Postural Drainage - Indications and Contraindications

Introduction

Postural drainage, which is also known as gravity-assisted drainage (GAD), is a form of chest physical therapy. When there are excessive breathing problems due to the excess accumulation of mucus in the lungs, the physical therapist performs postural drainage, which is a gravity-assisted therapy that uses gravity and percussion techniques to drain the excessive mucus by changing the positions of the patients. This article will discuss how postural drainage is performed and its various positions in detail.

What Are the Anatomical Considerations for Performing Postural Drainage?

Postural drainage can only be successfully performed when there is proper knowledge of the anatomy of the bronchial tree (respiratory system). The ultimate goal of postural drainage is to drain the bodily fluids from each lobe of the lungs so they can be coughed out. The respiratory system consists of a pair of lungs on both sides of the chest, separated by the heart and various structures in the mediastinum. The right-sided lung consists of three lobes:

• Upper lobe.

• Middle lobe.

• Lower lobe.

The left-sided lung consists of two lobes:

• Upper lobe.

• Lower lobe.

The upper lobe on each side of the lungs consists of three segments: the apical, posterior, and anterior. The upper lobe of the left lung contains a lingual segment that corresponds to the middle lobe of the right lung. The lower lobe of both lungs contains four segments:

• Anterior segment.

• Superior segment.

• Basal segment.

• Lateral and posterior basal segments.

These bronchial segments comprise 50 to 80 terminal bronchioles, alveolar ducts, blood vessels, and alveolar sacs, which are responsible for the exchange of gasses between oxygen and carbon dioxide. Based on these anatomical considerations, gravity is used to assist the drainage of excess mucus secretions from the lung through various positioning.

What Are the Indications of Postural Drainage?

Postural drainage is shown to be effective in patients with cystic fibrosis, bronchiectasis, and various other pulmonary disorders. It is indicated in patients at high risk of respiratory complications to prevent excessive mucus secretions, such as:

• Lung diseases with increased production of mucus with high viscosity.

• Patients under general anesthesia.

• Bedridden patients.

• Patients with restricted deep breathing and severe coughing.

• Ventilated patients.

Postural drainage is indicated to remove the accumulated mucus secretions in the lung on conditions such as:

• Lung diseases - acute or chronic.

• Geriatric patients.

Who Is Contraindicated to Receive Postural Drainage?

Postural drainage is contraindicated in the following conditions:

• Patients with hemoptysis (coughing up blood).

• Patients with pulmonary edema (excessive fluid accumulation in the lung sacs).

• Heart failure patients.

• Recent history of myocardial infarction.

• Excess fluid accumulation in the pleural space.

• Hypertension and Hypotensive patients.

• Cardiac arrhythmia.

• Patients with head injuries.

• Recent history of neurosurgery.

How Does Postural Drainage Therapy Work?

The mucus lining in a normal and healthy lung is watery and slippery. Whereas in lung diseases such as cystic fibrosis, the mucus secretions become thick and viscous. The mucus lining, which normally acts as a lubricant, clogs the ducts and airway passages, making breathing difficult.

In postural drainage therapy, the body is positioned in a way that the head is lower than the chest allowing the mucus to drain better. Gravity facilitates mucus drainage from the lung segments to enter the central airways. Other techniques, such as percussion and vibration, are used along with postural drainage to loosen the thick and sticky mucus so it can be brought up and coughed out. Additionally, therapeutic agents such as bronchodilators and antibiotic agents might be taken along with postural drainage. The chest physical therapist may involve other techniques, such as percussion and vibration.

Percussion: It is a manual technique requiring another person to do it. Percussion involves rhythmic clapping on the chest wall with a cupped hand to break up the thick mucus in the lungs.

Vibration: This technique is similar to the percussion technique, which uses vibration to clear the thick mucus from the lung segments to large airways with a flat hand.

What Is the Recommended Timing to Perform Postural Drainage?

Each session of the postural drainage techniques might last for 20 to 40 minutes. It is recommended to be performed before a meal or two hours post-meal to prevent vomiting. The most recommended sessions are the early morning and night sessions. The length and duration of sessions and the number of sessions depend on the severity of the condition in patients.

What Are the Various Positions for Performing Postural Drainage?

Postural drainage position for each lobe/segment of the lung:

Upper Lobes of the Lung

• Anterior segment: The patient lies in a supine position, and a pillow is placed under the knee to enhance breathing. Percussion and vibration techniques are performed between the collarbone and the nipple region.

• Apical segment: The patient sits upright over a table at a 30 degree angle. The percussion and vibration techniques are performed between the collarbone and the top of the shoulder bone on both sides.

• Posterior segment: The patient sits leaning forward at an angle of 30 degrees over a pillow. The percussion and vibrations are performed on the upper back on both sides.

Middle Lobes of the Lung

• Right middle segment and left lingular segment: The foot of the table is elevated to 15 degrees. The patient lies down on the right side with 1⁄4 turned backward. A pillow might be placed behind. Percussion and vibrations are performed on the right and left nipple areas for the right middle and left lingual segments, respectively.

Lower Lobes of the Lung

• Superior segment: The patient lies on the abdomen over a flat table with two pillows under the hip. The percussion and vibrations are performed on the middle region of the back in the lower part of the shoulder on both sides.

• Anterior segment: The foot of the table is elevated to 30 degrees. The patient lies on the right side with a pillow placed behind to drain the left side of the chest. The percussion and vibrations are performed over the lower ribs of the left chest and vice versa to drain the right side of the chest.

• Lateral basal segment: The foot of the table is elevated to 30 degrees. The patient lies head down on the side, which has to be drained and leans ¼ forward. A pillow is placed between the flexed knees. Percussion is done over the upper portion of the lower ribs.

Conclusion

Postural drainage is one of the effective forms of chest physiotherapy in treating patients with lung problems. It is performed based on the anatomical considerations of the lung. This procedure uses gravity to drain excess fluids from the lungs. The effectiveness of this technique still needs to be determined. However, it is believed to be effective in patients with mucosal secretions of more than 30 milliliters per day.