COLLEGE OF NURSING

Silliman University
Dumaguete City

RESPIRATORY CARE PROCEDURES

PERCUSSION AND VIBRATION

Definition:

Percussion is the manual application of light blows to the chest wall. These blows are
transmitted through the tissue and help loosens secretions in the lung segment immediately below the
area struck. Percussion is done over areas that need to be drained. Percussion over a patient gown other
light clothing, not against the bare skin to decrease friction.

Cupping is used for the manual percussion of lung areas to loosen pulmonary secretions so that
they can be expectorated with greater case. The patient may be taught to percuss surfaces of his chest
wall. Family members are often taught to percuss posterior surfaces.

Vibration is the rhythmic contraction and relaxation of the arm and shoulder muscles while
holding the hands flat on the patient’s chest wall.

The skill of percussion and vibration can be delegated to respiratory and physical therapists
and appropriately trained assistive personnel. Before delegating this skill the patient chest x-ray films
should be assessed and the patient’s chest should be examined for the proper position to use. Assistive
personnel should be warned to be alert for the patient’s tolerance of procedure and any patient
precautions related to disease or treatment.

The procedure:
STEP RATIONALE
ASSESSMENT

1. Assess breathing pattern, including muscles Certain disease states place patient at risk for
used for breathing, respiratory rate and depth, developing an ineffective breathing pattern.
extent of excursion and chest wall movement. Rapid, shallow breathing with patient using
accessory muscles is seen in chronic obstructive
 Critical Decision Point lung disease, asthma, pain, hypoxemia,
Percussion and vibration and shaking may be pneumonia and atelectasis.
contraindicated in certain situations, including
rib fracture, fracture of other rib cage
structures such as clavicle or sternum, pain,
severe dyspnea and severe osteoporosis, so
nurse should obtain physician’s order. Thin,
frail patient’s with osteoporosis are most
susceptible to injury and should be taught other
secretion control measures (e.g. forceful
coughing, humidification).

2. Identify signs and symptoms and conditions When tolerated and not contraindicated, these
that indicate need to perform these skills. techniques are done during postural drainage.

3. Identify and assess rib cage over bronchial Chest wall areas to be assessed and to receive
segment being drained for pain, tenderness, percussion and vibration and shaking vary with
abnormal configuration, abnormal excursion each postural drainage position.
or chest wall movement during breathing,
muscle tension.
 STEP RATIONALE
4. Assess patient’s understanding and ability to Assessment allows nurse to identify potential need
cooperate with therapy, both in hospital and at for instruction of patient, family, or significant
home. others.

NURSING DIAGNOSIS

Nursing Diagnoses

Ineffective airway clearance

Ineffective breathing pattern
Impaired gas exchange
Deficient knowledge regarding the technique of
chest therapy
Related factors are individualized based on
patient’s condition or needs.

PLANNING

1. Identify expected outcomes following

completion of procedure:
 Breathing pattern improves.
 Sputum is more easily expectorated. Airways are clear of retained secretions.
 Secretions appear more normal in color
consistency.
 Dyspnea is decreased.
 Results of pulmonary function and blood
gas studies improved.
 Body temperature, white blood cell count, No infectious process developing
and chest x-ray films are normal.

2. Prepare patient:
a. Explain procedure in detail: how it will be Percussion and vibration and shaking cannot be
done, how long will it take, and any done effectively without patient’s cooperation.
discomfort and side effects.
b. Encourage and help patient to relax and Percussion and vibration and shaking are most
deep breathe during procedure. Have effective if patient breathes properly and works
patient practice exhaling slowly through well with therapist, if done properly, this
pursed lips while relaxing chest wall technique should not cause pain or discomfort.
muscles. Patient should blow using
abdominal muscles, not rib cage muscles.

IMPLEMENTATION

PERCUSSION

1. With patient placed in appropriate drainage In general, for any given posture, rib cage area to
position, assess and identify chest wall area tobe percussed and vibrated is in highest vertical
be percussed and vibrated. position. Careful assessment of rib cage
movement guide nurse in following natural
movement during vibration and shaking.
2. Instruct patient to relax by using one of these Patient should not lie passively but should relax
techniques: take slow, deep breaths and exhale; and take deep breaths.
use abdominal, diaphragmatic, or pursed-lip
breathing.
 STEP RATIONALE

3. Use good body mechanics when cupping: Use of good body mechanics avoids undue strain
elevate bed to comfortable working height, on therapist’s back and legs.
and stand close to bed with arms directly in
front and knees slightly bent. Avoid bending
over.

4. Begin percussion on appropriate part of chest Percussion helps clear mucus and should be
wall over draining area. Perform percussion painless, because air in hand acts as a cushion.
for 3 to 5 minutes in each posture as tolerated.
Always ask if patient is experiencing any
discomfort, such as undue pressure or stinging
of the skin.
a. Place hands side by side on chest wall This hand position creates an air pocket that sends
over area to be drained. Hands should be vibrations through the chest wall but is not
cupped with fingers and thumbs held painful.
tightly together. Make sure that entire
outer portion of hand makes contact with
chest wall to avoid air leaks.
b. When cupping, most of arm movement Using the larger muscles of the arms and
should come from the elbow and wrist shoulders improves endurance.
joint. Cupping can be done for 5 minutes
without stopping or 2 to 3 minutes,
alternating with vibration and shaking.
c. Alternately cup chest with cupped hands The popping sound comes from the air pocket that
to create rhythmic popping sound is formed between the hand and the chest wall.
resembling galloping horse. Cupping can
be done at moderate or fast speed;
whichever is most comfortable.

VIBRATION

1. Perform chest wall vibration and shaking over Vibration and shaking during slow exhalation and
each area being drained. Vibrations are coughing help to clear mucus.
usually done in sets of three followed by
coughing so that any mobilized mucus can be
expectorated.
a. To perform vibration, gently place hands Slow inhalation promotes relaxation.
over area being drained, and have patient
take slow, deep breath through nose.
b. Gently resist chest wall as it rises during Slight resistance on inhalation aids in expansion
inhalation. of rib cage.
c. Have patient hold breath and exhale Purse-lip breathing makes exhalation easier.
through purse-lips, while contracting Relaxation of the chest wall makes vibrations
abdominal muscles. Chest wall should more effective.
relax and fall.
d. While patient is exhaling, gently push Vibrate only during exhalation so as to follow the
down and vibrate with flat part of hand. natural downward movement of the rib cage.
e. Repeat vibration three times, then have Coughing with vibrations aids in clearing mucus.
patient cascade cough by taking deep
breath and doing series of small coughs
until end of breath. Patient should no
inhale between coughs. Vibrate chest wall
as patient coughs. When applying pressure
to ribs, always follow natural movement of
 STEP RATIONALE

rib cage during exhalation, chest wall

movement and flexibility will increase.
Allow patient to sit up and cough as
needed.

2. Assess patient’s tolerance of vibration and Patient’s poor tolerance may necessitate
ability to relax chest wall and breathe properly discontinuing procedure.
as instructed.

EVALUATION

1. Evaluate changes in chest assessment These maneuver usually relieve signs of

following procedure. congestion, slow respiratory rate and improve
chest mobility an expansion.
2. Inspect character of mucus. Inspection determines if mucus is adequately
thinned.
3. Review diagnostic test results for pulmonary This determines airway clearance and
function. oxygenation status.

4. Observe caregiver during percussion and Return demonstration is an effective means to

vibration and shaking. measure learning.

RECORDING AND REPORTING

1. For treatment along with postural drainages,

record in nurse’s notes pre-therapy and post-
therapy assessment of chest; assessment of
chest mobility, patient cooperation with the
tolerance of procedure; patient’s ability to
relax and breathe properly; duration of
percussion; number of vibration and shaking
series; cough effective; suctioning.

2. If patient and family receive instruction in

home care, chart skills given. Document
demonstration of procedure, return
demonstration and follow-up activities.

3. Immediately report severe dyspnea,

hemoptysis, severe bronchospasm, or
hypotension to physician.

UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS

 Patient experiences severe dyspnea with bronchospasm, hypoxemia, and hypercarbia

(hypercapnea).
 Identify patients at risk for this unexpected outcome.
(1) those with status asthmaticus; and
(2) those with severe exacerbation of bronchitis who are debilitated and tired and whose
blood gas levels are consistent with severe hypoxemia and hypercarbia.

 Chest therapy may have to be discontinued or modified for this patients. They may tolerate
only 3 to 5 minutes drainage per hour.

 Bronchodilator inhalation should be scheduled 20 minutes before postural drainage.

 Hemoptysis occurs:
 This may be caused by infection, erosion of blood vessels, or other causes.
 In severe hemoptysis, stop therapy, call physician, remain calm, stay with patient, request
assistance, and keep patient comfortable, calm, warm and quiet.

 No secretions are obtained

 Continue therapy for several days to 1 week. There may be a lack for secretions, or
secretions may be too thick to mobilize.
 Secretions are not always mobilized and coughed up after each posture. If, after two or
more three coughs, nothing is expectorated, proceed with next posture. Often sections are
coughed up 30 to 60 minutes after postural drainage.
 Improve hydration.

 There is no improvement in chest assessment: adventitious sounds are present, dyspnea occurs,
there is poor chest excursion.
 Increase frequency of therapy.
 Consult physician for potential sputum culture and initiation of antibiotics.
 Teach coughing exercises.

 Patient experiences rib fracture, rib pain, or tenderness of chest wall.

 Notify physician.
 Obtain chest x-ray examination.
 Stop percussion, vibration, and shaking.

TEACHING CONSIDERATIONS

 Best time for treatments are:

1. In morning before breakfast, when patient can clear secretions that accumulate overnight; and
2. about 1 hour before bedtime, so that lungs are clear before sleeping and patient has time after
treatment to cough up and mobilized secretions. Frequency depends on need and patient’s
tolerance and may vary from once daily to every 2 to 4 hours in an acute situation.

 If patient is receiving inhaled bronchodilators or aerosol treatment, postural drainage should be

done 20 minutes after such therapy. Plan for rest period after postural drainage.

 Do not schedule major activities (such as exercise or bath) right after therapy treatment especially
in patients with severe obstructive lung disease.

 Instruct patient’s family or primary caregiver to recognize when the patient’s respiratory status
requires breathing exercises or postural drainage.\

 Encourage primary caregiver or family member to encourage the patient to participate in physical
activities that will increase respiratory efficiency.

 Teach patient and significant others how to assume postures at home. Some postures may need to
be modified to meet individual needs; for example, side-lying Trendelenburg’s position to drain
lateral lower lobes may have to be done with patient lying flat on side or in side-lying semi-
Fowler’s position if patient is very short of breath.
Student’s Name:

Instructor:

Instructor’s Signature: Date:

RESPIRATORY CARE PROCEDURES – PERCUSSION AND VIBRATION

PERFORMANCE CHECKLIST

S US NP REMARKS
ASSESSMENT

1. Assessed breathing pattern, including muscles

used for breathing, respiratory rate and depth,
extent of excursion and chest wall movement. _____ _____ _____ ___________________

2. Identified signs and symptoms and conditions

that indicate need to perform these skills. _____ _____ _____ ___________________

3. Identified and assess rib cage over bronchial

segment being drained for pain, tenderness,
abnormal configuration, abnormal excursion
or chest wall movement during breathing,
muscle tension. _____ _____ _____ ___________________

4. Assessed patient’s understanding and ability

to cooperate with therapy, both in hospital and
at home. _____ _____ _____ ___________________

NURSING DIAGNOSIS

Developed appropriate nursing diagnoses based

on assessment data. _____ _____ _____ ___________________

PLANNING

1. Identified expected outcomes following

completion of procedure: _____ _____ _____ ___________________
 Breathing pattern improves. _____ _____ _____ ___________________
 Sputum is more easily expectorated. _____ _____ _____ ___________________
 Secretions appear more normal in color
consistency. _____ _____ _____ ___________________
 Dyspnea is decreased. _____ _____ _____ ___________________
 Results of pulmonary function and blood
gas studies improved. _____ _____ _____ ___________________
 Body temperature, white blood cell count,
and chest x-ray films are normal. _____ _____ _____ ___________________

2. Prepared patient: _____ _____ _____ ___________________

a. Explained procedure in detail. _____ _____ _____ ___________________
b. Encouraged and help patient to relax and
deep breathe during procedure. Asked
patient to practice exhaling slowly through
pursed lips while relaxing chest wall
muscles. _____ _____ _____ ___________________
IMPLEMENTATION

PERCUSSION

1. With patient placed in appropriate drainage

position, assess and identify chest wall area to
be percussed and vibrated. _____ _____ _____ ___________________

2. Instructed patient to relax by using one of

these techniques: take slow, deep breaths and
exhale; use abdominal, diaphragmatic, or
pursed-lip breathing. _____ _____ _____ ___________________

3. Used good body mechanics when cupping:

elevate bed to comfortable working height,
and stand close to bed with arms directly in
front and knees slightly bent. Avoid bending
over. _____ _____ _____ ___________________

4. Begun percussion on appropriate part of chest

wall over draining area. Perform percussion
for 3 to 5 minutes in each posture as tolerated.
Always ask if patient is experiencing any
discomfort, such as undue pressure or stinging
of the skin. _____ _____ _____ ___________________
a. Placed hands side by side on chest wall
over area to be drained. Hands should
be cupped with fingers and thumbs
held tightly together. Make sure that
entire outer portion of hand makes
contact with chest wall to avoid air
leaks. _____ _____ _____ ___________________
b. When cupping, most of arm movement
should come from the elbow and wrist
joint. Cupping can be done for 5
minutes without stopping or 2 to 3
minutes, alternating with vibration and
shaking. _____ _____ _____ ___________________
c. Alternately cup chest with cupped
hands to create rhythmic popping
sound resembling galloping horse.
Cupping can be done at moderate or
fast speed; whichever is most
comfortable and effective. _____ _____ _____ ___________________

VIBRATION

1. Performed chest wall vibration and shaking

over each area being drained. Vibrations are
usually done in sets of three followed by
coughing so that any mobilized mucus can be
expectorated. _____ _____ _____ ___________________
a. To perform vibration, gently place hands
over area being drained, and have patient
take slow, deep breath through nose. _____ _____ _____ ___________________
b. Gently resist chest wall as it rises during
inhalation. _____ _____ _____ ___________________
 c. Have patient hold breath and exhale
through purse-lips, while contracting
abdominal muscles. Chest wall should
relax and fall. _____ _____ _____ ___________________
d. While patient is exhaling, gently push
down and vibrate with flat part of hand.
Vibrate the chest wall by contacting and
relaxing your arm and shoulder muscles
quickly and rhythmically. _____ _____ _____ ___________________
e. Repeat vibration three times, then have
patient cascade cough by taking deep
breath and doing series of small coughs
until end of breath. Patient should no
inhale between coughs. Vibrate chest wall
as patient coughs. When applying pressure
to ribs, always follow natural movement of
rib cage during exhalation, chest wall
movement and flexibility will increase.
Allow patient to sit up and cough as
needed. _____ _____ _____ ___________________

2. Assessed patient’s tolerance of vibration and

ability to relax chest wall and breathe properly
as instructed. _____ _____ _____ ___________________

EVALUATION

1. Evaluated changes in chest assessment

following procedure. _____ _____ _____ ___________________

2. Inspected character of mucus. _____ _____ _____ ___________________

3. Reviewed diagnostic test results for

pulmonary function. _____ _____ _____ ___________________

4. Observed caregiver during percussion and

vibration and shaking. _____ _____ _____ ___________________

RECORDING AND REPORTING

1. For treatment along with postural drainages,

recorded in nurse’s notes pre-therapy and
post-therapy assessment of chest; assessment
of chest mobility, patient cooperation with the
tolerance of procedure; patient’s ability to
relax and breathe properly; duration of
percussion; number of vibration and shaking
series; cough effective; suctioning. _____ _____ _____ ___________________

2. If patient and family received instruction in

home care, chart skills given. Document
demonstration of procedure, return
demonstration and follow-up activities. _____ _____ _____ ___________________

3. Immediately reported severe dyspnea,

hemoptysis, severe bronchospasm, or
hypotension to physician. _____ _____ _____ ___________________