4.3 Pulmonary Conditions & Airway Clearance
Key Takeaways
- Chronic Obstructive Pulmonary Disease (COPD) produces an obstructive Pulmonary Function Test (PFT) pattern: low Forced Expiratory Volume in 1 second to Forced Vital Capacity (FEV1/FVC) ratio (less than 0.70) and air trapping.
- Restrictive lung diseases (pulmonary fibrosis, neuromuscular disease, kyphoscoliosis) reduce Total Lung Capacity (TLC) and Forced Vital Capacity (FVC) but keep the FEV1/FVC ratio normal or elevated.
- Pursed-lip breathing slows the respiratory rate, creates back-pressure in the airways, and prevents premature airway collapse - a first-line teaching point for any COPD shortness of breath flare.
- Postural drainage positions the affected lung segment 'up' so gravity drains mucus toward the larger airways; percussion and vibration are timed with expiration.
- The Active Cycle of Breathing Technique (ACBT) and Positive Expiratory Pressure (PEP) devices are self-administered airway clearance options used heavily in Cystic Fibrosis (CF) care.
Obstructive vs Restrictive Lung Disease
PFTs separate lung disease into two big buckets. The PTA must recognize the pattern because the breathing strategy and exercise tolerance differ.
| Pattern | FEV1 | FVC | FEV1/FVC | Lung Volumes | Classic Examples |
|---|---|---|---|---|---|
| Obstructive | Decreased | Normal or decreased | Decreased (less than 0.70) | Increased Total Lung Capacity (TLC) and Residual Volume (RV) due to air trapping | COPD (emphysema, chronic bronchitis), asthma, cystic fibrosis |
| Restrictive | Decreased | Decreased | Normal or increased | Decreased TLC and FVC | Pulmonary fibrosis, kyphoscoliosis, neuromuscular weakness, obesity hypoventilation |
Breathing Re-Education for COPD
COPD patients trap air, flatten the diaphragm, and rely on accessory muscles. PTAs teach two foundational techniques:
Pursed-Lip Breathing (PLB)
- Inhale slowly through the nose for about 2 seconds.
- Exhale through pursed lips (as if blowing out a candle) for 4-6 seconds.
- Match a 1:2 inspiration-to-expiration ratio.
PLB creates a small amount of back-pressure that splints small airways open, reduces respiratory rate, and lowers the work of breathing. Use it during stair climbing, dressing, and any flare.
Diaphragmatic ('Belly') Breathing
- Hand on abdomen, hand on chest.
- Inhale through the nose so the abdominal hand rises and the chest hand stays quiet.
- Exhale slowly, ideally with pursed lips.
Energy Conservation
PTAs reinforce pacing, planning, and prioritizing during ADLs: sit to dress, slide rather than lift, exhale during exertion, use long-handled tools, and schedule rest. The 'blow as you go' rule (exhale through pursed lips during the hard phase of a task) reduces breath-holding and Valsalva.
Postural Drainage Basics
Postural drainage uses gravity to move secretions from peripheral airways toward the trachea. The general rule: position the affected lung segment uppermost.
| Lung Segment | Position |
|---|---|
| Upper lobes, apical segments | Upright sitting, leaning slightly back or forward |
| Upper lobes, anterior segments | Supine, flat |
| Upper lobes, posterior segments | Sitting, lean forward over a pillow |
| Right middle lobe / Lingula (left) | Trendelenburg (head down) about 12-16 inches, quarter-turn to the opposite side |
| Lower lobes, anterior basal segments | Trendelenburg, supine |
| Lower lobes, posterior basal segments | Trendelenburg, prone |
| Lower lobes, lateral basal segments | Trendelenburg, side-lying with affected side up |
Trendelenburg positions are contraindicated with severe shortness of breath at rest, recent neurosurgery, uncontrolled hypertension, severe gastroesophageal reflux, or unstable cardiac status.
Manual Techniques
- Percussion: rhythmic clapping with cupped hands over the draining segment for 3-5 minutes. Avoid over fractures, recent surgery, tumor sites, or bony prominences.
- Vibration: fine oscillation applied during expiration only to move loosened secretions toward larger airways.
- Shaking: coarser version of vibration, also expiration-only.
Active Cycle of Breathing Technique (ACBT)
A self-administered three-part cycle used heavily in CF and bronchiectasis:
- Breathing Control: relaxed, low-rate diaphragmatic breathing.
- Thoracic Expansion Exercises: three to four deep inhalations with a brief hold to mobilize secretions.
- Forced Expiration Technique (FET) / huffing: one or two huffs at low to medium lung volumes to clear central airways.
Positive Expiratory Pressure (PEP) Devices
PEP and oscillating PEP devices (Flutter, Acapella, Aerobika) create back-pressure during exhalation, splint airways open, and vibrate secretions loose. They let patients clear independently and are favored in CF home programs.
Cystic Fibrosis Considerations
CF patients usually combine multiple airway clearance modes (ACBT plus PEP plus exercise) and often require sodium replacement and high-calorie intake. Infection-control isolation between CF patients is strict - never treat two CF patients in the same gym at the same time, and follow facility cohorting policies.
A patient with right middle lobe pneumonia needs postural drainage. The most appropriate position is:
A patient with COPD becomes dyspneic climbing six stairs. The PTA's first cueing priority is: