Activities to increase pulmonary function in the absence of disease
Pacing
Rationale: breathing technique used to spread the metabolic demands of an activity to improve performance
Example: An individual running on a treadmill attempting not to become short of breath with the activity
How to perform:
Break the activity into manageable components
Inhale at rest or at concentric activation
Exhale through pursed lips (to slow breathing) during eccentric activation
Repeat until the activity is complete
Energy conservation
Rationale: strategic planning of normal activities during the day to allow for decreased fatigue and improve pulmonary function. This can be used with those in the presence of a pulmonary disorder and those without.
How to perform:
Recognize activities that are performed with ease and those with increased difficulty
Organize the day from easy to hard to allow for the completion of all activities
Breathing exercises for pulmonary function
Diaphragmatic breathing
Rationale for use: increased ventilation, decreased work of breathing, and increased relaxation
Patient population: individuals with restrictive or obstructive lung disease, postoperative patients
How to perform:
Position the patient in semi-Fowler’s position
Place a hand on the subcostal angle of the thorax
Apply pressure with the hand during exhalation
Increased pressure with the hand at the end of inhalation
Each cycle increased pressure with the 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 hyperventilated 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 the individual to provide access to the lung segment, such as postural drainage positions (see later in this chapter)
Apply pressure with the hand over the thorax at the 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, decrease respiratory rate, and improve gas exchange for those with COPD
Patient population: primarily used with individuals with obstructive lung disease
How to perform:
Inhale through the nose
Exhale slowly through pursed lips
Airway clearance techniques
Cough
Rationale: remove secretions from all the major and central airways
Performed independently by the patient
Assisted cough
Rationale: used when the patient’s abdominal muscles can not generate sufficient pressure to aid in effective cough
How to perform:
Individual positioned supine or semi-fowler with hand placement at the 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:
The 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 an independent cough, an assisted cough, or huffing to provide airway clearance. Likely to perform when the patient is on mechanical ventilation
How to perform: A suctioning catheter is used to remove secretions either through an 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:
An individual performs diaphragmatic breathing
Followed by thoracic expansion exercises
Lastly, forced expiration with a series of huffing
Repeat cycle until the airway is 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 a 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 a small flow of air (low vital capacity)
Collect phase: performance of increasing respiratory reserve volume (deep breath in) until secretions move to the central airways and are ready to be expelled. Breathing is occurring at a 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 the 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 are removed
Flutter or an a acapella device
Rationale: used to provide intermittent positive airway support to allow for adequate secretion clearance
How to perform:
Inhale through the nose or around the device
Exhale through the device
Perform huffing or coughing as appropriate
Repeat until all secretions are 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 over the face with inspiration hold for 2-3 seconds before expiration (~10 breaths)
Remove the 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 a mask in place (~10 breaths)
Huffing is performed with a mask in place
Repeat until all secretions are removed
Manual secretions removal techniques
Postural bronchial drainage
Rationale: provides removal of secretions by positioning the lung (i.e., lung segments) to be assisted by gravity to remove secretions
How to perform:
Specific to the lung segment
Postural drainage positions
Shaking (vibration)
Rationale: used in conjunction with postural drainage positions to aid in the removal of secretions from the tracheobronchial tree
How to perform:
Place in appropriate postural drainage position
The individual inhales, and the therapist’s hands are placed over the appropriate segment parallel to the ribs
At exhalation, the therapist provides a fast, rhythmic bouncing motion to the ribcage at the frequency and duration of the patient’s pulmonary needs
Percussion
Rationale: Rationale: used in conjunction with postural drainage positions to loosen and mobilize secretions by loosening secretions in the lungs.
Percussion is typically performed at a rate of 100 to 480 beats per minute (BPM). A common frequency is 150 to 200 BPM, which translates to about 2 to 3 claps per second.
How to perform:
Place in appropriate postural drainage position
Place a barrier between the hand and the 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.
Trendelenburg position
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 the position
Placement in side-lying
Axillo-femoral graft
Humeral fractures
Arthritis
Shoulder or hip bursitis
General discomfort from the 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 the techniques
Decreased platelet count
Increased clotting time- on anti-coagulation medication
Fractured rib
Degenerative bone disease
Bone metastases
Pulmonary medications
Bronchiodilators
Mechanism of action: medications that assist with improving ventilation by providing relaxation of bronchioles (bronchodilation) in either short-acting or long acting
Mechanism of action: an anti-inflammatory that reduces the inflammation that is present in the bronchial lining
Appropriate diagnoses: chronic obstructive pulmonary disease (COPD), asthma, interstitial lung disease (ILD), sarcoidosis, and severe acute respiratory illness.
Physical therapy considerations: typically, long-term use can cause osteoporosis, increased blood sugar, increased risk for infections, and development of glaucoma or cataract
Common name: prednisone
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