Physical Therapy Intervention For Pulmonary Diseases
Dr. Mohamed Seyam PhD. PT. Assistant professor of physical therapy Physical Therapy Intervention for Pulmonary diseases
Breathing Exercise Thoracic Mobilization Techniques Inspiratory Muscle Training Airway Clearance Techniques Mechanical Ventilators 1. BREATHING EXERCISES Prevent postoperative pulmonary complications.
GOALS: Improve or redistribute ventilation. Prevent postoperative pulmonary complications. Improve the strength, endurance, and coordination of themuscles of ventilation. Correct inefficient or abnormal breathing patterns anddecrease the work ofbreathing. Promote relaxation and relieve stress. Teach the patient how to deal with episodes of Dyspnea. Types of Breathing Exercises
a. Diaphragmatic breathing exercise b. Segmental breathing exercise c. Pursed- lip Breathing exercise d. Glossopharyngeal breathing e. Preventing and Relieving Episodes of Dyspnea a. Diaphragmatic breathing exercise
These are designed to improve the efficiency of ventilation, decreasethe work of breathing, increase the excursion (descent or ascent) of thediaphragm, and improve gas exchange and Oxygenation. Position: Semi-Fowlers position (in which gravityassists the diaphragm), long sitting or supine. Procedure Of Diaphragmatic breathing exercise
Start instruction by teaching the patient how to relax the accessory muscles of inspiration those muscles (shoulder rolls or shoulder shrugscoupled with relaxation). Place your handon the rectus abdominals just below the anterior costalmargin on the epigastric angle. Ask the patient to breathe in slowly and deeply through the nose. Have the patientkeep the shoulders relaxed and upper chest quiet,allowing the abdomen to rise slightly. Then tell the patient to relax and exhale slowly through the mouth. After the patient understands and is able to control breathing using a diaphragmatic pattern, practice diaphragmatic breathing in a variety of positions (sitting, standing)and during activity(walking, climbing stairs). b. Segmental breathing exercise
Segmental breathing techniques may need to be directed to the lobes ifthere is accumulation of secretions or insufficient lung expansionin theseareas. 1.Lateral Costal Expansion called lateral basal expansion, can be carried out unilaterally or bilaterally. Position: Hook-lying position; later progress to a sitting position. Procedure Place your hands along the lateral aspect of the lower ribs todirect the patients attention to the areas where movement is to occur. 1)Lateral Costal Expansion
Ask the patient to breathe out, and feel the rib cage move downward and inward. As the patient breathes out, place pressure into the ribs with the palms of yourhands. Just prior to inspiration, apply a quick downward and inward stretch to thechest. This places a quick stretch on the external intercostals to facilitate theircontraction. Apply light manual resistance to the lower ribs to increase sensory awarenessas the patient breathes in deeply and the chest expands. Teach the patient how to perform the maneuver independently by placing his or her hand(s) over the ribs or applying resistance with a towel or beltaround the lower ribs 2) Posterior Basal Expansion
Deep breathing emphasizing posterior basal expansion is importantfor the postsurgical patient who is confined to bed in asemi recliningposition for an extended period of time becausesecretions oftenaccumulate in the posterior segments of the lower lobes. Procedure Have the patient sit and lean forward on a pillow, slightly bending thehips. Place your hands over the posterior aspect of thelower ribs. Follow the same procedure just described for lateral costal expansion. c. Pursed-Lip Breathing
Pursed-lip breathing is a strategy that involves lightly pursing the lips together duringcontrolledexhalation. p r e c a u t i o n : The use of forceful expiration during pursed-lip breathing must beavoided because this can causefurther restriction of the small bronchioles. PositionAny comfortable position Procedure: Have the patient breathe in slowly and deeply through the nose and then breathe outgentlythrough lightly pursed lips as if blowing on and bendingthe flame of a candle butnot blowing it out. Explain to the patient that expiration must be relaxed and that contractionof theabdominals must be avoided. Place your hand over the patients abdominal muscles to detect any contraction of theabdominals. d. Glossopharyngeal breathing
It is a means of increasing the inspiratory capacity when there is severe weakness of therespiration muscles. It is used primarily by patients who areventilator-dependent because of absent orIncomplete innervations of the diaphragm as the result of a high cervical-level spinalcord lesion or other neuromuscular disorders Procedure Glossopharyngeal breathing involves taking several gulps of air, usually 6 to 10gulpsin series, to pull air into the lungs when action of the inspiratory muscles isinadequate. After the patient takes several gulps of air, the mouth is closed, and the tonguepushes the air back and traps it in the pharynx. The air is then forced into the lungswhen the glottis is opened. This increases the depth of the inspiration and thepatients inspiratory and vital capacities e. Preventing and Relieving Episodes of Dyspnea
If the patient becomes slightly short of breath, he must learn to stop anactivity and use controlled, pursed-lip breathing until the dyspneasubsides. Procedure 1. Have the patient assume a relaxed, forward-bent posture. A forwardbent positionstimulates diaphragmatic breathing (the viscera drop forward and the diaphragmdescends more easily). 2. Have the patient gain control of his or her breathing and reduce therespiratory rateby using pursed-lip breathing during expiration. 3. After each pursed-lip expiration, teach the patient to use diaphragmaticbreathingand minimize use of accessory muscles during each inspiration. 2. Thoracic Mobilization Techniques
Chest mobilization exercises are any exercises thatcombine active movements of the trunk or extremitieswith deep breathing. They are designed to maintain or improve mobility of thechest wall, trunk, and shoulder girdles when it affectsventilation or postural alignment. Exercises that combine stretching of these muscles withdeep breathing improve ventilation on that side of thechest. a. Specific Techniques To Mobilize One Side of the Chest 1. While sitting, have the patient bend away from the tight side to lengthen hypo mobile structures and expand that side of the chest during inspiration 2. Then, have the patient push the fisted hand into the lateral aspect of the chest, bend toward the tight side, and breathe out 3. Progress by having the patient raise the arm overhead on the tight side of the chest and side-bend away from the tight side. This places an additional stretch on hypo mobile tissues. b. To Mobilize the Upper Chest and Stretch the pectoralis muscle
While the patient is sitting in a chair with hands elongatingthe clasped behind the head, horizontally abduct thearms have him or her Pectoralis major) during a deepinspiration. Then instruct the patient to bring the elbows together andbend forward during expiration. c. To Mobilize the Upper Chest and Shoulder
While sitting in a chair, have the patient reach with botharms overhead (180 bilateral shoulder flexion and slightabduction) during inspiration. Then bend forward at the hips and reach for the floorduring expiration 3.Respiratory muscle Training (RRT)
RRT is advocated to improve ventilation in patients with pulmonarydysfunction associated with weakness, atrophy, or inefficiency ofthe muscles of inspiration or to improve the effectiveness of thecoughmechanism in patients with weakness of the abdominalmuscles or other expiratory muscles. Types of Training a. Inspiratory Muscle Training (IMT) b. Incentive Spirometer a. Inspiratory muscle training
Procedur The patient inhales through a resistive training device placed in themouth. These devices are narrow tubes of varying diameters or amouthpiece and adapter with an adjustable aperture that provideresistance to airflow during inspiration and therefore place resistanceon inspiratory muscles. The smaller the diameter of the tube and, the greater istheresistance. The patient inhales through the device for a specified period of timeseveral times each day. b. Incentive spirometer
Incentive spirometer is a form of ventilatory training that emphasizes sustainedmaximum inspirations. The purpose of incentive spirometer is to increase the volume of air inspired. It is used primarily to prevent alveolar collapse and atelectasis in post operativepatients. Procedure. Have the patient assume a comfortable position (semi reclining, if possible) andinhale and exhale three to four times and then exhale maximally with the fourthbreath Then have the patient place the spirometer in the mouth, inhale maximally throughthemouthpiece to a target setting and hold the inspiration for several seconds. This sequence is repeated five to ten times several times per day. 4. Airway Clearance Techniques
Sputum in perspective Hydration and humidification Exercise Postural drainage Manual techniques modified Postural drainage Breathing techniques Mechanical aids Cough Pharyngeal suction Nasopharyngeal airway Minitracheostomy 4. Airway Clearance Techniques
An effective cough is necessary to eliminate respiratory obstructionsandkeep the lungs clear. A cough may be reflexive or voluntary. The Cough Mechanism 1. Deep inspiration occurs. 2. Glottis closes, and vocal cords tighten. 3. Abdominal muscles contract and the diaphragm elevates, causingan increase in intra thoracic and intra-abdominal pressures. 4. Glottis opens. 5. Explosive expiration of air occurs. Factors that Decrease the Effectiveness of the Cough Mechanism and Cough Pump:
1. Decreased inspiratory capacity. 2. Inability to forcibly expel air. 3. Decreased action of the cilia in the bronchial tree. 4. Increase in the amount or thickness of mucus. Teaching an Effective Cough
1. Assess the patients voluntary or reflexive cough. 2. Have the patient assume a relaxed, comfortable position - Sitting or leaning forward 3. Teach the patient controlled diaphragmatic breathing, emphasizing deep inspirations. 4. Demonstrate a sharp, deep, double cough. 5. Demonstrate the proper muscle action of coughing (contraction of the abdominals). 6. Take a deep but relaxed inspiration, followed by a sharp double cough. The second cough during a single expiration is usually more productive. Additional Techniques to Facilitate a Cough
1.Manual-Assisted Cough If a patient has abdominal weakness manual pressure on theabdominal area assistsin developing greater intra-abdominal pressure for a more forceful cough. a. Therapist-Assisted Techniques b. Self-Assisted Technique 2. Splinting If chest wall pain from recent surgery or trauma is restricting the cough, teach thepatient to splint over the painful area during coughing. 3. Tracheal Stimulation The therapist places two fingers at the sternal notch andapplies a circular motionwith pressure downward into the trachea to facilitate areflexive cough 5. Aerosol therapy Indications
A therapeutic administration of a drug in the form of an aerosol. Indications Bronchospasm Inflammation Mucosal edema Copious secretion For mobilization of secretion Aerosol drug delivery systems
Delivery systems: a) Nebulizer b)MDI (Metered dose-inhalers) a) Nebulizer It is a device used to converting a liquid drug into a fine mist which can then beinhaled easily. Types: a) Jet Nebulizer b) Ultrasonic Nebulizer Purposes: To administer medication directly into the respiratory tract to induce sputumexpectoration in case of sputum induction To reduce the difficulty in bringing out the secretions To increase Vital capacity metered-dose inhaler (MDI)
Ametered-dose inhaler (MDI)is a device that delivers a specific amount ofmedication to thelungs, in the form of a short burst of aerosolized medicinethat is inhaled by the patient. It is the most commonly used delivery system for treatingasthma,chronicobstructive pulmonary disease (COPD) and other respiratory diseases. The medication in a metered dose inhaler is most commonlyabronchodilator,corticosteroidor a combination of both for thetreatment of asthma and COPD. Thank you