Description #
This unit is designed to help students and clinically registered physiotherapists develop a better understanding of the skills involved in performing the technique of Percussion. It will also provide an understanding of the clinical reasoning process behind the application of Percussion. The prerequisites to this unit are CCBSP-001 to CCBSP-003. At the end of this unit the subject will have an understanding of the clinical reasoning, contraindications/restrictions, and proper application of Percussion
Learning Objectives #
At the completion of this unit the student will be able to:
- Understand the principle behind the application of Percussion.
- Know the contraindications for the application of Percussion.
- Know the precautions for the application of Percussion.
- Know when and how to safely apply Percussion as a treatment technique.
Introduction to Percussion #
In this section we will briefly discuss the evidence behind the Manual Technique of Percussion’s, along with some of the documented side effects.
Please note that there is a Lecture On Demand available for your viewing at any time.
Percussions are used as a means to facilitate the clearance of secretions. They are performed by positioning the patient appropriately and using cupped hands to ‘clap’ against the thorax. Percussion’s are often combined with breathing exercises like deep breathing or the Active Cycle of Breathing Technique and also used in conjunction with Vibrations to improve outcomes (Irwin & Tecklin, 1990).
Evidence suggests that Percussion’s are most effective when patients have increased secretion production (>25-30 ml/day) (McCool & Rosen, 2006; Vines, Shelledy & Peters, 2000; Langenderfer, 1998). Perez (2004) found that the addition of Percussion’s to position changes increased alveolar clearance in their treatment of Pulmonary Alveolar Proteinosis. McCool and Rosen (2006) also reports on several studies that suggest that the use of Percussion is more effective than just Postural Drainage alone, however the majority of these studies were on Cystic Fibrosis or Bronchiectasis patients, which by nature have an increased daily sputum production. There are numerous studies that report inconclusive evidence about the positive and negative effects of Percussion.
We do know that there are some negative effects associated with Percussion as a treatment. In a meta-analysis by Hess (2001) he reports such adverse effects as hypoxemia, increased oxygen consumption, rib fractures, increased intracranial pressures, and several other complications unique to preterm infants. Irwin and Tecklin(1990) also adds arrhythmias to the list, and suggests in the Heart Monitored patient (ECG), pausing Percussion to check Heart Rhythm is a useful strategy to ensure no arrhythmias result from treatment. Pryor and Webber (1998) also reports similar negative effects, adding bronchospasm as another potential complication. Interestingly, Pryor and Webber (1998) notes that “when short periods of chest clapping (less than 30 seconds) have been combined with three to four thoracic expansion exercises no fall was seen in oxygen saturation”.
In summary, it seems that Percussion’s are most beneficial in the patient population with increased sputum production or thick tenacious secretions. Percussion should not be used routinely, nor without clinical reasoning.
Theory behind Percussion #
The idea behind Percussion’s is a relatively simple one.
It is to manually loosen the secretions in the airways and facilitate their movement up the bronchial tree, allowing the patient to expectorate them.
According to Frownfelter (1987) “Percussion initiates waves of mechanical energy which are applied to the chest wall and transmitted to the lungs”, thus facilitating the movement of secretions up the bronchial tree.
Percussion appears to work best when combined with gravity, by allowing gravitational kinetic energy to work with the force provided by Percussion’s to move secretions into larger airways.
Always remember that if possible, you should try to mobilise your patient prior to treatment, and position them appropriately during treatment. This will help to increase the effectiveness of your treatment with Percussion
The Application of Percussion #
Percussions are generally performed in lying or sitting. A towel or clothing is appropriately draped on the patient’s skin to reduce irritation and dampen the sound of the Physiotherapist’s hands making contact with the patient’s thorax. The Physiotherapist’s hands are cupped and Percussion is performed with relaxed wrists. Percussion is usually performed using both hands, but if needed can be altered by using just one hand.
Traditionally compliance with treatment is an issue, and Langenderfer (1998) reports compliance rates of between 40-50% with treatment regimes involving Percussion and Postural Drainage. However, some patients find the technique soothing and relaxing.
There is no available evidence to suggest that one technique is better than the next. Treatments need to be tailored to the patient and their tolerance of Percussion. It is important to take the following into consideration when choosing Percussion’s as a treatment option.
Percussions are performed during both the Inspiration and Expiration phases of breathing.
The Force used during percussions needs to be tailored to the patient. Importantly, Percussion’s are not supposed to be painful
A healthy teenager with Cystic Fibrosis will be able to tolerate more force than an elderly patient with severe Osteoporosis.
The Frequency of Percussion is also patient dependent. Some studies report that only high frequency Percussion is effective. However, this is not corroborated by other studies. Most commonly Percussion’s are performed at a frequency around 5 Hz (Hz = Hertz = beats per second).
The Duration of Percussion as a treatment will depend on both the Patient and Physiotherapist’s level of fatigue and tolerance to treatment. Usually Percussion’s performed for several minutes (up to 5) at a time are sufficient however there is no evidence to suggest that shorter or longer periods result in more benefits or increased sputum production levels. As noted during the Introduction to Percussion short spells of Percussion have been shown not to produce desaturation episodes.
When Percussion is combined with an appropriate Position, the effect of gravity appears to increase the effect of the treatment, thus correct positioning should always be considered. In some cases modification will be required due to anatomical, surgical and medical limitations.
By Combining Percussion with other techniques they have been shown to have an advantage over individual techniques. Studies have combined Chest Physiotherapy with exercise to get significantly better results than just Chest Physiotherapy alone.
Step by Step Guide #
Below is a step by step guide on how to perform Percussion.
- Wash hands. (Donning Personal Protective Equipment (PPE))
- Don appropriate PPE as per VCH Infection Control Manual (Donning Personal Protective Equipment (PPE))
- Position patient appropriately (i.e., Postural Drainage position for affected lung segment) unless contraindicated.
- Instruct the patient on correct breathing technique for treatment (If patient is on a ventilator, consider performing MHI during treatment).
- Drape the patient with a towel or bed clothing over the segment to be treated.
- With hands cupped the wrists are quickly flexed and extended repeatedly causing the hands to ‘clap’ against the chest wall (the clapping sounds occur as air is trapped between the therapist’s hands and the chest wall).
- During treatment the patient should periodically be instructed to take deep breaths (consider MHI if patient is on ventilator). (Active Cycle of Breathing Technique)
- After 1-5 minutes or if the patient needs to clear secretions they should be instructed to cough/huff or if unable, suctioning is performed to clear secretions.
- The process should be repeated as many times the Physiotherapist feels needed, with care taken to avoid fatiguing the patient to exhaustion.
- Once treatment is completed remove PPE and wash hands
Active Cycle of Breathing Technique #
Below is a video on how to teach your patient the Active Cycle of Breathing Technique, or ACBT.
Donning Personal Protective Equipment (PPE) #
Please watch the video below on how to Don your Personal Protective Equipment.
Considerations, Precautions and Contraindications #
In this section we will be looking at the Considerations, Precautions and Contraindications to performing Percussion as a treatment technique.
Considerations:
A variety of factors need to be considered prior to treatment with Percussions. These include, but are not limited to the patient’s age; co-morbidities; endurance; Oxygen status and potential benefits/adverse effects from treatment.
Once all these factors are considered it is vital that the patient is checked for the following Precautions and Contraindications.
It is important to note that the Precautions and Contraindications for both Vibrations and Percussions are very similar. However, there are some subtle but very important differences.
One should also note that a Precaution is not a contraindication. But rather exactly as it says, a Precaution, therefore Precautions require sound clinical reasoning to determine if treatment with a particular technique is valid treatment option.
Precautions #
The following is a list of Precautions that do not preclude treatment using Percussion. However, adequate clinical reasoning is required if Percussions are to be performed safely when any of the precautions exist.
Precautions for use of Percussion
- Haemoptysis
- Acute Pleuritic Pain
- Platelet count <30 or anticoagulation therapy
- Unstable Cardiovascular status
- Subcutaneous Emphysema of neck/thorax
- Fresh burn, open wound or skin infection of thoracic area
- Pulmonary Emboli
- Bronchospasm
- Prolonged Steroid therapy
For Example:
- Haemoptysis
– Depending on the reason for Haemoptysis, Percussion can potentially exacerbate the amount of bleeding.
- Acute Pleuritic Pain
– Percussion can increase pleuritic chest pain, if treatment is indicated it should be limited by patient pain or well timed with analgesics.
- Platelet count <30 or anticoagulation therapy
– A low platelet count, or altered coagulation due to therapy increases the risk of causing trauma and haemorrhage in patients treated with Percussion. Ensure benefits of treatment outweigh potential complications.
- Unstable Cardiovascular status
– Percussion has been known to alter Heart Rhythms, ensure patient is being monitored take note of Heart Rhythm pre treatment and frequent pauses during treatment to observe Rhythm for changes.
- Subcutaneous Emphysema of neck/thorax
– Ensure that underlying reason for Subcutaneous Emphysema has been treated prior to commencing treatment with Percussion.
- Fresh burn, open wound or skin infection of thoracic area
– Treatment around the area of infection/burn/wound is acceptable. If the area covers the entire thorax, then ensure benefits of treatment are warranted. Appropriately dress area prior to treatment.
- Pulmonary Emboli
– Prior to beginning treatment confirm that patient is being treated for Pulmonary Emboli and their INR/PTT is in the therapeutic range.
- Bronchospasm
– Percussion can potentially cause Bronchospasm, therefore ensure that treatment is warranted, and monitor the patient for signs of distress or increased bronchospasm.
- Prolonged Steroid therapy
– Prolonged Steroid use is known to reduce bone density. If possible check with medical team about patients bone density prior to beginning treatment with Percussion.
Contraindications to Percussion #
The following list of Contraindications is not exhaustive, clinical judgement should always be utilised.
Contraindications for Percussion’s
- Severe Osteoporosis
- Metastatic Bone Cancer
- Active Tuberculosis
- Treatment over rib/sternal fractures including flail chest
- Recent thoracic spinal fusion
- Recent skin graft/flap to thorax
- Untreated tension Pneumothorax
For Example:
- Severe Osteoporosis
– Due to the decreased bone density in this patient population, there is an increased risk of causing rib fractures with Percussion’s.
- Metastatic Bone Cancer
– Bone Cancer in the Thorax significantly weakens boney stability. Percussion’s could potentially damage weakened and fragile Thoracic Bones.
- Active Tuberculosis
– The use of Percussion in Active TB can facilitate the spread of the disease; both within the patient and to others close proximity.
- Treatment over rib/sternal fractures including flail chest
– The movement of the thorax caused by Percussion will delay the union of the bone, by damaging the fragile new bone formation. Treatment over these areas also causes the patient to experience pain.
- Recent thoracic spinal fusion
– Post Thoracic spine fusion the costo-vertebral joints can become stiff, reducing their ability to freely move and absorb the forces produced during Percussion thus causing pain. There is also the potential to delay healing of the bone around the instrumentation.
- Recent skin graft/flap to thorax
– Skin grafts/Flaps are very fragile in the early stages; therefore using Percussion over areas recently grafted is likely to produce significant shearing forces that will likely damage the graft, or its vascular supply.
- Untreated tension Pneumothorax
– A Tension Pneumothorax is a medical emergency; Percussion is not going to help resolve this issue.
References and Suggested Readings #
Frownfelter, D.L. Chest physical therapy and pulmonary rehabilitation: an interdisciplinary approach. Year Book Medical Publishers. 2nd Edition, (1987) Chicago.
Hess, D.R. The evidence for secretion clearance techniques. Respiratory Care. (2001) 46(11), 1276-1293
Irwin, S & Tecklin, J.S. Cardiopulmonary physical therapy. The C.V. Mosby Company. 2nd Edition (1990) Toronto.
Langenderfer, B. Alternatives to percussion and postural drainage: a review of mucus clearance therapies. Journal of Cardiopulmonary Rehabilitation. (1998) 18(4), 283-289.
McCool, F.D. & Rosen, M.J. Nonpharmacologic airway clearance therapies: ACCP Evidence-Based Clinical Practice Guidelines. Chest. (2006) 129(1) 250-259, suppliment.
Perez, A & Rogers, R. Enhanced alveolar clearance with chest percusion therapy and positional changes during whole-lung lavage for alveolar proteinosis. Chest. (2004) 125(6), 2351-2356.
Pryor J.A. & Webber, B.A. Physiotherapy for respiratory and cardiac problems. Churchill Livingstone. 2nd Edition (1998) Sydney.
Vines, D; Shelledy D. & Peters, J. Current respiratory care, Part 1: Oxygen therapy, oximetry; bronchial hygiene. Journal of Critical Illness. (2000) 15(9), 507-515.