ROLE OF PHYSIOTHERAPY IN THE MANAGEMENT OF

RESPIRATORY CONDITIONS

A SEMINAR PRESENTED

BY

ELOCHUKWU PEACE UJUAKU (BMR) PT

DEFINITION:

Respiratory disease/condition is a medical term that encompasses pathological conditions affecting the organs and tissues that make gas exchange possible in the body. They include conditions of the upper respiratory tract, trachea, bronchi, bronchioles, alveoli, pleura and pleural cavity, and muscles of breathing.

Respiratory diseases range from mild and self-limiting, such as the common cold, to life-threatening conditions like bacterial pneumonia, pulmonary embolism, and lung cancer etc.

The human lungs are the organs of respiration in humans.

Humans have two lungs, a right lung and a left lung.

The right lung consists of three lobes while the left lung is slightly smaller consisting of only two lobes (the left lung has a "cardiac notch" allowing space for the heart within the chest).

The various muscles of respiration aid in both inspiration and expiration, which require changes in the pressure within the thoracic cavity.

The respiratory muscles work to achieve this by changing the dimensions of the thoracic cavity.

The principal muscles are

The diaphragm,

The external intercostal and

The interchondral part of the internal intercostal muscles.

Both the external intercostal muscles and the intercondral elevate the ribs, thus increasing the width of the thoracic cavity, while the diaphragm contracts to increase the vertical dimensions of the thoracic cavity, and also aids in the elevation of the lower ribs.

Accessory muscles are typically only used when the body needs to process energy quickly (e.g. during strenuous exercise, during the stress response, or during an asthma attack). The accessory muscles of inspiration can also become engaged in everyday breathing when a breathing pattern disorder exists.

Respiratory disease is a common and important cause of illness and death around the world.

In the US, approximately 1 billion "common colds" occur each year.

In the UK, approximately 1 in 7 individuals are affected by some form of chronic lung disease, most commonly chronic obstructive pulmonary disease, which includes asthma, chronic bronchitis and emphysema.

Respiratory diseases (including lung cancer) are responsible for over 10% of hospitalizations and over 16% of deaths in Canada.

In Nigeria, Pulmonary TB is the leading cause of morbidity among respiratory conditions by 42.1%, followed by asthma 17.5% and pneumonia 15.3%.

Lung cancer was uncommon in only 0.6%. Pulmonary TB was the leading cause of hospitalization for

respiratory disease in 32%. Pulmonary TB, asthma, pneumonia and pleural pathologies

were more common in women, whereas COPD was more common in men.

Respiratory diseases can be broadly divided into two:

Obstructive diseases: These include conditions in which there is a resistance to airflow either through reversible factors like inflammation or irreversible factors such as airway fibrosis owing to damage to the airways and the Alveoli making breathing difficult. E.gs are chronic bronchitis, emphysema, asthma, bronchiectasis, cystic fibrosis etc

Restrictive diseases: These are characterised by reduced lung compliance leading to the loss of lung volume which may be caused by disease affecting the lungs, pleura, chest wall or neuromuscular mechanisms. E.gs are pneumonia, pleurisy, pleural effusion, pneumothorax, acute respiratory distress syndrome [ARDS], fibrosing alveolitis etc

Mixed restrictive and obstructive diseases: These are lung disorders that fit into neither of the two categories but need to be included owing to their prevalence within the hospital or community.

They include lung abscess, pulmonary tuberculosis, bronchial and lung tumours, respiratory failure etc

Obstructive lung diseases are actually group of disease with differing etiologies. Common obstructive diseases include asthma, bronchitis, and emphysema.

They are characterised by the following:

>inflammation of the bronchial wall through out the course of the disease and during exarcerbations ,

>destruction of the lung parenchyma,

>remodelling and narrowing of the small airways which normally leads to loss of elasticity,

>difficulty in breathing In which the flow of air is impeded.

Airway obstruction causes an increase in resistance.

During normal breathing, the pressure volume relationship is no different from in a normal lung.

However, when breathing rapidly, greater pressure is needed to overcome the resistance to flow, and the volume of each breath gets smaller.

Chronic obstructive pulmonary Disease is the most common type

Clinical features include:

Persistant Cough

Sputum production [ mucoid and tenacious]

Wheeze

Dyspnoea or shortness of breath

Exercise intolerance

Chest wall deformity

Cyanosis

Cor pulmonale

Reduction of FEV1 [forced expiratory volume] and FVC [forced vital

capacity].

The RV [residual volume] will be increased at the expense of vital

capacity

Restrictive lung diseases are also group of disease with differing etiologies. Egs include: pneumonia, pleurisy, pleural effusion, pneumothorax, fibrosing alveolitis

They are characterised by the following:

Stiffening of the lung parenchyma which prevents the lungs from expanding fully

Vital capacity, inspiratory capacity and total lung capacity are reduced, residual volume can be reduced or normal

The common link among these disorders is difficulty in expanding the lung and the reduction in lung volume.

The restriction can come from changes in chest wall such as kyphosis and scoliosis,

The most common among those disorders are the restrictive disease of the lung parenchyma and or the pleura.

In a restrictive lung disease, the compliance of the lung is reduced, which increases the stiffness of the lung and limits expansion.

They include the following:

Cough

Breathlessness

Pain

Consolidation seen as opaquacity of the lungs are shown in the

radiograph

On auscultation, bronchial breathing can be heard with wheezing

sounds

Lethargy

Cyanosis

Absence of breath sounds at the apex of the affected side of the lungs

Lung volumes and lung capacities refer to the volume of air associated with different phases of the respiratory cycle.

Lung volumes are directly measured; Lung capacities are inferred from lung volumes

Tidal breathing is normal, resting breathing; the tidal volume is the volume of air that is inhaled or exhaled in only a relaxed single breath.

TLC-Total lung capacity: the volume in the lungs at maximal inflation.

The average human respiratory rate is 30-60 breaths per minute at birth, decreasing to 12-20 breaths per minute in adults

The lung volumes include:TLC >> Total lung capacity:- the volume in the lungs at maximal inflation

TV >> Tidal volume:- that volume of air moved into or out of the lungs during quiet breathing

RV>> Residual volume: the volume of air remaining in the lungs after a maximal exhalation

ERV>> Expiratory reserve volume: the maximal volume of air that can be exhaled from the end-expiratory position

IVC Inspiratory vital capacity: the maximum volume of air inhaled from the point of maximum expiration

IRV>> Inspiratory reserve volume: the maximal volume that can be inhaled from the end-inspiratory level

IC >> Inspiratory capacity: the sum of IRV and TV

VC Vital capacity: TLC − RV

VT Tidal volume: that volume of air moved into or out of the lungs during quiet breathing.

FRC Functional residual capacity: the volume in the lungs at the end-expiratory position

FVC Forced vital capacity: the determination of the vital capacity from a maximally forced expiratory effort

FEVt Forced expiratory volume (time): a generic term indicating the volume of air exhaled under forced conditions in the first t seconds

FEV1 Volume that has been exhaled at the end of the first second of forced expiration

Factors affecting volumes

Several factors affect lung volumes; some can be controlled and some cannot. Lung volumes vary with different people as follows:

Larger volumes Smaller volumes

taller people shorter people

people who live at higher altitudes and people who live at lower altitudes

non obese obese[4]

Average lung volumes in healthy adults Volume Value (litres)

In men In women

Inspiratory reserve volume

3.3 1.9

Tidal volume 0.5 0.5

Expiratory reserve volume

1.0 0.7

Residual volume 1.2 1.1

In men In women

Vital capacity 4.8 3.1

Inspiratory capacity 3.8 2.4

Functional residual capacity

2.2 1.8

Total lung capacity 6.0 4.2

The assessment/evaluation of patients with respiratory diseases include the following:

Patient complaintHistory taking: obtaining a thorough and

accurate patient history is truly an art. One important goal of history taking is to establish a good patient-therapist rapport.

Past medical history Family and social historyObservation and examinationSegmental examination:

This is a holistic type of examination which involves the different parts of the body like;

Head and neck

Upper limbs

Thorax and abdomen

Back

Pelvis/perineum

Lower limbs

Functional abilities of the patient is also assessed

The clinical impression

Treatment plan: this includes the aim of treatment and the means of treatment which can be divided into:

Short-term goals Long-term goals.

PULMONARY ASSESSMENTThe following are assessed in chest

examination: Vital Signs: this include: Temperature Respiratory rate (14-20/min) Heart rate (80-100 bpm) BP (120/80) SpO2 (95-100% on room air)

General Survey: Here, the therapist checks for the following:

◦ General apperance: does the patient appear comfortable? Any evidence of respiratory distress or effort of breathing? Is the patient alert or disoriented? Is there nasal flaring or pursed lip breathing? Is there use of accessory muscles for breathing?

◦ Colour: the colour of the skin and nails are observed here like Cyanosis, clubbing etc

Neck :Are the accessory muscles of respirations being recruited for a resting breathing pattern? Do the sternocleidomastoid or trapezius muscles appear prominent?

This consists of

Inspection

Palpation

Percussion

Auscultation

INSPECTION OF THE CHEST Deformities or asymmetry Shape of the chest◦ Pectus excavatum◦ Pectus carinatum◦ Barrel chest ◦ Flail chest (multiple rib fractures)◦ Kyphosis◦ Scoliosis

Pectus excavatum Pectus carinatum

Barrel chest

Increased effort of breathing◦ Retractions

Impaired respiratory movement Trauma, masses Old surgical scars, skin lesions

PALPATION Touch is an integral part of physical therapy.

As part of chest examination, palpation is used to assess areas of tenderness, abnormalities, chest wall excursion, oedema, tactile fremitus, and tracheal deviation.

Chest wall Excursion: evaluation of thoracic expansion allows the therapist to observe a baseline level by which to measure progress or decline in a patients condition.

In accentuating normal chest excursion, Place your hands on the patient's back with thumbs pointed towards the spine. Remember to first rub your hands together so that they are not too cold prior to touching the patient. Your hands should lift symmetrically outward when the patient takes a deep breath. Processes that lead to asymmetric lung expansion, as might occur when anything fills the pleural space (e.g. air or fluid), may then be detected as the hand on the affected side will move outward to a lesser degree. There has to be a lot of plerualdisease before this asymmetry can be identified on exam.

Abnormal chest excursions indicate • Bronchial obstruction• Pleural effusion• Lobar pneumonia

Tactile Fremitus: Normal lung transmits a palpable vibratory sensation to the chest wall.

This is referred to as fremitus and can be detected by placing the ulnar aspects of both hands firmly against either side of the chest or the palmar surface of one or both hands while the patient says the words "Ninety-Nine.“

This maneuver is repeated until the entire posterior thorax is covered. The presence or absence of tactile fremitus provides information about the density of the underlying lungs and thoracic cavity.

Absent or decreased tactile fremitus shows• Bronchial obstruction• COPD• Pneumothorax• Tumor Pleural effusion Increased tactile fremitus shows Consolidation (lobar

pneumonia) of the lungs.

The trachea’s midline position can be examined anteriorly. The physical therapist places an index finger in the medial aspect of the suprasternalnotch. This is repeated on the opposite side.

An equal distance between the clavicle and the trachea should exist bilaterally.

Tracheal deviation may be caused by pneumothorax, atelectasis, or a tumour among possible conditions. Tracheal deviation can occur under the following conditions:

Deviated towards diseased side ◦ Atelectasis◦ Agenesis of lung

Pneumonectomy

Pleural fibrosis

Deviated away from diseased side

Pneumothorax

Pleural effusion

Large mass

Mediastinal masses

Tracheal masses

Kyphoscoliosis

Percussion: If the normal, air-filled tissue has been displaced by fluid (e.g. pleural effusion) or infiltrated with white cells and bacteria (e.g. pneumonia), percussion will generate a deadened tone.

Alternatively, processes that lead to chronic (e.g. emphysema) or acute (e.g. pneumothorax) air trapping in the lung or pleural space, respectively, will produce hyper-resonant (i.e. more drum-like) notes on percussion.

Allow your hand to swing freely at the wrist, hammering your finger onto the target at the bottom of the down stroke.

A stiff wrist forces you to push your finger into the target which will not elicit the correct sound. In addition, it takes a while to develop an ear for what is resonant and what is not.

Auscultation is the art of listening to sounds produced by the body with the aid of a stethoscope.

Chest sounds

Chest sounds are divided into the following:

Breath sounds- normal, abnormal and adventitious sounds

Voice sounds- egophony, bronchophony, whispered pectoriloquy

Extrapulmonary sounds-pleural or friction rubs

Heart sounds

Vesicular◦ Peripheral lung fields ◦ Soft, low pitched, I>E

Bronchovesicular◦ Over the bronchi◦ Medium intensity, medium pitch, I=E

Bronchial◦ Over the trachea ◦ Loud, high pitched, E>I

Also known as tracheal sounds

Absent or decreased breath sounds• ARDS• Asthma• Atelectasis• Pneumothorax• Consolidation of the lungs

This occurs as a result of changes in the sound transmission as a result of an underlying pathologic process. They are:

Bronchial sounds- occurs when lung tissue is airless because of obstruction of segmental or lobar bronchi by secretions

Decreased sounds –sounds transmission is diminished

Absent sounds – no sounds audible

These are the extraneous noises produced over the bronchopulmonary tree and are indicative of an abnormal condition.

They are more identifiable than abnormal sounds.They include:

Crackles/rales (sounds like velcro) Occurs during inspiration

◦ Fine (shorter, higher pitched, softer)◦ Coarse (longer, lower pitched, louder)

WheezesHigh pitched and continuous

Occurs during expiration Rhonchi (sounds like snoring)

Low-pitched but continuousOccur during inspiration and expiration

Stridor (predominantly inspiratory, louder in the neck than over the chest wall -> large airway obstruction

Bronchophony

Egophony◦ Normal “eee”

◦ Egophony

Whispered pectoriloquy

These are vibrations heard through a stethoscope produced by the speaking voice.

They are low-pitched and of mumbled quality

The transmission can be increased or decreased in the presence of an underlying pathology

Chronic obstructive pulmonary disease:

This is the most common obstructive respiratory condition

Chronic bronchitis is the major cause

The survival rate varies between 5 and 30 years, but eventually cardiac and ventilatoryfailure will occur

Signs and symptoms:

Cough

Sputum production

wheezes

Dyspnoea or shortness of breath

Exercise intolerance

Deformity of the chest cavity[barrel chest]

Cyanosis

Reduction in lung function

Wheezes

Medical treatment

The principles of treatment include

To decrease the bronchial irritation to a minimum

Control infections

Control bronchospasm

Control the amount of sputum production

Oxygen therapy

Medications include:

The relievers: are used to reduce bronchospasm and they are the beta 2 agonists, the anthcholinergics etc

The preventers: are used to prevent bronchial hyperactivity and reduce bronchial mucosal inflammatory reactions and they are the corticosteroids

Physiotherapy Treatment in Chronic Obstructive Pulmonary Disease:

General aims of treatment are:

To relieve bronchospasm

Facilitate the removal of secretions

To improve the pattern of breathing

To teach local relaxation, improve posture and help allay fear and anxiety

To improve exercise tolerance and ensure a long term commitment to exercise

To give advise about self management in activities of daily living

Means of treatment:

Use of FET [forced expiratory technique]and ACBT[active cycle of breathing technique] to remove secretions

Postural drainage for removal of sputum

Advise on how to increase and maintain exercise tolerance

Humidification with nebuliser if the secretions are very thick

Use of pursed lip breathing and deep breathing to improve the pattern of breathing

RESTIRCTIVE DISEASESPLEURAL EFFUSION

Pleural effusion is an excessive accumulation of fluid in the pleural cavity

Fluid accumulation varies depending on the underlying condition eg tuberculosis, pneumonia

Signs and symptoms Breathlessness Cyanosis Pyrexia Lethargy Pain Thoracic expansion is restricted on the

affected side Fluid level can be identified on the x-ray Dullness on percussion Breath sounds are absent over the effusion

although bronchial breathing can be heard just above the effusion

The fluid is drained if it does not get absorbed naturally Medical treatment

Pleurodesis. This is where a special chemical (a sclerosant) is injected into the pleural space. This causes inflammation of the pleural membranes and helps them to 'stick' together. This helps to prevent fluid building up again into an effusion. Sclerosingchemicals that are commonly used include tetracycline, sterile talc and bleomycin.

Leaving a permanent drain in place so the fluid can drain out as and when it forms.

An operation to insert a shunt (like an internal drain) to allow the fluid to drain out from the chest into the tummy (abdominal) cavity. This is called a 'pleuroperitoneal shunt'. It is only occasionally used.

Pleurectomy. This is an operation to remove the pleura. It is sometimes used in people with effusions due to cancer when other treatment options have failed.

Physiotherapy treatment:

Aims of treatment

To prevent the formation of disabling adhesions between the two layers of pleura

To obtain full expansion of the affected lung

To increase the ventilation of the lungs

To increase exercise tolerance following immobility

Means of treatment

Use of pursed lip breathing and deep breathing to improve the pattern of breathing

Use of vibrations on the chest wall

Use of incentive spirometry

Advise on how to increase and maintain exercise tolerance

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THANKS FOR YOUR TIME