Postural Drainage

We’ve all seen that dreaded picture in our textbooks… All the human figures laying in so many different positions with pillows and tables tilted all over… and I very clearly remember thinking, “How on earth am I supposed to remember all of those?” Well, good news. You really don’t have to. It’s great if you do, don’t get me wrong, but for the purpose of general patient care, you can take a less specific approach and still have good results. Many of those positions cannot be achieved without a hospital bed unless you have a young, strong, and flexible patient, and if your patients is that young, strong, and flexible, they probably don’t need postural drainage.

Yea, let’s be honest. Some of those are just not going to happen in any setting other than a hospital. So, if you don’t work in a hospital, how can you hope to achieve postural drainage? Good news, it’s no where near as difficult as it may seem. There is one solid rule to follow: Put the bad sound on top.

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Step 1: Auscultate

As with so many cardiovascular and pulmonary interventions I’ve discussed, you have to know what you are listening for before you can ever hope to position someone properly. You can read all about lung auscultation in this post to get the details on that. But, basically, you have to auscultate to identify a segment that requires drainage.

Step 2: Identify the Segment

If you auscultated properly, you can compare the points you auscultated to an image for the underlying lung anatomy and figure out which segment is giving you adventitious sounds. If you you can’t google the picture really quick on your phone or computer, at least identify the lung side (right or left) and general lobe (superior, middle, lower). Remember, the left lung doesn’t have a middle lobe. Please don’t ever say you are assessing or treating the left middle lobe. It doesn’t exist.

Step 3: Put the Bad Sound on Top

Position the patient in a comfortable way so that the portion of the lung that produced the adventitious sound on auscultation is at the highest point of the body. Many of these can be achieved laying down in some way, but it will usually mean positioning the patient in sidelying at the very least. As you can see above, 6 of the 12 positions have some component of sidelying. So, if you are getting your patient in sidelying with the lung making bad sounds on top, you’ll make something better. Use as many pillows as it takes.

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That’s it! Not so bad, right??? But you can’t stop there. Postural drainage positions are great and all, but, as with most other pulmonary interventions, they should not be used in isolation. While you have your patient in the drainage position, apply some other interventions to improve secretion mobility and clearance. Postural drainage positions should continue after your chosen interventions to facilitate further secretion clearance, about 10 minutes or so after you are done. Here is a list of ideas:

• Active Cycle of Breathing
• Positive Expiratory Pressure Device
• Forced Expiratory Techniques
• Autogenic Drainage (Cycle of Deep and Less Deep Breaths)
• Segmental Breathing
• Vibration or Percussion
• Any combination of the above items utilizing the proper force progression!
• EXERCISE

And, if you think about it, some of those positions probably won’t be needed by the majority of our patients. Sure, there are people with hypersecretion diseases, like cystic fibrosis, that may require drainage from all segments of their lungs on a regular basis. But your typical patient with COPD may only need a segment or two at a time, and may only be able to tolerate a segment or two at a time. And you can always refer back to your favorite diagram if you need specifics!

If we put it in the scope of the bigger picture, most of our patients are upright and sitting or standing during the day. Some are supine. If your patient is spending the majority of the day in standing or sitting already, they will likely not require that position for drainage, as the apical and anterior segments being drained all day long. If they are supine all day, they won’t likely need the anterior segments drained because they have been draining all day. You’ll be much more likely to need to opposite postures to address the bases, as secretions get trapped in them more easily due to their dependent position. Smaller segments such as the lingular segment may need more attention than others due to the position and somewhat closed off nature of the anatomy.

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You’ll also need to remember that, although these may seem like simple positional changes, they are not for everyone. There is a reason this is part of skilled rehab intervention. Positioning is far more important than many give it credit for. Here’s some examples:

ICP Concerns – Patients who have concerns regarding intracranial pressure monitoring, such as those with recent neurosurgery, brain injury, or placement of an ICP bolt for any reason should not be inverted for postural drainage.

Orthopnea – patients with cardiac conditions in addition to pulmonary may have difficulty breathing when laying supine. This is typical for patients in advanced heart failure and some patients who have COPD. This will definitely interfere with your positioning, but you can compensate using pillows or power bed controls to give them a little elevation to their comfort.

Prone Positioning – patients with respiratory conditions may initially be very hesitant to lie in prone as they feel it will restrict their breathing, especially if pillows are used around their face or head. However, we know that prone positioning actually increases ventilation, so physiologically, this is not a concern. Patients may still not tolerate this positioning due to fear or anxiety. Note that patients who are proned (such as when inpatient ICU status while ventilated) are typically sedated because this is a taxing posture for people who have difficulty breathing. Don’t expect a high tolerance in the begining.

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All in all, I’ve had even the most severe end-stage COPD patients in prone over the edge of their beds with their hands on the floor to facilitate secretion mobilization while on supplemental oxygen with their spouse performing vibration. It can be done. And you can do it, too!

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I feel like that superior lingular segment is the culprit 75% of the time. Do you find yourself regularly treating a specific lung segment? Tell me which one in the comments!

References:

Fink J. B. (2002). Positioning versus postural drainage. Respiratory care, 47(7), 769–777.

Hewitt, N., Bucknall, T., & Faraone, N. M. (2016). Lateral positioning for critically ill adult patients. The Cochrane database of systematic reviews, 2016(5), CD007205. https://doi.org/10.1002/14651858.CD007205.pub2

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