13.1 Pneumonia, Infection and Atelectasis

Quick Answer: Gate every “chest physio” choice by wet vs dry physiology. Wet/secretions → ACBT/huff, supported cough, mobility. Dry/volume loss → deep breathing, upright posture, early mobilisation—not percussion. Practise infection control, protect wounds with supported cough, and escalate rising oxygen need, new confusion, or sepsis—do not treat deterioration as a technique failure.

Acute pulmonary problems dominate hospital cardiorespiratory cases on the APC Written Assessment. You will not be asked to prescribe antibiotics or interpret full CT reports in isolation. You will be asked to recognise pneumonia and atelectasis patterns, choose appropriate breathing and clearance strategies, mobilise safely, apply infection control, and escalate when the patient is deteriorating. This section builds a practical map: infection and consolidation, volume loss (atelectasis), wet versus dry physiology, and entry-level techniques that match Australian ward practice.

Pneumonia and Lower Respiratory Tract Infection: Working Map

Pneumonia is infection of the lung parenchyma with inflammation and often consolidation of alveoli. Related labels you will see include community-acquired pneumonia (CAP), hospital-acquired pneumonia (HAP), aspiration pneumonia, and lower respiratory tract infection (LRTI). Pathogens and antimicrobial choice are medical decisions. Physiotherapy contributes by supporting gas exchange, secretion clearance when indicated, early functional recovery, and prevention of secondary complications (further deconditioning, pressure injury, venous thromboembolism risk themes, and postoperative pulmonary complications when infection follows surgery).

Common clinical features in vignettes:

• Fever, malaise, productive or dry cough, pleuritic chest pain
• Tachypnoea, increased work of breathing, use of accessory muscles
• Localised crackles, bronchial breath sounds, reduced air entry over consolidation
• Hypoxaemia or increased oxygen requirement
• Confusion (especially older adults) and reduced exercise tolerance

Aspiration risk appears in stroke, reduced conscious state, dysphagia, and post-anaesthesia cases. Positioning for safe oral intake is largely speech pathology and nursing led, but physiotherapists should avoid aggressive supine exercise in high-risk patients until swallow safety is clarified, and should share observations of coughing with oral intake or wet voice.

Infection control for physiotherapists

Infection control is a professional competency, not optional etiquette:

• Hand hygiene before and after patient contact and after glove removal
• Personal protective equipment (PPE) as per hospital transmission-based precautions (contact, droplet, airborne)
• Careful handling of sputum specimens and contaminated equipment
• Cleaning shared gait aids and respiratory devices per unit policy
• Minimising unnecessary aerosol-generating procedures when precautions require it; use local guidance for cough-inducing techniques

If a case mentions multi-resistant organism status or influenza-like illness, the best answer usually includes correct PPE and isolation behaviour alongside the respiratory technique—not only “do ACBT harder.”

Atelectasis: Collapse Without Assuming Sputum

Atelectasis is collapse or incomplete expansion of alveoli or lung segments. Mechanisms include:

Postoperative basilar atelectasis is extremely common after abdominal and thoracic surgery because of diaphragmatic dysfunction, recumbency, and pain-limited inspiration. Your default toolkit is early upright posture, mobilisation, deep breathing / volume-oriented exercises, and effective cough with wound support—not prolonged bed rest “until the X-ray looks perfect.”

Wet Versus Dry Conditions: The Decision Gate

APC-style traps punish candidates who apply the same “chest physio package” to every lung problem. Use a simple gate:

Wet (secretions predominant)

• Productive cough, audible/felt secretions, loose crackles that change with cough
• History of chronic sputum (bronchiectasis, CF, some COPD exacerbations) or acute infective sputum load
• Techniques: active cycle of breathing techniques (ACBT), forced expiratory technique (FET/huff), supported cough, positioning to assist drainage where indicated, positive expiratory pressure (PEP) devices if available and appropriate, hydration and mobility as adjuncts

Dry (volume loss / shallow breathing without excess sputum)

• Dry cough or non-productive pattern, reduced chest expansion, basal dullness from collapse without loose secretions
• Post-op hypoventilation, restrictive pain, neurological weakness of respiratory muscles
• Techniques: deep breathing exercises, incentive spirometry concepts (volume-oriented inspiration with breath-hold if taught), thoracic expansion exercises, positioning for better ventilation–perfusion, early mobilisation; avoid aggressive percussion and postural drainage that adds pain without target secretions

Mixed pictures are common (pneumonia with both consolidation and sputum). Prioritise medical stability and oxygen, then match technique to the dominant problem at that moment. Reassess after each session: if SpO2, work of breathing, or sputum yield does not change, revise the plan rather than escalate force.

What “incentive / deep breathing” means at entry level

• Diaphragmatic and thoracic expansion exercises to increase tidal volume and reopen dependent zones
• Slow deep inspiration → brief hold → relaxed expiration patterns (exact cueing varies by service)
• Incentive spirometry as a feedback tool for volume when available; it is not a substitute for walking and upright time
• Frequency matters more than heroic single breaths: short, repeated sets while awake, especially after surgery

If pain limits depth of breath, fix the limiter: wound support, timing with analgesia, sitting out of bed, and avoiding forced techniques that provoke breath-holding or panic.

Secretion Management Toolbox (Entry Level)

Active cycle of breathing techniques (ACBT)

A flexible cycle combining breathing control, thoracic expansion, and FET/huff. Use when the patient can follow instructions and secretions are the target. Adapt cycles for breathlessness: more breathing control, fewer forced manoeuvres. Do not force full ACBT in severe acute distress—stabilise first.

Supported cough

Teach the patient (or assist) to support the incision or painful chest wall with hands, pillow, or towel during cough. Reduces pain, improves cough effectiveness, and protects surgical wounds. Essential after laparotomy, thoracotomy, sternotomy, and rib injury.

Positioning

• Upright sitting and standing improve functional residual capacity versus pure supine
• Side-lying can target regional ventilation; avoid prolonged positions that worsen SpO2 without monitoring
• Head-up postures help many dyspnoeic patients; document response

Early mobilisation

Sitting out, marching on the spot, walking with oxygen as prescribed, and progressive ambulation reduce atelectasis risk and improve secretion clearance more than isolated bed exercises for many ward patients. Screen for falls risk, orthostatic hypotension, lines/drains, and medical stability before each session.

Assessment Snapshot Before You Treat

1. Medical status: diagnosis, day of illness/surgery, antibiotics, oxygen prescription, mobility orders, precautions
2. Symptoms: dyspnoea, pain, cough quality/quantity, sputum colour (document, do not over-interpret colour alone)
3. Signs: respiratory rate, SpO2, work of breathing, auscultation pattern, chest expansion, temperature trends if available
4. Function: sit-to-stand, walk distance, assistance level
5. Red flags: rapid deterioration, new confusion, SpO2 falling despite oxygen, chest pain of cardiac character, haemoptysis large volume, suspected pneumothorax after intervention—stop and escalate

Australian Clinical Scenarios (Reasoning Style)

Scenario A — CAP on medical ward: 68-year-old, day 2 of antibiotics, SpO2 94% on 2 L/min, productive cough, mobilises with frame. Best plan: infection control, oxygen during activity as prescribed, ACBT or huff if secretions, frequent upright mobility, monitor response. Wrong plan: bed rest only until “lungs clear on X-ray.”

Scenario B — Day 1 post-laparotomy, dry atelectasis pattern: shallow breathing, basal reduced air entry, minimal sputum, pain 7/10 on cough. Best plan: wound support, deep breathing, sit out, short walks with assistance, analgesia liaison. Wrong plan: head-down postural drainage and vigorous percussion.

Scenario C — Deteriorating pneumonia: rising oxygen from 2 L to 8 L over hours, new confusion, RR 32. Best action: urgent nursing/medical escalation, do not start a long clearance session as first response.

APC Traps

• Treating all “chest physio” as percussion and vibration regardless of wet/dry status
• Ignoring infection control while focusing only on technique names
• Delaying mobilisation until radiology is perfect
• Forcing cough without wound support after abdominal surgery
• Interpreting hypoxia and sepsis as a need for more aggressive manual techniques alone
• Confusing pleural effusion compression atelectasis with simple mucus plugging and promising full re-expansion with ACBT only

APC Case Patterns and Competency Links

Common item stems:

• Day-1 laparotomy, dry bases, high pain → volume recruitment + sit-out + wound support, not head-down percussion
• Productive pneumonia on droplet precautions → PPE + ACBT/mobility, not “skip physio until isolation ends”
• Rising O2, new confusion, RR 30+ → urgent medical escalation, not longer percussion
• Aspiration risk after stroke with wet voice on sips → share with speech pathology/nursing, avoid aggressive supine loading until swallow safety is clear
• Multi-resistant organism label in the stem → include transmission-based precautions in the best answer

Map to Thresholds: assessment and problem identification (wet vs dry), risk management (sepsis, hypoxia), collaborative practice (nursing, medical, infection control, speech pathology), and professional practice (hand hygiene, PPE). Cultural safety still applies: explain isolation and breathing plans in plain language, use interpreters when needed, and avoid blaming patients for “not coughing hard enough” when pain or fear is the limiter.

Hospital-acquired and ventilator-associated themes: when a stem mentions onset ≥48 hours after admission (HAP) or after invasive ventilation (VAP themes), physiotherapy still uses the same wet/dry and mobility logic, but infection control and medical escalation thresholds are higher. Do not invent antibiotic choices; do document sputum changes, SpO2 trends, and functional response clearly for the team.

Closing Exam Anchor

Match the technique to wet or dry physiology, mobilise early when safe, protect the wound when coughing, practise infection control, and escalate medical deterioration before you escalate force.