CVR Physiotherapy › Technique cards › Airway clearance
Postural drainage, percussion, vibration and shaking
Postural drainage was asked as contraindications (S18, any six) and for a neonate (W18), and it belongs in every answer on airway clearance or bronchiectasis. Learn the positions by lobe, the head-down contraindications, and when percussion is not allowed.
- Syllabus
- Ch 4(a) Bronchial hygiene therapy: postural drainage; practical: postural drainage and percussions
- Priority
- Core technique. In 2 of 20 papers on its own (2016–2026), and part of every airway-clearance answer.
- Asked as
- 7m W18 (neonate) 3m S18
- Usual split
- 3-mark contraindications; part of 7-mark airway-clearance and bronchiectasis answers
- Checked against
- BTS/ACPRC physiotherapy guideline (2009); Cystic Fibrosis Foundation drainage positions; classic positions (Pryor & Prasad). Full list under Sources.
- Content checked
- 19 October 2026. Next review due October 2027.
- My revision
-
1What it is
Postural drainage (gravity-assisted positioning) places the patient so that the bronchus of the affected segment points downwards towards the trachea, letting gravity help secretions drain to the large airways, where they are huffed or coughed out. It is almost always combined with a breathing technique (ACBT) and sometimes with percussion, vibration or shaking.
- Classic: 11–12 positions, many with the foot of the bed raised (head-down tilt).
- Modified postural drainage: the same side-lying and prone positions without head-down tilt, used when tilting is contraindicated or not tolerated (infants, reflux, breathlessness).
Dose: usually about 10 minutes in each productive position, with the whole session kept to about 20–40 minutes; once or twice a day for chronic sputum, more during infection. Not straight after meals.
2Positions for each lobe
| Lobe and segment | Position | Bed |
|---|---|---|
| Upper lobes: apical | Sitting upright, leaning back slightly (about 30°) | Flat or sitting |
| Upper lobes: posterior | Sitting, leaning forward over a pillow (about 30°); or lying on the opposite side turned a quarter towards prone | Flat |
| Upper lobes: anterior | Lying flat on the back | Flat |
| Lingula (left) | Lying on the right side, turned a quarter backwards, pillow behind | Foot raised, about 15° |
| Middle lobe (right) | Lying on the left side, turned a quarter backwards, pillow behind | Foot raised, about 15° |
| Lower lobes: superior (apical) | Lying prone, two pillows under the hips | Flat |
| Lower lobes: anterior basal | Lying on the back, or on the opposite side turned slightly back | Foot raised, about 20–30° |
| Lower lobes: lateral basal | Lying on the opposite side, turned a quarter forward | Foot raised, about 20–30° |
| Lower lobes: posterior basal | Lying prone, pillow under the hips | Foot raised, about 20–30° |
Tilt angles differ between books (raising the foot of the bed by about 35–45 cm). The direction of lying is what matters most. Stick-figure drawings of four key positions are on the bronchiectasis page.
Bad side up, bronchus down
Lie on the healthy side for a lateral segment; turn towards prone for posterior segments and towards supine for anterior segments; raise the foot for lower lobes and the middle lobe or lingula.
3Indications
- Large amounts of sputum: bronchiectasis, cystic fibrosis, lung abscess (affected segment uppermost).
- Retained secretions or collapse of a known lobe or segment (on X-ray or by auscultation).
- Patients too weak or too young to do active techniques alone (infants, ventilated or unconscious patients) using modified positions.
4Contraindications (3 marks in S18)
- Recent or active haemoptysis
- Raised intracranial pressure, recent head injury or neurosurgery
- Uncontrolled hypertension, unstable heart condition, arrhythmia, pulmonary oedema or heart failure
- Severe breathlessness or bronchospasm
- Gastro-oesophageal reflux, hiatus hernia, recent oesophageal surgery, just after meals or feeds
- Aortic aneurysm, recent eye surgery
- Gross obesity, abdominal distension, late pregnancy
- Untreated pneumothorax, large pleural effusion or empyema, rib fractures, painful recent surgery
Use modified (flat side-lying or sitting) positions instead.
- Rib fractures, flail chest, osteoporosis, bone metastases, recent spinal surgery
- Haemoptysis; low platelets or clotting problems
- Unstable BP or heart rhythm; bronchospasm (percussion can worsen it)
- Burns, fresh skin grafts, open wounds or a recently inserted pacemaker over the area; surgical emphysema
- Pain the patient cannot tolerate
Newborns (W18, 7 marks): head-down tilt is avoided (reflux, intraventricular haemorrhage risk in preterm babies); handle minimally; see the neonatal chest physiotherapy page for the full list.
5Percussion, vibration and shaking
| Technique | How | Effect |
|---|---|---|
| Percussion (clapping) | Rhythmic clapping with cupped hands and relaxed wrists over the affected segment, through a thin towel or clothing; for about 30 seconds to a few minutes, alternating with breathing control or thoracic expansion | The air cushion transmits an energy wave that loosens mucus from the airway walls |
| Vibration | Fine, rapid shaking from the therapist's tensed arms with gentle compression, during the breath out only | Increases expiratory flow and moves mucus towards larger airways |
| Shaking | Coarser, rhythmic bouncing compression of the chest wall during the breath out, usually after a deep breath in | Stronger version of vibration; helps move thick mucus |
- Use them only when the patient has secretions and finds them helpful; they are added to, not instead of, a breathing technique.
- Infants: gentle percussion with fingertips or a soft cup; no head-down tilt.
- Ventilated patients: vibrations or shaking timed with expiration, often after manual or ventilator hyperinflation.
Classic answer vs current guideline: percussion and head-down tilt
Classic
Postural drainage with head-down tilt and percussion for every patient with sputum.
Current (BTS/ACPRC 2009)
Gravity-assisted positions help when secretions are in a known area, but active, independent techniques (ACBT, autogenic drainage, PEP) are preferred; head-down tilt is used only when it helps and is safe; percussion is not routine. Choose the method the patient will actually do.
Write in the exam
"Gravity-assisted positions for the affected lobe, combined with ACBT; modified positions without head-down tilt where contraindicated; percussion and vibration as adjuncts if helpful."
6Exam corner
Past questions (MUHS, 2016–2026)
- S18 Q1(a), 3 marksAny six contraindications for postural drainage.
- W18 Q2(a), 7 marksPrecautions and contraindications for postural drainage in a neonate (see the paediatric page).
- RelatedDrainage positions are part of the bronchiectasis long answers (S16 middle lobe, S19 and W16 right lower lobe, W24 left lung).
Test yourself
3 mGive six contraindications to head-down postural drainage.
Haemoptysis; raised intracranial pressure; uncontrolled hypertension or unstable heart disease; pulmonary oedema; severe breathlessness; gastro-oesophageal reflux or just after meals; aortic aneurysm; late pregnancy or abdominal distension; untreated pneumothorax (any six).
MCQTo drain the right middle lobe, the patient lies:A. On the right side, turned a quarter forward, flatB. On the left side, turned a quarter backwards, foot raisedC. Prone, foot raisedD. Sitting upright
B. Left side down, turned back onto a pillow, foot of the bed raised about 15°.
Sources
- MUHS BPTh syllabus (2012) and MUHS IV BPTh question papers 2016–2026 (muhsonline.com, unofficial archive; Dhole Patil College of Physiotherapy past-paper page).
- Bott J, et al. Guidelines for the physiotherapy management of the adult, medical, spontaneously breathing patient (BTS/ACPRC). Thorax 2009;64 Suppl 1:i1–51.
- Cystic Fibrosis Foundation. Postural drainage and percussion positions (patient education).
- Structure and classical content: Pryor & Prasad (2008); Frownfelter & Dean (2022); Hough, Physiotherapy in Respiratory and Cardiac Care.
Educational notes for exam preparation. Not medical advice.
Version 1. Content checked 19 October 2026. Next review October 2027.