MANAGEMENT OF PULMONARY CONDIATIONS

Rahul.AP , MPTMANAGEMENT OF PULMONARY CONDITIONS

BREATHING EXERCISEBreathing ex: and ventilatory training are the fundamental interventions for the prevention for acute and chronic pulmonary disease mainly for COPD (chronic bronchitis, emphysema and asthma), patients with high spinal cord lesion and who underwent thoracic and abdominal surgery and bedridden patients.Studies indicate that breathing exercise and ventilatory training have affect and alter a patients rate and depth of ventilation ,so these technique is used to improve the pulmonary status and increase patients overall endurance.

GOALS OF BREATHING EXERCISEImprove ventilationIncrease the effectiveness of cough and promote airway clearanceTo prevent post operative pulmonary complicationsTo improve the strength endurance coordination of the muscles of ventilationMaintain and improve chest and thoracic spine mobilityPromote relaxation and relive stressTo teach the patient how to deal with episodes of dyspnea Assisting in removal of secretions.

Correct abnormal breathing patterns and decrease the work of breathing.Aid in bronchial hygiene---Prevent accumulation of pulmonary secretions, mobilization of these secretions, and improve the cough mechanism.

GUIDELINE FOR TEACHING BREATHING EXERCISESChoose a quiet area-to get a proper interaction with minimal distractionExplain the patient about the aim and how it works for his impairmentHave the pat: in relaxed position and loosen the clothes, make him in semi-fowlers position with head and trunk elevated approx: 45 (total support to the head and trunk and flexing the hip and knees with pillow support) the abdominal muscle become relaxedOther positions, such as supine, sitting, or standing, may be used as the patient progresses during treatment.

SEMI-FOWLERS POSITION

Observe and access the patients spontaneous breathing pattern while at rest and during activityDetermine whether Rx is indicated or not

If necessary teach the patient relaxation techniques, relax the muscles of upper thorax neck and shoulder to minimize the use of accessory muscle work. Special attention on sternocleidomastoids,upper trapezius and levator scapulae

Demonstrate the breathing pattern to the patientHave the patient practice the correct technique in verity of positions at rest and with activity

PRECUATIONSNever allow the patient to force expiration-it may increase the turbulence in the air way which leads to bronchospasm and airway resistanceAvoid prolonged expiration-it cause the patient to gasp with the next inspiration and the breathing pattern become irregular and inefficientDo not allow the patient to initiate inspiration with accessory muscles and upper chest ,advise him that upper chest should be quiet during breathingAllow the patient to perform deep breathing only for 3-4 times (inspiration and expirations) to avoid hyperventilation

INDICATIONSCystic fibrosisBronchiectasisAtelectasisLung abscessPneumoniasAcute lung diseaseCOPD emphysema, chronic bronchitisFor patients with a high spinal cord lesion/ spinal cord injury, myopathies etc.After surgeries (thoracic or abdominal surgery)For patients who must remain in bed for an extended period of time.(obstruction due to retained secretions)As relaxation procedure.

CONTRAINDICATIONS Severe pain and discomfortAcute medical or surgical emergencyPatients with reduced conscious level

TYPES OF BREATHING EXERCISESDiaphragmatic breathing Glossophryngeal breathingPursed lip breathing Segmental breathing(costal expansion exercise) a) Apical breathing b) Lateral costal expansion c) Posterior basal expansion

BREATHING EXERCISE TECHNIQUES DIAPHRAGMATIC BREATHINGDiaphragm is the primary muscle for breathing (inspiration) diaphragm controls breathing at an involuntary level ,a patient with primary pulmonary disease like COPD can be taught breathing control by optimal use of diaphragm and relaxation of accessory muscles Diaphragmatic breathing ex: are also use to mobilize lung secretion in PD

PROCEDUREPrepare the patient in relaxed and comfortable position in which the gravity assist the diaphragm such as semi-fowlers positionIf you notice any accessory muscle activation stop him and do relaxation techniques (shoulder roll or shrugs coupled with relaxation)Place your hands over the rectus abdominis just below the ant: costal margin ask the patient to breath slowly and deeply via nose by keeping the shoulder relaxed and upper chest quiet allowing the abdominal to rise now ask him to slowly let all the air out using controlled expiration through mouth.

Have him to practice this for 2-4 times if he finds any difficulty in using diaphragm have the patient inhale several times in succession through the nose by using sniffing action this facilitates the diaphragmFor self monitor have the patients hand over the ant: costal margin and feel the movt: (hand rise and fall) by placing one hand over abdomen he can also feel the contraction of abdominal muscles which occurs with controlled expiration or coughing After he understands and able to do the controlled breathing using a diaphragmatic pattern keep the shoulder relaxed and practice in verity of positions (supine sitting standing) and during activity (walking and climbing stair)

RE EDUCATION OF DIAPHRAGM: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.

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Resisted diaphragmatic breathing

PT use small weight, such as sandbag to strengthen and improve the endurance of the diaphragm Have the patient in a head up positionPlace a small weight (3-5 lb) over the epigastric region of his abdomen (1.30- 2.20 kg)Tell the patient to breath in deeply while trying to keep the upper chest quietGradually increase the time that the patient breaths against the resistance of weight Weight can be increased when he can sustain diaphragmatic breathing pattern with out the use of any accessory muscles of inspiration for 15minuts

Glossophryngeal breathingIt is a means of increasing a patients inspiratory capacity when there is a severe weakness of the muscle of inspiration It is taught to patients who have difficulty in deep breathing.This type of breathing pattern was originally developed to assist post polio patients with severe muscle weakness

PROCEDUREPatient take several gulp of air by closing the mouth the tongue pushes the air back and trap it in the pharynx the air is then forced to lungs when the glottis is opened

PURSED LIP BREATHINGPursed-lip breathing is a strategy that involves lightly pursing the lips together during controlled exhalation.Taught to patients with COPD to deal with episodes of dyspnea. It helps to Improves ventilation and Releases trapped air in the lungsKeeps the airways open longer and Prolong exhalation slow the breathing rateIt moves old air out of the lungs and allow new air to enter the lungs

PROCEDUREPatient in a comfortable position and relaxed, explain the patent about the expiration phase (it should be relaxed and passive) abdominal muscle contraction must be avoided (therapist hand over the patients abdominal to check for contraction)Ask the patient to breathe in slowly and deeply through the nose and then breathe out gently through lightly pursed lips (blowing on and bending the flame of a candle )By providing slight resistance an increased positive pressure will generate with in the airway which helps to keep open small bronchioles that otherwise collapse

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.

SEGMENTAL BREATHINGIt is performed on a segment of lung, or a section of chest wall that needs increased ventilation or movement.Hypoventilation occur in certain areas of the lungs because of chest wall fibrosis, pain after surgery, atelectasis , trauma to chest wall, pneumonia and post mastectomy scarTherefore, it will be important to emphasize expansion of such areas of the lungs and chest wall

ADVANTAGES OF SEGMENTAL BREATHING

Prevent accumulation of pleural fluid and secreationsDecreases paradoxical breathingDecrease panicImprove chest mobility

Lateral costal expansionThis is sometimes called lateral basal expansion and may be done unilaterally or bilaterally.The patient may be sitting or in a hook lying position.Place your hands along the lateral aspect of the lower ribsAsk the patient to breathe out, and feel the rib cage move downward and inward.As the patient breathes out, place firm downward pressure into the ribs with the palms of your hands.Just prior to inspiration, apply a quick downward and inward stretch to the chest. This places a quick stretch on the external intercostals to facilitate their contraction. These muscles move the ribs outward and upward during inspiration.

Apply light manual resistance to the lower ribs to increase sensory awareness as the patient breathes in deeply and the chest expands. When the patient breathes out, assist by gently squeezing the rib cage in a downward and inward direction.The patient may then taught to perform the maneuver independently, ask him to apply resistance with his hand or with a towel

LATERAL COSTAL EXPANSION SUPINE

LATERAL COSTAL EXPANSION SITTING

Lateral Costal

Upper costal

Lower Costal

BELT EXERCISES TO REINFORCE LATERAL COSTAL BREATHING (A) by applying resistance during inspiration(B) by assisting with pressure along the rib cage during expiration.

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Posterior basal expansionThis form of segmental breathing is important for the post surgical patients who is in bed in a semi-reclining position for an extended period of timeSecretion often accumulate over the posterior segments of lower lobesProcedureHave the patient sit and lean forward on a pillow, slightly bending the hips

Place the PT hand over the posterior aspect of the lower rib and do the same procedure in lateral costal expansion

Right middle lobe or lingula expansionWhile the patient in sitting place your hand at either the right or left side of the patients chest just below the axilla, and follow the same procedure in lateral costal expansion

FORCED EXPIRATORY TECHINIQUES

The FET employs a forced expiration or huff following a medium size breath to mid lung volume then tighten the abdominal muscle firmly while huffing (expiring forcefully with an open glottis) with out contracting the throat musclesThere should be a period of 15-30 sec relaxation with gentle diaphragmatic breathing that follow 1 or 2 huffsOnce secretions is felt on the upper most airway a huff or double cough can remove it

Thank you