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
• 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
• 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.

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