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com

A. Definition

1. Respiratory System Definition

The respiratory system is a specific physiological system for exchanging oxygen (O2) and
carbon dioxide (CO2) gases through the act of breathing (Rao & Srinivas, 2012). Oxygen
(O2) that comes from outside the body is inhaled through the respiratory organs and the body
will exhale carbon dioxide (CO2) by exhaling so that in the body there is a balance between
oxygen (O2) and carbon dioxide (CO2) (Tortora & Derrickson, 2014).

Figure 2. 1 Respiratory System (Totora & Derrickson, 2014)

2. Respiratory System Anatomy

The human respiratory system consists of the upper respiratory system consisting of the
nose, pharynx and larynx and the lower respiratory system consisting of the trachea, bronchi
and lungs.

a. Nose

The nose and nasal cavity are divided into two parts by the nasal septum. The external
part of the nose is made of cartilage and skin. The nasal cavity has a mucous membrane
and fine hair which has the function of capturing foreign objects that will enter the
respiratory tract and the blood capillaries function to warm the incoming air (Hillegass,
2017; Wibowo, 2015).
b. Pharynx
The pharynx is a tube-like channel that connects the posterior nasal cavity and mouth to
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the larynx and esophagus. The pharynx has a funnel-like shape with a length of 13 cm.
The walls of the pharynx are continued by skeletal muscles which are lined by a mucous
membrane. The pharynx is in a fixed position when the skeletal muscles relax and is in
the process of swallowing when the skeletal muscles contract. The pharynx is divided
into nasopharynx, oropharynx, and laryngopharynx. The pharynx has a function as a
channel for incoming and outgoing air, a channel for swallowed food, and provides a
reverberation space (resonance) for conversational sounds (Tortora & Derrickson, 2014;
Wibowo, 2015).

c. Larynx
The larynx is a collection of muscle fibers composed of 9 parts of cartilage tissue, 3
single parts and 3 paired parts. The paired parts are the arytoneid, cuneiform and
corniculate cartilages. Arytenoid cartilage is a very significant part, this network
influences the movement of the mucous membranes in producing sound. The single parts
are the thyroid, epiglottis and cricoid. The thyroid and cricoid function to protect the
vocal cords. The epiglottis has a function as a protector of the airways and helps in the
process of transitioning food and drink to pass through the esophagus (Hillegass, 2017;
Wibowo, 2015).
d. Trachea
The trachea is a tube that is approximately 4-4.5 inches long and about 1 inch in diameter
and extends downward along the midline of the neck, ventral to the esophagus. The
trachea has 16 to 22 cartilages that resemble horseshoe ribbons (c-shaped). The posterior
tracheal wall is devoid of cartilage and is supported by tracheal muscles. The trachea is
lined with ciliated columnar epithelium which works to trap substances other than
incoming air so that they are pushed upwards across the esophagus which will later be
swallowed or excreted through phlegm (Hillegass, 2017; Patwa & Shah, 2015).
e. Bronchi
The throat branches into two parts, namely, the right and left bronchi. The structure of
the mucous lining of the bronchi is the same as that of the trachea. The cartilage in the
bronchi has an irregular shape and in the larger bronchi, the cartilage rings completely
encircle the lumen. The two bronchi lead to the lungs where they branch into
bronchioles. The right bronchus has 3 branches: superior, medial and inferior.
Meanwhile, the left bronchus has 2 branches, namely superior and inferior (Hillegass,
2017; Wibowo, 2015).
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f. Lungs
The lungs are organs that are shaped like pyramids and are paired together and
connected to the trachea via the right and left bronchi. The lungs are located in the chest
cavity (mediastinum) and are protected by the clavicle structure (Somantri, 2012). The
right and left lungs are separated by the mediastinum, where the heart, large blood
vessels, bronchi, esophagus and other organs are located. Each lung consists of
respiratory tract and alveoli. Healthy lungs have a soft and light texture. The lung stroma
consists of elastic fibrous connective tissue that can help the lungs to deflate during
expiration. The lungs are lined by visceral pleura while the chest cavity is lined by
parietal pleura (Aung et al., 2019; Hillegass, 2017).
The lungs have a conical shape which is described as having an apex, a base or floor,
three sides (anterior, inferior, posterior), and three surfaces (costal, medial, and
diaphragm). The right lung has three lobes namely, right upper lobe, right middle lobe,
and right lower lobe. Meanwhile, the left lung is relatively smaller than the right lung.
The left lung has two lobes namely, the left upper lobe and the left lower lobe. These
lobes will further divide into segments. In the right lung there are ten segments namely
three segments are in the superior lobe, two segments in the medial lobe, and five
segments in the inferior lobe. The left lung has eight segments, namely four segments in
the superior lobe and four segments in the inferior lobe (Algifari et al., 2020; Hillegass,
2017; Wibowo, 2015).
The lungs consist of bronchioles, alveoli, elastic tissue, and blood vessels. The
bronchioles are the last air passages before entering the alveoli, where gas exchange
occurs. The alveolus is composed of epithelial and endothelial cells. The number of
alveolar bubbles is around 700,000,000 in the right and left lungs (Hillegass, 2017; Patwa
& Shah, 2015).

Figure 2. 2 Lungs (Hillegass, 2017)

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3. Lung Physiology

The lungs have the main function of gas exchange between the blood and the atmosphere.
The gas exchange aims to provide oxygen to the tissues and expel carbon dioxide. Changes in
lung volume occur through contraction of the skeletal muscles, especially those that insert into
the rib cage and the diaphragm during inspiration. In addition to this, the elastic recoil of the
lungs so that they can be stretched and can return to their original position during expiration also
plays a role in the respiratory cycle. External respiration includes four stages, namely pulmonary
ventilation, distribution, diffusion, and perfusion. Pulmonary ventilation is a process that
functions to process the entry and exit of air between the alveoli and the atmosphere. While the
process after ventilation is diffusion, namely, movement of oxygen from the alveoli into the
blood vessels and vice versa for carbon dioxide. Diffusion can occur from areas of high pressure
to low pressure (Putra, 2016; Tortora & Derrickson, 2014).

There are two types of respiratory cycles, namely the inspiratory and expiratory cycles. At the
start of the respiratory cycle intrapulmonary (intra-alveolar) pressure and atmospheric pressure
are equal and there is no air movement (0 pressure gradient). Inspiration is an active process and
involves one or more of the diaphragm and external intercostal muscles. Contraction of the
diaphragm flattens the floor of the chest cavity, increasing chest volume and gradually decreasing
intrapleural pressure. This pressure drops to about -4 to -6 mm Hg. During this period the
intrapulmonary pressure fell to -1 mmHg which was followed by the entry of air into the lungs
(Laitupa & Amin, 2016; Tortora & Derrickson, 2014).

Expiration is generally a passive process, but can be active depending on the level of
respiratory activity. In quiet breathing, the diaphragm relaxes and the elastic recoil properties of
the lungs (elastic recoil), the chest wall and abdominal structures will compress the lungs so that
when expiration begins, intrapleural pressure and intrapulmonary pressure increase rapidly
pushing air out of the lungs. At the end of expiration, there is no more air movement as there is
no longer a difference between intrapulmonary pressure and atmospheric pressure. The amount
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of air that enters is the same as that which leaves the lungs, this is called tidal volume (Laitupa &
Amin, 2016).

B. ANATOMY OF THE RESPIRATORY SYSTEM

The following is the anatomy of the respiratory system:

1. NOSE CAVITY

The nose is the main organ of the respiratory tract which is directly in contact with the outside
world which functions as a passage for air to enter and exit through the breathing process. In
addition, the nose also functions to maintain and warm incoming air, as a filter in cleaning
incoming foreign objects and plays a role in sound resonance, as a location for alfactory
receptors.
2. PHARYNX

The pharynx is the intersection between the respiratory tract and the food passageway, located
under the base of the skull, behind the nasal cavity and mouth in front of the cervical spine.

3. LARYNX
The larynx is a respiratory tract that is located between the oropharynx and the trachea, the
function of the larynx is as a passage for air, clearing the passage for food to enter the
esophagus and as sound production.
The larynx is often referred to as the voice box and consists of:
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- Epiglottis: a flap of cartilage that covers the ostium towards the larynx
during swallowing
- Glottis: the ostium between the vocal cords in the larynx

4. TRACHEA

The trachea is a tube organ between the larynx and the apex of the lung, about 10-12 cm long,
as high as the 6-thoracic cervical 5 Also called the windpipe The end of the trachea branches
into two bronchi called the carina
5. BRONCHUS
The bronchi are branches of the trachea that branch into the right lung and the left lung. The
right bronchus is shorter and larger in diameter. The left bronchus is more horizontal, longer
and narrower.
1. Bronchi
- Divided into right and left bronchi. Called right lobar bronchus (3
lobe) and left lobar bronchus (2 bronchi)
- The right lobar bronchus divides into 10 segmental bronchi
The left lobar bronchus divides into 9 segmental bronchi
- These segmental bronchi then subdivide into subsegmental bronchi which are surrounded by
connective tissue which have: arteries, lymphatics and nerves
2. Bronchioles
- Segmental bronchi branch into bronchioles
- The bronchioles contain submucous glands that produce submucous glands that form a
continuous blanket to line the inside of the airway
3. Terminal bronchioles
Bronchioles branch into terminal bronchioles
(which does not have mucous glands and cilia)
4. Respiratory bronchioles
Terminal bronchioles then become respiratory bronchioles
Respiratory bronchioles are considered transitional channels between passageways
breath conduction and airway gas exchange

6. LUNGS
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The lungs are an organ that is mostly located in the upper chest cavity, limited on the sides by
muscles and ribs and on the bottom by a strong muscular diaphragm.
An elastic, conical organ Located in the thoracic or thoracic cavity The two lungs are separated
by a central mediastinum which contains the heart and several great vessels Each lung has an
apex and a base The right lung is larger and is divided into 3 lobes by the interlobar fissure The
left lung is smaller and divided into 2 lobes. These lobes are divided into several segments
according to the bronchial segments.

7. ALVEOLUS

It is the terminal part of the bronchial branches and is responsible for the structure of the lungs
which resembles a small bag open on one side and a place for the exchange of O2 and CO2.
There are around 300 million of which, if united to form one sheet, would cover an area of 70
m2.

C. PHYSIOLOGY OF THE RESPIRATORY SYSTEM

The function of the lungs is the gas exchange of oxygen and carbon dioxide. In
breathing through the lungs or external breathing, oxygen is collected through the nose and
mouth when breathing; oxygen enters through the trachea and bronchial tubes to the
alveoli, and can be in close contact with blood in the pulmonary capillaries. Only one layer
of membrane, namely the alveoli-capillary membrane, separates oxygen from the blood.
Oxygen penetrates this membrane and is picked up by the hemoglobin of red blood cells
and carried to the heart. From here it is pumped in the arteries to all parts of the body.
Blood leaves the lungs at an oxygen pressure of 100 mm Hg and at this level the
hemoglobin is 95 percent saturated with oxygen.
In the lungs, carbon dioxide, one of the waste products of metabolism, penetrates the
alveolar-capillary membranes from the blood capillaries to the alveoli and after passing
through the bronchial tubes and trachea, is breathed out through the nose and mouth.
All these processes are regulated so that the blood leaving the lungs receives the right
amount of CO2 and O2. During exercise, more blood enters the lungs carrying too much
CO2 and too little O2; The amount of CO2 cannot be removed, so its concentration in
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arterial blood increases. This stimulates the respiratory center in the brain to increase the
speed and depth of breathing. This additional ventilation removes CO2 and picks up more
O2.
Tissue respiration or internal respiration. Blood that has saturated its hemoglobin with
oxygen (oxyhemoglobin) circulates throughout the body and finally reaches the capillaries,
where the blood moves very slowly. Tissue cells pick up oxygen from hemoglobin to allow
oxygen flow, and the blood receives, in return, carbon dioxide.

A. DISEASES OF THE RESPIRATORY SYSTEM

The respiratory system in humans can also experience disorders or abnormalities that affect the
system itself. The following are various types of diseases in the human respiratory system:
1. Pharyngitis
Pharyngitis is inflammation of the pharynx due to infection, causing pain when
swallowing food or when the throat feels dry. This disorder is caused by a bacterial
or viral infection. The bacteria that usually attacks this disease is Streptococcus
pharyngitis. Inflammation can also occur due to smoking too much, characterized
by pain when swallowing and a dry feeling in the throat.
2. Asthma
Asthma is an inflammatory lung disease that causes repeated attacks of shortness of
breath and wheezing. Asthma is one of the most common and varied lung disorders,
affecting one in four children in some areas. The muscles in the walls of the
airways contract like spasms, causing the airways to narrow, resulting in attacks of
shortness of breath. The narrowing is made worse by excessive mucus secretion.
Most cases occur in childhood and are usually related to allergic diseases such as
eczema and both have hereditary factors.
3. Influenza (Flu)
Influenza disease is caused by the influenza virus. Symptoms include a runny nose,
stuffy nose, sneezing and an itchy throat. Influenza is an acute infectious disease of
the respiratory tract, mainly characterized by fever, chills, muscle aches, headaches
and is often accompanied by a runny nose, sore throat and cough without phlegm.
The illness lasts between 2-7 days and usually resolves on its own.
4. Sinusitis

Sinusitis is an inflammatory disease of the upper part of the nasal cavity or paranasal
sinuses. Sinusitis is caused by bacterial, fungal, viral infections, decreased
immunity, flu, stress, smoking addiction, and dental infections. (Herbal Sinusitis
Medicine)
5. Tuberculosis (TB)
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Tuberculosis (TB) is a disease caused by systemic infection with the Mycobacterium

tuberculosis germ, which can manifest in almost all organs of the body with the
most frequent location being the lungs, which is usually the location of primary
infection. This bacteria attacks the lungs so that inside the alveoli there are nodules.
This disease causes the oxygen diffusion process to be disrupted due to the presence
of small spots on the alveolar walls.
6. Pneumonia
Pneumonia or also called Pneumonia is a disease of the lungs in which the pulmonary
aveoli which are responsible for absorbing oxygen from the atmosphere become
inflamed and filled with fluid. Lung inflammation can be caused by several causes
including bacterial, viral, fungal or parasitic infections. Lung inflammation can be
caused by streptococcus and mycopalsma pneumoniae bacteria. Pneumonia can also
be caused by chemical or physical injury to the lungs or as a result of another
disease, such as lung cancer or excessive drinking of alcohol.
7. Diphtheria
Diptheria is an infection of the upper respiratory tract. In general, it is caused by
Corynebacterium diphterial. At an advanced level, sufferers can experience damage
to the lining of the heart, fever, paralysis, and even death.
8. Lung cancer
This disease is one of the most dangerous. Cancer cells in the lungs continue to grow
uncontrollably. Over time, this disease can attack the entire body. One of the
triggers for lung cancer is smoking. Smoking can trigger lung cancer and lung
damage.
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D. Chest Therapy

1. Definition of chest therapy

Chest physiotherapyis a broad term in research that combines physiotherapeutic

treatment techniques that address the disposal of secretions and increases airway clearance
so as to increase respiratory efficiency (Gabriela et al., 2019).

Chest therapyis one of the physiotherapy interventions that can be used in patients with
respiratory diseases or children with diseases related to chronic neuromuscular. Chest
therapy can be used as an alternative treatment for respiratory problems with several
conditions. This intervention can improve gas exchange, limit pathological progression, and
reduce the need for ventilation support (Abdullahi, 2020; Hanafi & Arniyanti, 2020).

2. Purpose of Chest Therapy

According to Chaves et al., (2013); Lisy, (2014) the aim of chest therapy in children is to
help clear secretions in the tracheobronchial tract thereby reducing respiratory obstruction
and making it easier to breathe. This therapeutic treatment can also improve gas exchange,
increase chest expansion and increase the strength of respiratory muscles (Prabawa et al.,
2021; Thomas et al., 2020).

3. Chest Therapy Indications and Contraindications

The indication for chest therapy is if there is a buildup of secretions in the respiratory
tract which has been proven by physical examination and clinical data, there is difficulty in
removing or coughing up secretions in the respiratory tract. This chest therapy can be
applied to everyone regardless of age, both in infants and adults. Meanwhile,
contraindications for chest therapy are patients with heart failure, status asthmaticus or
severe asthma conditions, susceptibility or decreased blood pressure, and bleeding
(Maidartati, 2014).

4. Chest therapy technique

Chest therapyor chest physiotherapy has several techniques that can be applied to
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improve lung function. Chest therapy has several techniques which can be classified as
conventional, modern and instrumental techniques (Gabriela et al., 2019). These techniques
are recommended as an intervention to clear the airway due to a buildup of secretions (Amin
et al., 2018; Putri et al., 2018).

5. Conventional Technique

Chest therapythe conventional technique also known as traditional chest physiotherapy

was first recommended in 1915. This technique uses manual handling to facilitate mucus
clearance. Postural drainage, percussion and vibration (PDPV) is a conventional technique of
chest physiotherapy. Coughing and huffing exercises are also added as a technique. This
PPDV shows effective results and can be done independently or with the help of other
people (physiotherapists, parents, or caregivers) (Gabriela et al., 2019).
1) Deep Breathing
Deep breathing exerciseis one of the respiratory muscle exercises in
increasing lung vital capacity which can optimize the diffusion process. This happens
because during long, deep and slow inspiration it will affect the elasticity of the lung
recoil which will stimulate lung function to return to normal by increasing
transpulmonary pressure and lung volume during inspiration. Normal chest
development will increase thoracic expansion and train the inspiratory and expiratory
muscles so as to increase the amount of air in and out of the lungs resulting in an
increase in lung volume and vital capacity (Putri et al., 2018; Rahmawati et al., 2021)
2) Postural Drainage
Based on the “AARC (American Association for Respiratory Care) Clinical
Practice Guideline. Postural Drainage Therapy.," (1991) explained that postural
drainage is a technique that performs positioning of a person with the help of gravity
to assist in the mechanism of normal airway clearance. The position of postural
drainage varies according to the specific lung segment and the amount of secretions.
Postural drainage is the drainage of secretions by gravity from one or more lung
segments into the central airways (secretions can be removed by coughing or
mechanical aspiration).
In general, this position should be held for 3-15 minutes (longer in special
conditions). The standard position is applied according to the patient's tolerance and
condition. Before performing postural drainage, it is important to auscultate the lungs
and identify the lung segments where additional sounds are heard (crepitus, rhonchi).
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This technique can also be performed by applying percussion and vibration (Gabriela
et al., 2019; Kuswardani et al., 2017).

Figure 2. 3 Postural drainage (Hazari et al., 2017)

3) Percussion

Percussion techniques are also called cupping, clapping, and tapotement. The
purpose of this percussion is to provide kinetic energy intermittently to the chest wall
and lungs. This technique is performed by delivering rhythmic blows to the chest
with cupped hands or using a mechanical device directly over the lung segment to be
cleared of secretions. According to Astriani et al., (2021), giving clapping in a semi-
flower position can increase oxygen saturation. After being given the semi flower
position for 30 minutes, the average oxygen saturation value has increased (Astriani
et al., 2021; Gabriela et al., 2019).
4) Vibration and Clapping
Vibration techniques are applied by providing subtle vibrations. In this
technique, rapid vibrational impulses are transmitted across the chest wall from the
therapist's flattened hands by isometric contraction of the flexor and extensor muscles
of the forearm, to loosen and expel secretions in the airways (Gabriela et al., 2019).
Vibration and clapping aims to make it easier to remove secretions so that the
airways are smoothed and secretions can be removed through the mouth with a
coughing mechanism. According to Astriani et al., (2021), giving vibration and
clapping in the semi-flower position for 30 minutes, on average, can increase oxygen
saturation (Made et al., 2021).
5) Effective Cough
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Effective coughing is a form of exercise to clear secretions in the respiratory tract.

Effective coughing aims to increase the mobilization of secretions and prevent a high
risk of retention of secretions, helps expel phlegm attached to the airways and keeps
the lungs clean (Suzanna, 2013).
6. Modern Engineering
Non-invasive cleaning methods have improved over the years and have been
developed to improve upon this traditional approach. Modern techniques use flow variations
through breath control for secretion mobilization (Gabriela et al., 2019; Nicolini et al., 2018).
This technique consists of active cycle breathing technique and autogenic drainage.
1). Active Cycle of Breathing Technique(ACBT)
Active Cycle of Breathing Technique(ACBT) is an active breathing technique
performed by the patient and can be used to mobilize and clear excessive secretions
in the lungs. This technique can generally improve lung function. ACBT has three
main series of phases: breathing control, chest expansion, and forced expiratory
techniques.
2). Autogenic Drainage
Autogenic drainageis a three-phase active breathing technique that uses a high
expiratory flow rate and varying lung volumes to release, collect and evacuate
secretions. This technique is performed in a sitting position, back, straight and head
slightly hyperextended with hands on the left and upper right chest. The three phases
of this technique are displacement, collection, and elimination. In the first phase, the
patient is asked to breathe at a low lung volume to release secretions in the
peripheral airways. Then the second phase, breathing at medium volume to collect
secretions in the central airways, and then the third phase, breathing at high volume
to clear secretions and lungs. This technique does not require special equipment and
can be applied in everyday life (Gabriela et al., 2019; Thomas et al., 2020).
3). Airway Pressure Release Ventilation(APRV)
Airway Pressure Release Ventilation(APRV) is a pressure controlled
ventilation mode that provides almost continuous positive pressure with intermittent
cycle discharge with short time cycles at lower pressures. Spontaneous ventilation is
encouraged, and the relatively increased mean airway pressure allows 'open lung'
ventilation (Ganesan, 2019; Ibarra-Estrada, 2022).
Sustained high mean airway pressure of APRV is aimed at improving
alveolar recruitment, increasing lung homogeneity and increasing functional residual
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capacity while maintaining the benefits associated with spontaneous breathing.

During APRV, the lung unit remains open more consistently. Theoretically, this
reduces the cycle of opening and collapsing atelectatic units thereby minimizing the
occurrence of lung injury (Beitler et al., 2016; Swindin et al., 2020).
4). Prolonged Slow Expiration
Prolonged slow expirationis one of the chest therapy techniques that helps
clear bronchial secretions in infants. This technique is effective for cleansing with a
calming effect (Lievens et al., 2021; Mishra & Samuel, 2018). This technique is
performed in a supine position, one of the therapist's hands is on the thorax, below
the suprasternal notch and the other hand is on the stomach. The therapist applies
compression forces with both hands at the end of the expiratory phase. The expiratory
phase is determined by visually observing the movement of the torajs by the
therapist. The therapist's hand that is above the chest is moved in a cranial-caudal
direction and the hand that is on the stomach is moved in a caudal-cranial direction.
By providing compression at the end of the expiratory phase, the next three
inspiratory phases will be hampered. The sequence of this three-phase cycle was
carried out 3 times repetition,

Figure 2. 4 Prolonged slow expiration (Mishra & Samuel, 2018)

7. Instrumental Engineering
Instrumental techniques such as non-invasive ventilation may also be used as
adjunctive therapy to clear the airway and provide support to the respiratory system.
Common instrumental techniques are as follows (Yadav et al., 2020):
1). Positive end-expiratory pressure(PEEP)
Positive end-expiratory pressure(PEEP) is a component of mechanical
ventilation that must be considered in the management of patients with Acute
Respiratory Distress Syndrome (ARDS). This PEEP is applied by applying pressure in
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the lungs (alveolar pressure) above atmospheric pressure (external pressure) at the end
of expiration to ensure that the alveoli do not collapse easily (Cavalcanti et al., 2017;
Levenbrown et al., 2020). The two types of PEEP are extrinsic PEEP (ventilator-applied
PEEP) and intrinsic PEEP (PEEP caused by incomplete exhalation). The pressure
applied or increased during inspiration is called support pressure (Levenbrown et al.,
2020).
Positive end-expiratory pressureExtrinsic PEEP (PEEP) can be used to
increase oxygenation. Based on Henry's law, the solubility of a gas in a liquid is directly
proportional to the pressure of the gas above sea level. This also applies to mechanical
or non-invasive ventilation as increasing PEEP will increase the pressure in the system.
This, in turn, increases the solubility of oxygen and its ability to cross the alveocapillary
membrane and increases the oxygen content in the blood. Extrinsic PEEP can also be
used to improve ventilation-perfusion mismatch. Application of positive pressure in the
airways can open or “bandage” airways that may have collapsed, reducing atelectasis,
increasing alveolar ventilation, and reducing ventilation-perfusion mismatch (Carpio,
2022; Cavalcanti et al., 2017).
Positive end-expiratory pressure(PEEP) intrinsic or also auto-PEEP is a
complication of patients who use mechanical ventilation. Ordinarily, passive breathing
will allow complete emptying of air in the lungs until lung pressure equals atmospheric
pressure, but in some cases the lungs may not fully deflate, leaving air trapped in the
lungs at the end of the breath to produce a higher pressure. remain in the lungs (Carpio,
2022; Sahetya et al., 2017).
2). Continuous Positive Airway Pressure(CPAP)
Continuous positive airway pressure(CPAP) generated by exhalation against
constant opening pressure; this results in positive end expiratory pressure (PEEP).
Continuous positive airway pressure can also be provided by commercially available
pressure drivers. This generally requires a well-fitting nasal fork or a CPAP face mask.
Bubble CPAP can be used in low resource settings and in the pediatric population. It
consists of an interface (nasal cannula), inspiratory tube, and expiratory tube immersed
in an underwater bottle system (Gabriela et al., 2019).
3). High-flow Nasal Cannula(HFNC)
4). High-flow nasal cannula(HNFC) is a relatively safe and effective non-invasive
ventilation method that has recently been accepted as a treatment for acute respiratory
assistance that previously used endotracheal intubation or invasive ventilation (Drake,
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2018; Wraight & Ganu, 2015). HNFC therapy is most often used in babies with acute
bronchiolitis. Other indications for HNFC therapy are asthma, sleep apnea, pneumonia
and post-extubation respiratory support (Lodeserto et al., 2018; Mikalsen et al., 2016).

Figure 2. 5 High-flow nasal cannula device (C. Chang et al., 2021)

5). Intrapulmonary Percussive Ventilation(IPV)

Intrapulmonary Percussive Ventilation(IPV) is designed to support the mobilization of
bronchial secretions and improve ventilation efficiency and distribution, provide
intrathoracic percussion and vibration and an alternative system for positive pressure
delivery to the lungs. Each IPV session lasts fifteen minutes and is carried out twice a
day (morning and evening). Intrapulmonary percussion ventilation uses a pneumatic
device to deliver a series of mini-bursts of pressurized gas at 100 to 225 cycles per
minute into the airways, via a mouthpiece. The duration of each percussion cycle is
controlled manually with a thumb button. During the cycle, constant PAP is maintained
in the airway. It also incorporates a nebulizer for aerosol delivery (Yadav et al., 2020).
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RESPIRATORY EXAMINATION OSCE

In an Objective Structured Clinical Examination (OSCE) for a respiratory examination, you will be evaluated
on your ability to perform a thorough and systematic examination of a patient's respiratory system. OSCEs are
typically used in medical education to assess clinical skills. Here's a step-by-step guide on how to approach a
respiratory OSCE station:

1. Introduction:
 Enter the examination room confidently.
 Greet the patient appropriately, introduce yourself, and confirm the patient's name and date of
birth.
 Explain that you are going to conduct a respiratory examination, its purpose, and obtain the
patient's consent.
 Ensure privacy and draping.
2. General Inspection:
 Begin by observing the patient's overall appearance and position (e.g., sitting upright, using
accessory muscles).
 Note any signs of respiratory distress, such as cyanosis, clubbing, or pursed lip breathing.
3. Hands-On Examination:
 Inspect the patient's hands and nails for clubbing or peripheral cyanosis.
 Palpate the patient's chest for tenderness or deformities.
4. Assess chest expansion:
 Place your hands on the patient's chest, thumbs at the level of the 10th rib.
 Ask the patient to take a deep breath; note the symmetrical expansion of the chest.
 Perform percussion over the anterior, lateral, and posterior chest, comparing resonance.
5. Auscultate lung sounds:
 Use a stethoscope to listen to breath sounds at various lung fields (apex, base, axilla, posterior).
 Describe normal vesicular breath sounds, and mention if you hear any abnormal sounds (e.g.,
crackles, wheezes).
6. Special Tests (if required in the scenario):
 Perform additional tests based on the scenario (e.g., egophony, whispered pectoriloquy,
bronchophony) and interpret the findings.
7. Assessment of Accessory Muscles and Respiratory Rate:
 Observe for the use of accessory muscles and assess the respiratory rate.
 Mention if you see any paradoxical breathing or abnormal patterns (e.g., Kussmaul breathing).
8. Summary and Discussion:
 Summarize your findings concisely.
 Offer a provisional diagnosis or differential diagnosis based on the examination findings.
 Discuss further investigations or additional examinations that may be required (e.g., chest X-ray,
spirometry).
 Explain the importance of follow-up and management.
 Address any questions or concerns the patient may have.
 Thank the patient and ensure they are comfortable before leaving the room.
Remember to maintain good communication skills throughout the OSCE station, be attentive to patient
comfort and dignity, and demonstrate professionalism. Time management is crucial, so try to complete all
tasks within the allotted time frame for the station. Practice and familiarity with the OSCE format are essential
for success.