PT Intervention I: Cardiopulmonary rehabilitation Lecturer : Mr. Akhilanand P. Raghunandan COURSE NUMBER: BMP 4104
Week 3: Principle and techniques of physiotherapy in diseases of respiratory and cardiopulmonary system: Body positioning, P.D ( Postural Drainage), breathing exercises and thoracic mobility exercises, PNF techniques of respiration, chest clearance techniques- PEP mask, flutters, ACBT, autogenic drainage cough- assisted techniques , techniques of facilitations of accessory muscles, Mecanical Aids-incentive Spirometry, CPAP,(periodic continuous positive airway pressure IPPB (Intermittent positive pressure breathing)
Body positioning Rounded shoulders, thoracic kyphosis and head thrust forward are common postural abnormalities. The effect is to diminish thoracic spine mobility and chest expansion. Therefore it is essential to teach patients to relax the shoulder girdle, straighten the spine and keep the head erect. This must be applied in positions of work and when sitting resting, e.g. reading or watching television.
Pulmonary Capacity Vital capacity (VC) Amount of air that can be forcefully exhaled following a maximum inspiration. ( ≈4700 mL) VC = ERV + TV + IRV Inspiratory capacity (IC) Maximum amount of air that can be inhaled following a normal expiration. ( ≈3500 mL) IC = TV + IRV Functional residual capacity (FRC) Amount of air remaining in the lungs following a normal expiration. ( ≈2500 mL) FRC = RV + ERV Total lung capacity Maximum amount of air in the lungs at the end of a maximum inspiration. ( ≈6000 mL) TLC = RV + VC
Pulmonary Capacity Tidal volume (TV) Amount of air inhaled or exhaled in one breath during quiet breathing. ( ≈500 mL) Inspiratory reserve volume (IRV) Amount of air in excess of tidal volume that can be inhaled with maximum effort. ( ≈3000 mL) Expiratory reserve volume (ERV) Amount of air in excess of tidal volume that can be exhaled with maximum effort. ( ≈1200 mL) Residual volume (RV) Amount of air remaining in the lungs after maximum expiration; that is, the amount of air that can never be voluntarily exhaled. ( ≈1300 mL)
The lung contains 4 Volumes each of which contains two or more capacities Vital capacity (VC) Inspiratory capacity (IC) Functional residual capacity (FRC) Total lung capacity
Pulmonary Capacity
P.D ( Postural Drainage), This comprises positioning the patient so that gravity helps drain a lobe or bronchopulmonary segment.
Breathing exercises and thoracic mobility exercises Mobilization and exercise refer to the application of progressive exercise to elicit cardiopulmonary and cardiovascular responses to enhance oxygen transport. In the context of cardiopulmonary physiotherapy, 'mobilization‘ refers to low-intensity exercise for typically acutely ill patients or those with severely compromised functional work capacity
PNF( techniques of respiration
Chest clearance techniques- PEP mask The positive expiratory pressure (PEP) mask was described by Falk et al (1984) who found an increase in sputum yield and an Improvement in transcutaneous oxygen tension when Compared with postural drainage, percussion and breathing exercises. It was suggested that the increase in sputum yield was produced by the effect of PEP on peripheral airways and collateral channels.
The PEP apparatus consists of a face mask and a one-way valve to which expiratory resistances can be attached. A manometer is inserted into the system between the valve and Resistance to monitor the pressure which should be between 10 and 20 cmH20 during mid-expiration (Falk & Andersen 1991).The patient sits leaning forward with his elbows supported on a table and holding the mask firmly over the nose and mouth (Fig. 8.35). A mouthpiece and nose clip can be used in place of the mask if this is preferred. The patient breathes at tidal volume with a slightly active expiration for about six to ten breaths and the lung volume should be kept up by avoiding complete expiration. This is followed by the forced expiration technique to clear the secretions mat have been mobilized. The duration and frequency of treatment are adapted to each individual, but treatment is usually performed for 15 minutes twice a day in patients withstable chest disease with excess bronchial secretions (Falk & Andersen 1991).
PEP(positive expiratory pressure) Mask
High-pressure PEP is a modified form of PEP mask treatment described for the treatment of patients with cystic fibrosis by Oberwaldner et al (1986). By using high pressures of PEP (50-120 cmH:0), secretions may be mobilized more easily in patients with unstable airways. While sitting upright the patient holds the mask firmly against the face. Six to ten rhythmical breaths at tidal volume are followed by an inspiration to total lung capacity and men a forced expiratory manoeuvre against the resistance to low lung volume which usually results in the expectoration of sputum (Oberwaldneretall991). An individual optimum expiratory resistance is carefully determined by spirometry. It is theresistance that allows the patient to expire to a volume greater than his usual forced vital capacity. The technique is only recommended for use where full lung function equipment is available for regular reassessment of the appropriate expiratory resistance for each individual. Meticulous care must be taken as an incorrect resistance can lead to a deterioration in lung function
The Cornet The Cornet consists of a curved hard plastic tube within which sits a soft flexible rubber tube. It works in a very similar way as the flutter, producing a vibration and PEP effect in the airways. The degree of PEP and vibration can be altered by changing the twist in the rubber tube. The Cornet can be used in any treatment position and like the flutter a combination of breathing techniques are used to help to move and clear secretions.
Flutters The Flutter is a small pipe shaped device which contains a metal ball in a cone. During the breath out the ball moves up and down in the cone. This interrupts the flow of air and gives an intermittent “back pressure” to the airways as well as causing them to vibrate. Flutter treatment is usually done in sitting. The angle at which the Flutter is held will change the area where the vibrations are felt and so it should be held at an angle where maximum vibrations are felt within the chest.
The Acapella The Acapella device also works in a very similar way to the flutter. It consists of a plastic outer shell, inside which is a lever and magnets. The lever action and the attraction between the magnets during the breath out provide the vibration and PEP. The degree of PEP and vibration can be altered by a dial at the end of the device. Treatment can take place in any position and is very similar to that of the Flutter. Thorough, daily cleaning and drying is vital for all devices as unwashed devices can harbour bacteria. There will be individual cleaning instructions for different devices.
Flutters
Method of Usage The Flutter is placed in the mouth and inspiration is either through the nose or through the mouth by breathing around the Flutter (it is not possible to breathe in through the Flutter). A slow deep breath in with a breath hold of 3-5 seconds is followed by a breath out, through the Flutter, at a faster rate than normal After four to eight of these breaths many patients use huffing either through the Flutter or without the Flutter. This may precipitate expectoration and should be followed by a pause for breathing control. Originally the recommended technique for the Flutter was a gentle exhalation through the device. Treatment was continued for a period of 10 minutes. Secretions were expectorated by spontaneous coughing.
ACBT (active cycle of breathing techniques ) The active cycle of breathing techniques (ACBT) is used to mobilize and clear excess bronchial secretions
Breathing Control (BC) This is a period of relaxed breathing. It is a very important part of this technique as it allows pauses for rest and helps avoid any tightening of the airways, which can make it difficult to clear secretions. The upper chest should remain relaxed with most of the movement occuring in the lower chest. The length of time spent on breathing control depends on the individual. The physiotherapist will advise you on timings.
Thoracic Expansion Exercises (TEE) These are also known as deep breathing exercises. They help the lungs to expand more effectively and allow air to get behind any secretions so that they can then be “pushed” up the airways towards the mouth. The breath in should be slow and deep. At the end of the breath in, the breath is held for a few seconds. Breathing out is relaxed and “quiet”. TEE are sometimes accompanied by percussion or vibrations (see below) but this may not be necessary.
The Forced Expiration Technique (FET) This technique consists of huffing and must be combined with breathing control. It helps to move secretions from the smaller to the larger airways from where they can be cleared more easily. A medium sized breath in is followed by a forced, but not violent, breath out (often called a huff). It should be made by squeezing the abdominal/ tummy muscles while keeping the mouth and throat open - just as if trying to steam up a mirror with your breath. Huffing at different levels can move secretions in different parts of the lungs, your physiotherapist will teach you about this. One or two huffs are followed by a period of breathing control. Often a huff is not sufficient to clear the secretions completely and therefore it is necessary to cough afterwards. Coughing should not be very forced or go on for a long time. If secretions are not cleared after one or two coughs, then the ACBT should be resumed until they are higher up and can be cleared more easily.
Active cycle of breathing technique Breathing control Thoracic expansion FET Forced expiration Technique
Flg. 8.12 Examples to demonstrate the flexibility of the active cycle of breathing techniques: BC, breathing control; TEE, thoracic expansion exercises; FET, forced expiration technique.
Autogenic Drainage Autogenic drainage (AD) aims to maximize airflow within the airways to improve the clearance of mucus and ventilation, it is breathing at different lung volumes and an active expiration is used to mobilise the mucus.
Autogenic drainage is a respiratory self-drainage technique that utilises controlled experitory airflow (tidal breathing) to mobilise secretions. It consists of three phases: Loosening peripheral secretions by breathing at low lung volumes (slow, deep air movement) Collecting secretions from central airways by breathing at low to middle lung volumes (slow, mid-range air movement) Expelling secretions from the central airways by breathing at mid to high lung volumes (shallow air movements) The velocity or force of the expiratory airflow must be adjusted at each level of inspiration so that the highest possible airflow is reached in that generation of bronchi, without being high enough to cause the airways to collapse during coughing. Autogenic drainage does not utilise Postural Drainage positions but is performed while sitting upright.
Instruction Posture: Choose a breath-stimulating position like sitting or reclining. Relax, with the neck slightly extended. Clear your nose and throat by blowing your nose and huffing. Breathing in Slowly breathe in through the nose to keep the upper airways open. Use the diaphragm and/or the abdomen if possible. First take a large breath in, hold it for a moment. Breathe all the way out for as long as you can. Now you are at low lung volume. The size of breath and level at which you breathe depends on where the mucus is located. Take a small to normal breath in, and pause. Hold your breath for about 3 seconds. All the upper airways should be kept open. This improves the even filling of all lung parts. The pause allows time for the air to get behind the mucus. Breathing out
Breathe out through the mouth. Keep the upper airways open Breathe out through the mouth. Keep the upper airways open. This is your glottis, throat and mouth. Breathing out is done in a sighing manner. When you force your breath out the airways can collapse. You will hear a wheeze. At low lung level breathing use your abdominal muscles. Squeeze all the air out until you can breathe out no more. You hear the mucus rattling in the airways when breathing the right way. Put a hand on your upper chest, and feel the mucus vibrating. High frequencies mean that the mucus is in the small airways. Low frequencies mean that the mucus is in the large airways. Using this feedback lets you easily adjust the technique. Repeat the cycle. Inhale slowly to avoid sending the mucus back down. Keep breathing at the low level until the mucus collects and moves upward. Signs of this are: Crackling of the mucus can be heard as you exhale. You feel the mucus moving up. You feel a strong urge to cough.
The level of breathing is raised when any of the above occurs The level of breathing is raised when any of the above occurs. Refer to the picture below. Moving the breathing from lower to higher lung area takes the mucus with it. Finally the collected mucus reaches the large airways where it can be cleared by a high lung volume huff. Don't cough until the mucus is in the larger airways. Cough only if a huff did not move the mucus to the mouth. You have now finished one cycle. Take a break of one to two minutes. Relax and perform breathing control before you start on the next cycle. The cycles are repeated during the session. A session lasts between twenty to forty-five minutes or until you feel all the mucus has been cleared. Do sessions of AD more often if you still have mucus present at the end of a session.
Cough- assisted techniques Percussion and vibration Percussion This technique is also known as chest clapping, and is used to help loosen secretions. It is usually combined with modified PD or PD and is sometimes also used during the Thoracic Expansion Exercise phase of the ACBT. To perform percussion a cupped hand is used to clap the chest firmly and rhythmically (over a layer of clothing or a towel). Vibrations/ Chest shaking This technique consists of several short rhythmical squeezes to the chest wall as the child/adult breathes out. Some people find this to be helpful in mobilising secretions. Like percussion, vibrations/chest shaking is sometimes used with TEE (in ACBT).
Techniques of facilitations of accessory muscles
Mecanical Aids-incentive Spirometry Incentive spirometers are mechanical devices introduced in an attempt to reduce postoperative pulmonary complications. The patient takes a slow deep breath in, with his lips sealed around the mouthpiece and is motivated by visual feedback, for example a ball rising to a preset marker. The patient aims to generate a predetermined flow or to achieve a preset volume and he is encouraged to hold his breath for 2-3 seconds at full inspiration. A short sharp inspiration can activate the flow-generated incentive spirometry devices with little increase in tidal volume, but with a volume-dependent device an increase in tidal volume must be achieved before the preset level can be reached
Indications - Pre-operative screening of patients at risk of post-operative complications to obtain a baseline of their inspiratory flow and volume - Presence of pulmonary atelectasis or conditions predisposing to atelectasis - Abdominal or thoracic surgery - Prolonged bed rest - Surgery in patients with COPD - Lack of pain control - Restrictive lung disease associated with a dysfunctional diaphragm or involving respiratory musculature - Patients with inspiratory capacity less than 2.5 litres - Patients with neuromuscular disease or spinal cord injury
Contraindicaciones or Precautions - Patients who cannot use the device appropriately or require supervision at all times. - Patients who are non-compliant or do not understand or demonstrate proper use of the device. - Very young patients or paediatrics with developmental delay - Hyperventilation. - Hypoxaemia secondary to interruption of oxygen therapy. - Fatigue. - Pain.
Incentive spirometer.
Use of the 'Coach* incentive spirometer.
CPAP Continuous positive airway pressure (CPAP) is the maintenance of a positive pressure throughout inspiration and expiration during spontaneous breathing. Periodic continuous positive airway pressure (PCPAP) is the application of this on a periodic or intermittent basis.
IPPB Intermittent positive pressure breathing (IPPB) is the maintenance of a positive airway pressure throughout inspiration, with airway pressure returning to atmospheric pressure during expiration.
The Bird Mark 7 ventilator.
Positive pressure. The range of pressures is likely to be from 0-35 cmH20.
IPPB in side lying.