Practical Respiratory Physiotherapy for Hospitalized Patients

 

Practical Respiratory Physiotherapy for Hospitalized Patients: A Clinician's Guide

Dr Neeraj Manikath , claude.ai

Abstract

Respiratory physiotherapy represents a critical yet often underutilized intervention in the management of hospitalized patients with acute and chronic respiratory conditions. This comprehensive review examines evidence-based respiratory physiotherapy techniques applicable to inpatient settings, with practical guidance for internal medicine physicians. We explore patient selection, contraindications, and specific techniques including airway clearance, breathing exercises, and mobilization strategies, emphasizing practical pearls that can immediately enhance clinical practice.

Introduction

Respiratory physiotherapy encompasses a diverse array of therapeutic interventions designed to optimize lung function, improve gas exchange, prevent pulmonary complications, and facilitate weaning from mechanical ventilation. Despite robust evidence supporting its efficacy, respiratory physiotherapy remains inconsistently implemented in many healthcare settings. Internal medicine physicians must understand when to initiate these interventions, how to select appropriate techniques for specific clinical scenarios, and recognize potential contraindications.

Hospitalized patients face multiple risk factors for respiratory complications, including immobilization, pain, sedation, neuromuscular weakness, and underlying comorbidities. Atelectasis develops in up to 90% of patients undergoing general anesthesia and affects a significant proportion of critically ill patients. Respiratory physiotherapy, when appropriately applied, can reduce pulmonary complications, decrease hospital length of stay, and improve functional outcomes.

Patient Selection and Assessment

Clinical Indications

Respiratory physiotherapy benefits several patient populations:

Acute respiratory conditions: Community-acquired pneumonia, hospital-acquired pneumonia, acute exacerbations of chronic obstructive pulmonary disease (COPD), bronchiectasis, and atelectasis represent primary indications. Patients with copious secretions, ineffective cough, or evidence of retained secretions on chest imaging particularly benefit from airway clearance techniques.

Post-operative patients: Thoracic and upper abdominal surgery patients face heightened risk of postoperative pulmonary complications (PPCs). Early mobilization combined with breathing exercises reduces PPCs by approximately 50% in high-risk surgical patients.

Mechanically ventilated patients: Both invasive and non-invasive mechanical ventilation patients require specialized respiratory physiotherapy to prevent ventilator-associated pneumonia, facilitate weaning, and maintain airway patency.

Neuromuscular conditions: Patients with Guillain-Barré syndrome, myasthenia gravis, or critical illness polyneuropathy often develop respiratory muscle weakness requiring assistive techniques.

Contraindications and Precautions

Absolute contraindications include untreated pneumothorax, massive hemoptysis, acute pulmonary embolism with hemodynamic instability, and unstable cardiovascular status (acute myocardial infarction, uncontrolled arrhythmias).

Relative contraindications warrant careful consideration: platelet count below 20,000/μL, INR above 3.0 without reversal, rib fractures (technique modification required), recent esophageal surgery, and raised intracranial pressure above 20 mmHg.

Pearl: Always assess hemodynamic stability before initiating respiratory physiotherapy. A systolic blood pressure below 90 mmHg or above 180 mmHg, heart rate above 120 bpm at rest, or oxygen saturation below 90% despite supplemental oxygen should prompt reassessment.

Core Respiratory Physiotherapy Techniques

1. Airway Clearance Techniques

Active Cycle of Breathing Technique (ACBT)

ACBT combines three breathing phases: breathing control (relaxed tidal breathing), thoracic expansion exercises (deep breathing with inspiratory hold), and forced expiratory technique (huffing). This sequence mobilizes secretions from peripheral to central airways without causing bronchospasm, which can occur with aggressive coughing.

Technique: Instruct patients to perform 3-4 cycles of relaxed breathing, followed by 3-4 deep breaths with 2-3 second inspiratory holds, concluding with 1-2 huffs at mid-to-low lung volumes. Repeat the cycle 3-4 times per session.

Clinical pearl: ACBT proves particularly effective in bronchiectasis and COPD patients with chronic sputum production. Unlike percussion and postural drainage, ACBT can be self-administered after initial training, promoting patient independence.

Autogenic Drainage

This technique uses controlled breathing at different lung volumes to mobilize secretions progressively from small to large airways without coughing. Patients breathe at low lung volumes (unsticking phase), mid-lung volumes (collecting phase), and higher lung volumes (evacuating phase).

Hack: For patients struggling with the concept, use visual feedback with a spirometer to help them recognize different lung volume phases. This technique is superior to conventional chest physiotherapy in cystic fibrosis patients and applicable to other secretion-retention disorders.

Positive Expiratory Pressure (PEP) Therapy

PEP devices create expiratory resistance (10-20 cmH₂O), preventing airway collapse and facilitating secretion mobilization. Patients breathe through a mask or mouthpiece with a one-way valve and resistor.

Protocol: 10-15 breaths followed by huffing/coughing, repeated 4-6 times per session, twice daily. High-frequency oscillatory PEP devices (Acapella, Flutter) add vibrations that may further enhance mucus clearance.

Oyster: PEP therapy demonstrates equivalent or superior efficacy compared to conventional chest physiotherapy in bronchiectasis and post-operative patients, with better patient adherence due to ease of use.

2. Breathing Exercises and Lung Expansion Techniques

Incentive Spirometry (IS)

IS provides visual feedback for sustained maximal inspiration, preventing or reversing atelectasis. Despite widespread use, evidence supporting IS remains controversial when used in isolation.

Evidence-based approach: IS proves most effective when combined with early mobilization and adequate analgesia rather than as a standalone intervention. Target 10 breaths per hour while awake, with each breath held for 3-5 seconds at maximal inspiration.

Pearl: Coach patients to focus on slow, deep inspiration rather than rapid inhalation, which closes the glottis and reduces alveolar inflation. Place the device at eye level to optimize patient positioning.

Diaphragmatic Breathing

This technique emphasizes diaphragmatic excursion while minimizing accessory muscle use, particularly beneficial in COPD patients with hyperinflation and in weaning from mechanical ventilation.

Technique: Position patient semi-recumbent, place one hand on abdomen and one on chest. Instruct slow nasal inspiration focusing on abdominal rise with minimal chest movement, followed by pursed-lip expiration.

Hack: For patients with poor proprioception, place a 1-2 kg weight on the abdomen to provide tactile feedback during diaphragmatic breathing practice.

3. Positioning and Mobilization

Therapeutic Positioning

Positioning represents the most underutilized yet effective respiratory intervention. Gravity-assisted positions enhance ventilation-perfusion matching and secretion drainage.

Prone positioning: In acute respiratory distress syndrome (ARDS), prone positioning for 12-16 hours daily reduces mortality in patients with PaO₂/FiO₂ ratios below 150 mmHg. Even in non-intubated patients with severe COVID-19 pneumonia, awake proning improves oxygenation, though mortality benefits remain uncertain.

Lateral positioning: Place the good lung down to improve oxygenation in unilateral lung disease, or place the bad lung down to facilitate secretion drainage.

Semi-recumbent positioning: Elevating the head of the bed to 30-45 degrees reduces ventilator-associated pneumonia risk by approximately 25% and should be standard practice for all intubated patients.

Early Mobilization

Progressive mobilization represents arguably the most impactful respiratory physiotherapy intervention. Mobilization increases tidal volume, enhances secretion clearance, prevents atelectasis, and improves overall functional capacity.

Stepwise protocol:

• Level 1: Bed exercises (ankle pumps, knee bends, arm raises)
• Level 2: Sitting at edge of bed
• Level 3: Standing at bedside
• Level 4: Marching in place
• Level 5: Walking with assistance
• Level 6: Independent ambulation

Safety parameters: Initiate mobilization when mean arterial pressure exceeds 60 mmHg, heart rate is 50-120 bpm, respiratory rate is below 30/min, and oxygen saturation exceeds 88%. Cease activity if heart rate increases more than 20 bpm above baseline, systolic blood pressure drops more than 20 mmHg, or oxygen saturation falls below 88%.

Pearl: Early mobilization within 48-72 hours of ICU admission reduces ICU-acquired weakness and may decrease ventilator days. Even patients on mechanical ventilation can participate in supervised mobilization with appropriate monitoring.

4. Manual Techniques

Percussion and Vibration

While traditional postural drainage with percussion has fallen out of favor due to limited evidence and patient discomfort, modified manual techniques still have roles in specific situations.

Indications: Large mucus plugs, lobar collapse not responding to other interventions, or patients unable to perform active techniques due to altered consciousness.

Contraindication reminder: Avoid in patients with osteoporosis, rib fractures, thrombocytopenia, or anticoagulation.

Manual Hyperinflation

Performed by skilled physiotherapists, manual hyperinflation uses a bag-valve device to deliver slow, deep breaths with inspiratory hold, followed by rapid release, creating a high expiratory flow that mobilizes secretions.

Evidence: Studies demonstrate improved compliance and oxygenation in mechanically ventilated patients, though risks include barotrauma and hemodynamic instability.

Special Populations

COPD Exacerbations

Combine bronchodilator therapy with pursed-lip breathing, diaphragmatic breathing exercises, and controlled mobilization. Avoid aggressive chest physiotherapy during acute episodes as it may worsen bronchospasm.

Hack: Teach patients the "blow-as-you-go" technique—exhaling during exertion (such as standing or walking)—to reduce dynamic hyperinflation and dyspnea.

Post-Operative Thoracic Surgery

Pain control is paramount. Combine patient-controlled analgesia or thoracic epidural with breathing exercises, early mobilization, and cough assistance techniques.

Pearl: The "huff" technique (forced expiration with open glottis) generates less intrathoracic pressure than coughing, causing less incisional pain while effectively clearing secretions.

Mechanically Ventilated Patients

Coordinate physiotherapy with sedation holds when possible. Combine manual hyperinflation, suctioning, and positioning changes. Implement spontaneous breathing trials according to weaning protocols.

Oyster: Subglottic secretion drainage (continuous or intermittent suctioning above the endotracheal tube cuff) reduces ventilator-associated pneumonia by approximately 50%.

Implementation Strategies

Building an Effective Respiratory Care Team

Successful respiratory physiotherapy requires interprofessional collaboration among physicians, physiotherapists, respiratory therapists, and nurses. Clear communication about goals, techniques, and patient responses optimizes outcomes.

Morning rounds checklist:

• Review chest imaging for atelectasis, consolidation, or effusions
• Assess secretion burden and cough effectiveness
• Identify mobility barriers
• Confirm adequate analgesia
• Set specific mobilization and respiratory therapy goals

Patient Education

Educate patients about the rationale for interventions to improve adherence. Demonstrate techniques at bedside rather than providing written instructions alone.

Hack: Use smartphone videos to record patients performing techniques correctly, allowing them to review proper form independently.

Documentation and Monitoring

Document specific techniques used, patient tolerance, secretion characteristics, oxygen requirements, and functional progress. Standardized assessment tools like the Medical Research Council dyspnea scale or the Physical Function ICU Test facilitate outcome tracking.

Common Pitfalls and How to Avoid Them

1. Over-reliance on incentive spirometry: IS alone, without mobilization and other interventions, provides minimal benefit. Always combine with early ambulation.

2. Inadequate pain control: Uncontrolled pain prevents effective breathing exercises and mobilization. Address analgesia before physiotherapy sessions.

3. Premature discontinuation: Respiratory physiotherapy should continue until patients demonstrate adequate independence in airway clearance and functional mobility, not simply when acute illness resolves.

4. Ignoring contraindications: Always reassess hemodynamic and respiratory stability before each session.

Emerging Evidence and Future Directions

High-flow nasal cannula therapy has emerged as both a respiratory support device and potentially a physiotherapy adjunct, allowing patients to perform exercises while maintaining adequate oxygenation. Neuromuscular electrical stimulation shows promise in preventing ICU-acquired weakness. Non-invasive ventilation during exercise may facilitate earlier mobilization in selected patients.

Conclusion

Respiratory physiotherapy represents an essential component of comprehensive inpatient care that internal medicine physicians must understand and advocate for. By recognizing appropriate indications, selecting evidence-based techniques, and coordinating interprofessional care, clinicians can significantly reduce pulmonary complications and improve patient outcomes. The techniques outlined in this review—from simple positioning and early mobilization to more specialized airway clearance methods—should be integrated into routine practice for hospitalized patients with respiratory conditions. As the evidence base continues to evolve, maintaining familiarity with current best practices ensures that our patients receive optimal respiratory care during hospitalization and beyond.

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