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 the muscles of ventilation. Correct inefficient or abnormal breathing patterns and decrease the work of breathing. 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, decrease the work of breathing, increase the excursion (descent or ascent) of the diaphragm, and improve gas exchange and Oxygenation. Position: Semi-Fowler’s position (in which gravity assists 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 shrugs coupled with relaxation). Place your hand on the rectus abdominals just below the anterior costal margin on the epigastric angle. Ask the patient to breathe in slowly and deeply through the nose. Have the patient keep 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 if there is accumulation of secretions or insufficient lung expansion in these areas. 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 to direct the patient’s 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 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. Apply light manual resistance to the lower ribs to increase sensory awareness as 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 belt around the lower ribs

2) Posterior Basal Expansion Deep breathing emphasizing posterior basal expansion is important for the postsurgical patient who is confined to bed in a semi reclining position for an extended period of time because secretions often accumulate in the posterior segments of the lower lobes. Procedure Have the patient sit and lean forward on a pillow, slightly bending the hips. Place your hands over the posterior aspect of the lower 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 during controlled exhalation. p r e c a u t i o n : The use of forceful expiration during pursed-lip breathing must be avoided because this can cause further restriction of the small bronchioles. Position Any comfortable position Procedure: Have the patient breathe in slowly and deeply through the nose and then breathe out gently through lightly pursed lips as if blowing on and bending the flame of a candle but not blowing it out. Explain to the patient that expiration must be relaxed and that contraction of the abdominals must be avoided. Place your hand over the patient’s abdominal muscles to detect any contraction of the abdominals.

d. Glossopharyngeal breathing It is a means of increasing the inspiratory capacity when there is severe weakness of the respiration muscles. It is used primarily by patients who are ventilator-dependent because of absent or Incomplete innervations of the diaphragm as the result of a high cervical-level spinal cord lesion or other neuromuscular disorders Procedure Glossopharyngeal breathing involves taking several “gulps” of air, usually 6 to 10 gulps in series, to pull air into the lungs when action of the inspiratory muscles is inadequate. After the patient takes several gulps of air, the mouth is closed, and the tongue pushes the air back and traps it in the pharynx. The air is then forced into the lungs when the glottis is opened. This increases the depth of the inspiration and the patient’s inspiratory and vital capacities

e. Preventing and Relieving Episodes of Dyspnea If the patient becomes slightly short of breath, he must learn to stop an activity and use controlled, pursed-lip breathing until the dyspnea subsides. Procedure 1. Have the patient assume a relaxed, forward-bent posture. A forward bent position stimulates diaphragmatic breathing (the viscera drop forward and the diaphragm descends more easily). 2. Have the patient gain control of his or her breathing and reduce the respiratory rate by using pursed-lip breathing during expiration. 3. After each pursed-lip expiration, teach the patient to use diaphragmatic breathing and minimize use of accessory muscles during each inspiration.

2. Thoracic Mobilization Techniques Chest mobilization exercises are any exercises that combine active movements of the trunk or extremities with deep breathing. They are designed to maintain or improve mobility of the chest wall, trunk, and shoulder girdles when it affects ventilation or postural alignment. Exercises that combine stretching of these muscles with deep breathing improve ventilation on that side of the chest.

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 elongating the clasped behind the head, horizontally abduct the arms have him or her Pectoralis major) during a deep inspiration. Then instruct the patient to bring the elbows together and bend forward during expiration.

c. To Mobilize the Upper Chest and Shoulder While sitting in a chair, have the patient reach with both arms overhead (180 bilateral shoulder flexion and slight abduction) during inspiration. Then bend forward at the hips and reach for the floor during expiration

3.Respiratory muscle Training (RRT) RRT is advocated to improve ventilation in patients with pulmonary dysfunction associated with weakness, atrophy, or inefficiency of the muscles of inspiration or to improve the effectiveness of the cough mechanism in patients with weakness of the abdominal muscles 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 the mouth. These devices are narrow tubes of varying diameters or a mouthpiece and adapter with an adjustable aperture that provide resistance to airflow during inspiration and therefore place resistance on inspiratory muscles. The smaller the diameter of the tube and, the greater is the resistance. The patient inhales through the device for a specified period of time several times each day.

b. Incentive spirometer Incentive spirometer is a form of ventilatory training that emphasizes sustained maximum 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 operative patients. Procedure. Have the patient assume a comfortable position (semi reclining, if possible) and inhale and exhale three to four times and then exhale maximally with the fourth breath Then have the patient place the spirometer in the mouth, inhale maximally through the mouthpiece 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 7. Hydration and humidification Exercise 8. Postural drainage Manual techniques 9. modified Postural drainage Breathing techniques 10. Mechanical aids Cough 11. Pharyngeal suction Nasopharyngeal airway 12. Minitracheostomy

4. Airway Clearance Techniques An effective cough is necessary to eliminate respiratory obstructions and keep 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, causing an 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 patient’s 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 the abdominal area assists in 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 the patient to splint over the painful area during coughing. 3. Tracheal Stimulation The therapist places two fingers at the sternal notch and applies a circular motion with pressure downward into the trachea to facilitate a reflexive 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 be inhaled easily. Types: a) Jet Nebulizer b) Ultrasonic Nebulizer Purposes: To administer medication directly into the respiratory tract to induce sputum expectoration in case of sputum induction To reduce the difficulty in bringing out the secretions To increase Vital capacity

metered-dose inhaler (MDI) A metered-dose inhaler (MDI) is a device that delivers a specific amount of medication to the lungs, in the form of a short burst of aerosolized medicine that is inhaled by the patient. It is the most commonly used delivery system for treating asthma, chronic obstructive pulmonary disease (COPD) and other respiratory diseases. The medication in a metered dose inhaler is most commonly a bronchodilator, corticosteroid or a combination of both for the treatment of asthma and COPD.

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