1. Restrictive Lung Diseases
DR. MOHAMED SEYAM PHT.PT.
ASSISTANT PROFESSOR OF PHYSICAL THERAPY

2. Definition
Restrictive lung disease (RDL) is a chronic disorder that causes a decrease in the ability to expand the lung (breathe in).
Disorders that inhibit normal lung excursion.

4. 1- Pulmonary Causes of Restrictive Lung Disease
Idiopathic Pulmonary Fibrosis
Coal Workers' Pneumoconiosis
Silicosis
Asbestosis
Broncho pulmonary Dysplasia
Bronchogenic Carcinoma
Pleural Effusions
Pneumonia

5. 2-Neuromuscular Causes of RLD
Spinal Cord Injury
Amyotrophic Lateral Sclerosis
Poliomyelitis
Guillain-Barre Syndrome
Myasthenia Gravis
Duchenne Muscular Dystrophy
Other Muscular Dystrophies

6. 5- Connective Tissue Causes
3- Cardiovascular Causes
Pulmonary Edema
Pulmonary Emboli
4- Musculoskeletal Causes
Diaphragmatic Paralysis or Paresis
Kyphoscoliosis
Ankylosing Spondylitis
Pectus Excavaturn
Pectus Carinatum
5- Connective Tissue Causes
Rheumatoid Arthritis
SystemIc Lupus Erythematosus
6- Immunologic Causes
Goodpasture‘s Syndrome
Wegeners Granulomatosis

7. 7-Pregnancy as a- Cause of Restrictive Lung.
8- Nutritional and Metabolic Causes
obesity
Diabetes Mellitus
9- Traumatfc causes
Crush Injuries
Penetrating Wounds
10- Therapeutic Causes
Surgical Therapy
Lung Transplantation
Drug Therapy
Radiation Therapy

8. Pleural diseases Dry pleurisy and Pleural effusion. Heamothorax
Empyema
Pneumothorax

9. PLEURAL EFFUSION caused by
The pleural space normally contains less than 20 mL of fluid.
Pleural effusion occurs when there is excess fluid in the pleural cavity.
caused by
disturbed osmotic or hydrostatic pressure in the plasma,
changes in membrane permeability.
Malignancy causes 25% of pleural effusions .
Other causes are heart, kidney or liver failure,
abdominal or cardiac surgery,
pneumonia or TB.

10. Types of Pleural effusion
Transudates
Exudates
clear
low-protein,
caused by
liver or kidney problems,
heart failure,
malnutrition or fluid imbalance.
cloudy,
high-protein effusions
caused by
associated with malignancy,
trauma
infection.

11. Clinical features a stony dull percussion
decreased breath sounds over the affected area, with bronchial breathing
A small effusion of less than 500 mL creates few or no symptoms.
A large effusion displaces the mediastinum and causes breathlessness.
Radiologically there is a fluid line, occurs when fluid accumulates in pockets.

12. Medical treatment treatment the cause
symptomatic relief of breathlessness by
needle aspiration (thoracocentesis), performed slowly to avoid ere-expansion pulmonaryoedema‘ .
Surgery
may be needed for a thickened restrictive pleura.
The symptoms of malignant invasion of the pleura

13. The left shows Bilateral pleural effusions. The right side
shows a dense opacity with a smooth horizontal border and
meniscal edge.
The left shows
a small effusion obliterating
the costophrenic angle.

14. Physiotherapy Deep breathing exercises.
Positioning can be used to optimize gas exchange.
People with moderate unilateral effusion may benefit from side-lying with the affected side uppermost because both ventilation and perfusion are greater in the lower lung.
Large effusions are more likely to show improved Pa02 with the effusion downwards to minimize compression of the unaffected lung .
Some patients require assistance with mobilization.

15. 2- HEAMOTHORAX
Heamothorax is blood in the pleura as a result of malignancy or trauma,
managed by treating the cause, plus tube drainage if necessary.

16. 3- EMPYEMA
It is pus in the pleural cavity following localized infection.
It can complicate pneumonia, bronchiectasis, chronic aspiration, abscess or chest surgery, especially oesophageal surgery.
The patient may be asymptomatic or toxic, depending on the organism and volume of pus.

17. TREATMENT OF EMPYEMA Local and systemic antibiotics.
Needle aspiration,
Tube drainage either into a bag or with strong suction
An underwater seal system,
Lavage,
Debridement via thoracoscopy,
Open drainage with rib resection, or thoracotomy with decortication.
Surgery is required if pus fills more than 40% of the hemithorax Surgical patients are debilitated and need attention to mobility.

18. 4- PNEUMOTHORAX Definition
Air collects between the visceral and parietal pleura.
Types
1. Spontaneous pneumothorax
2. Traumatic pneumothorax

20. Types
1.Spontaneous pneumothorax: It may be secondary to an underlying disease. Causes a. Asthma or bullous emphysema b. Infections (e.g. Staphylococcal pneumonia, tuberculosis) c. Cystic fibrosis d. Marfan's syndrome.

21. 2.Traumatic pneumothorax Causes:
Penetrating injury to the chest (e.g. by stab wound or a bullet)
Non-penetrating injury to the chest wall (e.g. Rib fracture)
During the insertion of an intravenous (e.g. subclavian) line
During surgery to the chest wall
During pleural aspiration or biopsy.

22. Pathological changes
As air escapes into the pleural cavity and reduces the sub atmospheric pressure (i.e. less negative)causes the lung collapse.
Air then enters the pleural cavity on inspiration but cannot escape during expiration.
The lung remains collapsed and, as air accumulates in the pleural cavity and the pressure increases, there is displacement of the heart together with compression of the other lung and great vessels.
This is termed a tension pneumothorax

23. Clinical features Increased respiratory rate Dyspnea
Chest pain that worsens with a deep breath
Fatigue and weakness
Tachycardia
Cyanosis
Hypotension
Decreased or absent lung sounds on affected side

24. Investigations
The chest X-ray shows absence of lung markings and the edge of the collapsed lung can be seen. This will confirm the diagnosis

25. Medical Management A) small pneumothorax
Requires no treatment apart from a few days bed rest until it resolves.
B) large pneumothorax (i.e. more than 25% of the pleural space is filled with air)
It is treated by needle aspiration or by an intercostal drain which connects the pleural cavity to a drainage bottle creating an underwater seal.
SURGERY: is indicated for a recurrent pneumothorax.
- PLEURODESIS: comprises the insertion of a powder into the pleural cavity to adhere both the pleura together.
- PLEURECTOMY: is the removal of the parietal pleura from the chest wall leaving a raw surface to which the visceral layer sticks.

27. CHEST DEFORMITIES Pectus carinatum, Pectus Excavatum, Scoliosis,
Kyphosis and
Kyphoscoliosis

28. 1- Pectus Carinatum Pectus Carinatum (pigeon chest)
It is a Structural abnormality characterized by the sternum protruding anteriorly.
Fifty percent of patients with atrial or ventricular septal defects have Pectus carinatum.
It also has been associa1ed with severe prolonged childhood asthma.

30. 2- PECTUS EXCAVATUM (funnel chest)
It is a congenital abnormality characterized by sternal depression and decreased anteroposterior diameter.
The lower portion of the sternum is displaced posteriorly, and the anterior rib5 are bowed markedly.
If the deformity is very severe, the patient may have
decreased TLC, VC and maximum voluntary ventilation and
may complain of dyspnea on exertion, precordial pain, palpitation, and dizziness.

32. 3- scoliosis
This is characterized by lateral deviation of the spine on either side, mainly in thoracic or lumbar or both region.
Structural scoliosis involves an irreversible lateral deviation of the spine.
Nonstructural scoliosis is reversible and also called postural scoliosis.

34. 4- Kyphosis
Kyphosis may cause restrictive lung defects secondary to musculoskeletal deformity and subsequent compression of the alveoli

35. 5- Kyphoscoliosis
It is a combination of excessive anter0posterior and lateral curvature of the thoracic spine .
A distorted spine increases the work of breathing because of
Reduced chest wall compliance
Micro atelectasis
Altered alveolar surface tension .
The configuration of the chest wall forces the diaphragm to work inefficiently.
Surgery is sometimes undertaken to prevent progression of scoliosis or improve body image and improve pulmonary function .

36. PT program in RLD depends on
The problem and manifestation of the pt.
The pathological changes of the disease
The duration and progression of the disease
The associated condition and complications

37. Goals Maintain and restore adequate ventilation
Re-expand affected lung
Prevent permanent or recurrent atelectasis
Adequate ROM in upper limps and trunk
Prevent deformity and maintain good posture
Assist the removal of secretions if present
Assist and control drainage by under water seal
Maintain adequate peripheral circulation
Improve exercise tolerance and endurance
Relieve pain and anxiety
Help in reducing dyspnea and breathing rate
Break down any adhesion

38. Respiratory exercise Nose training Segmental breathing
Diaphragmatic breathing
Exercise connected with breathing
Belt breathing exercise
Breathing training with devices

39. Mobilizing exercise Active free exercise Gymnastic exercise Swimming
Shoulder wheel and raw machine
Supported and unsupported exercise

42. Clearing lung fields Clapping, shaking and percussion
- Humidification
Clapping, shaking and percussion
breathing exercises may all be necessary in a
postural drainage position to the area of the lung affected.
Modified postural drainage
Suctioning
Cough and huff
Autogenic drainage