Download - Physiotherapy
Role of Physiotherapy in respiratory conditionsTreatment administered to increase
Ventilation & OxygenationTreatment administered to reduce O2
consumption Treatment administered to improve secretion
clearanceTreatment administered to improve exercise
tolerance (endurance exercise)Treatment administered to reduce pain(Pain
relieving electrotherapy modalities)
Treatment administered to increase Ventilation & Oxygenation
a)Breathing exercise b)Positioning technique• Treatment administered to reduce O2
consumption a)To reduce work of breathing b)To reduce general body work
• Treatment administered to improve secretion clearance
a)To enhance muco-ciliary transport(Postural drainage)
b)To enhance cough( techniques to improve cough)
c) Bronchial hygiene techniques ACB,(FET)Autogenic drainage),PEP, Flutter, Acapella, High frequency chest wall oscillations
Treatment administered to improve exercise tolerance (endurance exercise)
Treatment administered to reduce pain(Pain relieving electrotherapy modalities)
Treatment administered to increase ventilation & Oxygenation Alveolar ventilation depends on the magnitude
of tidal volume and dead spaceDecrease in alveolar ventilation are the result of
decreased tidal volume or increased dead space Physiotherapist aim is to increase tidal volume
or decrease dead space(physiological) or both Tidal volume can be increased by Breathing
exerciseDead space can be decreased by proper
positioning technique
Breathing exercise Inspiration is done through nose and
expiration through mouth Inspiration through nose has four advantage a)It acts as a filter to prevent dust and other
particles from getting into the lungs, b) It warms the air c) It prevents gas from getting into the
stomach d) It naturally controls the intensity of
breathing by controlling the correct balance of oxygen and carbon dioxide.
Afferent stimuli from the nerves that regulate breathing are in the nasal passages. The inhaled air passing through the nasal mucosa carries the stimuli to the reflex nerves that control breathing. Mouth breathing bypasses the nasal mucosa and makes regular breathing difficult.
Patient is asked to exhale through mouth with whistling sound to identify the expiration phase as he has to perform the chest manipulations
Types of Breathing exercise Relaxed Diaphragmatic breathing Pursed lip breathing Segmental breathing(costal expansion
exercise) a)Apical breathing b)lateral costal expansion c)Posterior basal expansion
• Sustained maximal inspiration (deep breathing)
Technique Starting position is Half lying (Explain)Diaphragmatic breathing enhance
diaphragmatic descent during inspiration and diaphragmatic ascent during expiration
Physiotherapist assist diaphragmatic ascent by directing the patient to allow the abdomen to retract gradually during exhalation or by contracting abdominal muscles actively
Diaphragmatic descent is assisted by directing the patient to protract the abdomen gradually during inhalation
Dominant hand is placed on abdomen and non dominant hand is placed on the chest
Instruct the patient to move the dominant hand and not to move the non- dominant hand so that patient concentrates on diaphragm and not the external inter-costal muscles or accessory muscles
When subjects inhale diaphragmatically after maximal expiration increases Lower lung zone ventilation (Cottle, 1972:Rohrer, 1915)
Re education of diaphragmAs other skeletal muscles, diaphragm also shares
the property of skeletal muscle Place the index and middle finger below the lower
costal margin anteriorly in half lying position over the insertion of diaphragm (central tendon)
At the end of expiration when diaphragm is relaxed, stretch stimulus is given to the diaphragm to elicit Stretch reflex of the diaphragm and patient is instructed to take breath in
Resisted diaphragmatic breathing
Manual resistance by therapist over the abdomen
Placing appropriate weight over abdomen in By slightly elevating the foot end of the bed
Physiological outcomes of Diaphragmatic breathing
Reduces work of breathingReduces the incidence of post operative
pulmonary complicationsImprove ventilation and oxygenationEliminates accessory muscle activity Decrease respiratory rate Increase tidal ventilation Improve distribution of ventilation
Pursed lip breathing –Indication
COPD Emphysema leads to Hyperinflation by two
mechanism a)Passive hyperinflation b)Dynamic hyperinflation
Passive hyperinflation
Is caused by reduced elastic recoil which allows the airway to collapse on expiration
Dynamic hyperinflation Is caused by the patient having to actively
sustain inspiratory muscle contraction in order to hold open the airway ,this unfortunate but necessary process is achieved at the cost of excess work of breathing
Intrinsic PEEP : airway obstruction reduces expiratory flow which prevents expired air from being expelled before next inspiration starts causing air trapping which creates positive pressure in the chest known as PEEP(Intrinsic PEEP)
An average positive pressure is 2cmH2o which imposes an extra threshold load at the start of inspiration because inspiratory muscle have to offset this positive pressure before inspiration can begin
Distended airway require a grater than normal pressure for inflation
In Emphysema excess WOB is required to Overcome the resistance of obstructed
airway Assist expiration (active instead of passive )Sustain inspiratory muscle action through out
respiratory cycle so that high lung volume are maintained
Overcome threshold resistance at the start of inspiration ,caused by Intrinsic PEEP
Pursed lip breathing -Technique1. Relax neck and shoulder muscles.
2. Breathe in (inhale) slowly through nose for two counts, keeping your mouth closed. Don't take a deep breath; a normal breath will do.
Breathe out (exhale) slowly and gently through your pursed lips while counting to four.
Note that exhalation should not be too hard. Hyperventilation will worsen the symptoms. Blow out with the about same force that you would use to cool hot soup on a spoon so that you do not blow it off the spoon.
Uses of pursed lip breathingImproves ventilationReleases trapped air in the lungsKeeps the airways open longer and decreases
the work of breathingProlongs exhalation to slow the breathing rateImproves breathing patterns by moving old air
out of the lungs and allowing for new air to enter the lungs
Relieves shortness of breathCauses general relaxation
It can be applied:- as a 3-5 minutes “rescue exercise” or an Emergency Procedure to counteract acute exacerbations or dyspnea (shortage of air or breathlessness) in COPD and asthma (Nield et al, 2007; Puente-Maestu & Stringer, 2006; Garrod et al, 2005;
Pursed-lip breathing reduces hyperventilation-induced broncho-constriction (Wardlaw et al, 1987).
Segmental breathing (costal expansion exercise)
Apical costal expansion (for apical lobes)
Lateral costal expansion (for middle and lingular lobes)
Posterior basal expansion(for lower lobes)
Advantages of segmental breathing(indication)
Prevent accumulation of pleural fluidPrevent accumulation of secretions Decreases paradoxical breathingDecrease panicImprove chest mobility
TechniqueThe technique uses manual counter pressure to
encourage the expansion of specific part of the lung
Identify the surface landmark and place hand on the chest wall overlying the bronco-pulmonary segment requiring treatment
Apply firm pressure to that area at the end of patients expiratory maneuver
Instruct the patient to inspire attempting to direct the inspired air toward the therapist hand saying “breath into my hand”
Reduce the hand pressure at the end of inspiration and repeat the procedure
If the aim of the treatment is to expand the lung tissue the emphasis should be on holding the maximum inspiration for 3 sec and then sniff little more air
Holding the breath also allows time for the air to diffuse through the pores of Khon and sniff will provide a little more expansion
Once the patient has learned correct technique he is taught to give pressure himself
Self resistance technique
When using this technique patient should not elevate his shoulder or achieve costal expansion by side flexion of spine
Positioning technique-Effect of body position on perfusion Pulmonary pressure system is low pressure
system than systemic circulation Pulmonary artery pressure is 25/10mmhgGravity affects the low pressure pulmonary
vascular system than systemic high pressure system (120/80mmhg)
Eg: when a person is standing the gravity dependent areas of the lungs receive the greatest amount of blood flow and apices are gravity independent lobes and receive least amount of perfusion
Effect of body position on ventilationRegional differences are found in the
ventilatory aspect of lung which is caused by the intra-pleural pressure gradient
Intra-pleural pressure gradient is more negative at the upper part of the lung(apices) & less negative at the lower part of the lung (base)
Eg : in standing this pressure gradient result in the greater resting expansion in apical areas of lung than in the basal region
When the air is inhaled the apices being almost full at the onset of inhalation receive very little of the new volume of air
The bases however being almost empty receive most of the inhaled volume of air ,hence more ventilation in the basal area &less ventilation in apical area
When position is changed the areas of greatest ventilation also changed
Ventilation perfusion inequality occurs in diseased states
Three examples of possible relation are a)Physiologic dead space (normally aerated
alveoli with no capillary perfusion) b)physiologic shunt(normally perfuced
capillary with no alveolar aeration ) c)silent unit (non aerated alveoli next to a non
perfused capillary )
Positioning technique Lung volume is related to displacement of
diaphragm and abdominal contents Lung compliance decreases and work of
breathing increases progressively from standing to supine lying
Position affects VA/Q ratio ,VA & Q is greater in dependent lungs
Bad lung up ruleIt promotes comfort following thoracotomy or
chest drain placement Facilitates postural drainageHelps to improve lung volume when
atelectatic lung is positioned upper most to encourage expansion
With atelectasis the uppermost areas are stretched and better expanded
To optimize gases exchange a person with moderate unilateral effusion may benefit from side lying with affected side uppermost because both ventilation and perfusion are greater in lower lobe
Large effusion are more likely to show improved Pao2 with the effusion downwards to minimize compression of unaffected lung
Exception to the bad lung up rule
Recent pneumonectomy Large pleural effusion Broncho pleural fistula
Treatment administered to improve chest clearance – coughing
Techniques to improve cuff
Positioning for coughForced expiration stimulates coughPressure over extra thoracic trachea (supra sternal notch) elicit reflex cuffNuero muscular facilitation –intermittent
application of ice over paraspinal muscle 3-5 sec of thoracic spine
Reflex cuff are stronger than voluntarily produced
Cont..
Therapist should determine the phase or phases of cuffing are reducing its effectiveness ,when inspiration is too shallow, deep breathing or lateral costal expansion exercise is taught to patient
Bronchial hygiene technique-ACBTActive cycle of breathing originally called
Forced expiratory technique(FET)It was renamed to emphasize all of its
components It is a combination of breathing
control ,thoracic expansion and Forced expiratory technique
This combination is performed in cycle which is repeated until the huff is clear and dry
Forced expiratory technique Is popularly known as “huff” is forced
exhalation through an open mouth and glottis Properly performed this technique maximizes
airflow and minimizes airway collapse Huffing prior to coughing will optimize
airway clearance by moving secretions further up the airway
FET is recommended with all of the airway clearance technique
Gravity assisted position will be more effective
Percussion and vibration can be applied if desired
ACBT uses the concept of Equal pressure point theory(EPP)
Bronchial hygiene technique-Autogenic drainage
Autogenic drainage is a technique designed to mobilize secretions by breathing control rather than postural drainage
The goal of therapy is to reach the highest possible airflow in different generations of bronchi
This is achieved by breathing at three different levels and adjusting expiratory flow rates to avoid airway collapse
Mechanism
It consist of a cycle of huff from mid to low lung volume with deep breathing and relaxed abdominal breathing
During huffing or forced expiration the pleural pressure becomes positive and equals the alveolar pressure at a point along the airway called Equal pressure Point(EPP)
Towards the mouth from this point the transmural pressure gradient is reversed so that pressure outside the airway is higher than inside thus squeezing the air way by the process called Dynamic compression
Squeezing of airways mouth wards from this point mobilizes secretions
Cont..
At high lung volume the EPP is more proximal because pleural pressure decreases and alveolar elastic recoil increases
Location of EPP
Forced expiratory maneuver (huff or cuff)at low lung volume mobilizes secretions from alveoli
Forced expiratory maneuver at mid lung volume mobilizes secretion from lobar and segmental bronchi
Forced expiratory maneuver at high lung volume mobilizes secretions from larger airways ( trachea and main bronchi)
FEM in Low lung volume
EPP
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Alveoli
Upper respiratory way
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FEM in Mid lung volume
EPP
Alveoli + + +
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Upper respiratory way
FEM in High lung volume
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EPP
Alveoli
Upper respiratory way
Treatment administered to improve exercise tolerance –Raising resting respiratory levelResting respiratory level is the point at which the
tidal volume rests within the vital capacityIt is the point at which the elasticity or recoil of
the rib cage is in balance with the elasticity of the lung tissue
In emphysema portion of the lung shut down sooner than others , gross expiration obstruction occours at late expiration
Continuing expiration only increases muscle work while an ever decreasing amount of air is being moved
Positive Expiratory Pressure
Flutter valve therapy
Flutter is an expiratory device that ,in addition to positive pressure ,creates vibrations of the airways as a result of oscillating airflow and pressure ,these vibrations are thought to further aid in the loosening of mucus
Flutter
Flutter valve therapy
Acapella
It is new generation of vibratory PEP therapy ,which is similar to flutter with the benefits of PEP therapy and vibrations ,but is different as we can adjust the frequency and resistance by simply turning a dial
This unique feature makes it more user –friendly
Acapella
High frequency chest wall oscillationsHigh frequency chest wall oscillations utilizes a
mechanical device called the vestThis system is an air –pulse generator
connected to an inflatable vest worn by the patient
The vest oscillates the chest wall creating vibrations and air movement throughout the airways
This movement is described as “mini- coughs” and this action helps to loosen and move secretions
High frequency chest wall oscillations
Treatment administered to improve exercise tolerance –Raising resting respiratory levelResting respiratory level is the point at which the
tidal volume rests within the vital capacityIt is the point at which the elasticity or recoil of
the rib cage is in balance with the elasticity of the lung tissue
In emphysema portion of the lung shut down sooner than others , gross expiration obstruction occours at late expiration
Continuing expiration only increases muscle work while an ever decreasing amount of air is being moved
Breathing cycle is lifted between 200-300 ml from the obstructed point the ventilation will be more effective (greater airflow for less work)
Improved function & exercise tolerance can be achieved without altering the course of the disease
The relaxed expiratory phase is watched by the physiotherapist who directs the patient to begin the inspiration a little sooner in the respiratory cycle ,thus avoiding prolong expiration
The tidal volume is maintained ,thus it is not just the expiratory level which is raised but the whole respiratory level
This technique is designed to help the patients with airway obstruction due to emphysema ,it is also useful in helping to improve airflow during an episode of reversible airway obstruction
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