1. Hemorrhage (severe hemoptysis)

• Copious amounts of blood in the sputum.
• NOTE: This is different from lightly blood–streaked sputum.

2. Untreated acute conditions

• Severe pulmonary edema.
• Congestive heart failure.
• Large pleural effusion.
• Pulmonary embolism.
• Pneumothorax.

3. Cardiovascular instability

• Cardiac arrhythmia.
• Severe hypertension or hypotension.
• Recent myocardial infarction.

4. Recent neurosurgery
Manual Techniques Used During Postural Drainage Therapy
In addition to the use of body positioning, deep breathing and effective cough to facilitate clearance of secretions from the airways, a variety of manual techniques are used in conjunction with postural drainage to maximize the effectiveness of the mucociliary transport system. They include:

1. Percussion

• This technique is used to further mobilize secretions by mechanically dislodging viscous or adherent mucus from the lungs.
• Percussion is performed with cupped hands over the lung segment being drained. The therapist’s cupped hands alternately strike the patient’s chest wall in a rhythmic fashion. The therapist should try to keep shoulders, elbows, and wrists loose and mobile during the maneuver. Mechanical percussion is an alternative to manual percussion techniques.
• Percussion is continued for several minutes or until the patient needs to alter position to cough.
• This procedure should not be painful or uncomfortable. To prevent irritation to sensitive skin, have the patient wear a lightweight gown or shirt. Avoid percussion over breast tissue in women and over bony prominences.
• Relative contraindications prior to implementing, percussion in a postural drainage program, the therapist must compare the potential benefits with the possible risks to the patient. In most instances, avoid the use of percussion.
• Over fractures, spinal fusion, or osteoporosis.
• Over tumor area.
• If a patient has a pulmonary embolus.
• If a patient has a condition in which hemorrhage could easily occur, such as in the presence of a low platelet count, or if a patient is receiving anticoagulation therapy.
• If a patient has unstable angina.
• If a patient has chest wall pain, for example, after thoracic surgery.

2. Vibration

• The technique is used in conjunction with percussion in postural drainage. It is applied only during expiration as the patient is deep breathing to move the secretions to the larger airways.
• Vibration is applied by placing both hands directly on the skin and over the chest wall (or one hand on top of the other) and gently compressing and rapidly vibrating the chest wall as the patient breathes out .
• Pressure is applied in the same direction as that in which the chest is moving.
• The vibrating action is achieved by the therapist’s isometrically contracting (tensing) the muscles of the upper extremities from shoulders to hands.

3. Shaking

• Shaking is a more vigorous form of vibration applied during exhalation using an intermittent bouncing maneuver coupled with wide movements of the therapist’s hands.
• The therapist’s thumb are locked together and the open hands are placed directly on the patient’s skin and fingers are wrapped around the chest wall. The therapist simultaneously compresses and slakes the chest wall.