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Premium member Presentation Transcript Role of Physiotherapy in Respiratory conditions: Role of Physiotherapy in Respiratory conditions Dr. Hari Babu M.H.Sc.PT (Orthopedics ) Department of Physiotherapy MGM Medical college and M.Y.Hospital IndoreRole of Physiotherapy in respiratory conditions: Role of Physiotherapy in respiratory conditions Treatment administered to increase Ventilation & Oxygenation Treatment administered to reduce O2 consumption Treatment administered to improve secretion clearance Treatment administered to improve exercise tolerance (endurance exercise) Treatment administered to reduce pain(Pain relieving electrotherapy modalities)PowerPoint Presentation: Treatment administered to increase Ventilation & Oxygenation a)Breathing exercise b)Positioning technique Treatment administered to reduce O2 consumption a)To reduce work of breathing b)To reduce general body workPowerPoint Presentation: Treatment administered to improve secretion clearance a)To enhance muco-ciliary transport(Postural drainage) b)To enhance cough( techniques to improve cough) c) Bronchial hygiene techniques ACB,(FET)Autogenic drainage),PEP, Flutter, Acapella, High frequency chest wall oscillations Treatment administered to improve exercise tolerance (endurance exercise) Treatment administered to reduce pain(Pain relieving electrotherapy modalities)Treatment administered to increase ventilation & Oxygenation : Treatment administered to increase ventilation & Oxygenation Alveolar ventilation depends on the magnitude of tidal volume and dead space Decrease in alveolar ventilation are the result of decreased tidal volume or increased dead space Physiotherapist aim is to increase tidal volume or decrease dead space(physiological) or both Tidal volume can be increased by Breathing exercise Dead space can be decreased by proper positioning techniqueBreathing exercise : Breathing exercise Inspiration is done through nose and expiration through mouth Inspiration through nose has four advantage a)It acts as a filter to prevent dust and other particles from getting into the lungs, b) It warms the air c) It prevents gas from getting into the stomach d) It naturally controls the intensity of breathing by controlling the correct balance of oxygen and carbon dioxide.PowerPoint Presentation: Afferent stimuli from the nerves that regulate breathing are in the nasal passages. The inhaled air passing through the nasal mucosa carries the stimuli to the reflex nerves that control breathing. Mouth breathing bypasses the nasal mucosa and makes regular breathing difficult. Patient is asked to exhale through mouth with whistling sound to identify the expiration phase as he has to perform the chest manipulationsTypes of Breathing exercise : Types of Breathing exercise Relaxed Diaphragmatic breathing Pursed lip breathing Segmental breathing(costal expansion exercise) a)Apical breathing b)lateral costal expansion c)Posterior basal expansion Sustained maximal inspiration (deep breathing)Technique : Technique Starting position is Half lying (Explain) Diaphragmatic breathing enhance diaphragmatic descent during inspiration and diaphragmatic ascent during expiration Physiotherapist assist diaphragmatic ascent by directing the patient to allow the abdomen to retract gradually during exhalation or by contracting abdominal muscles actively Diaphragmatic descent is assisted by directing the patient to protract the abdomen gradually during inhalationPowerPoint Presentation: Dominant hand is placed on abdomen and non dominant hand is placed on the chest Instruct the patient to move the dominant hand and not to move the non- dominant hand so that patient concentrates on diaphragm and not the external inter-costal muscles or accessory muscles When subjects inhale diaphragmatically after maximal expiration increases Lower lung zone ventilation (Cottle, 1972:Rohrer, 1915)Re education of diaphragm: Re education of diaphragm As other skeletal muscles, diaphragm also shares the property of skeletal muscle Place the index and middle finger below the lower costal margin anteriorly in half lying position over the insertion of diaphragm (central tendon) At the end of expiration when diaphragm is relaxed, stretch stimulus is given to the diaphragm to elicit Stretch reflex of the diaphragm and patient is instructed to take breath inResisted diaphragmatic breathing : Resisted diaphragmatic breathing Manual resistance by therapist over the abdomen Placing appropriate weight over abdomen in By slightly elevating the foot end of the bedPhysiological outcomes of Diaphragmatic breathing : Physiological outcomes of Diaphragmatic breathing Reduces work of breathing Reduces the incidence of post operative pulmonary complications Improve ventilation and oxygenation Eliminates accessory muscle activity Decrease respiratory rate Increase tidal ventilation Improve distribution of ventilationPursed lip breathing –Indication : Pursed lip breathing –Indication COPD Emphysema leads to Hyperinflation by two mechanism a)Passive hyperinflation b)Dynamic hyperinflationPassive hyperinflation : Passive hyperinflation Is caused by reduced elastic recoil which allows the airway to collapse on expirationDynamic hyperinflation : Dynamic hyperinflation Is caused by the patient having to actively sustain inspiratory muscle contraction in order to hold open the airway ,this unfortunate but necessary process is achieved at the cost of excess work of breathing Intrinsic PEEP : airway obstruction reduces expiratory flow which prevents expired air from being expelled before next inspiration starts causing air trapping which creates positive pressure in the chest known as PEEP(Intrinsic PEEP)PowerPoint Presentation: An average positive pressure is 2cmH2o which imposes an extra threshold load at the start of inspiration because inspiratory muscle have to offset this positive pressure before inspiration can begin Distended airway require a grater than normal pressure for inflationIn Emphysema excess WOB is required to : In Emphysema excess WOB is required to Overcome the resistance of obstructed airway Assist expiration (active instead of passive ) Sustain inspiratory muscle action through out respiratory cycle so that high lung volume are maintained Overcome threshold resistance at the start of inspiration ,caused by Intrinsic PEEPPursed lip breathing -Technique: Pursed lip breathing -Technique 1. Relax neck and shoulder muscles. 2. Breathe in (inhale) slowly through nose for two counts, keeping your mouth closed. Don't take a deep breath; a normal breath will do. Breathe out (exhale) slowly and gently through your pursed lips while counting to four. Note that exhalation should not be too hard. Hyperventilation will worsen the symptoms. Blow out with the about same force that you would use to cool hot soup on a spoon so that you do not blow it off the spoon.Uses of pursed lip breathing: Uses of pursed lip breathing Improves ventilation Releases trapped air in the lungs Keeps the airways open longer and decreases the work of breathing Prolongs exhalation to slow the breathing rate Improves breathing patterns by moving old air out of the lungs and allowing for new air to enter the lungs Relieves shortness of breath Causes general relaxationPowerPoint Presentation: It can be applied: - as a 3-5 minutes “rescue exercise” or an Emergency Procedure to counteract acute exacerbations or dyspnea (shortage of air or breathlessness) in COPD and asthma (Nield et al, 2007; Puente-Maestu & Stringer, 2006; Garrod et al, 2005; Pursed-lip breathing reduces hyperventilation-induced broncho-constriction (Wardlaw et al, 1987).Segmental breathing (costal expansion exercise): Segmental breathing (costal expansion exercise) Apical costal expansion (for apical lobes) Lateral costal expansion (for middle and lingular lobes) Posterior basal expansion(for lower lobes)Advantages of segmental breathing(indication) : Advantages of segmental breathing(indication) Prevent accumulation of pleural fluid Prevent accumulation of secretions Decreases paradoxical breathing Decrease panic Improve chest mobilityTechnique: Technique The technique uses manual counter pressure to encourage the expansion of specific part of the lung Identify the surface landmark and place hand on the chest wall overlying the bronco-pulmonary segment requiring treatment Apply firm pressure to that area at the end of patients expiratory maneuver Instruct the patient to inspire attempting to direct the inspired air toward the therapist hand saying “breath into my hand”PowerPoint Presentation: Reduce the hand pressure at the end of inspiration and repeat the procedure If the aim of the treatment is to expand the lung tissue the emphasis should be on holding the maximum inspiration for 3 sec and then sniff little more air Holding the breath also allows time for the air to diffuse through the pores of Khon and sniff will provide a little more expansion Once the patient has learned correct technique he is taught to give pressure himselfSelf resistance technique : Self resistance technique When using this technique patient should not elevate his shoulder or achieve costal expansion by side flexion of spinePositioning technique-Effect of body position on perfusion : Positioning technique-Effect of body position on perfusion Pulmonary pressure system is low pressure system than systemic circulation Pulmonary artery pressure is 25/10mmhg Gravity affects the low pressure pulmonary vascular system than systemic high pressure system (120/80mmhg) Eg: when a person is standing the gravity dependent areas of the lungs receive the greatest amount of blood flow and apices are gravity independent lobes and receive least amount of perfusionEffect of body position on ventilation: Effect of body position on ventilation Regional differences are found in the ventilatory aspect of lung which is caused by the intra-pleural pressure gradient Intra-pleural pressure gradient is more negative at the upper part of the lung(apices) & less negative at the lower part of the lung (base) Eg : in standing this pressure gradient result in the greater resting expansion in apical areas of lung than in the basal regionPowerPoint Presentation: When the air is inhaled the apices being almost full at the onset of inhalation receive very little of the new volume of air The bases however being almost empty receive most of the inhaled volume of air ,hence more ventilation in the basal area &less ventilation in apical area When position is changed the areas of greatest ventilation also changedPowerPoint Presentation: Ventilation perfusion inequality occurs in diseased states Three examples of possible relation are a)Physiologic dead space (normally aerated alveoli with no capillary perfusion) b)physiologic shunt(normally perfuced capillary with no alveolar aeration ) c)silent unit (non aerated alveoli next to a non perfused capillary )Positioning technique : Positioning technique Lung volume is related to displacement of diaphragm and abdominal contents Lung compliance decreases and work of breathing increases progressively from standing to supine lying Position affects VA/Q ratio ,VA & Q is greater in dependent lungsBad lung up rule: Bad lung up rule It promotes comfort following thoracotomy or chest drain placement Facilitates postural drainage Helps to improve lung volume when atelectatic lung is positioned upper most to encourage expansion With atelectasis the uppermost areas are stretched and better expandedPowerPoint Presentation: To optimize gases exchange a person with moderate unilateral effusion may benefit from side lying with affected side uppermost because both ventilation and perfusion are greater in lower lobe Large effusion are more likely to show improved Pao2 with the effusion downwards to minimize compression of unaffected lungException to the bad lung up rule: Exception to the bad lung up rule Recent pneumonectomy Large pleural effusion Broncho pleural fistulaTreatment administered to improve chest clearance – coughing: Treatment administered to improve chest clearance – coughingTechniques to improve cuff: Techniques to improve cuff Positioning for cough Forced expiration stimulates cough Pressure over extra thoracic trachea (supra sternal notch) elicit reflex cuff Nuero muscular facilitation –intermittent application of ice over paraspinal muscle 3-5 sec of thoracic spine Reflex cuff are stronger than voluntarily producedCont..: Cont.. Therapist should determine the phase or phases of cuffing are reducing its effectiveness ,when inspiration is too shallow, deep breathing or lateral costal expansion exercise is taught to patientBronchial hygiene technique-ACBT: Bronchial hygiene technique-ACBT Active cycle of breathing originally called Forced expiratory technique(FET) It was renamed to emphasize all of its components It is a combination of breathing control ,thoracic expansion and Forced expiratory technique This combination is performed in cycle which is repeated until the huff is clear and dryForced expiratory technique : Forced expiratory technique Is popularly known as “huff” is forced exhalation through an open mouth and glottis Properly performed this technique maximizes airflow and minimizes airway collapse Huffing prior to coughing will optimize airway clearance by moving secretions further up the airway FET is recommended with all of the airway clearance techniquePowerPoint Presentation: Gravity assisted position will be more effective Percussion and vibration can be applied if desired ACBT uses the concept of Equal pressure point theory(EPP)Bronchial hygiene technique-Autogenic drainage: Bronchial hygiene technique-Autogenic drainage Autogenic drainage is a technique designed to mobilize secretions by breathing control rather than postural drainage The goal of therapy is to reach the highest possible airflow in different generations of bronchi This is achieved by breathing at three different levels and adjusting expiratory flow rates to avoid airway collapseMechanism: Mechanism It consist of a cycle of huff from mid to low lung volume with deep breathing and relaxed abdominal breathing During huffing or forced expiration the pleural pressure becomes positive and equals the alveolar pressure at a point along the airway called Equal pressure Point(EPP)PowerPoint Presentation: Towards the mouth from this point the transmural pressure gradient is reversed so that pressure outside the airway is higher than inside thus squeezing the air way by the process called Dynamic compression Squeezing of airways mouth wards from this point mobilizes secretionsCont..: Cont.. At high lung volume the EPP is more proximal because pleural pressure decreases and alveolar elastic recoil increasesLocation of EPP: Location of EPP Forced expiratory maneuver (huff or cuff)at low lung volume mobilizes secretions from alveoli Forced expiratory maneuver at mid lung volume mobilizes secretion from lobar and segmental bronchi Forced expiratory maneuver at high lung volume mobilizes secretions from larger airways ( trachea and main bronchi)FEM in Low lung volume: FEM in Low lung volume EPP ++ + + Alveoli Upper respiratory way + + + + +FEM in Mid lung volume: FEM in Mid lung volume EPP Alveoli + + + + + + + + + Upper respiratory wayFEM in High lung volume: FEM in High lung volume + + + + + + + + + EPP Alveoli Upper respiratory wayTreatment administered to improve exercise tolerance –Raising resting respiratory level: Treatment administered to improve exercise tolerance –Raising resting respiratory level Resting respiratory level is the point at which the tidal volume rests within the vital capacity It is the point at which the elasticity or recoil of the rib cage is in balance with the elasticity of the lung tissue In emphysema portion of the lung shut down sooner than others , gross expiration obstruction occours at late expiration Continuing expiration only increases muscle work while an ever decreasing amount of air is being movedPositive Expiratory Pressure : Positive Expiratory PressureFlutter valve therapy : Flutter valve therapy Flutter is an expiratory device that ,in addition to positive pressure ,creates vibrations of the airways as a result of oscillating airflow and pressure ,these vibrations are thought to further aid in the loosening of mucusFlutter: FlutterFlutter valve therapy : Flutter valve therapyAcapella : Acapella It is new generation of vibratory PEP therapy ,which is similar to flutter with the benefits of PEP therapy and vibrations ,but is different as we can adjust the frequency and resistance by simply turning a dial This unique feature makes it more user –friendlyAcapella : AcapellaHigh frequency chest wall oscillations: High frequency chest wall oscillations High frequency chest wall oscillations utilizes a mechanical device called the vest This system is an air –pulse generator connected to an inflatable vest worn by the patient The vest oscillates the chest wall creating vibrations and air movement throughout the airways This movement is described as “mini- coughs” and this action helps to loosen and move secretionsHigh frequency chest wall oscillations: High frequency chest wall oscillationsTreatment administered to improve exercise tolerance –Raising resting respiratory level: Treatment administered to improve exercise tolerance –Raising resting respiratory level Resting respiratory level is the point at which the tidal volume rests within the vital capacity It is the point at which the elasticity or recoil of the rib cage is in balance with the elasticity of the lung tissue In emphysema portion of the lung shut down sooner than others , gross expiration obstruction occours at late expiration Continuing expiration only increases muscle work while an ever decreasing amount of air is being movedPowerPoint Presentation: Breathing cycle is lifted between 200-300 ml from the obstructed point the ventilation will be more effective (greater airflow for less work) Improved function & exercise tolerance can be achieved without altering the course of the disease The relaxed expiratory phase is watched by the physiotherapist who directs the patient to begin the inspiration a little sooner in the respiratory cycle ,thus avoiding prolong expirationPowerPoint Presentation: The tidal volume is maintained ,thus it is not just the expiratory level which is raised but the whole respiratory level This technique is designed to help the patients with airway obstruction due to emphysema ,it is also useful in helping to improve airflow during an episode of reversible airway obstruction You do not have the permission to view this presentation. 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