1. chronic obstructive pulmonary disease in the elderly
Dr/Rehab F. Gwada

2. Definition
 COPD is a chronic inflammatory lung disease that usually becomes clinically apparent later in life, and it can lead to significant morbidity and premature death.
It characterized by limitation of expiratory airflow
Airflow limitation is mostly due to fixed airway obstruction
Progressive in nature
It comprised primarily of - chronic bronchitis and emphysema.

4. Prevalence
Chronic obstructive pulmonary disease (COPD) is common in older people, with an estimated prevalence of 10% in the US population aged ≥75 years. 
Effect equal numbers of men &women.
Age-related physiologic changes contribute to impaired pulmonary function and to the increased prevalence of COPD with age.

5. Prevalence
 While the prevalence and morbidity of COPD in the elderly are high, it is often undiagnosed and thus undertreated.
The diagnosis of COPD is primarily based on spirometry. 
 the elderly often suffer from physical or cognitive disabilities that can prevent compliance with prescribed medications.
Adverse effects from medications prescribed for treatment of COPD may be more pervasive in elderly patients.

6. Age Related changes in respiratory system & COPD
All of the following changes contribute to an increased likelihood of COPD in the elderly, and critical to geriatric considerations, these age-related changes may be less amenable to treatment.
a progressive reduction in compliance of the chest wall.
reduction in strength of the respiratory muscles
and anatomical changes to the lung parenchyma and peripheral airways.
Changes in thorax shape due to osteoporosis and kyphosis may induce inefficiencies in chest wall mechanics. 
decreased peak inspiratory and expiratory airflows, vital capacity, and efficiency of gas exchange. 
at age 70 years, FEV1 would be expected to decrease by about 30% and forced vital capacity (FVC) would be expected to decline by about 20% compared with values at age 20 years. 

7. Age Related changes in respiratory system & COPD
at age 70 years, the expected FEV1/FVC ratio would be about 74%, a value approaching the 70% criterion used for diagnosing significant obstruction.
 Additionally, the area for gas exchange declines linearly from the third decade of life.
 Loss of elastin leads to significant increases in dead space.

8. What causes COPD? Cigarette smoking and second-hand smoke
Air pollution
Occupational exposure to organic or inorganic dusts & to noxious gases
Alpha-1 antitrypsin deficiency(AAT)

9. What are the symptoms of COPD?
COPD symptoms
Advanced COPD symptoms
Chronic cough
Sputum production
Dyspnea.
Frequent respiratory infections
Chest tightness
Cyanosis
Morning headaches
Weight loss
Cor pulmonale
hemoptysis.

10. Signs of COPD tachypnea wheezing
breathing out taking a longer time than breathing in
active use of muscles in the neck to help with breathing
breathing through pursed lips
increased anteroposterior to lateral ratio of the chest (barrel chest).

11. Diagnosis of COPD in the elderly
history of smoking
Physical examination &Respiratory symptoms
Spirometry testing is indicated to confirm the diagnosis of COPD and to determine the severity of the disease so that appropriate therapy can be initiated
FEV1/FVC ratio <0.70 is considered diagnostic of COPD
FEV1 <80% of predicted value for age, weight &hight, indicat COPD
Increase total lung capacity & residual volume.
Six minute walking test (6MWT)
Chest X-ray & CT scan

12. The goals of COPD treatment
to prevent further deterioration in lung function.
to get symptoms control.
to improve performance of daily activities and quality of life.

13. The treatment strategies
Smoking cessation.
medications.
vaccination against flu influenza and pneumonia.
regular oxygen supplementation .
Replacement of the missing or inactive Alpha-1 antitrypsin deficiency by injection
pulmonary rehabilitation .
Surgery [ Lung volume reduction surgery, lung transplantation]

14. Physical therapy treatment
Humidification to allow the function of respiratory tract
A heated water bath has less irritation effect on sensitive airways and help in removal secretion
Chest PT. to manage secretion:
Conversion techniques of posture drainage may be not suitable for elderly due to:
Feeling discomfort able
Fear out of hand on approach with percussion as chest manipulation
Risk of pathological fracture of osteoporotic ribs
Active cycle of breathing & Autogenic drainage technique are alternative techniques.

15. 1-Autogenic drainage technique
Autogenic drainage is a respiratory self-drainage technique that utilizes controlled expiratory airflow (tidal breathing) to mobilize secretions. Autogenic drainage performed while sitting upright or reclining.
It consists of three phases:
Loosening peripheral secretions by breathing at low lung volumes . "Unsticking"
Collecting secretions from central airways by breathing at low to middle lung volumes . "Collecting"
Expelling secretions from the central airways by breathing at mid to high lung volumes . "Evacuating"

16. Autogenic drainage technique
The Three Lung Levels of Autogenic Drainage:
Level One: "Unsticking" of mucus by low lung level breathing.  First, exhale completely; inhale a small to normal breath.  Hold the breath for 1-3 seconds, then exhale completely again.  This step is repeated for 2-3 minutes.  Repeat until crackles are heard when breathing out.
Level Two: "Collecting" the mucus in larger or mid-sized airways.  Take in a slightly larger breath.  Hold for 1-3 seconds, and then exhale, but not as low as in level one.  Repeat this step for 2-3 minutes.  Listen for crackles at the end of exhaling.  Continue for 2-3 more breaths.  Then proceed to level III.
Level Three: "Evacuating" the mucus in the central airways is achieved by breathing at normal to high volumes.  Take in a slow deep breath.  Hold the breath for 1-3 seconds.  Exhale forcefully with open glottis.  This moves the mucus into your mouth.  Then spit it out into a container or tissue.
Each level requires about 2-3 minutes.  The full cycle takes 6-9 minutes.   When mucus is felt in the larger, central airways, do 2-3 effective "Huff" type coughs.  The Huff cough uses the mid to high lung volumes of level III.
Coughing should be avoided if possible in levels I and II.  Do 2-3 Huff coughs if you must cough.
Important Remarks
When mucus has been cleared out as described, some of the remaining mucus has moved partially up the respiratory tract.  This makes the collection and clearing of the next mucus plug easier and quicker.
In AD, it is best to first clear mucus from the small airways.  Using low lung breathing, the flow rates in the larger airways are also affected.   Some mucus moves in all of the levels at the same time.  If the urge to cough is too strong that mucus should be cleared first.
Patients being introduced to AD can have problems breathing at low-lung volumes.  You may begin to breathe at your natural tidal volume level.  Slowly go down to low levels.  You will find that breathing out deeply is not as difficult as your skill increases.
The larger and thinner the mucus plug, then less force is needed to move it upwards.
The length of an AD session depends on the amount and thickness of the mucus.   Skilled patients drain their lungs quicker than others.  Drainage should always be done thoroughly.  This way lung function will improve over time.  You should never do more than 1 hour per session.  AD may be done at anytime of day.
Patient's who clear well, improve their lung function.  This improves their activity level which helps with drainage during the day.  The airways remain clearer over a longer period of time.
To practice these techniques you need to have the correct breathing pattern.   Breathing re-education, thoracic mobility exercises, relaxation training and physical activities, are important for aiding the movement of mucus.
Aerosol therapy improves drainage when it reaches the parts of the lung where it is needed.  Clearing your airways with AD makes it easier to get the aerosol where it needs to be.

17. 2- Active cycle of breathing
There are 3 components to this technique combining:
Breathing control: relaxed breathing
Deep breathing ( also called ‘Thoracic Expansion Exercises): expands your chest
‘Huffing’ (also called ‘Forced Expiration Technique): pushes air out of your lungs.

18. Active cycle of breathing

19. 3- Respiratory muscle training imposes a resistance to inhalation using a special training devices
improve the strength and endurance of respiratory muscle .
Decrease respiratory muscle fatigue
Reduce respiratory frequency
May Provide biofeedback

20. 4- Aerobic exercise Effects: Improve pulmonary function capacity
Reduce breathlessness & exertion during work
Improve QoL

21. 5- Strengthening exercise
To improve efficacy of peripheral musculature
This exercise is important for Patient who :
Can not participate in aerobic ex. Due to psychological fear .
Too much breathlessness

22. 6- Upper extremities ex.
To improve endurance & strength during arm activities.

23. Benefits of PT Goes down the level of perceived exercise dyspnea.
Improve patient ex. Tolerance
Reduce effect of osteoporosis
Improve QoL.

24. Precautions while administrate PT program
Percussion is not easy tolerate by elderly especially in osteoporosis.
Monitor the level of O2 saturation during ex.
Adjust the level of supplemental O2 during ex.
Update ex. Program periodically based on the progression of disease and patient ex. Tolerance .

25. Any Q?