Interventions for pulmonary system
Activities to increase pulmonary function in absence of disease
- Pacing
- Rationale: breathing technique used to spread the metabolic demands of an activity to improve performance
- Example: Individual running at treadmill attempting not to become short of breath with activity
- How to perform:
- Break the activity in management components
- Inhale at rest or at concentric activation
- Exhale through pursed lipped (to slow breathing) during eccentric activation
- Repeat until activity complete
- Rationale: breathing technique used to spread the metabolic demands of an activity to improve performance
- Energy conservation
- Rationale: strategic planning of normal activities during the day to allow for decreased fatigue and improve pulmonary function Can be used with those in presence of pulmonary disorder and those without.
- How to perform:
- Recognize activities that are performed with ease and those with increased difficulty
- Organize day from easy to hard to allow for completion of all activities
Breathing exercises for pulmonary function
- Diaphragmatic breathing
- Rationale for use: increased ventilation, decrease work of breathing, and increase relaxation
- Patient population: individuals with restrictive or obstructive lung disease, postoperative patients
- How to perform:
- Position patient in semi-Fowler’s position
- Place a hand of subcostal angle of thorax
- Apply pressure with hand during exhalation
- Increased pressure with hand during the end of inhalation
- Each cycle increased pressure with hand to allow for firm resistance specifically during inhalation
- Can be progressed to be performed in sitting upright and standing
- Segmental breathing
- Rationale: increased ventilation to a segment of hypoventilated lung, maintain or improve functional residual capacity, or prevent pulmonary compromise
- Patient population: individuals with immobility of part of the thorax such as from rib fractures, thorax incisions, or partial lung removal
- How to perform:
- Position individual to provide access to lung segment such as postural drainage positions (see later in this chapter)
- Apply pressure with hand over thorax at identified segment during exhalation
- Increase pressure during inhalation
- Allow for full pressure to be applied to allow for full inhalation
- Pursed lip breathing
- Rationale: provide pressure support to allow for bronchioles to remain dilated during exhalation, decreases respiratory rate, improves gas exchange for those with COPD
- Patient population: primarily used with individuals with obstructive lung disease
- How to perform:
- Inhale through nose
- Exhale slowly through pursed lips
Airway clearance techniques
- Cough
- Rationale: remove secretions from all the major and central airways
- Performed independently by patient
- Rationale: remove secretions from all the major and central airways
- Assisted cough
- Rationale: used when patient’s abdominal muscle can not generate sufficient pressure to aid in effective cough
- How to perform:
- Individual positioned supine or semi-fowler with hand placement at subcostal angle
- Individual inhales
- During exhalation, the hand is forcefully pushed up and in to aid in rapid exhalation thus causing a cough
- Huffing
- Rationale: effective to provide support for individuals with collapsed airways
- How to perform:
- Individual inhales deeply
- Upon exhalation, the individual then says “ha ha” to allow the airways to remain open and remove secretions
- Endotracheal suctioning
- Rationale: typically utilized when a patient is unable to perform independent cough, assisted cough, or huffing to provide airway clearance. Likely to perform when patient on mechanical ventilation
- How to perform: Suctioning catheter is used to remove secretions either through artificial airway, oral airway, or nares for 10-15 seconds
Independent secretion removal techniques
- Active cycle of breathing technique
- Rationale: removal of peripheral sections for those in which a combination of techniques must be utilized to remove secretions
- Patient population: Obstructive lung disease
- How to perform:
- Individual perform diaphragmatic breathing
- Followed by thoracic expansion exercises
- Lastly forced expiration with a series of huffing
- Repeat cycle until airway clear
- Autogenic drainage
- Rationale: used to remove peripheral secretions by controlling the rate, depth, and location of respiration due to increased irritability from coughing
- How to perform:
- Unstick phase: quiet breathing with 2-3 second hold at the end of inhalation moving into a deep expiration to allow for mucus to loosen and move into the airway. Breathing is occurring with small flow of air (low vital capacity)
- Collect phase: performance of increasing respiratory reserve volume (deep breath in) until secretions move to central airways and are ready to be expelled. Breathing is occurring at mid-high amount of air flow (mid-high vital capacity)
- Evacuation phase: performance cycles between normal inspiration and deep inspiration (respiratory reserve volume) until secretions move into central airways. Breathing is occurring at a mid-high amount of air flow (mid-high vital capacity). No coughing occurs during this phase.
- Repeat these cycles until all secretions removed
- Flutter or acapella device
- Rationale: used to provide intermittent positive airway support to allow for adequate secretion clearance
- How to perform:
- Inhale through nose or around device
- Exhale through device
- Perform huffing or coughing as appropriate
- Repeat until all secretions removed
- Low- pressure positive expiratory pressure mask
- Rationale: prevent lung collapse by providing a low amount of pressure to allow for adequate secretion removal in diagnoses of COPD, cystic fibrosis, or bronchiectasis
- How to perform:
- Seated or supine a mask is placed for face with inspiration hold for 2-3 seconds before expiration (~10 breaths)
- Remove mask for coughing or huffing
- Repeat until all secretions are removed
- High-pressure positive expiratory pressure mask
- Rationale: prevent lung airway collapse by providing a high amount of pressure to allow for adequate secretion removal in diagnoses of acute respiratory failure, pulmonary edema, or pneumonia
- How to perform:
- Seated or supine with normal breathing performed with mask in place (~10 breaths)
- Huffing is performed with mask in place
- Repeat until all secretions are removed
Manual secretions removal techniques
- Postural bronchial drainage
- Rationale: provides removal secretions by positioning lung (i.e. lung segments) to be assisted by gravity to remove secretions
- How to perform:
- Specific to lung segment
- Shaking (vibration)
- Rationale: used in conjunction with postural drainage positions to aid in removal of secretions from the tracheobronchial tree
- How to perform:
- Place in appropriate postural drainage position
- Individual inhales and therapist hands are placed over appropriate segment parallel to the ribs
- At exhalation, the therapist provides fast, rhythmic bouncing motion to the ribcage at the frequency and duration of patient’s pulmonary needs
- Percussion
- Rationale: used in conjunction with postural drainage positions to aid in removal of secretions from the tracheobronchial tree
- How to perform:
- Place in appropriate postural drainage position
- Place barrier between hand and segment that will be percussed
- Percuss over the identified segment with a cupped hand by the therapist at a rhythmic rate. Percussion is applied during inhalation and exhalation at the frequency determined by the patient’s pulmonary needs.
Image #100
Precautions for postural drainage positions
- Placement in Trendelenburg position
- Pulmonary edema
- Congestive heart failure
- Obesity
- Recent food consumption
- Recent neurosurgery
- Increased intracranial pressure <20 mmHg
- Shortness of breath
- Esophageal surgery
- General discomfort from position
- Placement in side-lying
- Axillo-femoral graft
- Humeral fractures
- Arthritis
- Shoulder or hip bursitis
- General discomfort from position
Contraindications for all postural drainage positions
- Active hemorrhage
- intracranial pressure >20 mmHg
- Embolism
- Large pleural effusion
- Emphysema
- Recent spinal surgery
- Non-stabilized head or neck injury
Considerations for initiating percussion or shaking
- Pain increased with techniques
- Decreased platelet count
- Increased clotting time- on anti-coagulation medication
- Fracture rib
- Degenerative bone disease
- Bone metastases
Pulmonary medications
- Bronchiodilators
- Mechanism of action: medications that assist with improving ventilation by providing relaxation of bronchioles (bronciodilation) in either short acting or long acting
- Appropriate diagnoses: asthma, chronic obstructive pulmonary disease
- Physical therapy considerations: trembling, palpitations, headache, muscle cramps
- Common name: Theophylline
- Expectorants
- Mechanism of action: thin mucus, increased secretions, increasing mucus production by cough, reduce viscosity of secretions
- Appropriate diagnoses: pneumonia, flu, cold, cystic fibrosis and any other diagnoses that produce increased mucus
- Physical therapy considerations: rash, difficulty breathing, dizziness
- Common name: Guaifenesin
- Corticosteroids
- Mechanism of action: anti-inflammatory that reduces the inflammation that is present in the bronchial lining
- Appropriate diagnoses:
- Physical therapy considerations: typically with long term use can cause osteoporosis, increased blood sugar, increased risk for infections, development of glaucoma or cataract
- Common name: prednisone