Pulmonary Rehabilitation Lesson PDF

P U L M O N A RY R E H A B I L I T AT I O N MSc. PT. Asya ALBAYRAK MANUAL TECHNIQUES PERCUSSION  PERCUSSION It aids in the mobilization of secretions by propagating mechanical oscillations on the chest wall. The frequency sho...

P U L M O N A RY R E H A B I L I T AT I O N MSc. PT. Asya ALBAYRAK MANUAL TECHNIQUES PERCUSSION  PERCUSSION It aids in the mobilization of secretions by propagating mechanical oscillations on the chest wall. The frequency should be between 100-480 Hz. It is not applied with the same intensity to everyone. It is applied during inspiration and/or expiration after 3-4 TEE ( throcal expansion exercise) cycles. In non-cooperative patients, it is applied for a maximum of 30 seconds. It should never be uncomfortable.  PERCUSSION It is commonly applied using both hands. Single-handed use cases:  Neonates  Pediatric age group  Small chest area  Self-percussion  INDICATIONS OF PERCUSSION Lung abscess Cystic Fibrosis Bronchiectasis Difficulty in clearing secretions Excessive sputum production of 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 that require caution during percussion: Chest pain, Unstable angina, Hemodynamic instability, Low platelet count (thrombocytopenia), Anticoagulant therapy, Unstable and potentially fatal dysrhythmias.  Orthopedic conditions that require caution during percussion: Osteoporosis, Long-term steroid therapy, Osteomyelitis, Osteogenesis imperfecta (impaired bone development), Spinal fusion, Rib fracture, flail chest  Pulmonary conditions that require caution during percussion: Bronchospasm, Hemoptysis, Severe dyspnea, Untreated lung abscess, Pneumothorax, Pneumonia or other infection conditions, Immediately after chest tube removal, Pulmonary embolism.  Oncological conditions that require caution during percussion: If there are cancer metastases to the ribs and vertebrae, Carcinoma in the bronchus, If there is a removable tumor.  Other conditions that require caution during percussion: New skin grafts, Burns, Open chest wounds, Thoracic skin infections, Subcutaneous emphysema, Immediately after cataract surgery.  VIBRATION It is applied to affected lung segments. Applied with upper extremity vibration. Applied only during expiration. Place both hands stacked with fingers open. The base of the lower hand makes contact with the thorax. Elbows are straight. Applied with the vibration of the upper extremity. The palmar surface of the hands should be in complete contact with the patient's chest wall. Body weight is used. Performed in the expiratory phase after 3-4 TEE cycles.  SHAKING Effects: Accelerates expiratory airflow. Facilitates the mobilization of secretions. Contraindications: Osteoporosis Metastatic conditions affecting ribs and vertebrae  OTHER TECHNIQUES Coughing Huffing Forced Expiration Active Respiratory Techniques Cycle COUGHING The physiotherapist can improve a weak cough by teaching the patient a good technique and providing treatments that increase tidal volume, enhance compression force, or stimulate the cough reflex. After surgery, an appropriate cough technique may also require splinting of the chest as an additional measure.  COUGHING The patient performs maximum inspiration, Closes the glottis, Contracts abdominal, perineal, gluteal, and shoulder depressor muscles, Is prompted to cough no more than 2 times during each expiratory phase. COUGHING POSITIONS  COUGHING ENHANCEMENT TECHNIQUES 1. Positioning: Leaning forward, neck flexed, supported by arms, feet in contact with the ground. 2. Forced Expiration, "Huffing": Stimulates pulmonary mechanoreceptors, leading to reflex coughing. 3. Pressure Application: Applying pressure to the extrathoracic trachea induces reflex coughing. Applying pressure to the middle of the rectus abdominis after inspiration enhances cough effectiveness when pressure is suddenly released. Pressure applied to the lower costal margins during exhalation may increase cough effectiveness.  COUGHING ENHANCEMENT TECHNIQUES 4. Hand Ventilation: Respiratory (inspiratory) flow rates obtained with the strong pressure of a manually applied ventilator stimulate pulmonary mechanoreceptors, leading to reflex coughing. 5. Mechanical Stimulation: Direct application of mechanical stimulation may also induce reflex coughing.  COUGHING ENHANCEMENT TECHNIQUES 6. Neuromuscular Facilitation: Paraspinal ice application to thoracic vertebrae for 3-5 seconds (intermittently) can initiate coughing. As ice application can potentially lead to hypertension, individuals suitable for this technique need to be carefully selected and closely monitored.  COUGHING Applied in the phase of removing mobilized secretions. Controlled coughing: After a deep breath, a quick and effective cough is produced by contracting the abdominal muscles. Supported coughing (surgical patients): Glottis is closed.  HUFFING The glottis is open. Command: 'Take a breath, exhale rapidly.’ The depth of inspiration varies depending on the region to be targeted.  ACTIVE RESPIRATORY TECHNIQUES CYCLE It consists of a combination of several techniques aimed at clearing secretions. It promotes a proper breathing pattern, minimizing fatigue. It prevents the occurrence of bronchospasm and hypoxemia. It is flexible and easily adaptable.  ACTIVE RESPIRATORY TECHNIQUES CYCLE TEE: Thoracal expansion exercises BC: Breath control FET: Forced expiratory technique  ACTIVE RESPIRATORY TECHNIQUES CYCLE BC 3-4 TEE BC FET (1-2 huffing + BC) Repeat this cycle 2-3 times, tolerating it as much as possible.  AUTOGENIC DRAINAGE Autogenic Drainage (AD) is a controlled breathing technique that regulates the speed, depth, and localization of respiration. It is used in the treatment of patients with muscle disorders, particularly in conditions related to AD pathology, with the aim of clearing mucus, increasing ventilation, and preserving chest wall mobility.  AUTOGENIC DRAINAGE AD is used in the treatment of various diseases affecting lung functions (cystic fibrosis, chronic bronchitis, asthma, bronchiectasis, atelectasis, kyphoscoliosis, muscular dystrophy,) and in postoperative conditions. The goal with this technique is to provide the highest airflow throughout the entire bronchial tree without causing airway collapse. AD is applied in Belgium and Germany with two different approaches.  AUTOGENIC DRAINAGE Belgium technique: Inhalation is done through the nose. After inhalation, the glottis is opened, ensuring that all segments are filled with air, and holding the breath for 2-3 seconds. The patient exhales with an open mouth. It consists of three phases:  AUTOGENIC DRAINAGE Phase 1: Dissolving Mucus from the Periphery Inhalation is performed following deep expiration. From the middle tidal volume, it decreases to normal expiratory reserve volume, mobilizing secretion from the periphery.  AUTOGENIC DRAINAGE Phase 2: Accumulation of Mucus in the Larger Airways Achieved through deeper inspiration and expiration. Tidal volume breathing changes from expiratory reserve volume to inspiratory reserve volume. Secretion will be transported to the apical region with long expiration. Coughing is avoided during this phase.  AUTOGENIC DRAINAGE Phase 3: Transport from Larger Airways to the Mouth Inspiratory reserve volume is increased. A short and gentle cough is induced with a short burst. The Belgian approach is applied when sitting upright. Diaphragmatic breathing is used in this method. It can be applied with exercise, sports, and relaxation techniques. In this approach, as breathing is challenging at the expiratory reserve limit, Germans have modified it.  AUTOGENIC DRAINAGE German technique: In Germany, physiotherapists have simplified AD. It is a two-phase respiration technique: The patient begins breathing from the middle tidal volume. Adaptation can be achieved without excessive effort or strain. A breath is held for 2-3 seconds at the end of each inspiration. Expiration is passively performed at the normal expiratory level. This is followed by active expiration.  MANUAL ASSISTED COUGH Anterior thorax assisted Costa-frenic assisted  MANUAL ASSISTED COUGH Heimlich type  MANUAL ASSISTED COUGH Self-coughing  MANUAL ASSISTED COUGH Mechanical support [email protected]