Role of Physiotherapy in respiratory conditionsTreatment administered to increase

Ventilation & OxygenationTreatment administered to reduce O2

consumption Treatment administered to improve secretion

clearanceTreatment administered to improve exercise

tolerance (endurance exercise)Treatment administered to reduce pain(Pain

relieving electrotherapy modalities)

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 work

• 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 Alveolar ventilation depends on the magnitude

of tidal volume and dead spaceDecrease 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

exerciseDead space can be decreased by proper

positioning technique

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.

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 manipulations

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 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 inhalation

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 diaphragmAs 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 in

Resisted diaphragmatic breathing

Manual resistance by therapist over the abdomen

Placing appropriate weight over abdomen in By slightly elevating the foot end of the bed

Physiological outcomes of Diaphragmatic breathing

Reduces work of breathingReduces the incidence of post operative

pulmonary complicationsImprove ventilation and oxygenationEliminates accessory muscle activity Decrease respiratory rate Increase tidal ventilation Improve distribution of ventilation

Pursed lip breathing –Indication

COPD Emphysema leads to Hyperinflation by two

mechanism a)Passive hyperinflation b)Dynamic hyperinflation

Passive hyperinflation

Is caused by reduced elastic recoil which allows the airway to collapse on expiration

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)

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 inflation

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 PEEP

Pursed lip breathing -Technique1. 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 breathingImproves ventilationReleases trapped air in the lungsKeeps the airways open longer and decreases

the work of breathingProlongs exhalation to slow the breathing rateImproves breathing patterns by moving old air

out of the lungs and allowing for new air to enter the lungs

Relieves shortness of breathCauses general relaxation

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)

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)

Prevent accumulation of pleural fluidPrevent accumulation of secretions Decreases paradoxical breathingDecrease panicImprove chest mobility

TechniqueThe 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”

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 himself

Self resistance technique

When using this technique patient should not elevate his shoulder or achieve costal expansion by side flexion of spine

Positioning technique-Effect of body position on perfusion Pulmonary pressure system is low pressure

system than systemic circulation Pulmonary artery pressure is 25/10mmhgGravity 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 perfusion

Effect of body position on ventilationRegional 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 region

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 changed

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 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 lungs

Bad lung up ruleIt promotes comfort following thoracotomy or

chest drain placement Facilitates postural drainageHelps to improve lung volume when

atelectatic lung is positioned upper most to encourage expansion

With atelectasis the uppermost areas are stretched and better expanded

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 lung

Exception to the bad lung up rule

Recent pneumonectomy Large pleural effusion Broncho pleural fistula

Treatment administered to improve chest clearance – coughing

Techniques to improve cuff

Positioning for coughForced expiration stimulates coughPressure over extra thoracic trachea (supra sternal notch) elicit reflex cuffNuero muscular facilitation –intermittent

application of ice over paraspinal muscle 3-5 sec of thoracic spine

Reflex cuff are stronger than voluntarily produced

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 patient

Bronchial hygiene technique-ACBTActive 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 dry

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 technique

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

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 collapse

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)

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 secretions

Cont..

At high lung volume the EPP is more proximal because pleural pressure decreases and alveolar elastic recoil increases

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

EPP

++

+

+

Alveoli

Upper respiratory way

+

+ +

+ +

FEM in Mid lung volume

EPP

Alveoli + + +

+ +

+ +

+

+

Upper respiratory way

FEM in High lung volume

+ +

+

+

+ +

+ +

+

EPP

Alveoli

Upper respiratory way

Treatment administered to improve exercise tolerance –Raising resting respiratory levelResting respiratory level is the point at which the

tidal volume rests within the vital capacityIt 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 moved

Positive Expiratory Pressure

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 mucus

Flutter

Flutter valve therapy

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 –friendly

Acapella

High frequency chest wall oscillationsHigh frequency chest wall oscillations utilizes a

mechanical device called the vestThis 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 secretions

High frequency chest wall oscillations

Treatment administered to improve exercise tolerance –Raising resting respiratory levelResting respiratory level is the point at which the

tidal volume rests within the vital capacityIt 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 moved

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 expiration

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

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