Methods of Chest Physical Therapy: Techniques and Benefits PDF

Methods of Chest Physical therapy By Dr. Shereen Hamed Afifi Associate Professor of Cardiopulmonary Physical Therapy  Chest Physical Therapy A valuable part of comprehensive respiratory care for both acute and chronic respiratory disorders. Therape...

Methods of Chest Physical therapy By Dr. Shereen Hamed Afifi Associate Professor of Cardiopulmonary Physical Therapy  Chest Physical Therapy A valuable part of comprehensive respiratory care for both acute and chronic respiratory disorders. Therapeutic measures may be curative or preventive.  General clinical problems of a patient with pulmonary disorders Impaired ventilation and oxygenation. Increased the work of breathing. Increased oxygen consumption. Impaired airway clearance. Impaired cough. Musculoskeletal dysfunction and postural abnormalities. Decreased exercise tolerance. Pain. The main goals are Improve ventilation. Improve the strength, endurance and coordination of respiratory muscles. Correct inefficient or abnormal breathing patterns. Teach the patient how to deal with shortness of breath attacks. Prevent pulmonary impairment.  Increase the effectiveness of the cough mechanism. Maintain and/or improve chest and thoracic spine mobility. Promote relaxation physically and mentally. Improve a patient overall functional capacity. Improve quality of life of these patients.  Respiratory treatment Proper management of a patient with respiratory problems requires an understanding of: The physiological derangements present. The effectiveness of a given treatment: The effectiveness of a given treatment must be measured by the suggested criteria  1- Treatment administered to increase ventilation and oxygenation Alveolar ventilation depends on the magnitude of: tidal volume (VT). dead space (DS). As: Alveolar ventilation = (VT – DS) × R.R. ** During normal breathing: Alveolar ventilation =(500 – 150) × 12 = 4200 ml/min. So, physical therapy strategies administered to increase ventilation should: Increase tidal ventilation. Decrease dead space ventilation. Or both. Decrease the arterial carbon dioxide tension (PaCo2). Increase the arterial oxygen tension (PaO2).  A - Positioning Techniques Supine Prone Lateral decubitus The changes in the positions may significantly alter arterial oxygenation. Changing in patient position depends on the Ventilation - Perfusion ( V/Q) ratio.  Ventilation – Perfusion ( V/Q) ratio At alveolar capillary level, the ventilation (V) and perfusion (Q) must be balanced so that optimal gas exchange occur. Optimal V/Q ratio equal 1 but this is theoretically as there are regional differences in ventilation and perfusion along different areas of the lungs. In general, these differences are due to the effect of gravity and intra-pleural pressure gradient, which is more negative at the upper part of the lung and less at the lower parts. On Supine position: The posterior aspects of the lungs is the most gravity– dependent areas and receive the most blood. On Standing: The bases of the lungs (gravity–dependent areas) receive the greatest amount of blood flow. When air is inhaled, the apices being almost full at the onset of inhalation, receive very little of new volumes of air. The bases being almost empty, receive most of the inhaled volumes of air. *** When the position is changed, areas of greatest ventilation also changed.  B -Breathing Retraining Breathing exercises (retraining) are designed to retrain the muscles of respiration and improve ventilation and oxygenation.  Muscles of respiration Muscles of inspiration: Main: Diaphragm. Accessory: as, SCM, pectoralis major, upper fibers of trapezius. Muscles of expiration: Relaxed: passive process. Forced :Abdominal muscles and internal intercostal muscles. Indications of breathing retraining – Acute or chronic lung disease. – Pain in the thoracic or abdominal area. – Airway obstruction secondary to bronchospasm or retained secretions. – Deficits in CNS that leads to muscle weakness. – Severe orthopedic abnormalities, e.g. scoliosis. – Stress management.  Goals of breathing retraining Improve ventilation function. Improve the strength, endurance and coordination of respiratory muscles. Increase the effectiveness of cough mechanism. Prevent atelectasis. Correct inefficient or abnormal breathing pattern. improve the position and function of respiratory muscles. Control the respiratory rate and breathing patterns thus decreasing air trapping. Maintain or improve chest and thoracic spine mobility. Promote relaxation by decreasing the work of breathing.  Types of breathing retraining techniques Diaphragmatic breathing: Benefits: – Improve diaphragmatic excursion. – Improve distribution of ventilation. – Increase total ventilation. – Eliminate the activity of accessory muscles. – Increase rib cage motion. **Technique. **Resisted diaphragmatic breathing. Pursed-lips breathing Benefits:  Slow the respiratory rate.  Reduction in airway narrowing during expiration. Technique: – Sit relaxed. – Inhale through nose while mouth is closed. – Purse lips. – Breathe out through pursed lips. – Breathe out twice longer as breathing in. – Ensure relaxed expiration (No contraction of abdominal muscles). Nose breathing: Benefits: To stimulate and strength diaphragm and intercostal muscles. Graduations.  Segmental (Localized) breathing: Benefits: Expand localized areas of the lungs. Prevent accumulation of pleural fluid. Prevent accumulation of tracheobronchial secretions. Improve chest mobility. Types: 1. Apical breathing. 2. Lateral costal (upper, middle, lower) breathing. 3. Posterior basal breathing. 4. Sternal breathing. Functions of the hands: 1. Guide. 2. Assistance. 3. Resistance. **Techniques.  Belt breathing exercise Belt: Length:1.5-2 m. Width:25-35cm. Uses: Post-operative. Home program. Technique:  Sustained Maximal breathing Breathing exercise during which hold for about 3 seconds at maximal inspiration is encouraged. Benefits: Slow respiratory rate.  Breathing exercise connected with postural exercise Benefits: Maintain or improve the mobility of the trunks and shoulders when it affects respiration. Reinforce or emphasize the depth of inspiration or expiration. Examples.  Breathing control techniques (Paced breathing) Benefits: Reduce the work of breathing during activity. Increase the breathing control. Technique: Walking: inhale two steps, then exhale four steps. Up stairs: exhale as stepping up, then inhale and rest before the next step. Pushing or pulling: exhale. Lifting: exhale. From lying to sitting to standing: exhale.  Monitoring of treatment to improve ventilation and oxygenation Arterial blood gases: Increase PaO2. Decrease PaCo2. 2-Treatment administered to reduce the O2 consumption There are two strategies to reduce the O2 consumption by: Reducing the work of breathing. Reducing the general body work.  1-Reduce the work of breathing By: Breathing exercises and Leaning forward postures: to decrease the rate of breathing and eliminate activity of accessory muscles.  2- Reduce the general body work By: 1-Relaxation therapy. 2- Work adjustment.  All the treatments administered to reduce the O2 consumption working by Reduce the basal metabolic rate. Minimize the unsupported body position. Minimize the antigravity work. Benefits of treatment to reduce O2 consumption: Elevate dyspnea threshold for a given activity. Elevate functional activity tolerance. Improve quality of life.  Relaxation Therapy **Definition: It is a state in which physical and mental stresses are reduced as much as possible.  Signs of tension and strain Appearance: hypertonic muscles. Mannerism: bite fingers. Restriction in joint flexibility. Restriction in breathing. Poor circulation and digestion. Pain: tension headache. Over activity and irritability. Insomnia. Sources of stress: Environment Individual Types of relaxation: Physical. Mental.  How to gain mental relaxation? The patient should lie in quiet room with quiet color in a suitable temperature. He should be well supported on a wide mattress. No tight clothes. Covered by light sheet. Try to fill his mind to forget his problems. Types of physical relaxation: General: for the body as a whole. Local: for specialized area. How to gain physical relaxation: 1- Positioning: using modifications of fundamental positions. 2- Exercises: Jacobsen's progressive relaxation technique.  Methods of gaining relaxation Hydrotherapy. Total suspension. Massage. Rhythmic passive movement. Cold immersion.  How to test relaxation Palpation of muscle tone. Inspection. Passive movement. Vital signs.  3- Treatment administered to improve the secretion clearance 1-Effective cough The normal cough mechanism Deep inspiration. Glottis closure and tightness of vocal cords. Abdominal muscles contraction and elevation of diaphragm which causes an increase in intra-abdominal and intra-thoracic pressure. Glottis opens. Sudden forced expiration of air. Each cough occurs through the stimulation of a complex reflex arc. This is initiated by the irritation of cough receptors which are found in the trachea, main carina, branching points of large airways, and more distal smaller airways; also, they are present in the pharynx. Laryngeal and tracheobronchial receptors respond to both mechanical and chemical stimuli. The cough reflex arc is constituted by: 1. Afferent pathway: Sensory nerve fibers (branches of the vagus nerve) located in the ciliated epithelium of the upper airways and cardiac and esophageal branches from the diaphragm. 2. Central Pathway (cough center): a central coordinating region for coughing is located in the upper brain stem and pons. 3. Efferent pathway: Impulses from the cough center travel via the vagus, phrenic, and spinal motor nerves to diaphragm, abdominal wall and muscles.  Factors that decrease the effectiveness of cough mechanism 1- Inability of the patient to take deep inspiration due to: - Pain. -Weakness of the diaphragm and accessory muscles of inspiration. 2- Inability of the patient to forcibly expel the air caused by: - Spinal cord injury above T-10. - Tracheostomy. - Critical illness that causes excessive fatigue. 3- Decrease in normal ciliary action in the bronchial tree secondary to: - General anesthesia and intubation. - COPD. - Smoking. 4- increase in the amount and viscosity of the mucus due to: - Cystic fibrosis and Chronic bronchitis - Dehydration.  Techniques to improve cough Positioning: sitting with leaning forward and arms supported. Forced expiration or huffing. Pressure applied to: – Trachea to elicit cough reflex. – Mid-rectus abdominis after inspiration. – Along the lower costal borders during exhalation. Mechanical stimulation and suctioning. Splinting. Neuromuscular facilitation: intermittent ice application for 3 to 5 seconds along the thoracic para-spinal areas. Monitoring of treatment to improve cough – X-rays. – Pain. – Sputum culture. – Respiratory rate. – Load on accessory muscles of respiration.