1 strategies for reduced of breathless sevgi ozalevli, phd, pt, assoc.prof. school of physical...
TRANSCRIPT
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STRATEGIES FOR
REDUCED OF BREATHLESS
Sevgi Ozalevli, PhD, PT, Assoc.Prof.
School of Physical Therapy and Rehabilitation,
Dokuz Eylul University, Izmir.
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Content of the presentation
Breathlessness = Dyspnea, Definition, Causes Of Dyspnea Treatment Of Dyspnea, Non-pharmacologic Methods Patients And Familiy Education Strategies For Reducing Work Of Breathing And Consumption Of Oxygen Tecniques For Regulating Breathing And increasing Capacity Of Pulmonary
Relaxation Exercise And PositionsForward LeaningPursed Lips Breathing Regulation in Breathing Pattern And Active Expiratory Tecnique Diaphragmatic Breathing Exercises
Exercise Training Respiratory Muscle Training Oxygen Therapy Rest Of Respiratory Muscles And Mechanic Ventilation Conductive Addition Therapies
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Breathless – Dyspnea, Definition
The sensation of difficulty in breathing
Breathing discomfort Inability to breathe deeply enough Increased respiratory effort that is
unpleasant and regarded as inappropriate by the patient
Awareness of respiratory distress Feeling breathless, suffocated Experiencing air hunger
Richards, 1935
Mahler, 1984
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Dyspnea - Definition
The experience derives from interactions among multiple physiological, psychological, social, and environmental factors, and may induce secondary physiological and
behavioral responses.
American Thoracic Society. Dyspnea: mechanisms, assessment and management-a consensus statement. Am J Respir Crit Care Med 1999
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Reduced elastic lung recoil Increased airway resistance
Expiratory flow limitation
Acute dynamic lung hyperinflation
Dyspnea
O’Donnell, 2007
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Causes of Chronic Dyspnea Airway disease Parenchymal lung disease Pneumonia Pleural disease Pulmonary vascular disease Chest wall disease Respiratory muscle dysfunction Cardiovascular Anemia Decondition Psychological factors
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Jones PW, 1998
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Possible mechanism contributing to dyspnea in COPD
1. Increased ventilatory demand
a. Increased physiological dead space
b. hypoxemia
c. Early onset of lactic acidosis
d. Limp muscle weakness due to deconditioning, systemic effects of COPD, and/or
poor nutrition.
2. Dinamic airway compression
3. Dynamic hyperinflation
a. Increase in elastic loading
b. Shortening of the vertical muscle fibers of the diaphragm (functional weakness)
4. Respiratory muscle weakness
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Treatment of Dyspnea
Pharmacologic treatment Treatment with non-pharmacologic methods
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Non-pharmacologic Strategies
1. Patient/Family Education 2. Strategies for reducing work of breathing and consumption of oxygen 3.Tecniques For Regulation Breathing And increasing Capacity Of Pulmonary
Relaxation Exercise And PositionsForward Leaning Pursed-lip Breathing Regulation in Breathing Pattern And Active Expiratory Tecnique Dyaphragmatic Breathing Exercise
4. Exercise Training5. Respiratory Muscle Training 6. Oxygen Therapy 7. Noninvasive Positive Pressure Ventilation8. Conductive Addition Therapies
YogaWalking Aids Walking And Exercise With MusicHypnosis Acupuncture-acupressırBiofeedback Neuromusculer Electric Stimulation (NMES) Use Cool Air To Face Organisation Of Environment Air And ConditionsPsychological SupportNutritional Support
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Patient/Family Education
in education program for reducing breathlessness It should be included
control of breathingorganization of home and environmentTo limit number of people in roomregulation of temperature and humiditystrategies for coping with stress, anxiety and depressiondeveloping self care coping strategies
AMA:EPEC 1999AMA:EPEC 1999
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Patient/Family Education
The “coaching” of nebulized bronchodilator therapy should be included on patients and familly
education.
During the therapy, unsupported seated and prolonged use of upper limbs, and
rapid and shallow breathing pattern should be keep down.
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Strategies for reducing work of breathing and consumption of oxygen
It is important to teach breathing with normal tidal volume and lower chest wall by relaxation to upper chest wall and shoulder and neck muscles
Effects of this strategiesQuality of sleepFunctional activities Quality of life
Work of breathing Heart rate Perception of dyspnea
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Strategies for reducing work of breathing and consumption of oxygen
Aims
Reduce unsupportive body positions Reduce works which is doing against gravity Reduce change positions Reduce speed and deep of ventilation Reduce activity of accessory respiratory muscles Use advantage body positions (forward leaning) Use breathing control during the daily living activities Use relaxation in daily life Improve strategies for cope with stress Mahler, 1990Mahler, 1990
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Christenbery, 2005
Strategies for reducing breathlessness in patients with COPD
%
Moved slower 72Kept still 68Used extra oxygen 53
Practiced breathing exercises 47
Planned a decrease in activity 43
Exposed self to cool air 40Change of daily living activities 37
Took extra inhaler 32Change dressing 27
Changed eating habits 24
Used assistive devices 9
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The effects of education on the dyspnea perception?
It has been determined that
the patient education
reduces dyspnea, increases quality of life,
improves life style adaptations, which include the use of inhaler, relaxation
tecniques, energy conservation techniques, and strategies for coping with stress.
Hunter & Hall, 1989.Howland, 1986.
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Tecniques For Regulating Breathing And increasing Capacity
Of Pulmonary
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Relaxation Exercise and Positions
EfficacyEnsure breathing controlRegularize breathing rateIncrease tidal volumeReduce severity of anxietyReduce working of breathingReduce heart rateImprove quality of sleepReduce accessory muscles activitiesReduce perception of dyspnea
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Relaxation Positions
High side lie Supin position with high
head lie Forward leaning with
supported upper extremities Forward leaning with
supported by table Supported forward and
rearward standing
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Progressive muscle relaxation This is important strategy of breathing which is teaching to patient, inspiration
with contraction of all muscles groups during 5-10 sec and expiration with relaxation.
Patients with chronic heart failure, n=158 Study group, 14 wks, progressive muscle relaxation by home program and workshopControl group, relaxation education, 45min
According to the control group, in study group; psyhologial stress, severity of dyspnea and fatigue were reduce..
Breathing rateAnxietyDyspnea
Yu, J Psychosom Res, 2007
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Progressive muscle relaxation
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Forward leaning
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Forward Leaning
Barach, 1974 Sharp, 1980Druz, 1982Delgato, 1982O’Neil, 1983
•Reduces scalen and sternomastoid muscles activities•Increases transdiaphragmatic pressure•Regulatesthoracoabdominal motions•Pectoral muscles by aid of supported upper extremities elevate upper ribcage•Regulates and increased diaphragm function•Increases Pimax
20-45°
Dyspnea Diaphragm function
Hyperinflation ?
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Pursed-lips Breathing
Reduces FRC by increase bronchial diameter Delayes air way collaps by increased end expiratory lung volume Reduces dinamic hyperinflation
Conclusion; It was determined that the PLBE was increased SaO2 and PaO2,alveolar ventilation, reduced PaCO2, breathing rate, minute ventilation byİmproved pulmonary gas change and reduced dyspnea by increased tidal
volume,İmproved deep and slow breathing and increased exercise capacity.
PLBE, a simple-easy technic, no need device, useable during the walking andother activities Puente-Maestu, 2006
Gigliotti, 2003Collins, 2001 Spahija, 2005
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12 wks, 1st wk-10 min, 4th wk- 25 min
in PLBE group, according to the expiratory muscle training andcontrol group,
Severity of dyspnea reducedInspiratory muscle strength and physical functional capacityincreased
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Reduced breathing frequence, increased tidal volume
and PaO2 improve alveolar ventilation, functional status and
reduce perception of dyspnea.
There is a positive correlation between the accessory respiratory muscles activity and severity of dyspnea
Breslin, Chest, 1990
Slow and Deep Breathing (lower frequency, higher tidal volume breathing)
Use for; improves of abnormal chest wall motions, reduces working of breathing, reduces activities of accessory respiratory muscles and dyspnea
Regulation in Breathing Pattern And Active Expiratory Tecnique
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Diaphragmatic Breathing
Increases abdominal motions and reduces upper rib cage motions
No changes ventilation distribution
Reduces working of breathing
Reduces severity of dyspnea
Sackner, 1984
Grimby, 1975
Diaphragmatic breathing increases work of breathing in patients
with severe COPD
Gosselink, 1995
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Exercise Training
Exercise training for reduce dyspnea; Interval training Upper extremities exercise Exercises must done with breathing
control Aerobic + strength exercises Respiratory muscle training Minimum 4 wks Patients education
Gigliotti, 2003, Ambrosino, 2004Reardon, 2005, Porta, 2005O’Donnell, 2005, Lacasse, 2006Georgiadou, 2007
Ventilatory limitation
Loss of physical
performance
Deconditioning
Dyspnea
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Respiratory Muscle Training
In COPD patients, hastenes respiratory muscles adaptation ↑ respiratory muscle strength and endurance ↓ nocturnal desaturation ↑ exercise capacity ↑ tidal volume without changed minute ventilation ↓ breathing frequence (by increases expiration time and tidal
volume) Reduces dyspnea
Gosselink, 2006Ries, 2007Geddes, 2008Shahin, 2008
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Respiratory Muscle Training
In generally, respiratory muscle training was programmed with;
Pimax 25-35 % 15 -30 min, 3-5 day/wk, 6-8 wks
Gosselink, 2006Ries, 2007Geddes, 2008Shahin, 2008
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Oxygen TherapyOxygen;
Obtaines bronchodilatation
Reduces ventilatory demand
Reduces lung hyperinflation
ALLEVIATES DYSPNEA
This effect is independent from oxygen desaturation at rest.
Fujimoto, Chest, 2002
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There was a low-grade scientific evidence that oxygen improves dyspnea in some patients with advanced pulmonary disease at rest.
Gallagher, J Pain Palliat Care Pharmacother, 2004
Oxygen Therapy in COPD
IC ↑, EELV ↓ Dyspnea and leg fatigue ↓ and exercise time ↑ Relief not always correlated to degree of hypoxemia
O’Donnell, 2001
Alvis, 2003Wouters, 2006
Peters, Thorax 2006
Low-density oxygen = heliox 72 % + O2, 28 % or Heliox 79 % + O2, 21%
in COPD patients;Dynamic hyperinflation ↓Severity of dyspnea ↓ exercise capacity ↑
Chiappa, 2009Barclay, 2006
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6-minute walking tests performed in room-air conditions (A6MWT) and with supplemental oxygen (O6MWT) in patients with chronic obstructive pulmonary
disease (COPD) and exercise-induced oxygen desaturation.
Walking distance was longer with the O6MWT than with the A6MWT (p=0.001). The O6MWT resulted in a smaller increase in dyspnea, leg fatigue, and heart rate
and a smaller drop in pulsed saturation than the A6MWT (p<0.05).
Ambulatory oxygen is useful.Eaton, 2002
Ozalevli, 2007
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not chronically hypoxic COPD patients, exertional desaturation 88% (n=41), 4L.min O2
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Rest of Respiratory Muscles and Mechanic Ventilation
CPAP; Reduces inspiratory muscles effort Reduces inspiratory breathing work Improves diaphragmatic activity Improves quality of sleep
Severe COPD, acute exacerbations COPD, severe congestive heart diseases, severe interstitial lung
disease, sleep-apnea and neuromuscular disease
Noninvasive Positive Pressure Ventilation
CPAP
With nasal mask, 30-60 min, 7.5-8 cmH2O CPAP
reduces dyspnea, improves QOL
Chest 2000; 118:1582-90
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1
2
3
4
5
M0 M12 M24
LTOT
NPPV
* *
MRC dyspneaMRC dyspnea
Stable hypercapnic COPD patients
6 months LTOT (n=47)
NPPV + LTOT (n=43)
Compared with long-term oxygen therapy alone, the addition of
noninvasive positive pressure ventilation to long-term oxygen therapy in stable chronic obstructive pulmonary disease patients with chronic ventilatory failure
improved dyspnoea.
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suppl. O2 (2.3 L/min) suppl. O2 (2.3 L/min) + NPPV (29±4 mbar, 20/min)
Six minute walking test
20, COPD, FEV1 %27
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Dreher, 2007
Dyspnea 6↓4 (M.Borg Scl) Walking distance 209↑252m
In chronic hypercapnic chronic obstructive pulmonary disease, high-intensity noninvasive positive-pressure ventilation can administered during walking
programs
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Conductive addition therapies
Yoga Walking aids Walking and exercise with music Hypnosis Acupuncture-Acupressır Biofeedback Neuromusculer Electric Stimulation (NMES) Organisation of Environment air and conditions Use cool air to face Nutritional support Psychological support
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Yoga
Yoga = Deep breathing + Relaxation
improves control of breathing by teaching deep and effective breathing and breathing awareness
COPD patients, 12 wks, 2 sessions/wk, yoga
Severity of Dyspnea ↓ ***Health-related quality of life →Functional capacity →
Donesky-Cuenco, 2009
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Improve forward leaning
support upper extremities position
stabilization to upper rib cage
Increase maximal volounter ventilation
Decrease perception of dyspnea and leg fatigue
Increase functional capacity and status in daily living activities
Improve courage and morale
Walking Aids (Rollators)
Solway, 2002Probst, 2004Gupta, 2006Crisafuli, 2007
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Walking Aids
Forty, stable, severe COPD patients, One 6MWT was performed unaided, and the other was performed with a rollator
Use of the rollator & reduction in dyspnea (p < 0.001)
Conclusion: Use of a rollator was effective in improvingfunctional exercise capacity by reducing dyspnea and rest duration.
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Walking And Exercise With MusicIn COPD patients, walking with music;
Not changes severity of dyspnea.Brooks, 2003
Pfiste, 1998
Decreases anxiety, fear of activity and dyspnea
Bauldoff, 2002Sidani, 2004
Exercise with music is a important strategy which make possible doing exercises with longer time and higher severity
De Peuter, 2004
Need more research
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Hipnoz
17 asthma and allergy patients (mean age 13.4)
Hypnosis for relaxation and symptom control1 month followDyspnea reduced in child specially which teaching self-hypnosis
There is not enough research about this issue
Pediatrics 2001;107(2).
Hypnosis
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Acupuncture&Acupressure
Acupuncturein COPD patients, No change in dyspnea
Lewith, 2004Vicker, 2005
reduces dyspnea severity Jobst, 1986Maa, 1997
Acupressure is a non-invasive method which can used at home.need to research of it’s effects
44 COPD patients, 7 sessions/week, 6 wks, acupressure
Severity of Dyspnea ↓ (p<0.05)Wu, J Adv Nurs, 2004
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BiofeedbackUsed with aim of
improving breathing controldeveloping functional staturegulating breathing patternincreasing tidal volumedeveloping relaxationdecreasing stress
It was found that biofeedback with breathing voice was reduced bronchospasm according to the control group in mild-modarate asthma patients in study
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Biofeedback Incentive spirometry Pulse Oksimetry PEF meter
EMG Biyofeedback
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Patients with COPD, n=20,Biofeedback with pulse oxymeter (with follow heart rate and peripheral saturation)
+ Walking program
10 wks,Increase walking distanceReduce dyspneaImprove quality of life
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Severe COPD patients (n=15)
Home based NMES 6 wks Peripheral muscle strength, maximal exercise capacity were
increase. Severity of Dyspnea (CRDQ) was reduce (p<0.05) Performance of daily life activities was improve.
Neder, Thorax, 2002
Neuromuscular Electrical Stimulation
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Conclusion: Electrical stimulation + usual rehabilitation was
reduce dyspnea during the daily life activities
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Strategies which are no evidence and need research
Use cool air to face the use air to face, nasal mucousa and pharinx with hand fan is reducing dyspnea by innerve fasial reseptors on trigeminal nerve
Cheap, simple method!!!
In health individual, effective (Schwartzstein, 1987)
In COPD patients, effective (Galbraith, 2007)
In severe COPD patients, not effective, In patients with cardiac disease, effective (Baltzan, 2000)
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Strategies which are no have evidence and need research
Organisation of enviroment air and conditions Humidity, very hot and dirty air = Bronchospasm + Dyspnea
Nutritional Support
High carbohydrate = Severe Dyspnea
High fat + Low carbohydrate = Mild Dyspnea
Psychological and Psychosocial Support
Anxiety and depression ↓ = Dyspnea ?
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Conclusion Breathlessness is a multifactorial problem
The best strategy for reducing it
Multifactorial assessment
Breathlessness
55THANKS