Pulmonary rehabilitation in a patient with disturbed airway

clearance

Sema SavcıPT, PhD, Prof

H.U. School of Physical Therapy Rehabilitation

Respiratory mechanics

Air flow

• Airway resistance

• Elastic recoil pressure

• Bronchial wall stability

• Mucus reology

• Ciliary beat and frequency

• Dynamic compression

Respiratory muscles Collateral ventilation

Airway clearance disorders

Altered mucus rheology (cystic fibrosis)

Altered mucociliary clearance (primer ciliar dyskinesia)

Structural defects (bronchiectasis)

Abnormal cough mechanisms (muscle weakness)

Goals of airway clearance

Maintainance of airway patency V/Q matching work of breathing oxygenation

Airway clearance techniques

Postural drainage and positioning Percussion, vibration and shaking Huffing, cough, forced expiration technique Active cycle of breathing techniques Autogenic drainage Positive expiratory pressure (PEP) therapy High frequency chest wall oscillations (VEST, Hayek) Intrapulmonary percussive ventilation (IPV) Exercise (aerobic, peripheral & respiratory muscle

training)

Postural drainage Use of gravitational forces

to promote mucus transport to central airways

12 positions: 5-10 min each

Modify positions to optimize patient tolerance & comfort

Never head down: ICP > 20, GER, risk of aspiration, orthopnea, hemodynamic instability

Percussion (clapping)

Clapping external thorax directly over lung segment being drained

Transmission of oscillatory forces to bronchi

Vibration & shaking

Manual oscillatory actions on expiration only in the direction of normal movement of the ribs

Fine movement: vibration

Coarse movement: shaking

Huffing & cough Huffing: modified

forced expiratory breaths-open glottis

Coughing: controlled cough-closed glottis

Equal pressure points

Forced expiration technique

Active cycle of breathing techniques

Breathing control: stabilizes airways

Thoracic expansion exercises (TEE): collateral ventilation

Forced expiration techniques: helps mobilize secretions

ACBT+NIMV, lenght of MV (1,7 days) length of stay in ICU (1,3 days) PaCO2 more stable

Austr J Physiother 2004.

Autogenic drainage

Utilizes expiratory air flow at various lung volumes to mobilize secretions

Three stages:

• Unstick

• Collect

• Evacuate

COPD(n= 30) 20 days, ACBT and AD Pulmonary function Secretion mobilization

Positive expiratory pressure (PEP)

Clears secretions in occluded airways by increasing collateral ventilation

Utilizes airway stabilization

Allows air to get behind secretions

Flutter ve Acapella

Utilizes internal expiratory vibrations

Oscillating endobronchial pressure clears mucus from small airways

PEP

To compare short-term effects of flow dependent PEP, flow independent PEP and ACBT

Stable cystic fibrosis patients(n=25, 6-17years) PFT, SaO2 dyspnea and fatigue perception were

evaluated Flow independent threshold PEP improved large and

middle airway function

To compare the short – term effects of PEP, CPAP and NPPV in cystic fibrosis patients with severe airway obstruction.

Wet and dry sputum weight, SaO2 and PFT were evaluated. Each patient received each treatment twice a day for consecutive days.

The highest sputum wet weight was produced with PEP treatment.

After mask PEP these patients felt more tired than after CPAP or NPPV.

To evaluate the acute efficacy and tolerability of Flutter, ACBT ve ACBT + PD in bronchiectatic patients (n=36)

Sputum wet weight for ACBT+PD was twice that either ACBT or flutter

Patient preference was

• 44% for Flutter, 22% ACBT, 33%ACBT+ PD

ACBT was superior in terms of acute efficacy.

High frequency chest wall oscillations (Hayek oscillator & VEST)

Generates increased airflow velocities via oscillation of chest wall

High airflow velocities create repetitive cough like shear forces

Shear forces decrease viscosity of secretions

Expensive Prefer mentally retarded

patients

Intrapulmonary percussive ventilation

Inhalation therapy High frequency puff

open atelectatic alveoli

Respiratory muscle training

Respiratory muscle endurance and strenght

Cough efficiency

Intensity: Pımax 30%Duration : 30 min/dayFrequency: 5 days/week

Mekanical IN-EXSUFFLATION

inhalation volume. lung recoil pressure Use in patients with

respiratory muscle weakness

DMD patients, Peak cough flow rate < 160 L/min Mechanical IN-EXSUFFLATION

• Prevent hospitalization need for tracheostomy

Exercise training

Essential component. exercise capacity. oxidative capacity in

peripheral muscle Mediator release in the

airway ventilation

To investigate the effects of heavy resistance training (RT) in the elderly males with COPD (n=18, 65-80 years)

Cross sectional area of quadriceps asssessed by MRI Isometric-isokinetic knee extension, isometric trunk strength, leg

extension power, stair climbing time, normal and max gait speed on a 30 m track.

RT performed twice a week for 12 weeks. Significant improvements in muscle size, knee extension

strength, leg extension power and functional performance in elderly male COPD patients.

ES

To evaluate whether ES was a beneficial tecnique in the rehabilitation programs for severely deconditioned COPD patients after acute exacerbation.

17 COPD patient participated in this study (FEV1, 30 3% pred, BMI 18 2.5 kg/m2)

usual rehab (UR) (n=8) , UR +ES (n=9) program for 4 weeks QMS, exercise capacity and HRQoL were measured before and

after rehabilitation.

Chest 2006; 129:1540-1548.

Conclusion

Airway clearance techniques should be used in patients with disturbed airway clearance.

Patients’ age, cooperation, social status, and compliance should be considered when choosing the method.

Exercise training is essential component of PR. Aerobic exercise training, peripheral and respiratory

muscle training should be included in PR program.

Sonuçlar

Number of patients

Controlled study

Different pathologies

Patient preference