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.
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
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
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