Pulmonary Rehabilitation Techniques

Pulmonary Rehabilitation

• Focuses on manual techniques for pulmonary rehabilitation.

Manual Techniques

• Percussion: Aids in mobilizing secretions through mechanical oscillations on the chest wall.
• Frequency: 100-480 Hz.
• Intensity: Varies per individual.
• Timing: During inspiration and/or expiration, after 3-4 thoracic expansion exercise cycles.
• Duration: Maximum 30 seconds for non-cooperative patients.
• Should not be uncomfortable.
• Hand application: Commonly applied using both hands.
• Single-handed use: For neonates, pediatric age groups, small chest areas; self-percussion is also noted.

Indications of Percussion

• Lung abscess
• Cystic fibrosis
• Bronchiectasis
• Difficulty clearing secretions
• Excessive sputum production (25-30 ml/day in adults)
• Atelectasis due to mucus plugs
• Foreign body in the airways

Contraindications of Percussion

• Massive hemoptysis
• Severe osteoporosis
• Rib fractures
• Pulmonary thromboembolism
• Patients with clotting problems or fat embolism
• Patients undergoing dialysis
• Over tumor tissues
• Over painful areas

Cardiovascular Conditions Requiring Caution

• Chest pain
• Unstable angina
• Hemodynamic instability
• Low platelet count (thrombocytopenia)
• Anticoagulant therapy
• Unstable and potentially fatal dysrhythmias

Orthopedic Conditions Requiring Caution

• Osteoporosis
• Long-term steroid therapy
• Osteomyelitis
• Osteogenesis imperfecta (impaired bone development)
• Spinal fusion
• Rib fracture, flail chest

Pulmonary Conditions Requiring Caution

• Bronchospasm
• Hemoptysis
• Severe dyspnea
• Untreated lung abscess
• Pneumothorax
• Pneumonia or other infection conditions
• Immediately after chest tube removal
• Pulmonary embolism

Oncological Conditions Requiring Caution

• Cancer metastases to ribs and vertebrae
• Carcinoma in the bronchus
• Removable tumor

Other Conditions Requiring Caution

• New skin grafts
• Burns
• Open chest wounds
• Thoracic skin infections
• Subcutaneous emphysema
• Immediately after cataract surgery

Vibration

• Applied to affected lung segments.
• Applied during expiration.
• Uses both hands stacked, fingers open, lower hand on thorax.
• Elbows straight
• Palmar surfaces of hands on chest wall.
• Body weight utilized.
• Performed after 3-4 thoracic expansion exercise cycles

Shaking

• Effects: Accelerates expiratory airflow, facilitates mobilization of secretions.
• Contraindications: Osteoporosis, metastatic conditions affecting ribs and vertebrae.

Other Techniques

• Coughing
• Huffing
• Forced expiration
• Active respiratory techniques cycle

Coughing

• Physiotherapists can improve weak coughs by teaching good technique to enhance volume and compression, or stimulate cough reflex.
• This is often needed after surgery and chest splinting may be required.
• The patient performs inspiration, closes the glottis, and contracts abdominal, perineal, gluteal, and shoulder depressor muscles, usually no more than 2 times per expiratory phase.
• Positions are important to support this process (sitting, leaning, laying).

Coughing Positions

• Various positions are depicted in the slides.

Cough Enhancement Techniques

• Positioning: Leaning forward, neck flexed, supported by arms, feet on the ground.
• Forced Expiration ("Huffing"): Stimulates pulmonary mechanoreceptors, initiating reflex coughing.
• Pressure Application: Applying pressure to the extrathoracic trachea, rectus abdominis after inspiration, or lower costal margins during exhalation can enhance cough efficacy.
• Hand Ventilation: Respiratory (inspiratory) flow rates from manual ventilator stimulate pulmonary mechanoreceptors, triggering reflex coughing.
• Mechanical Stimulation: Direct mechanical stimulation can also induce reflex coughing.
• Neuromuscular Facilitation: Paraspinal ice application to thoracic vertebrae for 3-5 seconds (intermittently) can initiate coughing. The use of ice should be carefully selected and closely monitored due to potential hypertension risks.

Controlled Coughing

• Deep breath, followed by quick, effective cough by contracting abdominal muscles.
• Useful for surgical patients.
• Glottis is closed.

Huffing

• Glottis is open.
• Command: "Take a breath, exhale rapidly."
• Inspiration depth varies based on the target region.

Active Respiratory Techniques Cycle

• Combination of techniques to clear secretions.
• Promotes proper breathing pattern, minimizes fatigue.
• Prevents bronchospasm and hypoxemia.
• Flexible and adaptable.

Active Respiratory Techniques Cycle (Continued)

• TEE (Thoracic Expansion Exercises): Listed as a component of the cycle.
• BC (Breath Control): Listed as a component.
• FET (Forced Expiratory Technique): Component, potentially involving huffing or other forced expiration.
• Repeating this cycle is recommended but tolerance is key.

Autogenic Drainage

• Controlled breathing technique regulating respiration, speed, depth, and localization.
• Used for patients with muscle disorders (especially those with AD pathology) to clear mucus, improve ventilation, and maintain chest wall mobility.
• Used in various conditions affecting lung function. (cystic fibrosis, chronic bronchitis, asthma, bronchiectasis, atelectasis, kyphoscoliosis, muscular dystrophy, postoperative conditions).
• Aims to provide highest airflow without causing airway collapse.
  • Applied in Belgium and Germany with different approaches.
• Belgium Technique: Inhalation via nose, glottis opening, holding breath for 2-3 seconds, exhaling with an open mouth.
  • Three Phases: dissolving mucus, accumulation, and transfer to mouth.
• German Technique (two-phase): Breathing from middle tidal volume, holding breath for 2-3 seconds at end of inspiration, passive expiration followed by active expiration.

Manual Assisted Cough

• Various types depicted including: anterior thorax assisted, cost-a-frenic assisted, Heimlich type, self-coughing, and mechanical support. Methods for supporting coughing are presented.

This quiz covers manual techniques used in pulmonary rehabilitation, focusing primarily on percussion methods. It discusses the frequency, intensity, timing, and indications for use, as well as contraindications that should be considered when administering these techniques. Ideal for healthcare professionals and students learning about respiratory health.