Chest Physiotherapy (Pulmonary Rehabilitation) PDF

# CHEST PHYSIOTHERAPY (PULMONARY REHANBLITATION) ## DR.MAHA SAMIR YOUNIS ### LECTURER OF PT FOR CARDIOPULMONARY DISORDERS & ITS SURGERY ## Aims of chest P.T uses physical means to: - Decrease work of breathing - Re-educate breathing - Improve gas exchange - Assist coughing - Remove excess secreti...

# CHEST PHYSIOTHERAPY (PULMONARY REHANBLITATION) ## DR.MAHA SAMIR YOUNIS ### LECTURER OF PT FOR CARDIOPULMONARY DISORDERS & ITS SURGERY ## Aims of chest P.T uses physical means to: - Decrease work of breathing - Re-educate breathing - Improve gas exchange - Assist coughing - Remove excess secretions ## 2-Cont. airway clearance techniques ### Manual techniques used with postural drainage - Percussion: - Percussion is a manual technique used by respiratory physiotherapists to improve airway clearance by mobilizing secretions in one or more lung segments to the central airways ## Types of Percussion - Manual Percussion (cupped hands) - Mechanical Percussion - Electric or pneumatic percussors of different models are available in variable intensities and frequencies for adults and older pediatric - Intrapulmonary Percussive Ventilation (IPV) - provides intrathoracic percussion and vibration and an alternative system for the delivery of the positive pressure to the lungs ## Technique of percussion: 1. Hands move in alternating rhythmic manner 2. Done during both phases of respiration 3. Rate of percussion, 100-480 times/min 4. The sound heard must be hollow and not of a slap. 5. The force applied must be equal 6. Done for several minutes ## Precautions: - avoided on bony prominence - avoided on floating ribs - Not be done over breast tissue ## Vibration: ### Definition: - A fine oscillatory movement combined with compression to the patient's chest used by physiotherapists to assist with the removal of secretions ### Application: - Gentle and high frequency hand movement - By placing hand on top of other or beside it on chest wall - Applied during expiration in same direction - Achieved by isometric contraction of therapist upper limb ## High-Frequency Chest Wall Oscillation (HFCWO) - An airway clearance technique in which external chest wall oscillations are applied to the chest using an inflatable vest that wraps around the chest. - These machines produce vibrations at variable frequencies and intensities, helping to loosen and thin mucus and separate it from airway walls. ## Shaking: - Vigorous vibration using intermittent bouncing maneuver coupled with wide hand movement - Done during expiration ## Cough & huff: ### Cough definition: - Is sudden expulsion of air against closed glottis voluntary or reflexively - Effective till the 7th generation of bronchi (out of 23) due to presence of cilia up to terminal bronchioles ### Mechanism: - Deep inspiration→ glottis closes & vocal cords tightens→ abdominal muscles contracts and diaphragm elevates→ increase thoracic and abdominal pressure→ glottis opens ## Methods for cough stimulation 1. Splinting (decrease incisional pain by hands or pillows) 2. Tracheal tickle (used in children and unconscious patients) by applying circular tracheal motion 3. Neuromuscular facilitation: intermittent 3-5sec ice application on paraspinal muscles to stimulate afferent nerve 4. Suction: in patients unable to cough or on artificial airways. However, it clears only trachea and main bronchi 5. Humidification: increase hot fluids intake to mobilize thick secretions ## Cough - Voluntary or reflexive - Productive or non productive - Doesn't stimulate huff - Closed glottis - Increase intra-abdominal pressure & intrathoracic pressure - Forced expiration ## Huff - Voluntary only - Non productive only - Stimulates cough - Open glottis - Deeper than cough with Less pressure - Less expiratory force ## 3-Stretching - Elongates pathologically shortened soft tissue and increase ROM and mobility ### Types: - 1-Active: where agonist stretch antagonist - 2-passive: external force ### Aims of stretching: - Lengthen soft tissues - Increase joint mobility - Break adhesions - Improve respiratory functions ## Pleural stretching techniques - The *pleura* are thin membranes that line the lungs, and while you can't directly stretch the pleura themselves, you can stretch the muscles and tissues surrounding the lungs and ribcage to improve lung expansion and reduce pleural restriction. - *Pleural stretching exercises* benefits: - Improve lung expansion - Reduce stiffness - Improve breathing in patient like asthma, COPD, or following surgery ## Pleural stretching techniques include: 1. Deep diaphragmatic breathing 2. Thoracic expansion exc. 3. Intercostal stretching 4. Side lying thoracic expansion 5. Segmental breathing 6. Cat-Cow Stretch (Thoracic Mobility) 7. Rib cage mobilization 8. Trunk rotation stretch 9. Pursed lip breathing 10. Incentive spirometer ## Cont. Pleural stretching techniques - Rib cage mobilization - Trunk rotation stretch - Pursed lip breathing - Incentive spirometer ## 4-Relaxation techniques: - Relaxation techniques are therapeutic exercises designed to assist individuals by decreasing tension and anxiety. ### Stress related physiological responses: - Increased heart rate - Palpitations - Excess sweating - Shortness of breath - Muscle tension ## Practicing relaxation techniques can have many benefits, including: - Slowing heart rate - Lowering blood pressure - Slowing your breathing rate - Improving digestion - Maintaining normal blood sugar levels - Reducing activity of stress hormones - Increasing blood flow to major muscles - Reducing muscle tension and chronic pain - Improving concentration and mood - Improving sleep quality - Lowering fatigue - Reducing anger and frustration - Boosting confidence to handle problems ## Relaxation Techniques include: 1. Deep breathing/diaphragmatic breathing 2. Guided Imagery: A relaxation exercise intended to assist patients with visualizing a calming environment. 3. Progressive Muscle Relaxation: Involves tensing and releasing muscles, progressing throughout the body, with the focus on the release of the muscle as the relaxation phase. ## What's the difference between relaxation and meditation: - Relaxation is to recharge and be calm, to relieve tension and stress in the body or the mind. - Meditation is to gain a deeper sense of inner peace and broaden one's perspective on life - Meditation requires a complete alertness, intentional presence and awareness. Meditation is an act of paying attention. ## 5-Devices used for respiratory muscle training: ### Weakness of the respiratory muscles is defined as - A reduction in muscle contractility, resulting in the inability of the respiratory muscles to generate normal levels of pressure and air flow during inspiration and expiration ### Etiology : - Respiratory diseases (COPD, emphysema, neurological lesions - Electrolyte disturbances - Blood gas abnormalities - Intense weight loss - Cardiac decompensation ## Respiratory muscle training ### Defined as: - Repetitive breathing exercises against an external load, which can be controlled by factors, such as time, intensity, and/or frequency of the training ### Aims of respiratory muscle training: - Increase the strength of the respiratory muscles - Improve exercise performance and functional capacity ### Overloading muscle fibers through: - Increasing training duration - Increasing intensities - Increasing frequency ## Muscle response to different stimuli: - Improving strength: by strength-training stimuli (high intensity and short duration) - Improving endurance by endurance-training stimuli (low intensity and long duration) ## Types of respiratory training devices 1. Devices impose an endurance-training stimulus: The endurance-training devices (require that the respiratory muscles work for prolonged periods of time (30 minutes)) 2. Devices that impose a resistance-training stimulus (flow resistance) ## The resistance-training devices subject the muscles to an external load that is akin to lift a weight ### Categories to: - Passive flow-resistance the load is given by a previously selected variable diameter orifice, so the narrowest the orifice is, the greatest is the resistive load - Dynamically adjusted flow-resistance allows continuous and dynamic adjustments of the flow resistance. This adjustment allows that the surface area of the flow orifice vary within a breath, according to the prevailing respiratory flow rate. ### Example: - Power-breath: an inspiratory muscle trainer with a response valve electronically controlled to generate the resistance - Pressure threshold valves - These devices require individuals to produce a respiratory pressure, sufficient to overcome a pressure load and, thereby, initiate the respiration. ## RESPIRATORY MUSCLE TRAINING DURING INSPIRATION ### Incentive spirometer - Is a device that measures the volume of the air inhaled into the lungs during inspiration. - When breathing in through an incentive spirometer, a piston rises inside the device and measures the volume of the inspired air. - The incentive spirometer uses visual feedback to assess a patient's inspiratory effort by measuring the inhalation volume. ## Types of incentive spirometer: - Flow-oriented incentive spirometer (FIS). An FIS device makes you work harder to breathe. It helps increase the muscles in your upper chest. - Volume-oriented incentive spirometer (VIS). It helps improve activity and movement in your diaphragm. ## INDICATIONS OF USE: - Ribcage injuries - Bed ridden - Asthma. - Pneumonia - Chronic obstructive pulmonary disease - Cystic fibrosis - Sickle cell anemia - Atelectasis ## Respiratory muscle training during expiration: ### Positive expiratory pressure: - Is breathing against resistance - Can be performed either through a device or against pursed lips. - The increase in pressure is transmitted to airways creating back pressure stenting them during exhalation ### ROLE OF PEP: - Preventing premature airway closure - Reducing gas trapping. - It promotes collateral ventilation, allowing pressure to build up distal to the obstruction. - Affective airway clearance promoting movement of mucus proximally. - During PEP therapy, the patient exhales against a fixed-orifice resistor, generating pressures during expiration that usually range from 10 to 20 cm H2O. ## Acapella - Combines the benefits of both PEP therapy and airway vibrations to mobilize pulmonary secretions and can be used in virtually any position allowing patient to move freely. - It facilitates opening of airways in patient with lung diseases with secretory problems as COPD, asthma, cystic fibrosis. - Color coded units (green for high flow >15 L/min, blue for low flow<15 L/min) helps customize treatment for each patient based on their clinical needs - Allows inhalation and exhalation without removing from mouth. - Prolongs expiratory airflows to increase secretion removal. ## Flutter - Simple and small device shaped like a pipe that creates a PEP and high frequency oscillation as expired air passes through it. - These vibrations and PEP are thought to mobilize airway secretions facilitating their clearance and improving airflow. ## A peak flow meter - Can help managing asthma. It can give healthcare provider information about how open the airways are in lungs. - The PFM can find small changes in the large airways before patient start to wheeze. - Using a PFM every day will help to know when peak flows are starting to drop to make early changes in patient medicine or routine. - This can help keeping asthma symptoms from getting worse. ## Peak flow zones - Are areas of measurement on a peak flow meter. - The goal of the peak flow zones is to show early symptoms of uncontrolled asthma. - **Green.** This means go. The green zone is 80% to 100% of your highest peak flow reading, or personal best. This is the zone person should be in every day. - **Yellow.** This means caution or slow down. The yellow zone is 50% to 80% of your personal best. Measurements in this zone are a sign that large airways are starting to narrow. - **Red** This means stop. The red zone is less than 50% of personal best. Readings in this zone mean severe narrowing of large airways.