Physiotherapy Methods for Pulmonary Rehabilitation PDF

Physiotherapy Methods for Pulmonary Rehabilitation (Chest P.T) BY Dr. Mohamed Taha Said Assistant Professor of Physical Therapy for Cardiovascular/Respiratory Disorder and Geriatrics. Aqaba University of Technology, Jordan  Introdu...

Physiotherapy Methods for Pulmonary Rehabilitation (Chest P.T) BY Dr. Mohamed Taha Said Assistant Professor of Physical Therapy for Cardiovascular/Respiratory Disorder and Geriatrics. Aqaba University of Technology, Jordan  Introduction Chest physical therapy is the area of practice that deals with evaluation and treatment of patients with acute and chronic lung disorders. It is a valuable part of comprehensive respiratory care. Therapeutic measures may be curative or preventive. 2  What is the respiratory system? Respiratory system is the organs and structures in the body that allow to breathe. It includes nose, mouth, lungs and the tubelike structures (airways) that connect them. You also have muscles and blood vessels that support the respiratory system, and ribs to protect it. These parts work together to bring oxygen into the body when inhaling and getting rid of carbon dioxide when exhaling.  What is the main function of your respiratory system? ❖ The main function of your respiratory system is to pull in oxygen for your body’s cells and get rid of carbon dioxide, a waste product. You do this by breathing in and out and through gas exchange between the small air sacs of your lungs (alveoli) and the blood vessels running nearby. ❖ Your respiratory system also: A. Warms and adds moisture to the air we breathe in. The respiratory system warms the air to match body temperature. It moisturizes the air to bring it to the humidity level that the body needs. B. Protects the body from particles breathed in. Parts of the respiratory system can block harmful germs and irritants from getting in — or push them out if they do get in. C. Allows to talk. Air vibrates vocal cords, which makes sounds. D. Helps to smell. Breathing in air moves its molecules past your olfactory nerve, which sends messages to the brain about the way something smells. E. Balances level of acidity in the body. Too much carbon dioxide lowers the blood’s pH, making it acidic. By removing carbon dioxide, your respiratory system helps maintain the acid-base balance in the body.  The process of pulmonary ventilation. Breathing, also known as pulmonary ventilation, is the movement of air into and out of the respiratory system. At rest, a normal adult breathes about 16 times per minute, and approximately 500 milliliters (0.5 L) of air are exchanged with the atmosphere per breath. The airflow exchange is caused by the muscular actions associated with inhalation and exhalation, as well as by differences in atmospheric air pressure and lung (intrapulmonary) air pressure. Gases are exchanged in the following cycle: Oxygen in the atmospheric air is drawn into the lungs by inhalation. Oxygen is transported to the body cells from the lungs by blood circulating through the cardiovascular system. Cells use the oxygen and generate carbon dioxide as a waste product. Blood transports the carbon dioxide from the body cells to the lungs. Carbon dioxide is added to the atmosphere during exhalation  Lung Diseases Overview Lung diseases are some of the most common medical conditions in the world. Smoking, infections, and genes cause most lung diseases. Lungs are part of a complex system, expanding and relaxing thousands of times each day to bring in oxygen and send out carbon dioxide. Lung disease is any problem in the lungs that prevents the lungs from working properly.  Types of lung disease I. Lung Diseases Affecting the Airways II. Lung Diseases Affecting the Air Sacs (Alveoli) III. Lung Diseases Affecting the Interstitium (Lung tissue diseases) IV. Lung Diseases Affecting Blood Vessels V. Lung Diseases Affecting the Pleura VI. Lung Diseases Affecting the Chest Wall I. Lung Diseases Affecting the Airways Your windpipe (trachea) branches into tubes called bronchi, which in turn become smaller tubes throughout your lungs. These diseases affect the tubes (airways) that carry oxygen and other gases into and out of the lungs. They usually cause a narrowing, resistance and blockage of the airways. Diseases that can affect these airways include: ❖ Asthma ❖ Chronic Obstructive Pulmonary Disease (COPD) A- Bronchitis B- Emphysema. ❖ Cystic fibrosis.  Lung Diseases Affecting the Airways 1- Asthma − Is a chronic respiratory disease that can be caused by genetics and environment factors like allergens. − Asthma never goes away, but you can control it with medications like steroid inhalers. − When asthma flares up, it's called an asthma attack. These attacks are caused by inflammation and the narrowing of your airways that make it harder to breathe.  Lung Diseases Affecting the Airways 2- Chronic Obstructive Pulmonary Disease (COPD) − Chronic obstructive pulmonary disease (COPD) is a group of conditions that cause breathing problems that get worse over time. The two types of COPD chronic bronchitis and emphysema. A- Bronchitis Bronchitis is the inflammation of your bronchial tubes. When these tubes are inflamed because of acute infection or chronic irritation, the airway can narrow and fill with mucus, making it more difficult to breathe. Bronchitis can be classified as follows: I. Acute bronchitis is often caused by a viral or bacterial infection. It can take a few weeks to recover from this type of bronchitis. II. Chronic bronchitis is caused by long-term exposure to irritants like air pollution, industrial chemicals, or cigarette smoke. ˗ There are medications that can help expand your airway, but chronic bronchitis cannot be cured and usually gets worse over time.  Lung Diseases Affecting the Airways B- Emphysema. − Emphysema is a disease that develops when the alveoli that move gases between the air you breathe, and your blood are destroyed. The tiny sacs are delicate and elastic, and long-term exposure to irritants like cigarette smoke and pollution or chemicals can damage them. − Medications and supplemental oxygen are treatment options for emphysema, but there is no cure for the condition, and it usually gets worse as time goes on. 3- Cystic fibrosis. − Cystic fibrosis (CF) is an inherited disorder that causes severe damage to the lungs, digestive system and other organs in the body. − Cystic fibrosis affects the cells that produce mucus, sweat and digestive juices. These secreted fluids are normally thin and slippery. But in people with CF, a defective gene causes the secretions to become sticky and thick. Instead of acting as lubricants, the secretions plug up tubes, ducts and passageways, especially in the lungs and pancreas.  II. Lung Diseases Affecting the Interstitium (Lung tissue diseases) With lung tissue diseases, parts of lung tissues are damaged—for example, by scarring or another injury. This subgroup of diseases is sometimes called interstitial lung disease. Regardless of the cause, the damage to lung tissue can make it harder for the body to move oxygen and other gases in and out of your blood. Without fresh oxygen in the blood, the tissues in the brain and heart can be damaged quickly. 1. Pulmonary fibrosis: is a type of interstitial lung disease in which the tissues deep in the lungs become scarred, making them thick and stiff. Certain diseases, medications, and environmental pollutants can cause this scarring. 2. Sarcoidosis: is a condition that causes inflammation that can affect lungs, skin, and lymph nodes. The cause of sarcoidosis is unknown, but certain groups of people are more at risk than others.  III. Lung Diseases Affecting Blood Vessels The right side of your heart gets low-oxygen blood from veins. It pumps blood into lungs through the pulmonary arteries. These blood vessels can have diseases, as well. ❖ Pulmonary embolism(PE). A blood clot (usually in a deep leg vein, called deep vein thrombosis) breaks off, travels to the heart, and gets pumped into lungs. The clot sticks in a pulmonary artery, often causing shortness of breath and low blood oxygen levels. ❖ Pulmonary hypertension. Many conditions can cause high blood pressure in pulmonary arteries. This can lead to shortness of breath and chest pain. If the cause can’t be found, they’ll be called idiopathic pulmonary arterial hypertension.  IV. Lung Diseases Affecting the Pleura The pleura is the thin lining that surrounds the lung and lines the inside of your chest wall. A tiny layer of fluid lets the pleura on lung's surface slide along the chest wall with each breath. Lung diseases of the pleura include: ❖ Pleural effusion. Fluid collects and increase in the space between lung and the chest wall. Pneumonia or heart failure usually causes this. Large pleural effusions can make it hard to breathe and may need to be drained. ❖ Pneumothorax. Air may get into the space between chest wall and the lung, collapsing the lung. ❖ Mesothelioma. is a rare condition that involves tumors growing in the mesothelium {which forms the lining of several body cavities: the pleura, pericardium and the perimetrium ‶the outer serous layer of the uterus″}. This tissue covers the lungs, the heart, as well as forming a cavity for the abdomen and those organs. Malignant pleural mesothelioma (affecting the chest and lungs) is the most common type.  Pleura and Pleural Cavities Pleural Membranes. The serous membranes associated with the lungs are called the pleura. The parietal pleura lines the inner surface of the thoracic cavity, and the visceral pleura covers the outer surface of the lungs. The thin space between these layers is called the pleural cavity.  V. Lung Diseases Affecting the Chest Wall Chest wall also plays an important role in breathing. Muscles connect ribs to each other, helping the chest to expand. The diaphragm descends with each breath, also causing chest expansion. Diseases that affect chest wall include: ❖ Obesity hypoventilation syndrome. Extra weight on the chest and belly can make it hard for the chest to expand. This may cause serious breathing problems. ❖ Neuromuscular disorders. Breathing trouble when the nerves that control respiratory muscles are affected. In neuromuscular disease (NMD), respiratory muscle weakness (RMW) is common, and death often results from respiratory failure. Amyotrophic lateral sclerosis and myasthenia gravis are examples of neuromuscular lung disease.  Lung volumes and compliance Remember These Terms Tidal Volume (TV) = volume of air entering the lung (inspiration) or the volume of air leaving the lung (expiration). [approx. 0.5L but depends on body size)]. Inspiratory Reserve Volume (IRV) = maximal amount of air that can be inspired above tidal volume. [approx. 3L]. Expiratory Reserve Volume (ERV) = maximal volume of air expired after normal expiration. [approx. 1.5L]. Residual volume (RV) = the volume of air remaining in the lungs after maximum forceful expiration. [approx. 1L]. Can not be measured with a spirometer. Functional Residual Capacity (FRC) = volume remaining in the lung after a normal expiration. [approx. 2.5L]. Decreases if chest muscles are weak ERV+RV Vital capacity (VC) = the maximal amount of air that a person can expire after maximal inspiration. VC = TV + IRV +ERV.  General clinical problems of a patient with pulmonary disorder 1. Impaired ventilation and oxygenation. 2. Increased work of breathing. 3. Increased oxygen consumption. 4. Decreased exercise tolerance. 5. Impaired cough mechanism. 6. Impaired airway clearance. 7. Musculoskeletal dysfunction and postural abnormalities. 8. Pain.  Goals of treatment 1. Improve ventilation and oxygenation. 2. Reduce work of breathing. 3. Decrease oxygen consumption. 4. Improve the strength, endurance and coordination of respiratory muscles. 5. Improve endurance and exercise tolerance. 6. Improve airway clearance. 7. Prevent airway obstruction and accumulation of secretions. 8. Maintain or improve chest mobility.  Goals of treatment (cont.) 9. Improve cough effectiveness. 10. Prevent pulmonary impairment. 11. Prevent or correct postural deformities associated with respiratory disorders. 12. Promote relaxation, physically and mentally. 13. Decrease pain. 14. Teach the patient how to deal with shortness of breath attacks. 15. Improve patients’ functional capacity. 16. Improve quality of life of these patients.  Methods of treatment Breathing exercises. Positioning techniques. Postural drainage. ACB, Autogenic drainage, PEP, Flutter, Acapella, High frequency chest wall oscillations. Assistive coughing. Relaxation. Stretching positions. Endurance exercise. Electrotherapeutic modalities.  Methods of PT to reach specific goals 1- Treatment administered to increase ventilation & oxygenation: a) Breathing exercises b) Positioning technique c) Using devices to assist or resist breathing. 2- Treatment administered to reduce O2 consumption: a)To reduce work of breathing b)To reduce general body work  Methods of PT to reach specific goals 3- 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. 4- Treatment administered to improve exercise tolerance (endurance exercise). 5- Treatment administered to reduce pain (Pain-relieving electrotherapy modalities)  Treatment administered to increase ventilation & oxygenation Physiotherapist aim is to increase tidal volume or decrease dead space or both. Tidal volume can be increased by breathing exercise Dead space can be decreased by proper positioning technique.  Breathing exercise Goals:- 1. Improve ventilation 2. Increase the effectiveness of cough and promote airway clearance 3. To prevent post operative pulmonary complications 4. To improve the strength endurance coordination of the muscles of ventilation 5. Maintain and improve chest and thoracic spine mobility 6. Promote relaxation and relive stress 7. To teach the patient how to deal with episodes of dyspnea 8. Assisting in removal of secretions. 9. Correct abnormal breathing patterns and decrease the work of breathing.   Breathing exercise Indications :- 1. Acute or chronic lung disease. 2. Pain in the thoracic or abdominal area. 3. Airway obstruction secondary to bronchospasm or retained secretions. 4. Deficits in the central nervous system that lead to muscle weakness. 5. Severe orthopedic abnormalities (scoliosis). 6. Stress management.   Breathing exercise  Inspiration is done through nose and expiration through mouth  Inspiration through nose has the following advantages: 1. It acts as a filter to prevent dust and other particles from getting into the lungs, 2. It warms the air 3. It moisturizes the air before getting into the lungs. 4. It prevents gas from getting into the stomach 5. It naturally controls the intensity of breathing by controlling the correct balance of oxygen and carbon dioxide.   Breathing exercise 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 must perform the chest manipulations.   Breathing Exercises General principles:- 1. If possible, choose a quiet area for instruction. 2. Explain to the patient the aims and rationale of breathing exercises. 3. Place the patient in a comfortable position and loosen restrictive clothes. 4. Initially a crook lying position in bed with trunk and head approximately 45 degrees, flexing hips and knees with pillows to relax abdominal muscles. 5. Observe and evaluate the patient natural breathing pattern. 6. Demonstrate the desired breathing pattern to the patient. 7. Have the patient practice the correct breathing pattern in a variety of positions at rest and with activity.  Breathing Exercises Precautions:- Never allow patient to force expiration. Do not allow patient to prolong expiration. Do not allow the patient to initiate inspiration with accessory muscles and the upper chest. Allow the patient to practice deep breathing for only 3-4 inspirations and expirations at a time to avoid hyperventilation.  Types of Breathing Exercise I. Nose breathing exercise. II. Diaphragmatic breathing (relaxed, resisted) III.Pursed lip breathing IV. Segmental breathing (costal expansion exercise) A. Apical breathing B. Lateral costal expansion C. Posterior basal expansion D. Sternal breathing V. Breathing exercise connected with postural exercise. VI. Buteyko Breathing Technique (BTT).  Types of Breathing Exercises I. Nose breathing exercise: Nose exercise: 1-Vibration beside the nose (stimulation). 2- Feel the air at the tip of nose (relaxed breathing). 3- Smelling (deep breathing). 4-Place your right thumb on your right nostril. Inhale through your left nostril. 5-Place your right ring finger on your left nostril. Exhale through your right nostril. 6-Inhale through your right nostril. 7-Return your right thumb to your right nostril. Exhale through your left nostril. This completes one set. 8- Repeat for 5 minutes. 9- Shaking (closure of both nostrils). 10- Sniffling (short interrupted breathing to stimulate diaphragm) 11- Snuffling (deep long breathing to strengthen diaphragm) 12- Vibration beside the nose (relaxation). II. Diaphragmatic breathing (relaxed, resisted) Re-education of diaphragm As 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  Diaphragmatic breathing exercise The semi reclining (as shown) and semi-Fowler’s positions are comfortable, relaxed positions in which to teach diaphragmatic breathing.  Resisted diaphragmatic breathing Manual resistance by therapist over the abdomen. Placing appropriate weight over abdomen. By slightly elevating the foot end of the bed.  Physiological outcomes of diaphragmatic breathing Increase tidal ventilation Improve ventilation and oxygenation Decrease respiratory rate Eliminates accessory muscle activity Reduces work of breathing Improve distribution of ventilation Reduces the incidence of post operative pulmonary complications  III. Pursed lip breathing Uses of pursed lip breathing 1. Improves ventilation 2. Releases trapped air in the lungs 3. Keeps the airways open longer and decreases the work of breathing 4. Prolongs exhalation to slow the breathing rate 5. Improves breathing patterns by moving old air out of the lungs and allowing for new air to enter the lungs 6. Relieves shortness of breath 7. Causes general relaxation 8. It can be applied as a 3-5 minutes “rescue exercise” or an emergency procedure to counteract acute exacerbations or dyspnea in COPD and asthma 9. Pursed-lip breathing reduces hyperventilation-induced broncho- constriction. IV. Segmental breathing (costal expansion exercise) A)- Apical costal expansion (for apical lobes) B)- Lateral costal expansion (for middle and lingular lobes). C)- Posterior basal expansion(for lower lobes) D)- Sternal breathing  Advantages of segmental breathing (indication) Prevent accumulation of pleural fluid Prevent accumulation of secretions Decreases paradoxical breathing (Paradoxical breathing occurs when the chest wall or the abdominal wall moves in when taking a breath and moves out when exhaling. This is the opposite of normal breathing movement) Decrease panic(a brief episode of intense anxiety, which causes the physical sensations of fear) Improve chest mobility  Self resistance technique When using this technique patient should not elevate his shoulder or achieve costal expansion by side flexion of spine. V. Exercise connected with breathing  VI. Buteyko Breathing Technique Used mainly to normalize CO2 level in the body. Indicated in many cases as bronchial asthma, COPD,.etc. (reduces hyperventilation)  Buteyko Breathing Technique: (BBT): is a breathing technique which help people with , asthma , smoking related diseases& sleep apnea. This method doesn’t cure asthma, but it can improve asthma symptoms, quality of life & reduce bronchodilator requirement. It provides you with the skills to breath correctly. Indications: Asthma, anxiety, bronchitis, emphysema, hyper ventilation, persistent cough, sleep apnea and sinusitis  Buteyko Breathing Technique: (BBT): Procedure: 1. Sitting down, close your mouth & breath normally through the nose for 30 sec. 2. Take a normal breath in through your nose. 3. Try to relax your respiration muscles. 4. Spend a few minutes breathing normally. 5. Follow the instructions for the Buteyko breathing Control Pause (for beginners) or the Maximum Pause (for those with more practice).  Buteyko Breathing Technique: (BBT): Control Pause: 6. After your last exhale, hold your breath. 7. Plug your nose using your index finger and thumb. 8. Try to hold your breath until you feel the urge to breathe, then let go of your nose and inhale. 9. Breathe as you normally would for 10 seconds. 10. Repeat these steps as many times as desired. Maximum Pause: 11. After your last exhale, hold your breath. 12. Plug your nose using your index finger and thumb. 13. Try to hold your breath for as long as possible, aiming for around double the length of the Control Pause. 14. Once you begin to feel uncomfortable, let go of your nose and allow yourself to inhale. 15. Breathe as you normally would for 10 seconds. 16. Repeat these steps as many times as desired Thank you 46