From passive to active: Clinical reasoning in acute care chest physiotherapy

Abstract

Background: Physiotherapy in acute care is often perceived as protocol-driven and limited to passive techniques. This case series illustrates how clinical reasoning informs individualized practice by tailoring interventions to patient-specific needs. Six patients with poor cough effort were initially managed with passive chest physiotherapy, which proved insufficient. Guided by jones’ clinical reasoning strategies and a client-centred approach, active expiratory training was introduced. Peak Expiratory Flow Rate (PEFR) was quantified pre- and post-intervention using a handheld peak flow meter, providing objective evidence of cough effectiveness. Interventions were delivered twice daily for 3–5 days, including supported coughing, huffing, breathing control, and incentive spirometry. Across cases, PEFR improved by 70–130 l/min, with patients achieving protective coughing and airway clearance within days. Clinical observation confirmed secretion clearance, while patients reported increased confidence and comfort with active participation. These findings demonstrate that even frail or postsurgical patients can benefit from carefully graded active strategies. This series highlights the essential role of physiotherapists in acute care hospital settings, emphasizing individualized reasoning as critical for optimizing outcomes and strengthening the evidence base for reasoning-driven care.