Introduction

The term chest physiotherapy (CPT) stands for a spectrum of physical and

mechanical interventions aimed at interacting therapeutically with acute and
chronic respiratory disorders. [1]Among various techniques for airway
clearance, postural drainage is one of the widely used methods since decades.

Definition
Postural drainage is the positioning of a patient with an involved lung
segment such that gravity has a maximal effect of facilitating the drainage of
broncho-pulmonary secretions from the tracheobronchial tree. [2]It is based on
the concept of gravity-assisted mobilization of secretions and transport it for
removal. It is a positioning technique to mobilize bronchial secretions.

Mechanism
During erect position only the segments of the right upper lobe and non-
lingular portion of the left upper lobe receive gravitational assistance whereas
the segment of the middle, lingular portion of left upper lobe and lower lobe
segments of both lungs must drain against gravity. In normal healthy state,
the mucociliary mechanism clears off the bronchial secretions. In diseased
state they get compromised and secretions get accumulated especially in the
smaller airways that cannot be emptied without gravity assistance which can
further lead to inflammation and scarring. [3]The natural methods of emptying
the tracheo-bronchial tree of accumulated secretion are on the whole
extremely inefficient. Ciliary action -only removes minute particulate matter
such as dust or bacteria, and is of no value when there is much secretion. [4]

Procedure
The patient is tilted or propped at an angle required and chest percussion is
performed to loosen the secretions. Frames, tilt tables, and pillows may be
used to support patients in these positions. [1] There are postural beds that have
a hinge in the middle.

In general, the upper lobe segments have the advantage of gravity drainage
both in erect as well as in semi recumbent position, so postural drainage can
be facilitated in sitting or lying posture. The middle and lower lobes do not
have the advantage of gravity drainage in erect, semi-recumbent or recumbent
postures.

A foot end elevation of 14-18 inches is requires for the drainage of middle and
lower lobes. [3] Each position consists of placing the target lung segment(s)
superior to the carina. Positions should generally be held for 3 to 15 minutes
(longer in special situations). Standard positions are modified as the patient's
condition and tolerance warrant.

In critical care patients, including those on mechanical ventilation, Postural

Drainage should be performed from every 4 to every 6 hours as indicated.
PDT order should be re-evaluated at least every 48 hours based on
assessments from individual treatments. Domiciliary patients should be
reevaluated every 3 months and with change of status. [5] . In the actively
cooperating patient, postural drainage can be complemented by thoracic
expansion exercises and by breathing control. [1]
Positions

Upper Lobe

APICAL SEGMENTS -The patient should sit upright, with slight variations
according to the position of the lesion which may necessitate leaning slightly j
backward, forward or sideways. The position is usually only necessary for
infants or patients being nursed in a recumbent j position, but occasionally
may be required if there is an abscess or stenosis of a bronchus in the apical
region.
ANTERIOR SEGMENTS - The patient should lie flat on his back with his arms
relaxed to his side; the knees should be slightly flexed over a pillow.

POSTERIOR SEGMENT

 Right - The patient should lie on his left side and then turn 450 on to his
face, resting against a pillow with another supporting his head. He r should
place his left arm comfortably behind his back with his right arm resting
on the supporting pillow; the right knee should be flexed.
 Left - The patient should lie on his right side turned 450 on to his face with
three pillows arranged to raise the shoulder 30cm (i2in) from the bed. He
should place his right arm behind his back with his left arm resting on the
supporting pillows; both the knees should be slightly bent.

Middle Lobe

LATERAL SEGMENT: MEDIAL SEGMENT The patient should lie on his back
with his body quarter turned to the left maintained by a pillow under the right
side from shoulder to hip and the arms relaxed by his side; the foot of the bed
should be raised 35cm (14in) from the ground. The chest is tilted to an angle
of 15°.

Lingula

SUPERIOR SEGMENT: INFERIOR SEGMENT - The patient should lie on his

back with his body quarter turned to the right maintained by a pillow under
the left side from shoulder to hip and the arms relaxed by his side; the foot of
the bed should be raised 35cm (14m) from the ground. The chest is tilted to an
angle of 15°.

Lower Lobe

APICAL SEGMENTS - The patient should lie prone with the head turned to
one side, his arms relaxed in a comfortable position by the side of the head
and a pillow under his hips.
ANTERIOR BASAL SEGMENTS - The patient should lie flat on his back with
the buttocks resting on a pillow and the knees bent; the foot of the bed should
be raised 46cm (i8in) from the ground. The chest is tilted to an angle of 20°

POSTERIOR BASAL SEGMENTS - The patient should lie prone with his head
turned to one side, his arms in a comfortable position by the side of the head
and a pillow under his hips. The foot of the bed should be raised 46cm (i8in)
from the ground. The chest is tilted to an angle of 20°.

MEDIAL BASAL (CARDIAC) SEGMENT - The patient should lie on his right
side with a pillow under the hips and the foot of the bed should be raised
46cm (i8in) from the ground. The chest is tilted to an angle of 20°.

LATERAL BASAL SEGMENT - The patient should lie on the opposite side
with a pillow under the hips and the foot of the bed should be raised 46cm
(i8in) from the ground. The chest is tilted to an angle of 20°.

Assessment
The following should be assessed and reported to establish a need for postural
drainage[5]:-

 A recent radiograph or bronchogram if available, is a useful adjunct in

isolating the affected areas.
 Pulmonary Function Test
 excessive sputum production
 effectiveness of cough
 history of pulmonary problems treated successfully with PDT
(e.g., bronchiectasis , cystic fibrosis , Lung Abscess )
 decreased breath sounds or crackles or rhonchi suggesting secretions in
the airway
 change in vital signs
 Abnormal chest x-ray consistent with atelectasis , mucus plugging, or
infiltrates
 deterioration in arterial blood gas values or oxygen saturation

Indications
The following are the indications for postural drainage [5]:-
 evidence or suggestion of difficulty with secretion clearance
 difficulty clearing secretions with expectorated sputum production greater
than 25-30 mL/day (adult)
 evidence or suggestion of retained secretions in the presence of an
artificial airway
 presence of atelectasis caused by or suspected of being caused by mucus
plugging
 diagnosis of diseases such as cystic fibrosis, bronchiectasis or cavitating
lung disease
 presence of foreign body in airway

Contraindications
The following are contraindications for postural drainage [6]

 often not suitable for infants in the NICU, who may have lots of equipment
attached to them [7].
 Head injuries including cerebral vascular accidents because intracranial
pressure would be increased.
 Severe hypertension as venous return is increased with tipping and this
can overload the heart.
 Following esophagectomy there can be undue stress on the anastomosis
and tipping may cause regurgitation.
 Severe hemoptysis, when all forms of physiotherapy should be
discontinued until there has been discussion with the doctors.
 Aortic aneurysms which would be put under tension if the patient is
tipped.
 Pulmonary edema which collects in the dependent areas; postural drainage
would cause extreme dyspnea and probably worsen the situation.
 Surgical emphysema which might track toward the face if the patient is
tipped and might result in dyspnea. Tension pneumothorax without an
intercostal drain. This condition should not require physiotherapy, but
must never be tipped as the cardiac embarrassment may lead to a cardiac
arrest.
 Cardiac arrhythmias which can be worsened by postural drain-1 age; in
some positions the myocardial oxygen demand would be greater and so its
sensitivity to abnormal rhythms is increased
 Hiatus hernias should not be tipped as the patient may regurgitate gastric
juices.
 The filling cycle of peritoneal dialysis. The descent of the diaphragm is
impeded during this phase and tipping may cause more respiratory
distress.
 Facial edema from burns will be increased with tipping
 Eye operations where there may be some associated edema which could be
increased with tipping.