considered abnormal. Tracheal
breath sounds are high-pitched, loud noises that sound
like wind blowing through a pipe. There is a distinct
absence of sound during the transition from inspira-
tion to expiration. These sounds are considered normal
when heard over the trachea. Bronchial breath sounds,
which are similar to but quieter than tracheal sounds,
are normal when heard next to the sternum near the
major airways. When heard in any other area of the
lungs, bronchial sounds usually indicate lung tissue that
is consolidated, compressed, filled with fluid, or airless
because of atelectasis. Vesicular breath sounds are low-
pitched muffled sounds that have been described as
a rustling sound similar to a gentle breeze blowing
through the leaves of a tree.39 Vesicular sounds are louder,
longer, and higher in pitch during inspiration than
expiration and are considered normal over all areas of
the lung except where tracheal or bronchial sounds are
expected. Vesicular breath sounds are abnormal if they are
diminished or absent. Diminished or absent vesicular
breath sounds can occur when underlying lung tissue is
poorly ventilated, or when extensive hyperaeration
reduces the transmission of vesicular sounds from the
lung tissue. Bronchovesicular sounds, as one might
expect, combine characteristics of bronchial and vesicular
sounds. Inspiration and expiration are heard for similar
times, at the same pitch, and with a slight break between
the two phases. These sounds are normal when heard next
to the sternum at the costosternal border at the sternal
Airway Clearance Dysfunction • CHAPTER 24 647
angle and between the scapulae from about T3 through
T6.40
Adventitious breath sounds are breath sounds that are
always abnormal. These sounds are commonly placed into
two categories (although more exist): Crackles, previously
called rales, and wheezes, previously called rhonchi. Crack-
les are nonmusical sounds that may be mimicked by
rolling several strands of hair near your ear or by listen-
ing to a bowl of cereal that crackles when the milk is
added. Crackles may be heard throughout inspiration or
only at its termination. Inspiratory crackles are common
at the bases of the lungs in an erect subject. Inspiratory
crackles may represent the sudden opening of airways pre-
viously closed by gravity and therefore may be a sign of
abnormal lung deflation.41,42 Expiratory crackles may be
rhythmical or nonrhythmical. Rhythmical crackles may
indicate the reopening of previously closed airways. Non-
rhythmical crackles are generally low pitched and occur
throughout the ventilatory cycle. They may indicate the
presence of fluid in the large airways.
Wheezes are continuous and musical sounds that
sound like whistling or growling. Wheezes are probably
produced by air flowing at high velocities through nar-
rowed airways. Their pitch varies with the velocity of
airflow and the diameter of the airway. Wheezes may be
monophonic (single tone) or polyphonic (multiple tones)
and may be heard during inspiration or expiration. Inspi-
ratory wheezes may be caused by airway stenosis and
other types of intrinsic or extrinsic obstruction such as
bronchospasm or foreign-body aspiration. Expiratory
wheezes are more common than inspiratory wheezes.39
They tend to be low pitched and polyphonic and may
reflect unstable airways that have collapsed. Expiratory
wheezes are associated with diffuse airway obstruction as
may occur in patients with extensive secretions in their
airways as associated with chronic bronchitis or cystic
fibrosis. Monophonic expiratory wheezes occur when only
one airway reaches the point of collapse.
Other adventitious sounds that may be detected during
auscultation of the lungs include rubs and crunches. Rubs
are coarse, grating leathery sounds. Pleural rubs are heard
concurrently with the ventilatory cycle, whereas pericar-
dial rubs are heard during the cardiac cycle. Rubs gener-
ally indicate inflammation.39 Crunches are crackling
sounds heard over the pericardium during systole and
suggest the presence of air in the mediastinum, called
mediastinal emphysema.
With these definitions and descriptions in mind, the
therapist compares the quality, intensity, pitch, and dis-
tribution of the breath and voice sounds of homologous
bronchopulmonary segments of the anterior, lateral, and
posterior aspects of the chest. Fig. 24-2 presents one
method for auscultating the chest.
On completing auscultation, the therapist must record
and interpret the findings in a nomenclature acceptable
to the institution. Normal breath and voice sounds in all
bronchopulmonary segments suggest a normal examina-
tion. If inspection was also normal and the patient denied
all pulmonary symptoms, one considers this portion of
the chest examination normal and further examination is
deferred. If breath sounds are abnormal or if adventitious
648 PART 3 • Cardiopulmonary System
A B
FIG. 24-2 A suggested method for chest auscultation.
A, Anteriorly; B, posteriorly. From Buckingham EB: A Primer
of Clinical Diagnosis, ed 2, New York, 1979, Harper & Row.
In Irwin S, Tecklin JS: Cardiopulmonary Physical Therapy: A
Guide to Practice, ed 4, St. Louis, 1995, Mosby.
sounds are present, the examination findings are abnor-
mal but at this point inconclusive. Generally, decreased or
absent breath sounds or inspiratory crackles suggest
reduced ventilation. Crackles during both ventilatory
cycles suggest impaired secretion clearance. Monophonic,
biphasic wheezing suggests stenosis or bronchial
smooth–muscle spasm. Polyphonic wheezing suggests
diffuse airway obstruction. The absence of crackles and
wheezes does not, however, ensure the absence of acute
disease because patients with chronic obstructive lung
disease may have hyperinflation so severe that adventi-
tious sounds cannot be heard through the excessive air in
the lungs. In summary, auscultation either confirms the
findings of inspection or identifies areas of impaired ven-
tilation or impaired secretion clearance.
Palpation. In general, palpation refines the information
obtained previously. It further identifies any thoracoab-
dominal asymmetry or asynchrony detected during inspec-
tion by further examining the position of the mediastinum
and motion of the thorax. Palpation of accessory muscles
of inspiration permits specific examination of muscle activ-
ity identified grossly during inspection. The sternocleido-
mastoid and scalene muscle groups are the primary
accessory muscles of inspiration.43 Normally, accessory
muscles are inactive during quiet breathing. Palpation of
increased accessory muscle activity during inspiration indi-
cates that the work of breathing is increased. Their use
during stressful situations, such as physical exertion or
acute illness, may be appropriate, but accessory muscle use
during rest may add unnecessarily to the work of breath-
ing. Patients with airway clearance dysfunction who have
chronic lung disease often habitually and unnecessarily use
their accessory muscles. Intervention may be directed at
reducing accessory muscle use to conserve energy.
Steps for palpating the activity of accessory
muscles of breathing
1. Position the patient with his or her back toward
you.
2. Place your thumbs over the spinous processes so
that your fingers reach around to the anterolateral
aspect of the neck.
FIG. 24-3 Palpation of scalene muscle activity. From Irwin S,
Tecklin JS: Cardiopulmonary Physical Therapy: A Guide to
Practice, ed 4, St. Louis, 1995, Mosby.
3. Feel for activity and movement of scalenes and
sternocleidomastoid muscles (Fig. 24-3).
4. Examine the area through at least two respiratory
cycles.
The position of the mediastinum is generally deter-
mined by palpating the position of the trachea, which is
normally in the midline. A lateral shift in the medi-
astinum, as determined by a shift of the trachea, occurs
when intrathoracic pressure or lung volume differs
between the two hemithoraces. The mediastinum shifts
toward the affected side when lung volume is unilaterally
decreased. The mediastinum shifts toward the unaffected
side or contralaterally when pressure or volume is unilat-
erally increased.
Palpation can also be used to compare expansion of the
upper, middle, and lower lobes of the lungs during quiet
and deep breathing. In each case the therapist places the
hands on the appropriate portion of the thorax and asks
the patient to take in a normal or deep breath. The ther-
apist compares the timing and extent of movement of
each hand as the chest expands. Lobar motion, as reflected
by thoracic motion, is considered normal when both
hands move the same amount at the same time. This
phase of palpation allows the therapist to localize any dis-
proportionate expansion observed during inspection. For
example, if inspection reveals asymmetrical chest expan-
sion, palpation may not only localize the problem to the
right upper lobe but may also identify a shift of the medi-
astinum to the right of midline. Together these signs
suggest that the problem is either a loss of volume in the
 Airway Clearance Dysfunction • CHAPTER 24 649

right upper lobe or an increase of volume in the left upper illustrates the distribution of the cervical and thoracic
lobe. dermatomes.
Vocal fremitus is the vibration produced by the voice When chest pain is identified, the therapist should also
and transmitted to the chest wall, where it can be detected ask about the onset, character, duration, and severity of
by the hand as a tactile vibration called fremitus. The ther- this pain. Chest pain associated with cardiac disease is
apist evaluates fremitus by comparing the intensity of the important to identify because of its serious potential con-
vibrations detected by each hand during quiet breathing sequences. Such pain is often described as heaviness or
and speech. It is normal for the vibrations to be equal and crushing pain that radiates toward the neck, jaw, left
moderate during speech. Fremitus is abnormal when it is
increased or decreased. Increased fremitus suggests a loss
or decrease in ventilation in the underlying lung because TABLE 24-3 Segmental Innervation of the
sound is transmitted more strongly through non–air-filled Chest and Abdomen
lung tissue.44 Decreased fremitus suggests increased air
within the underlying lung because sound is transmitted Cord
more poorly through hyperinflated lung tissue.37 Segments Structure
Rhonchal fremitus describes vibrations detected during T1-4 Mediastinal contents: Heart, aorta, pulmonary vessels
quiet breathing caused by turbulent airflow through or T3-8 Descending aorta
around retained secretions in the airways. Rhonchal fremi- T4-8 Esophagus
tus is therefore always abnormal. Identification of rhon- T3-5 Trachea and bronchi
chal fremitus permits the therapist to locate secretions or T7-9 Upper abdominal viscera
C5-T1 Chest wall; apical parietal pleura
to better identify reasons for decreased breath sounds
T2-8 Remainder parietal; upper pericardial pleura
found during auscultation. T6-8 Peripheral diaphragm
Palpation may also be used to identify and localize C3-5 Central diaphragm; lower pericardial pleura
some types of chest pain to help determine the safety of T2-10 Intercostal muscles; ribs
continuing further examination and intervention. Palpa- C5-T1 Pectoral muscles
tion facilitates identification of characteristics and descrip- C3-4 Skin overlying shoulders
tors associated with the pain for more complete and T1-2 Upper arms, inner surface
effective communication with the patient’s physician and T3-8 Skin on chest wall
may provide information about the source of chest pain,
Adapted from Edmeads J, Billings RF: Neurological and psychological
which may include musculoskeletal problems, coronary aspects of chest pain. In Levene DL (ed): Chest Pain: An Integrated
artery disease, malignancy, cervical disk or nerve root Diagnostic Approach, Philadelphia, 1977, Lea and Febiger.
disease, thoracic outlet syndrome, herpes zoster, or pul-
monary embolism. Identifying the probable anatomical
C2
source of chest pain requires associating the type of pain V1 C2
and its stimulus (Table 24-2). Matching the sensory distri- Trigeminal
V2 C3
bution of the pain to the appropriate anatomical structure C3 cranial nerve (V)
C4
V3
C5
may also help the therapist identify the anatomical source C4
C7
C6
T1 C5 C8
of the pain. Table 24-3 presents the segmental innervation T2
T1
T2
T3 T3
of the structures of the chest and abdomen. Fig. 24-4 T4
C6
T4
T5
T5 T6
T1 T1
T6 T7
C6 T8
T7
T9
T8 T10
T9 T11
T12
C5 T10 L1
TABLE 24-2 Guideline for Identifying the T11
C5
L2
L3
Probable Source of Chest Pain S2
T12
L1 L4
S3
C8
Symptom Characteristics Effective Anatomical L2 L2
L5 S3
C8 C7 S4
Stimulus Source CX S1
S5
S2
Sharp Fine touch Skin
L1
Superficial Pinprick L3
L2

Burning Heat L3

Precisely localize Cold

L3
Dull or sharp Movement Chest wall
L4 L4
Intermediate depth Deep pressure
L5 L5
Aching
Generally located L4
S S2 S
Dull Ischemia Thoracic viscera S1
L R R L
Deep Distention S2 S2 L5
Aching Muscle spasm I I S1

Diffuse, vaguely localized

Adapted from Edmeads J, Billings RF: Neurological and psychological FIG. 24-4 Dermatome distribution of the spinal nerves.
aspects of chest pain. In Levene DL (ed): Chest Pain: An Integrated From Thibodeau GA, Patton KT: Anatomy and Physiology,
Diagnostic Approach, Philadelphia, 1977, Lea and Febiger. ed 6, St. Louis, 2006, Mosby.
650 PART 3 • Cardiopulmonary System

FIG. 24-5 Palpation of diaphragmatic motion. A, At rest.

B, At the end of a normal inspiration. From Cherniack RM,
Cherniack L, Naimark A: Respiration in Health and Disease,
ed 2, Philadelphia, 1972, WB Saunders. In Irwin S, Tecklin JS:
Cardiopulmonary Physical Therapy: A Guide to Practice, ed
4, St. Louis, 1995, Mosby.

upper extremity, and midscapular region and generally is

not affected by palpation.45
During the last phase of palpation, movement of the
diaphragm is identified as normal or abnormal. Fig. 24-5 FIG. 24-6 Normal resonance pattern of the chest with
percussion. A, Anteriorly; B, posteriorly. Adapted from Irwin
presents one method of examining diaphragmatic
S, Tecklin JS: Cardiopulmonary Physical Therapy: A Guide to
motion. Normal motion of the diaphragm produces equal Practice, ed 4, St. Louis, 1995, Mosby.
upward motion of the costal margins. Inward motion of
the costal margins during inspiration is associated with a
flattened diaphragm that commonly occurs in individuals
with chronic airway clearance dysfunction and COPD.46
Flattening of the diaphragm caused by severe hyperinfla-
tion may reduce the ability of the diaphragm to contract
because it alters the length-tension relationship of the
muscle fibers.46
Percussion. Percussion (mediate percussion) is the
fourth and final part of the chest examination. It enables
the clinician to associate any symptoms and signs previ-
ously uncovered that suggest changes in lung density, and
it allows one to establish the borders of abnormally dense
lung areas and normally occurring organs. Finally, per-
cussion allows examination of the extent of diaphrag- FIG. 24-7 Correct hand position for diagnostic percussion.
matic motion. Percussion is performed by tapping the Adapted from Buckingham EB: A Primer of Clinical Diagnosis,
finger of one hand against the middle finger of the other ed 2, New York, 1979, Harper & Row.
hand placed on the chest wall. The middle finger should
be placed at rib interspaces. The sound produced by the
tapping will be affected by the density of the underlying hyperinflated lung. A tympanic note can be simulated by
tissue, with denser tissue (poorly inflated lung or other percussion over the empty stomach.
solid tissue) sounding flat or dull and less dense tissue Normally dense, resonant lung can be found from the
(hyperinflated lung) sounding hyperresonant or tym- clavicle to the sixth rib anteriorly, the eighth rib laterally,
panic. When examining lung density by percussion, the and the tenth rib posteriorly (Fig. 24-6). The correct hand
therapist may identify one of three sounds or notes: position for percussion is presented in Fig. 24-7.
Normal, dull, or tympanic. (It should be noted that physi- In a normal examination, the resonance is similar
cians identify five notes: Tympanic, hyperresonant, reso- across homologous lung segments (i.e., in lung segments
nant, dull, and flat, but three serve the purpose for PTs.) in similar positions within each hemithorax). Moreover,
A normal note is produced when percussion is performed to be normal, the resonance must extend throughout the
over the thorax adjacent to resonant lung of normal anatomical limits of the lungs. Abscesses, tumors, cysts,
density. A dull note is soft, brief, high-pitched, and thud- pneumonia, and areas of atelectasis can produce changes
like and is heard over the thorax with lung of increased in lung density and result in abnormal percussive notes.
density because it is less air-filled. A dull note can be sim- Lung borders are affected by volume changes in either the
ulated by percussion over the liver or the thigh. A tym- abdomen or lungs. Abnormally high lung bases are asso-
panic note is loud, lengthy, low pitched, and hollow and ciated with increased abdominal volume as seen in preg-
is heard over the thorax in areas of excessive air such as nancy. Abnormally low lung bases are associated with

increased lung volumes because of hyperinflation as is
typical in chronic obstructive lung disease. These and
other variations in lung borders can be identified by
mediate percussion.47
Aerobic Capacity and Endurance. Among the many
reasons for testing for aerobic capacity and endurance are
the following: (1) identifying through standardized pro-
tocols the baseline ability of the patient, (2) determining
the capacity of the patient to perform functional activi-
ties, (3) predicting the response of the patient to physio-
logical demands during periods of increased or stressful
physical activity, and (4) recognizing symptoms that may
limit the patient’s ability to respond to an increased work-
load. The many modes of testing range from noting symp-
tomatic responses to a standard exercise challenge to
instrumented technically sophisticated invasive aerobic
testing in an exercise laboratory. Exercise testing to deter-
mine aerobic capacity typically involves progressive or
incremental increases in exercise intensity while walking
on a treadmill or riding a bicycle ergometer, as described
in detail in Chapter 23.
Function
Orthotic, Protective, and Supportive Devices. Individ-
uals with respiratory difficulty leading to airway clearance
dysfunction often use supplemental oxygen devices,
including metal oxygen cylinders of various sizes, liquid
oxygen systems, oxygen concentration devices, and
oxygen from wall-mounted oxygen sources in hospitals
and nursing homes (as described in detail in Chapter 26).
Oxygen may be delivered from these sources by nasal
cannula or mask. The PT must determine the level of
oxygen being used and portability of the oxygen device if
gait training and ambulation activities are employed.
EVALUATION, DIAGNOSIS,
AND PROGNOSIS
Outcomes from therapy for the patient with airway clear-
ance dysfunction can include significant reduction in a
pathological process such as atelectasis. Most commonly,
impairments that improve will include ABG levels, pul-
monary function test performance, breathing pattern and
rate, and dyspnea scores. Rating of perceived exertion
during activities will also commonly improve, as well as
participation in functional abilities such as transfers,
ambulation and other modes of mobility. Safety, health,
wellness, and patient satisfaction can also be affected by
instruction of the patient and family in home use of
airway clearance techniques.
INTERVENTION
COORDINATION, COMMUNICATION,
AND DOCUMENTATION
Coordination, communication, and documentation are
interventions used for all patients and are particularly
important for this preferred practice pattern because
patients with impaired airway clearance generally have
needs for intervention by many different types of health
care professionals. Patients may need various types of
equipment, help at home, or placement in some type of
Airway Clearance Dysfunction • CHAPTER 24 651
assisted living situation and often require ongoing case
management. In addition, collaboration with various
agencies, such as home care practitioners, equipment
providers, and third party payers, is often necessary to
ensure continuation of care across varied settings.
Complex cases often include an interdisciplinary effort
that requires communication across and between dis-
ciplines, with occasional referral to other professionals
not involved with the team.
PATIENT/CLIENT-RELATED INSTRUCTION
Education and training about the lung disease underlying
the airway clearance dysfunction is critically important for
self-efficacy in patients in this preferred practice pattern.48
The American Thoracic Society cites education as one of
the four major components of any pulmonary rehabilita-
tion program and includes the items in the following list
as important parts of the educational component:49
1. Structure and function of the lung
2. Information regarding their specific disease
3. Instruction and participation in correct inhaler
technique
4. Airway clearance techniques
5. Breathing, relaxation, and panic control techniques
6. Respiratory muscle training
7. Exercise principles
8. ADLs and instrumental ADLs (IADLs)
9. Nutrition interventions and considerations
10. Medications—their effects and side effects
11. Psychosocial interventions and means of coping
with stress, anxiety, and depression
12. Avoidance of environmental irritants
13. Smoking cessation
14. Oxygen rationale and proper use of oxygen-
delivery devices
15. Travel and leisure activities
16. Sexuality
17. End-of-life issues and planning for those with pro-
gressive diseases
Individualized teaching or a series of short, interactive
lectures are commonly employed. Videotapes, digital
video disks (DVDs), and CD ROMs are available regarding
specific topics as are various Internet web sites. If the
patient seems overwhelmed by the amount of information
presented, it may be helpful to provide them with a well-
organized notebook to refer to as needed. The ultimate
goal for patient-related instruction in individuals with
airway clearance dysfunction is to provide basic knowl-
edge about their disease, its medical management, and
daily techniques and activities to enhance their quality of
life while recognizing the limitations imposed by the
disease process.
AIRWAY CLEARANCE TECHNIQUES
Airway clearance techniques include a range of therapeu-
tic interventions intended to clear the airways of secre-
tions and other debris in individuals with pulmonary
disease or respiratory impairment or those who are at risk
for developing those conditions. The interventions
include various physical maneuvers, manual procedures,
breathing techniques, use of equipment, and instruction.
652 PART 3 • Cardiopulmonary System
A PT, a respiratory therapist, a nurse or other health care
worker, a family member, or the patient may apply airway
clearance techniques to maintain patent airways and
thereby reduce or eliminate airway obstruction, enhance
ventilation, and reduce the likelihood of new or continu-
ing infection of the respiratory tract.
The medical profession recognizes that providing
airway clearance intervention is important despite its high
costs in terms of treatment time and financial resources.
Several major “state-of-the-art” reviews on airway clear-
ance interventions have appeared in the literature over the
past quarter century.50-52 At least two professions, physical
therapy and respiratory therapy, have promulgated stan-
dards of practice regarding some of the skills employed in
airway clearance.2,53 Interdisciplinary educational efforts
that incorporate the professions involved in airway clear-
ance have received federal funding in past decades. Fur-
thermore, more than “. . . two generations of physicians
have been taught that retention of excessive secretions in
the respiratory tract is not only bad for pulmonary func-
tion but can also be lethal to the patient.”54
Airway clearance, in one of its many forms, is a uni-
versally employed intervention for patients with virtually
all types of pediatric and adult lung diseases. There are
many approaches, specific techniques, and traditions for
removal of secretions and other debris from the patient’s
airway. However, there is a dearth of well-designed,
methodologically sound, properly carried out, statistically
adequately analyzed studies to support one particular
technique over another. The choice of airway clearance
approach should therefore be based on patient needs,
therapist skill, and personal choices regarding the effec-
tiveness of these techniques. This section presents the
major approaches and techniques for airway clearance.
Breathing Strategies for Airway Clearance
Forced Expiratory Technique. The forced expiratory
technique (FET) employs a forced expiration or huff after
a medium-sized breath.55 The patient is instructed to take
a medium breath (to midlung volume) then tighten the
abdominal muscles firmly while huffing (expiring forcibly
but with an opened glottis), without contracting the
throat muscles. The “huff” should be maintained long
enough to mobilize and remove distal bronchial secretions
without stimulating a spasmodic cough. The important
part of FET is the period (15-30 seconds) of relaxation with
gentle diaphragmatic breathing following 1 or 2 huffs.
This helps relax the airways as secretions continue to be
mobilized during the deep breathing. Once secretions are
felt in the larger, uppermost airways, a huff or double
cough should remove them.
Active Cycle of Breathing Technique. Because of
alleged misinterpretation of the technique by other prac-
titioners, the FET was reconfigured into the active cycle
of breathing technique (ACBT). ACBT uses several indi-
vidual breathing strategies in sequential combination
to accomplish the goals of mobilization and evacuation
of bronchial secretions. As with FET, self-treatment
without the need for an assistant or caregiver is the major
advantage to ACBT. A suggested sequence for ACBT is as
follows:
• Breath control, another name for diaphragmatic
breathing, is performed for 15-30 seconds in a quiet,
relaxed manner.
• Several attempts at thoracic expansion are per-
formed. (There is divergence of opinion regarding the
necessity of having the patient assume one of the
many postural drainage positions during this phase.
Some might also suggest using the manual tech-
niques of percussion or vibration during the expira-
tory phase of breathing.)
• Breath control is repeated for 15-30 seconds.
• Thoracic expansion is repeated.
This alternating cycle of breath control and thoracic
expansion may continue until the patient feels ready to
expectorate the built-up secretions. FET and huffing or
coughing, as described, is performed next to help evacu-
ate the accumulated secretions. The repeated sequence of
breath control and expansion is begun again.
Autogenic Drainage. Autogenic drainage (AD) is
another airway clearance technique that permits self-
treatment.56 AD is performed in a sitting position and
requires that patients determine (through proprioceptive,
sensory, and auditory signals) when bronchial secretions
are present in the smaller, medium, or larger airways. The
patient then learns to breathe at low, medium, and high
lung volumes to mobilize secretions in those airways.
Sequence of autogenic drainage
1. The patient sits upright with a minimum of
distractions in the room.
2. After a brief period of diaphragmatic breathing,
the patient exhales to a low lung volume and
breathes at a normal tidal volume at that low lung
volume. This is the “unsticking phase” of AD.
3. As the patient becomes aware of secretions in
those smaller airways, breathing becomes a bit
deeper and moves into midlung volume. This is
the “collecting phase” in which secretions are
mobilized proximally into the midsized airways.
4. At this point, breathing becomes deeper at normal
to high lung volumes. The patient is asked to
suppress coughing until it cannot be avoided. This
“evacuation phase” enables secretions to
accumulate in central airways and be evacuated
by huffing or a cough, using minimal effort.
Proponents of AD believe it can be applied in all types
of obstructive lung disease and for postoperative treat-
ment and can be taught to children as young as 5-6 years
of age. Intensive training in the technique is necessary
before it can be used effectively. Recent research on AD
found that ACBT and AD were comparable in improving
ventilation, removing secretions, and enhancing pul-
monary function.57 AD in subjects with CF was less likely
to cause oxygen desaturation during treatment than tra-
ditional postural drainage with percussion (as described in
the section on Manual and Mechanical Technique).58
Another study examined the effects of either AD or ACBT
randomized as a treatment to 30 males with COPD over a
 Airway Clearance Dysfunction • CHAPTER 24 653

20-day period. The two techniques were comparable in

that each improved performance on standard pulmonary
functions tests and perception of dyspnea. However, AD
resulted in better improvement in both oxygen saturation
and hypercapnia.59
Coughing and Huffing. Coughing and huffing is an
effective means of removing secretions and is critically
important for the individual with airway clearance dys-
function. Coughing may be reflexive or voluntary. A
reflexive cough has four phases: Irritation, inspiration,
compression, and expulsion, whereas a voluntary cough
has only the latter three phases. To be effective for airway
clearance, either type of cough must generate enough
force to clear secretions from the larger airways and move
secretions from as far down as the twelfth generation of
bronchial branching.60
Huffing is a popular airway clearance technique con-
sisting of a single large inspiration followed by short expi-
ratory efforts interrupted by pauses. The glottis remains
open during huffing to reduce the potential for side effects
that may occur from cough (bronchoconstriction, spasms
of coughing, and marked swings in thoracic pressure or
cerebral blood flow). Huffing has been recommended in
lieu of coughing because it is thought to reduce the phys-
ical work of the activity. However, research has not shown
huffing to be any more energy efficient than coughing.61
Some studies have shown that coughing alone can be
as effective at airway clearance as traditional bronchial
drainage with percussion in certain patient populations,
particularly those with intact strength such as patients
with CF.62,63 If these techniques fail to clear the airway, FIG. 24-8 Recommended position for effective coughing.
endotracheal suctioning may be necessary, but where pos- From Irwin S, Tecklin JS: Cardiopulmonary Physical Therapy:
sible, coughing or huffing are preferred because suction- A Guide to Practice, ed 4, St. Louis, 1995, Mosby.
ing can injure the tracheal epithelium and may cause
sudden hypoxemia or vagal stimulation, which may lead
to cardiac dysrhythmias.64,65 2. Tracheal stimulation—pressure or vibration applied
Proper cough technique, which facilitates airway clear- to the extrathoracic trachea—may elicit a reflex
ance, requires that the patient sequentially (1) inspires to cough.
or near a maximal inspiration; (2) closes the glottis; (3) 3. Pressure applied to the midrectus abdominis area
“bears down” by tightening the abdominal, perineal, after inspiration—may improve cough effectiveness
gluteal, and shoulder depressor muscles to increase if the pressure is suddenly released.
intrathoracic and intraabdominal pressures; and (4) sud- 4. Pressure applied along the lower costal borders
denly opens the glottis to enable the pressurized inspired during exhalation—may improve the effectiveness
air to suddenly escape to provide the expulsive force. The of an impaired cough.
patient should cough no more than two times during each
expulsive, expiratory phase—a “double cough.” To con- Manual and Mechanical Techniques
tinue beyond this “double cough” usually produces little Postural Drainage with Chest Percussion, Vibration,
added benefit. Proper cough technique after surgery may and Shaking. This group of techniques is often referred to
also require incisional splinting. Splinting an abdominal as “chest physiotherapy,” “chest PT,” “postural drainage,”
or thoracic incision is commonly performed by having the “bronchial drainage,” or simply “physio” and represents
patient hold a small pillow firmly against the incision the classic and traditional approach to airway clearance
while attempting to cough or using the hands to approx- that has been used for many decades. Although the evi-
imate the edges of the incision while attempting to cough. dence for superiority of this technique over other more
There is no scientific evidence that this type of splinting modern approaches is lacking, a number of studies have
improves cough, but there is a great deal of anecdotal com- found it to be as effective as some of the newer equipment-
mentary on the usefulness of the techniques. Following intensive approaches to airway clearance described,
are techniques that can be used to improve cough: including high-frequency chest compression,66 intrapul-
1. Positioning—sitting in the forward leaning posture monary percussive ventilation (IPV),67 and treatment with
with the neck flexed, the arms supported, and the Flutter devices.68 Furthermore, the experience of several
feet firmly planted on the floor—promotes effective generations of committed physicians, PTs, respiratory
coughing (Fig. 24-8). therapists and nurses has borne out the ongoing utility of
654 PART 3 • Cardiopulmonary System
Right
upper lobe
Right
middle lobe
Elevate foot 12–14"
Right
lower lobe
Elevate foot 18–20"
FIG. 24-9 Positions for postural drainage of different parts of the lungs.
this approach to airway clearance. In addition, the face
validity of airway clearance for properly selected patients
is undeniable. As a result, most patients with chronic and
acute respiratory problems that produce voluminous
secretions are currently treated with some airway clear-
ance technique, whether it be manual or mechanical.
Positioning. Before manual or mechanical approaches
are used to loosen and mobilize secretions, it is generally
recommended that the patient be positioned to optimally
drain a particular lung segment or lobe. This requires that
the area to be drained is uppermost, with the bronchus
from the area in as close to a vertical position as possible
or reasonable. Some refer to this notion as the “ketchup
bottle theory.” To get ketchup from the bottle, it must be
turned upside down (and shaken).69 Fig. 24-9 shows posi-
tions for postural drainage of different parts of the lungs.
These positions may need to be modified under certain
conditions, including increased intracranial pressure,
decreased arterial oxygen tension, decreased cardiac
output, decreased forced expiratory volume in 1 second
(FEV1), decreased specific airway conductance, pulmonary
hemorrhage (hemoptysis), gastroesophageal reflux (partic-
ularly common in infants and children), and severe
dyspnea. Typically, the modification consists of reducing
the angle for head-down positions for the middle lobe,
lingula, and lower lobes. With severe dyspnea or gastro-
esophageal reflux and with increased intracranial pressure,
all positions for the middle lobe, lingula, and lower lobes
Apical posterior
segment left
upper lobe
Lingular inferior
segment left
upper lobe
Elevate foot 12–14"
Left
lower lobe
Elevate foot 18–20"
should be performed with the patient flat with no decline.
Recent research indicates that in infants with CF, the
head–down tipped position should be avoided for the first
year of life because this position stimulates gastro-
esophageal reflux that can adversely affect lung tissue.70
Percussion and Vibration. Often referred to as “manual
techniques” of airway clearance, percussion and vibration
of the thorax are performed to loosen accumulated secre-
tions. These techniques are intended to enhance move-
ment of secretions to the more proximal airways during
positioning for gravity-assisted postural drainage. Some
clinicians also advocate “chest shaking,” a more vigorous
type of vibration. Percussion and vibration are usually
performed in an area of the thorax corresponding to the
lung segment being drained while the patient is positioned
specifically to allow gravity to assist in secretion drainage.
Percussion, a massage stroke originally called “tapote-
ment,” involves rhythmically clapping with a cupped
hand for 2-5 minutes over the appropriate area of thorax
being drained by gravity (Fig. 24-10). Percussion may
feel uncomfortable but should not be painful; a layer of
clothing or towel may be employed to reduce any
discomfort.
Vibration often follows percussion, although some
advocate its use in lieu of percussion, particularly in post-
operative treatment and in those for whom percussion
should be done with caution (see Table 24-4). Vibration
involves placing one’s hands on the area previously per-
 Airway Clearance Dysfunction • CHAPTER 24 655

TABLE 24-4 Conditions in Which Caution in

the Application of Therapeutic
Percussion Is Recommended
Type of Condition Characteristics
Cardiovascular Chest wall pain
Unstable angina
Hemodynamic lability
Low platelet count
Anticoagulation therapy
Unstable or potentially lethal
dysrhythmias
Musculoskeletal Osteoporosis
Prolonged steroid therapy
Costochondritis
FIG. 24-10 Correct hand position for therapeutic chest Osteomyelitis
percussion. From Potter PA, Perry AG: Fundamentals of Osteogenesis imperfecta
Nursing, ed 6, St. Louis, 2005, Mosby. Spinal fusion
Rib fracture or flail chest
Pulmonary Bronchospasm
Hemoptysis
Severe dyspnea
Untreated lung abscess
Pneumothorax
Immediately after chest tube removal
Pneumonia or other infectious process
Pulmonary embolus
Oncological Cancer metastasis to the ribs or spine
Carcinoma in the bronchus
Resectable tumor
Osteoporosis secondary to
chemotherapeutic agents
Miscellaneous Recent skin grafts
Burns
Open thoracic wounds
Skin infection in the thoracic region
FIG. 24-11 Correct hand position for chest vibration. From Subcutaneous emphysema in the head
Frownfelter D, Dean E: Cardiovascular and Pulmonary Physical or back regions
Therapy: Evidence and Practice, ed 4, St. Louis, 2006, Mosby. Immediately after cataract surgery

cussed (Fig. 24-11) and having the patient perform several
deep breaths using sustained maximal inspiration as in the
ACBT maneuver. During the expiratory phase, the thera-
pist performs a fine, tremulous vibration to the chest wall.
This may be repeated several times, although in individu-
als with copious secretions, the first vibratory effort often
stimulates coughing and evacuation of secretions and
debris.
As with positioning, there are pathological conditions
that may be contraindications to manual techniques or
that may require that such techniques be applied cau-
tiously (Table 24-4). The basis for the recommendations in
Table 24-4 is not always clear.
Mechanical Devices for Airway Clearance
High-Frequency Chest Wall Oscillation. High-
frequency chest wall oscillation (HFCWO) is provided by
a device that uses an air compressor and a garment (a vest)
that has inflatable bladders attached to the compressor by
large, flexible tubing (Fig. 24-12). The compressor pumps
bursts of air at varying frequencies (1-20 Hz) and varying
pressures into the bladders within the vest. The bursts
of air entering the vest bladder transmit oscillations or
vibrations to the chest wall. Studies on HFCWO in dogs
suggest that the bursts of air produce a shearing force on
secretions within the airways and increase airflow into and
out of the airways.70 Clinical studies have shown that
HFCWO is as effective in the short term as manual
bronchial drainage techniques.66,71 Warwick and Hansen
followed 16 patients with CF using HFCWO for a period
of 22 months. They determined that regression slopes for
pulmonary function were slightly improved when com-
pared to the period of time before instituting HFCWO.72
HFCWO produced changes in 50 patients with CF hospi-
talized for acute pulmonary exacerbation equivalent to
the improvements typically produced by traditional pos-
tural drainage with percussion and vibration.66 Tecklin and
colleagues found that HFCWO applied to 102 children
with CF produced similar outcomes in terms of various
pulmonary function tests, clinical radiology scores, and
days hospitalized across 1 year, as did bronchial drainage
techniques applied to 55 other children with CF.72
HFCWO, which is typically used twice each day at several
different frequencies for a total of 30 minutes per treat-
656 PART 3 • Cardiopulmonary System
FIG. 24-12 High-frequency chest wall oscillation (HFCWO)
device. Courtesy Electromed, Inc., New Prague, Minn.
ment, can be used concurrently with nebulized bron-
chodilators and mucolytics, whose deposition may
increased by the enhanced airflow generated by HFCWO.73
Originally used for young adults with CF, HFCWO is now
also used in other people with long-term need for airway
clearance such as those who have undergone heart/lung
transplantation and those with respiratory pump dys-
function secondary to chronic neuromuscular disorders.
Intrapulmonary Percussive Ventilation. Intrapulmonary
percussive ventilation (IPV) is a type of airway clearance
administered via a pneumatic device called a high-
frequency intrapulmonary percussive device. The patient
breathes through a mouthpiece that delivers a preset
driving pressure and frequency of intra-airway oscillations
from a nebulizer-like apparatus. The device automatically
activates during exhalation to provide intrapulmonary
percussion at 11-30 Hz. The device simultaneously deliv-
ers positive expiratory pressure at 2-8 cm H2O and an
aerosol inhalation of normal saline at 1 ml/min, with par-
ticle size distribution of 2-4 µm. During the percussive
bursts of air and saline into the lungs, the inspiratory flow
opens airways and enhances secretion mobilization.
Although it is not used as frequently in the United States
as other modes of airway clearance, some data support
the efficacy of IPV. Newhouse and colleagues found no
significant differences among IPV, traditional chest
physical therapy, and Flutter in the ability to produce
sputum in subjects with CF.74 Varekojis et al found that
dry sputum weights were not different among IPV,
HFCWO, and vigorous chest physical therapy delivered for
2 days each in 24 subjects with CF.67 IPV appears to be a
reasonable alternative for airway clearance, although it
has not been a particularly popular approach in the
United States.
Positive Expiratory Pressure. Positive expiratory pres-
sure (PEP) breathing employs another mechanical device
for airway clearance dysfunction (Fig. 24-13). This device
tries to maintain airway patency by applying positive pres-
sure during expiration with the goal of dislodging and
moving secretions proximally in the respiratory tract. PEP
was originally provided via an anesthesia face mask, but a
FIG. 24-13 A positive expiratory pressure (PEP) device.
Courtesy Smiths Medical, Rockland, Mass.
mouthpiece can also be used to deliver this treatment. As
the patient exhales, the valve of the PEP device provides
a positive pressure of 10-20 cm H2O within the airways.
This positive pressure stabilizes the small airways and pre-
vents their collapse, which would otherwise trap the secre-
tions distal to the point of collapse and interfere with
evacuation of secretions by huffing or coughing. In addi-
tion to assisting in secretion removal, PEP may help reduce
air trapping by stabilizing the small airways and thus
enhancing collateral ventilation through pores of Kohn
and canals of Lambert (interconnections between adjacent
alveolar sacs and respiratory bronchioles, respectively).
When using PEP, patients should take a large breath in and
then breathe out slowly. While breathing out, the patient
will experience positive pressure from the PEP device.
Many PEP devices have an indicator that shows how much
pressure is being exerted. Pressure of 10-20 cm H2O should
be maintained throughout the full expiration. This proce-
dure is repeated for 10-20 breaths and is followed by
huffing or coughing to expel accumulated secretions.
Some recommend performing the PEP maneuver while the
patient is in bronchial drainage positions.
PEP has been shown to be more effective than
bronchial drainage and vibratory positive expiratory pres-
sure in patients with cystic fibrosis.75,76 PEP is an effective,
inexpensive, well-researched, and universally employed
airway clearance device. It can be used effectively by
people who can understand and follow the instructions.
It is not particularly useful, however, for patients with sig-
nificant neuromuscular weakness or dyscoordination who
may not be able to achieve adequate flows to receive the
benefits.
Use of a PEP device
Therapist washes hands and assembles the PEP
device.

Patient sits upright with elbows resting on a table.
Patient completes a diaphragmatic breath with a
larger than normal volume.
Patient holds the inspiratory breath for 2-3 seconds.
Patient exhales fully but not forced to functional
residual capacity (FRC) through the device.
The pressure manometer should read 10-20 cm H2O
pressure during exhalation.
Therapist adjusts the orifice to result in an inspiratory-
to-expiratory time ratio of 1 : 3.
Patient performs 10-20 breaths.
Follow with huffing or coughing.
Repeat the cycle of 10-20 breaths at least 3-4 times.
Vibratory Positive Expiratory Pressure. Two vibratory
positive expiratory pressure devices, the Flutter (Axcan-
Pharma, Birmingham, Ala) (Fig. 24-14) and the Acapella
(Smiths Medical, Rockland, Mass) (Fig. 24-15), are com-
monly employed. Each adds oscillation during the expi-
A Patient repeats each inspiratory/expiratory cycle 5-10
Perforated
protective
cover
Circular
cone
Exhaled air
Mouthpiece High-density
steel ball
B
FIG. 24-14 The Flutter device. Courtesy Axcan Pharma,
Birmingham, Ala.
Airway Clearance Dysfunction • CHAPTER 24 657
ratory cycle of PEP breathing. The Flutter employs a
pipelike device with a metal ball that is dislodged and
reseated in its reservoir during expiratory effort. The dis-
lodgment and reseating of the ball opens and closes the
expiratory port, which in turn oscillates the expiratory
airflow. The Acapella oscillates airflow using a magnet and
a rocker with a metal pin. The variable distance between
the pin and the magnet should be matched and set to the
patient’s needs to create the appropriate resistance and
desired length of expiration.
The Flutter is more technique-dependent than the
Acapella because the Flutter must be positioned cor-
rectly for the ball to be properly dislodged against
gravity. The Flutter was shown to have similar clinical effi-
cacy to manual airway clearance techniques in a well-
designed and controlled 2-week study in hospitalized
patients in which patients with CF were randomized to a
Flutter group or a chest physical therapy group. After the
2-week period, there were no differences between the
groups in pulmonary function changes and exercise
tolerance.77
A recent paper by Volsko et al shows that performance
characteristics of the Acapella are similar to the Flutter.78
Additionally, the Acapella can be used at very low expira-
tory flows and can generate PEP at any angle because it is
not gravity dependent.78
Suggested sequence for use of the Flutter and
the Acapella
Therapist washes hands and makes sure device is
ready for use.
Patient is seated with back and head erect.
Patient places device in mouth and inhales more
deeply than normal but not fully.
Patient holds the inspiratory breath for 2-3 seconds.
Patient now exhales fully but not forced through the
device.
Patient must hold cheeks firmly (not puffed out) to
direct oscillation into the airways.
times and suppresses cough.
Patient next takes 2 deep breaths in and out through
the device.
Patient attempts to remove sputum via huffing or
coughing.
Patient repeats the entire process 2-3 times
FIG. 24-15 The Acapella airway clearance device. Courtesy
Smiths Medical, Rockland, Mass.
658 PART 3 • Cardiopulmonary System
Assistive Devices. Percussors and vibrators have been
used to assist with manual techniques of airway clearance
for many years. These devices have been shown to
produce similar changes in patients with CF in both pul-
monary function and secretion production as unassisted
manual airway clearance techniques alone but with less
effort.79 These devices may be powered by compressed gas
or electricity. Because an electrical motor could generate a
spark that could cause an explosion around high concen-
trations of oxygen, the use of electrically powered devices
is contraindicated around patients receiving supplemental
oxygen.
THERAPEUTIC EXERCISE
Aerobic Capacity/Endurance Conditioning or
Reconditioning. Patients with pulmonary disease with
associated inability to clear their airway often experience
dyspnea on exertion that leads to abstaining from any
activity that precipitates this unpleasant sensation. This
continued avoidance of activity further decreases exercise
tolerance and in turn lowers the patient’s dyspnea thresh-
old, thereby resulting in dyspnea with even minimal phys-
ical exertion such as produced by performing ADLs.
Exercise is the most common and useful intervention to
break this vicious cycle of deterioration. A cautionary note
is that the work of breathing during physical activity in
patients with airway clearance dysfunction and COPD
may constitute a major portion of their oxygen con-
sumption, which may reduce their ability to achieve the
workload one might expect. Therefore the therapist must
administer the exercise program judiciously and with
close monitoring for signs of early fatigue that may
include cyanosis and abnormal vital signs.
Rehabilitation interventions to improve aerobic capac-
ity and exercise tolerance vary widely. They may be formal,
based on a strictly derived exercise prescription, or infor-
mal, started from an arbitrary point and progressed accord-
ing to a patient’s symptoms and tolerance. They may
require equipment like treadmills or bicycle ergometers or
merely require enough space to permit obstacle-free
walking. Participants may have either subacute pulmonary
disease or chronic pulmonary disease of varying severity,
and the exercise regimen may begin in any setting from
intensive care to home. Exercise may be administered
while the patient breathes room air or supplemental
oxygen. Completion of the programs may require several
days, several months, or longer. Some indications for
oxygen-supplemented exercise include right heart failure,
cor pulmonale, resting partial pressure of arterial oxygen
(PaO2) of 50 mm Hg or less on room air, inability to toler-
ate exercise while breathing room air,80 and oxygen satu-
ration below 80% during physical exertion and while
performing ADLs when breathing room air.81
Preparation for any aerobic exercise program requires
determining the degree and type of monitoring needed to
preserve the patient’s safety. No formal guidelines that
establish the monitoring requirements for informal exer-
cise programs have been published; this determination
must be made according to individual circumstances.
Final preparation for any exercise program requires that
the therapist and patient identify a mutually acceptable
goal for the program and develop a plan for periodically
evaluating progress toward that goal, often with the advice
of a physician.
There are clear instances in which an exercise session
should be terminated. Some of these reasons for termina-
tion are physiological, and others are symptom related.
The exercise session should be terminated in the presence
of the following:
• Premature ventricular contractions in pairs, runs, or
increasing frequency
• New onset atrial dysrhythmias: Tachycardia, fibrilla-
tion or flutter
• Heart block, second or third degree
• Angina
• ST-segment changes of greater than or equal to 2 mm
in either direction
• Persistent HR or BP decline
• Elevation of diastolic pressure by more than 20 mm
Hg above resting or to more than 100 mm Hg
• Dyspnea, nausea, fatigue, dizziness, headache, blurred
vision
• Intolerable musculoskeletal pain
• Heart rate greater than target rate
• Patient pallor or diaphoresis
Aerobic exercise training for patients with airway clear-
ance dysfunction has been shown to produce benefits that
include improved exercise tolerance, reduced dyspnea,
and enhanced quality of life.82-85 Troosters et al randomly
assigned 100 individuals with COPD to either a 6-month
outpatient rehabilitation program that involved aerobic
exercise training or to regular medical therapy.85 Among
patients who completed the 6-month rehabilitation
program, significant and clinically important changes
were demonstrated in 6-minute walking distance,
maximal exercise performance, peripheral and respiratory
muscle strength, and quality of life. Although the formal
rehabilitation ended after 6 months, many of the benefits
were still evident at an 18-month follow-up session.61
Body Mechanics and Postural Stabilization
Training. Body mechanics and postural stabilization
training have two potential benefits for the patient with
airway clearance dysfunction and COPD. One benefit—
reducing general body work—is discussed more fully in
the section on Functional Training in Self-Care and Home
Management. The second benefit is to use postural stabi-
lization and proper body positioning to reduce the work
of breathing and diminish the effects of dyspnea. Many
anecdotal examples of dyspnea relief in the forward-flexed
posture have precipitated research into proper positions
for the patient with COPD. It is clear that the seated,
forward-leaning posture is the preferred position to reduce
dyspnea in patients with severe and moderate limitations
of maximal inspiratory pressure associated with COPD.
The forward-leaning posture produces a significant
increase in maximum inspiratory pressures, thereby reliev-
ing the sensation of dyspnea.86 In addition, this position
may increase FRC in those with airflow limitations because
the thorax approaches a similar position to prone in
which FRC is increased.87 In patients who are unable to
tolerate functional walking because of either muscu-
loskeletal stress or dyspnea, a high walker may be adapted

FIG. 24-16 A high walker to permit assumption of a
forward-leaning posture in standing. From Irwin S, Tecklin JS:
Cardiopulmonary Physical Therapy: A Guide to Practice, ed
4, St. Louis, 1995, Mosby.
to permit forward leaning, thereby reducing the work of
breathing and the perception of dyspnea to permit the
desired activity (Fig. 24-16).
Flexibility Exercises. Exercise to improve flexibility
for the patient with airway clearance dysfunction and
COPD may include stretching exercises to promote muscle
lengthening, exercises to improve ROM, and mobilization
exercises to improve joint function. There is little or no
experimental evidence to support the use of flexibility
exercises in this patient population. However, it seems
intuitive that maintaining or improving thoracic and
shoulder girdle flexibility would enhance respiratory effort
by increasing thoracic compliance. A more flexible chest
wall should require less muscular work to inflate the
thorax. A similar benefit of increased thoracic compliance
and reduced work of breathing may be implied for
improving motion of a tight shoulder girdle in the patient
with pulmonary disease. Many individuals with COPD
have an increased AP thoracic diameter and a hyperin-
flated and often fixed thoracic cage, particularly during
periods of dyspnea.88 One suspects that using exercise to
prevent or treat the fixed thoracic cage should be benefi-
cial despite the dearth of evidence.
A series of flexibility exercises has been recommended
as part of a traditional “warm-up” for a pulmonary reha-
bilitation session (Table 24-5). Although this program has
Airway Clearance Dysfunction • CHAPTER 24 659
not been formally evaluated from a scientific perspective,
it serves as a model for a major long-established pul-
monary rehabilitation program.89 These exercises may be
used as a regular exercise routine to improve or maintain
good thoracic and shoulder girdle motion.
Breathing Exercises. To increase alveolar ventilation,
therapists teach breathing exercises that are intended to
influence the rate, depth, or distribution of ventilation or
muscular activity associated with breathing. The breath-
ing strategies commonly recommended to improve venti-
lation and oxygenation include diaphragmatic breathing,
also referred to as breathing control, pursed-lip breathing,
segmental breathing, low-frequency breathing, and sus-
tained maximal inspiration breathing exercises. ACBT and
AD are also breathing strategies, but they are used prima-
rily with airway clearance and were discussed earlier in
this chapter.
Diaphragmatic Breathing Exercises. The diaphragm is
the principal muscle of inspiration. Historically, when
muscles other than the diaphragm assumed a role in inspi-
ration, therapeutic efforts were directed toward restoring
a more normal, diaphragmatic pattern of breathing. The
return to diaphragmatic breathing was thought to relieve
dyspnea.
Diaphragmatic breathing exercises are intended to
enhance diaphragmatic descent during inspiration and
diaphragmatic ascent during expiration. Diaphragmatic
descent is assisted by directing the patient to protract
the abdomen gradually during inhalation. One assists
diaphragmatic ascent by directing the patient to allow the
abdomen to retract gradually during exhalation or by
directing the patient to contract the abdominal muscles
actively during exhalation. Although the exact techniques
used to teach diaphragmatic breathing vary, in principle
they are similar. They all recommend that the patient
assume a comfortable position, usually one-half to three-
quarters upright sitting, before beginning, and that the
patient’s hips and knees be flexed to relax the abdominal
and hamstring muscles respectively. Diaphragmatic
breathing exercises are then taught as follows:
Diaphragmatic breathing exercises
1. Place the patient’s dominant hand over the
midrectus abdominis area.
2. Place the patient’s nondominant hand on the
midsternal area.
3. Direct the patient to inhale slowly through the
nose.
4. Instruct the patient to watch the dominant hand
as inspiration continues.
5. Encourage the patient to direct the air so that the
dominant hand gradually rises as inspiration
continues.
6. Caution the patient to avoid excessive movement
under the nondominant hand.
7. Apply firm counterpressure over the patient’s
dominant hand just before directing the patient
to inhale.
8. Instruct the patient to inhale as you lessen your
counterpressure as inspiration continues.
660 PART 3 • Cardiopulmonary System

TABLE 24-5 “Warm-up” Flexibility Exercises for Pulmonary Rehabilitation

Body Area Exercise
Cervical Look up/down (nod “yes”).
Look left/right (shake “no”).
Move left ear to left shoulder.
Move right ear to right shoulder.
Shoulder and upper extremity Shoulder circles forward and backward.
Shoulder shrugs (up/relax).
Shoulder blade squeeze: Rest your hands on your shoulders, touch your elbows together in
front of your body, pull them apart, try to push them backward. Squeeze your shoulder
blades together as you push back. Breathe IN as you push your elbows backward, and
breathe OUT as you bring your elbows together in front.
Front arm raises (shoulder flexion): Lift your arms overhead, lower them in front of you
slowly, as if pushing against resistance. Breathe IN when lifting, and breathe OUT when
lowering.
Side-arm raises (abduction): Lift your arms out to the side and up overhead, lower them
back to your sides slowly, as if pushing against resistance. Breathe IN as you lift, and
breathe OUT as you lower.
Arm circles forward: With your arms fully extended and raised to shoulder level, slowly make
small circles with your arms, then reverse. (If the patient is extremely short of breath, he
or she may lower the arms.)
Trunk Trunk rotation (side to side twists): Start with your arms extended in front of you and slowly
twist to the right and then to the left. Try not to move your hips.
Side-bending (right and left): Reach one arm up over your head and lean to the opposite
side, then reverse. Blow OUT as you bend, and breathe IN as you straighten.
Lower extremity Wall slide: Stand with your hips and buttocks pressed as flat as you can against a wall.
Shoulders should be relaxed. Slowly lower your body as if you were going to sit in a chair.
Keep your hips above the level of your knees. Hold this position. Try to increase the
holding time to at least 2 minutes.
Hip flexion: Marching in place.
Toe tapping.
Gastrocnemius/soleus stretch: Stand facing a wall about a foot away and put your hands on
the wall in front of you at about shoulder height. With knees extended, lean your body
into the wall to put a stretch on your large calf muscles.
General instructions Begin with 3-5 repetitions of each exercise and then increase gradually to 7-10 repetitions.
Once 10 repetitions of each can be done, a 1-lb weight may be added to the arm
exercises.
Perform pursed-lip breathing throughout your activity. Remember to have patients breathe
“IN” through the nose and “OUT” through pursed lips. Remind them to not hold their
breath.

9. Practice the exercise until the patient no longer
requires manual assistance of the therapist to
perform the exercise correctly.
10. Progress the level of difficulty by sequentially
removing auditory, visual, and tactile cues.
Thereafter, progress the exercise by practicing it
in varied positions including seated, standing,
and walking.
Diaphragmatic breathing exercises have also been
administered concurrently with relaxation training with
the goal of eliminating unnecessary muscle activity, par-
ticularly excessive use of the accessory inspiratory
muscles. In the past, increased diaphragmatic strength was
assumed when increased resistance to abdominal protrac-
tion was tolerated, as with weights placed over the
abdomen, but this notion has not held up to objective
scrutiny.90
Evaluation of the effectiveness of diaphragmatic
breathing exercises has been the objective of much
research over the past several decades. A recent and excel-
lent review by Cahalin et al concluded that “there was
great inconsistency among the many published studies
regarding the operational definitions and techniques
employed for teaching or demonstrating diaphragmatic
breathing.”91 The outcomes examined in the many studies
in this review included ventilation, severity of COPD
symptoms, thoracic motion, and various tests of pul-
monary function. Many normal subjects, as well as
patients with COPD, who were able to increase tidal
volume during diaphragmatic breathing exercises and
who had good chest wall biomechanics, were able to direct
greater ventilation toward the lower lobes during the exer-
cise session, albeit with some paradoxical chest wall
motion.92-95 However, in individuals with more advanced
COPD, diaphragmatic breathing resulted in reduced chest
wall coordination, increased dyspnea, and less mechani-

cally efficient breathing, making the use of these tech-
niques questionable in those with more advanced
disease.96,97 The effects of diaphragmatic breathing on pul-
monary function, respiratory rate and ABG measurements
are more encouraging. Sergysels et al examined diaphrag-
matic breathing with low frequency and high tidal
volumes in patients with moderate COPD while at rest and
during bicycle exercise and found that PaO2, peak oxygen
consumption, vital capacity and total lung capacity, and
diffusion capacity all increased when diaphragmatic
breathing was employed at rest and with exercise.98 In
Vitacca et al’s study, diaphragmatic breathing training,
although associated with impaired chest wall function and
increased dyspnea, resulted in a significant increase in
blood oxygenation along with a decrease in carbon
dioxide levels.97 Diaphragmatic breathing exercises will
continue to be used clinically as research more clearly
defines the optimal methods for this intervention and
the expected outcomes. The objectives and potential out-
comes of diaphragmatic breathing are summarized in
Table 24-6.
Pursed-Lip Breathing Exercises. Pursed-lip breathing is
another method, often associated with relaxation activities,
suggested for improving ventilation and oxygenation and
relieving respiratory symptoms in individuals with airway
clearance dysfunction.99 One method of pursed-lip breath-
ing advocates passive expiration,100 whereas the other rec-
ommends abdominal muscle contraction to prolong
expiration.101 Current use of the technique usually encour-
ages passive rather than forced expiration. Pursed-lip
breathing with passive expiration is performed as follows:
Pursed-lip breathing
1. Position the patient comfortably.
2. Place your hand over the midrectus abdominis
area to detect activity during expiration.
3. Direct the patient to inhale slowly.
4. Instruct the patient to purse the lips before
exhalation.
5. Instruct the patient to relax the air out through
the pursed lips and refrain from abdominal muscle
contraction.
6. Direct the patient to stop exhaling when
abdominal muscle activity is detected.
7. Progress the intensity of the exercise by
substituting the patient’s hand for yours, removing
tactile cues, and having the patient perform the
exercise while standing and exercising.
Thoman and colleagues found that pursed-lip breath-
ing significantly decreased respiratory rate, increased tidal
volume, improved alveolar ventilation as measured by
partial pressure of arterial carbon dioxide (PaCO2), and
enhanced the ventilation of previously underventilated
areas of the lungs in patients with COPD.102 Mueller and
colleagues also found that pursed-lip breathing improved
ventilation and oxygenation in individuals with COPD, at
Airway Clearance Dysfunction • CHAPTER 24 661
TABLE 24-6 Objectives and Potential
Outcomes of Diaphragmatic
Breathing Exercises
Therapeutic objectives Alleviate dyspnea
Reduce the work of breathing
Reduce the incidence of postoperative
pulmonary complication
Physiological objectives Improve ventilation
Improve oxygenation
Potential outcomes Eliminate accessory muscle action
Decrease respiratory rate
Increase tidal ventilation
Improve distribution of ventilation
Decrease need for postoperative therapy
rest and during exercise.100 Several studies have found that
this approach improves symptoms, as well as improving
objective measures of ventilation and enhancing exercise
tolerance and efficiency in patients with COPD.103-105
One study on the effects of providing external expira-
tory resistance to intubated patients with COPD found
that this intervention did not improve gas exchange or
breathing pattern in this group of subjects in ways it has
been shown to improve in nonintubated patients with
COPD.106
Research has failed to fully explain the symptomatic
benefits some patients ascribe to pursed-lips breathing.
One theory is that pursed-lip breathing is effective because
the slight resistance to expiration increases positive pres-
sure within the airways and helps to keep open the small
bronchioles that otherwise collapse because of loss of
support associated with lung tissue destruction. Alterna-
tively, or additionally, pursed-lip breathing could be effec-
tive because it slows the respiratory rate. At the very least,
pursed-lip breathing appears to reduce respiratory rate and
increase tidal volume, thereby not compromising minute
ventilation. It is recommended that clinicians continue to
teach pursed-lip breathing exercises to patients complain-
ing of dyspnea.
Segmental Breathing Exercises. Segmental breathing,
also referred to as localized expansion breathing, is
another type of exercise used to improve ventilation and
oxygenation in individuals with airway clearance dys-
function. This exercise presumes that inspired air can be
actively directed to a specific area of lung by emphasizing
and increasing movement of the thorax overlying that
lung area. This intervention has been recommended to
prevent the accumulation of pleural fluid, to reduce the
probability of atelectasis, to prevent the accumulation of
tracheobronchial secretions, to decrease paradoxical breath-
ing, to prevent the panic associated with uncontrolled
breathing, and to improve chest wall mobility.107 The
attempt to preferentially enhance localized lung expan-
sion uses manual counterpressure against the thorax to
encourage the expansion of that specific area of thorax in
the hopes of improving ventilation to a specific part of the
lung.
662 PART 3 • Cardiopulmonary System
Segmental breathing exercises
1. Identify the surface landmarks demarcating the
affected area.
2. Place your hand or hands on the chest wall
overlying the bronchopulmonary segment or
segments requiring treatment (i.e., the areas of
lung you hope to expand).
3. Apply firm pressure to that area at the end of the
patient’s expiratory maneuver. (Pressure should be
equal and bilateral across a median sternotomy
incision.)
4. Instruct the patient to inspire deeply through his
or her mouth, attempting to direct the inspired air
toward your hand, saying, “Breathe into my hand,
or make my hand move as you breathe in.”
5. Reduce hand pressure as patient inspires. (At end
inspiration, the instructor’s hand should be
applying no pressure on the chest.)
6. Instruct the patient to hold his or her breath for 2-
3 seconds at the completion of inspiration.
7. Instruct the patient to exhale.
8. Repeat sequence until patient can execute the
breathing maneuver correctly.
9. Progress the exercises by instructing the patient to
use his or her own hands or a belt to execute the
program independently.
Evaluation of the effectiveness of segmental breathing
begins with validation of its underlying premise that ven-
tilation can be directed to a predetermined area. One study
on lateral basal expansion exercises concluded that this
type of segmental breathing exercise failed to improve
local ventilation in patients with emphysema.108 Another
study also failed to find any change in the distribution of
ventilation when subjects with lung restriction breathed
segmentally but showed clearly that when subjects were
placed in sidelying, both ventilation and blood flow in the
dependent lung improved.109 There is a lack of persuasive
evidence linking segmental breathing with other thera-
peutic effects. However, it is quite clear and demonstrable
that improving local chest wall motion can improve
breathing by converting intercostal muscle shortening
into lung volume expansion.110
Sustained Maximal Breathing Exercises. Breathing
exercises during which a maximal inspiration is sustained
for about 3 seconds have also been associated with
improved oxygenation.111 Currently, sustained maximal
inspiration is more commonly employed as part of the
ACBT and is used in association with airway clearance
techniques as described previously.
Relaxation Exercise Techniques. Relaxation exercise
and training are currently used as adjunctive therapy for
many different diseases, including such divergent entities
as gastroesophageal reflux, nausea after chemotherapy,
behavioral aspects of autism, and mild hypertension.
However, despite many anecdotal reports, particularly
regarding care of the patient with asthma, there is little
data to demonstrate discrete pulmonary benefits of relax-
ation.112 Relaxation techniques coupled with breathing
strategies and hypnosis have recently been shown to result
in some symptomatic improvement in children with
dyspnea.113 Relaxation techniques are often administered
to decrease unnecessary muscle contraction throughout
the body and thereby reduce general body work. The tra-
ditional method or approach involves muscle contraction
followed by relaxation, whereas a newer technique
employs visual imagery to achieve the desired effects.
Strength, Power, and Endurance Training. Endurance
training that focuses primarily on aerobic benefits has
been used for decades in pulmonary rehabilitation pro-
grams. The issue of muscle strength and resistance exer-
cise to improve strength and reduce related symptoms has
only recently come to the fore as a means of improving
physical functioning in patients with chronic airway
clearance dysfunction. Recent work indicates that people
with COPD have peripheral muscle weakness that is likely
multifactorial in origin.114 Among those factors are disuse
atrophy, inadequate nutrition, long-term hypercapnia and
hypoxemia, reduced anabolic steroid levels, and myopa-
thy from continuous or periodic corticosteroid use. Muscle
strength, particularly lower extremity strength, is reduced
in individuals with COPD when compared to age-matched
controls.95 Although there is great patient-to-patient vari-
ability in this muscular dysfunction, research has demon-
strated a 20% to 30% deficit in quadriceps strength in
those with moderate-to-severe COPD. Muscle endurance
is similarly decreased in this population. These deficits
may limit exercise capacity and function in those with
COPD.12,115,116
There is a growing body of evidence that strength train-
ing is beneficial and should become part of a comprehen-
sive physical therapy program for patients with airway
clearance dysfunction and COPD. The primary benefits of
strength training in this population are improved muscle
strength, endurance, function, and exercise tolerance and
reduced dyspnea.117-120 Although these benefits are rea-
sonably well accepted, recent studies call into question the
benefit of such exercises on patients’ quality of life.121,122
Since the preponderance of evidence indicates that
strength training can improve impairments associated
with quality of life, a comprehensive intervention plan for
the patient with airway clearance dysfunction should
include resistance training, as well as endurance training.
Features of a resistance exercise program for patients
with airway clearance dysfunction are described in
Table 24-7.123
Functional Training in Self-Care and Home Manage-
ment, Work, Community, and Leisure Integration/Reinte-
gration. There is little direct evidence regarding
functionally specific training programs and improvement
in ADLs in patients with airway clearance dysfunction.
However, it appears from recent data that whether the
physical rehabilitation program focuses on endurance
training using treadmill or bicycle ergometry or employs
more traditional calisthenics, the intervention produces
significant improvement in functional performance and
overall health.124
Several studies have attempted to develop and validate
ADL profiles for the patient with chronic airway clearance
dysfunction. These profiles include the Manchester Respi-
 Airway Clearance Dysfunction • CHAPTER 24 663

TABLE 24-7 Features of a Resistance Exercise Program for Patients with Airway Clearance Dysfunction
Frequency Each major muscle group to be trained should be exercised 2-3× per week.
Specific suggestions will depend on where the program is carried out: At home, outpatient, inpatient, and other sites.
Intensity Muscle load is typically and reasonably safely initiated with 50%-60% of the 1 repetition maximum (1RM) established during
the examination.
Repetitions are typically 10 per muscle group at outset of program. One set of repetitions is a good starting point. A degree
of success should be built in to the prescription for the psychological benefits and to increase a likelihood of adherence.
A rest period should provide time between the sets for recovery.
Mode Various types of resistance devices may be employed—exercise tables, benches, pulleys, free weights, etc. Exercise should
focus on the large muscle groups of the lower and upper extremities, as well as trunk musculature such as latissimus dorsi.
To ensure continued interest and to vary the training stimulus, it is important to vary the types of exercise and consider
including eccentric, concentric, isometric, isotonic, and isokinetic exercises.
Duration ACSM recommends a 10-12 week duration followed by a period of active recovery using alternative forms of exercise.
Progression Begin with lighter loads and increase number of repetitions and sets as the patient begins to demonstrate tolerance at each
particular level of activity.

ACSM, American College of Sports Medicine.

ratory Activities of Daily Living questionnaire and the

London Chest Activity of Daily Living scale.125,126 One
study demonstrated improvement in physical function, as
measured by the Chronic Respiratory Questionnaire
(CRQ) and the Medical Outcomes Study 36-Item Short
Form Health Survey (SF-36), after pulmonary rehabilita-
tion.127 Unlike patients with neuromuscular or muscu-
loskeletal deficits who may need to learn new strategies
and adapted tasks to regain functional independence, it
appears that those with COPD need to gain control over
their dyspnea and disease to use existing functional skills.
These self-care skills have not been lost but have gone
unused because of the physical and emotional impact of
the severe dyspnea and resultant physical deconditioning
that has accrued over months and years of disabling lung
disease. Among the various functional tasks that may need
to be relearned or adapted are the following:
• Bed mobility and transfers—use of transfer boards
and overhead trapeze bars
• Self-care such as bathing, grooming, dressing—raised
toilet seat, long-handled brush, shower seat
• Household activities and related chores such as yard
work—long-handled tools, rolling bench
• Activity adaptation to conserve energy—break
complex or difficult tasks into component parts,
motorized mobility device
• Injury prevention—use of grab-bars, walking aids

DEVICES AND EQUIPMENT

There are various oxygen sources and delivery devices
available for use in the home, at work, or in the commu-
nity. Oxygen may be supplied in gas cylinders of varying
sizes. These cylinders must be replaced or refilled periodi-
cally to replenish the oxygen supply and most are large,
bulky, and heavy. However, recent technology has made
much smaller devices, such as liquid oxygen containers
and oxygen concentrators, available (Fig. 24-17). These
devices can supply oxygen for up to several hours of
oxygen, depending on patient usage. Liquid oxygen
systems have been available for use at home for many
years. There is usually a large reservoir in the home from
which a small, portable knapsack–size container may be
FIG. 24-17 Stationary and portable liquid oxygen units.
From Potter PA, Perry AG: Fundamentals of Nursing, ed 6, St.
Louis, 2005, Mosby.
filled for outside use. Oxygen concentrators, which have
also been available for several years, are electrically
powered and use a molecular sieve to separate oxygen
from the ambient air and concentrate and store the
oxygen. These devices are economical for use in the home
and for activities immediately around the house, such as
gardening, but are too large to take out into the commu-
nity.
664 PART 3 • Cardiopulmonary System

Oxygen must be delivered from its source to the patient
via a device. Oxygen catheters may be inserted into the
nasal passage or via a small surgical incision directly
into the trachea, with a transtracheal device. Oxygen
masks placed over the nose and mouth may also be
used. These sometimes have a reservoir that enables
high concentrations of oxygen to be provided. The most
commonly used device is a nasal cannula that provides
a small prong into each nostril for oxygen delivery (Fig.
24-18).
Mechanical ventilators are commonly used for patients
with airway clearance disorders when acute or chronic
respiratory failure occurs such as after acute disease
processes, trauma, or surgery (see Chapter 26). Basic
modes of mechanical ventilation are briefly identified in
Table 24-8. When the patient with airway clearance dys-
function is receiving mechanical ventilation, it is impor-
tant to note the parameters of ventilation, particularly
when breathing strategies and retraining are to be
employed. Certain modes and limitations of mechanical
ventilation may or may not allow certain breathing
strategies.
Assistive devices, such as canes and walkers, are often
indicated to assist with ambulation and enhance stability
and safety.2 When recommending such assistive devices
for the patient with airway clearance dysfunction, the
therapist must be aware that crutches, walkers, and similar
FIG. 24-18 Nasal cannula for oxygen delivery. From
Hillegass EA, Sadowsky HS: Essentials of Cardiopulmonary
Physical Therapy, ed 2, Philadelphia, 2001, Saunders.
devices tend to increase the oxygen requirement when
compared to unassisted ambulation.128 A cost-benefit deci-
sion about such devices must be made.129 A wheeled
walker can, however, be very helpful for individuals with
chronic airway clearance dysfunction. The walker not
only offers support and stabilization but with a basket or
small platform can be used to carry a small oxygen deliv-
ery system during community activities. Motorized scoot-
ers are useful for community mobility outside the home
for shopping, work, and recreational activities in individ-
uals with significant airway clearance dysfunction. There
are lift systems for automobile storage of the scooters to
facilitate patient use. Motorized scooters and the appro-
priate lift devices are expensive but often make the
difference between being housebound or active in the
community.
CASE STUDY 24-1
CHRONIC BRONCHITIS
Examination
Patient History
NT is a 66-year-old woman with a long-established history
of chronic bronchitis. She was admitted to the hospital in
acute respiratory distress and was diagnosed with bacter-
ial pneumonia. Because NT previously participated in a
pulmonary rehabilitation program, a physical therapy
consultation was requested. She reported a 110 pack per
year history of cigarette smoking. NT reported that it now
exhausts her to prepare her meals and perform other
IADLs. She has no significant medical or surgical history
other than her lung disease and recent osteoporosis of the
vertebrae, which she reports is secondary to her medica-
tions. She is currently taking antibiotics for her infection,
oral and inhaled bronchodilators, and oral and inhaled
corticosteroids. Her ABG values on admission were pH:
7.33, PaCO2: 45, bicarbonate (HCO3): 20, and base excess
(BE): −4. These values revealed the need for oxygen via
nasal cannula at 2 L/min. Pulmonary function testing was
deferred because of respiratory distress, but recent values
indicated a severe obstructive deficit with moderate
increases in residual volume consistent with COPD and
hyperinflation.

TABLE 24-8 Basic Modes of Mechanical Ventilation

Mode Description
Control The patient is guaranteed a predetermined number of mechanical breaths and is unable or not permitted to
initiate a mechanical breath or breathe spontaneously.
Assist The patient is permitted to initiate a mechanical breath but is not guaranteed a predetermined number of
mechanical breaths.
Assist-control The patient is guaranteed a predetermined number of mechanical breaths and is permitted to initiate additional
mechanical breaths.
Intermittent mandatory The patient is guaranteed a predetermined number of mechanical breaths but is permitted to initiate
ventilation (IMV) spontaneous breaths through the ventilator.

Systems Review
Heart rate is 100 beats per minute (bpm), RR is 24
breaths/min with clear distress, BP is 130/85 mm Hg.
Tests and Measures
Musculoskeletal
Posture NT has forward head and shoulders and a sig-
nificant thoracic kyphosis.
Range of Motion Grossly symmetrical and full func-
tional ROM.
Muscle Performance Mild loss of strength in the lower
extremities.
Cardiovascular/Pulmonary
Circulation NT has minimal pedal edema.
Chest Examination
Inspection NT is in acute respiratory distress with
tachypnea, flaring of the nares, use of accessory muscles
of inspiration, and prolonged expiration with an I : E ratio
of 1 : 4. Perioral cyanosis, digital clubbing, and cough pro-
duced thick, yellowish sputum without evidence of blood.
Her thorax appeared symmetrical.
Palpation NT has minimal thoracic excursion with a
very limited right hemithorax. No shift in the medi-
astinum was seen. Vocal fremitus was increased in the
lower right posterior and lateral thorax. Some rhonchal
fremitus was palpated in that same area. Dullness to
mediate percussion was noted in the lower right posterior
and lateral thorax in generally the same area in which
increased vocal fremitus was felt.
Auscultation Distant breath sounds throughout the
lungs, except for bronchial and bronchovesicular sounds
in the lower right posterior and lateral thorax. Coarse
crackles and low-pitched wheezing were noted in that area
on the right, along with some scattering of these sounds
throughout the lung fields. These findings were consistent
with hyperinflation throughout the lungs and consoli-
dation and increased mucus secretion in the right lower
lobe.
Aerobic Capacity and Endurance Testing NT’s recent
worsening of fatigue during community activities and her
decreasing ability to participate in ADLs are indications for
additional tests. NT was asked to perform a 6-minute walk
test. She was not able to complete this test. She could walk
100 feet in 2 minutes but could not continue because of
severe fatigue. She reported dyspnea that was consistent
with a rating of 4 on the American Thoracic Society
Breathlessness Scale. She also reported a rating of 9/10 on
the revised Borg RPE scale at the end of the 6-minute walk
test.
Integumentary: Cyanosis around the lips and nail
beds, along with some moderate clubbing of the fingers.
Evaluation, Diagnosis, and Prognosis
This case represents an acute exacerbation of a chronic
disability whose basic pathological changes are largely
irreversible. Nonetheless, through reduction of the many
impairments noted in the examination, one may expect
to see notable improvement in NT’s functional abilities.
Findings gathered during the examination lead to a
choice of diagnostic patterns between preferred practice
pattern 6C: Impaired ventilation, respiration/gas
Airway Clearance Dysfunction • CHAPTER 24 665
exchange, and aerobic capacity/endurance associated with
airway clearance dysfunction, or pattern 6F: Impaired ven-
tilation and respiration/gas exchange associated with res-
piratory failure. Because the medical criteria for respiratory
failure includes a PaCO2 of ≥50 mm Hg, this patient should
be classified as pattern 6C.
Goals
1. NT should be able to perform ADLs and IADLs in an
independent manner.
2. NT is expected to resume some of her community-
based activities without risk of physical deterioration.
3. With continued adherence to her home program as
identified during the outpatient portion of her plan of
care, NT should have a reduced risk of recurrence, as
well as an improved ability to manage her disease.
4. NT’s overall health status is expected to improve with
concomitant reduction in health care costs.
5. NT’s sense of self-confidence and her quality of life are
expected to improve.
Intervention
Airway Clearance Techniques
NT was treated with bronchial drainage, percussion, and
vibration during her hospital admission. Because NT lives
alone, she requires an airway clearance technique that she
can perform independently. She was instructed in proper
use of AD. She was able to demonstrate the technique, and
it was reviewed with her on a weekly basis for 3 consecu-
tive weeks as an outpatient to ensure that she was using
it correctly.
Therapeutic Exercise
Aerobic exercise training using bedside cycle ergometry
was performed until NT could travel to the physical
therapy department, after which she began endurance
walking on a motorized treadmill. She used supplemental
oxygen during her exercise until the point of hospital dis-
charge. She continued with outpatient rehabilitation that
included both treadmill exercise and free walking while at
home. Strengthening exercises were performed every
other day in an effort to improve muscle power through-
out her weakened lower extremities.
Flexibility exercises were used on alternate days to
the strengthening exercises. These exercises were aimed at
improving thoracic mobility in an effort to enhance
motion of the thorax and the thoracic spine and reduce
the degree of kyphosis. Relaxation exercises were inte-
grated with a program of instruction in diaphragmatic
breathing. These exercises were intended to reduce the
muscular effort associated with overly active accessory
muscles and to offer a means of dealing with the anxiety
associated with breathlessness and dyspnea.
Please see the CD that accompanies this book for a case
study describing the examination, evaluation, and inter-
ventions for a newborn patient with meconium aspira-
tion.
CHAPTER SUMMARY
This chapter focuses on individuals with airway clearance
dysfunction, particularly patients with COPD and CF. The
666 PART 3 • Cardiopulmonary System
principles and skills described are applicable to any patient
with airway clearance dysfunction, including infants in
the neonatal intensive care unit and young adults with
neurological trauma that has resulted in inability to cough
and clear secretions. Basic chest examination techniques—
inspection, palpation, mediate percussion, and ausculta-
tion—are described and are appropriate for any patient
with respiratory or pulmonary disease. Interventions
described include specific approaches to airway clearance
and therapeutic exercise for strength, aerobic fitness, and
breathing retraining.
ADDITIONAL RESOURCES
Useful Forms
Dyspnea Scale
Chronic Respiratory Disease Questionnaire (CRQ): www.atsqol.org/
sections/instruments/ae/pages/crq.html
St. George’s Respiratory Questionnaire: www.atsqol.org/sections/
instruments/pt/pages/george.html
Books
Irwin S, Tecklin JS (eds): Cardiopulmonary Physical Therapy: A Guide
to Practice, ed 4, Philadelphia, 2004, Elsevier.
Burton GG, Hodgkin JE, Ward JJ (eds): Respiratory Care: A Guide to
Practice, ed 4, St. Louis, 1997, Mosby-Yearbook.
Wilkins RL, Stoller JK: Egan’s Fundamentals of Respiratory Care, ed 7,
Philadelphia, 2004, Elsevier.
Web Sites
American Thoracic Society: www.thoracic.org/
American College of Chest Physicians: www.chestnet.org/
American Lung Association: www.lungusa.org/
Pulmonary Breath Sounds: http://jan.ucc.nau.edu/~daa/heartlung/
breathsounds/contents.html
GLOSSARY
Aerobic
. capacity: Another term for maximal oxygen uptake
(VO2max). The highest amount of oxygen consumed during
maximal exercise.
Alveolar ventilation: The volume of gas expired from the
alveoli to the outside of the body per minute.
Atelectasis: Alveolar collapse because of poor lung expansion or
complete obstruction of an airway.
Auscultation: Listening with a stethoscope.
Bronchodilator: Medication that reduces bronchial smooth
muscle spasm and thereby causes an increase in caliber of a
bronchial tube.
Crackles: Nonmusical sounds (previously called rales) that may
be mimicked by rolling several strands of hair near your ear or
by listening to a bowl of cereal that crackles when milk is
added. Crackles may represent the sudden opening of previ-
ously closed airways. Expiratory crackles may indicate the pres-
ence of fluid in the large airways.
Dyspnea: Shortness of breath. A subjective difficulty or distress
in breathing.
Fremitus: Vibrations within the thorax that can be palpated.
Hypercapnia: Increased carbon dioxide level in the arterial
blood.
Hypoxemia: Low or insufficient oxygen in the arterial blood.
Mucolytic: A medication capable of dissolving or decreasing the
viscosity of mucus.
Paradoxical breathing: Moving the belly in during inspira-
tion and out during expiration.
Stertor: A snoring noise created when the tongue falls back into
the lower palate.
Stridor: A crowing sound during inspiration.
Thoracic index: Ratio of the anteroposterior diameter to the
transverse diameter of the thorax.
Tidal volume: The volume of air inspired or expired in a single
breath during regular breathing.
Wheezes: Whistling sounds probably produced by air flowing at
high velocities through narrowed airways.
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