Chest Physiotherapy
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Direct answer
One round of the active cycle of breathing techniques moves through three stations — breathing control, thoracic expansion exercises and forced expiration — and the cycle repeats until secretions surface. That cycle, plus postural drainage positioning, percussion, vibration and cough training, forms the physiotherapist's core toolkit against retained bronchial secretions in bronchiectasis, cystic fibrosis, pneumonia and after abdominal or thoracic surgery. Gravity does half the work: each lung segment drains in a specific position, held with percussion for 5 to 10 minutes, and the whole session is kept at least one to two hours clear of mealtimes.
What you must remember
- ACBT in order: breathing control (relaxed tidal breathing at the patient's own rate, six or so breaths), thoracic expansion exercises (three to five deep breaths with a three-second hold at full inspiration), then the forced expiration technique — one or two huffs — followed by coughing only when secretions reach the larger airways; repeat the cycle.
- A huff is a forced expiration through an open glottis from mid (or low) lung volume; it moves peripheral secretions without the airway collapse a glotto-closed cough provokes in obstructed patients.
- Postural drainage positions are segment-specific: upper lobes drain upright or leaning forward, lower lobes in head-down variants, the apical lower segments prone; each position held 5–10 minutes, sessions one to four times daily as tolerated.
- Percussion is rhythmic cupped-hand clapping over the involved segment, about a minute per area, never over spine, sternum, kidneys, liver or bare skin; vibration with flattened hands is applied during expiration only.
- Incentive spirometry — roughly ten sustained maximal breaths every waking hour — prevents post-operative atelectasis; positive expiratory pressure masks and oscillating devices (flutter) add resistance-based clearance for selected patients.
- Assessment before and after: auscultation, sputum volume and colour, oxygen saturation, respiratory rate and effort; stop for distress, falling saturation or new haemoptysis.
- Contraindications and precautions: haemodynamic instability, raised intracranial pressure, undrained pneumothorax, active haemoptysis, rib fractures or flail chest, pulmonary embolism, acute spinal instability and immediate post-operative thoracic or abdominal repair — modify rather than abandon where possible.
Clearing the right lower lobe, start to finish
Auscultate first: crackles and reduced breath volume at the right base tell you where to work. The right lower lobe drains best prone, hips raised on pillows, head down about 25 degrees — a position checked against the contraindication list (no raised intracranial pressure, no reflux, no cardiac intolerance of head-down).
In position, percuss the lower rib area posteriorly for one to two minutes with a relaxed cupped hand — the hollow palm should land with a hollow sound, not a slap — then apply vibration with flattened hands through three expirations. Sit the patient upright for the ACBT cycle: breathing control until settled, three expansion breaths with a hold, breathing control again, then a huff from mid lung volume with the mouth open, chin tucked. A second huff often brings the secretions central; the cough that follows is now productive instead of exhausting. Two or three full cycles, with rest as needed, and the segment is re-auscultated: quieter entry, better air entry, sputum volume documented.
Sessions are timed before meals or at least an hour after, hydration is encouraged to keep secretions thin, and the whole regimen is taught to the patient — ACBT is self-administered for life in bronchiectasis and cystic fibrosis, which is the entire point.
How the exam frames it
The ACBT order is the perennial sequence MCQ, and percussion exclusion sites (spine, sternum, kidneys, liver) run close behind. Huff-versus-cough mechanics is the favourite viva distinction — open glottis, equal pressure point, no collapse — and the timing rule about meals is a standard one-liner. Head-down contraindications (raised intracranial pressure, reflux, cardiac failure) are asked as a list, and incentive spirometry dosage as a number.
Frequently asked questions
What are the three components of ACBT, in order?
Breathing control, thoracic expansion exercises, and the forced expiration technique (huff), cycled with rests.
When is vibration applied?
During expiration only, with flattened hands over the drained segment, following percussion.
What is a huff, and why huff before coughing?
A forced expiration through an open glottis from mid lung volume; it moves peripheral secretions without collapsing airways the way a closed-glottis cough can.
How is incentive spirometry dosed after upper abdominal surgery?
About ten slow, sustained maximal breaths every waking hour, with a breath hold at full inspiration.
Which conditions forbid head-down postural drainage?
Raised intracranial pressure, significant reflux or vomiting, severe cardiac or respiratory failure, and recent eye or certain neurosurgery.