Documente Academic
Documente Profesional
Documente Cultură
PHYSICAL AND
RESPIRATORY THERAPY
S.Y. 2016-2017
SUBMITTED TO:
Mr. Bernardo Tayaban Jr., PTRP, MDA
Ms. Eliza Pinlac, PTRP
SUBMITTED BY:
Defnition of Terms
GOLD Classification System for Severity of Female smokers are nearly 13 times as
COPD
likely to die from COPD as women who
Stage
0: At risk
Epidemiology
6th leading cause of death globally
Chronic mucus hypersecretion is
present in 20% of male smokers aged
40 years and 40-45% of male smokers
aged 70 years
Women generally report less than
men
Among middle-aged smokers, 14% of
men and 8% of women have chronic
airflow limitation to a degree
compatible to a degree compatible with
the diagnostic label of COPD
I: Mild COPD
Characteristics
Normal Spirometry
Chronic symptoms (cough,
sputum production)
FEV1/FVC <70%
FEV1 80% predicted
With or without chronic
symptoms (cough, sputum
production)
FEV1/FVC <70%
50% FEV1 <80% predicted
With or without chronic
symptoms (cough, sputum
production)
Alveoli
Pleurae
immediately adjacent to
pulmonary capiliaries.
Functional unit of the
lung.
Doubledlayered,
continuous
serous
membrane
lining
the
inside of the thoracic
cavity.
Divided into parietal
pleura (outer) and
visceral
pleura
(inner).
epithelium
clearance.
to
facilitate
secretion
Regulation of Respiration
Neural Control of Breathing
Pulmonary Ventilation
Voluntary system
o Located in the cerebral cortex
and send impulses to the
respiratory motor neurons via
the corticospinal tracts
Automatic system
o Located in the pons and
medulla, the efferent output of
which is located in the lateral
and ventral portions of the
spinal cord
*Reciprocal inhibition
Apneusis
Pneumotaxic center
Medullary centers
2 types of respiratory neurons
Respiratory center
Apneustic center
MUSCLES OF RESPIRATION
The respiratory muscles, their innervations,
and their functions are listed in Table 2-1.
The primary muscles of inspiration are the
diaphragm, external intercostal muscles, and
parasternal intercostals, as depicted in Figure
2-3. During deep or labored breathing, the
accessory muscles of inspiration are
recruited. At rest, expiration is a passive
process, occurring as the inspiratory muscles
relax and lung elastic recoil takes over.
During forced expiration and coughing, the
abdominal and internal intercostal muscles
RESPIRATORY PHYSIOLOGY
rest and during exercise, as well as the out of the lungs. During exertion, forced
implications
for
physical
therapy expiration, and coughing, active contraction
interventions.
of the expiratory muscles (plus closure of the
glottis during coughing) causes a marked
BASIC FUNCTIONS OF THE RESPIRATORY rise in intrathoracic pressure so that
SYSTEM
expiration
occurs
more
rapidly
and
completely; in addition, passive relaxation of
The basic functions of the respiratory system
these muscles at end-expiration promotes
include oxygenation of the blood, removal of
descent of the diaphragm and induces an
carbon dioxide, control of acidbase balance,
increase in lung volume toward its neutral
and production of vocalization.
resting position.
MECHANICS OF BREATHING
IV. ETIOLOGY
Alpha-1 antitrypsin
is
an
enzyme
produced by the liver
that maintains tissue
integrity
by
preventing
uncontrolled
proteolytic
destruction of the
alveolar tissue (see
below). An hereditary
deficiency
of
the
enzyme occurs in 1
in 5,000 live births in
the
UK
and
predisposes
to
destruction of the
alveoli with resulting
tendency
to
emphysema. The disease, which is inherited
as an autosomal recessive condition,
accounts for only 2% of all cases of
emphysema and, even in those subjects who
are homozygous for the condition, clinically
significant emphysema usually occurs only
when the subject is a cigarette smoker.
Emphysema due to alpha-1 antitrypsin
deficiency must be suspected in smokers
who exhibit symptoms and signs of the
disease at a relatively early age (under the
age of 40) and those with a family history of
emphysema.
OCCUPATIONAL FACTORS
Work in dusty environments, in particular
the coal mining industry, is acknowledged as
predisposing to the development of COPD. partridge
Other potential risk factors for developing
COPD include pre-existing bronchial hyperresponsiveness, lower socio-economic status,
and a poor nutritional status in utero.
ASTHMA
RESPIRATORY
SYSTEM
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V. Pathophysiology/Mechanism of Injury/Pathology
augment exertional dyspnea for any level of COPD patients who require intubation and
lung function.
mechanical ventilatory support for acute or
acute-on-chronic respiratory failure are at
Reductions in the diffusing capacity of lung risk for autopositive end-expiratory pressure
for carbon monoxide (DLCO) characterize (PEEP). Predisposing factors for auto PEEP
emphysematous COPD. The DLCO is a include tachypnea, which reduces the length
measure of the conductance of carbon of each respiratory cycle (ie, a respiratory
monoxide (CO) from alveolar gas to rate of 20 breaths/ min equals a 3-second
hemoglobin in pulmonary capillary blood.
respiratory cycle length), lower ventilator
peak inspiratory flow rates (which prolong
The pulmonary capillary blood volume is
the duration of the inspiratory phase within
normally approximately 75 ml. Alveolar
each respiratory cycle), and bronchospasm,
capillary loss and destruction in moderatewhich predisposes to incomplete expiratory
severe emphysema reduce capillary blood
lung emptying and higher end-expiratory
volume and thus, the DLCO. Increases in
lung volumes.
ventilation-perfusion ratio (V:Q) mismatching
ensue; most notably, an increase in dead
Pathophysiologic
hemodynamic
space ventilation from ventilation of alveoli consequences of auto PEEP include arterial
without corresponding alveolar capillary hypotension secondary to decreased venous
perfusion. The DLCO may not be a sensitive return and cardiac output. Overestimation of
measure of milder degrees of emphysema.
central venous and/or pulmonary artery
pressures also occurs, as these pressure are
Exertional oxygen (O2) desaturation in
routinely referenced to atmospheric pressure
COPD is increasingly common as the
rather than intrathoracic pressure. Of note,
patients DLCO falls below 40% of predicted
hemodynamic consequences of autoPEEP
values, as in sleep-related O2 desaturation.
result from parallel elevations in intrathoracic
Arterial hypoxemia along with acidosis are or intrapleural pressure; elevated airway
potent
stimuli
for
pulmonary pressure per se causes no hemodynamic
vasoconstriction, which over time results in effects.
abnormal vascular remodeling, luminal
narrowing, and an increased pressure
gradient for pulmonary venous blood flow
(ie, mean pulmonary artery pressure
pulmonary capillary wedge pressure). The
associated increases in pulmonary vascular
resistance
predispose
to
progressive
secondary pulmonary hypertension and right
ventricular hypertrophy (cor pulmonale).
Despite similar degrees of expiratory
airflow limitation in COPD as reflected by
decreased forced vital capacity (FVC) and
FEV1 values, wide ranges in partial pressure
of carbon dioxide (paco2) are observed. Two
main determinants affect arterial paco2
levels in COPD: (1) reductions in the FEV1 of
60% to 70%, and (2) the ventilatory drive
(more
specifically,
the
hypercapnic
ventilatory response to paco2).
response
that
stimulates
pathological
CHRONIC BRONCHITIS
Pathophysiology
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EMPHYSEMIA
Pathophysiology
Inflammation of the bronchial walls, due
to acute or chronic infection or possibly
defective regulation of the inflammatory
response caused by congenital syndromes,
immune deficiencies, and many other
disorders, results in mucociliary clearance
dysfunction, which leads to a vicious cycle
of persistent bacterial colonization, chronic
mucosal inflammation, and progressive
tissue destruction.
Bronchial dilation and distortion
caused by destruction of the elastic
muscular
airway
components
hypertrophy and hyperplasia of
surrounding undamaged musculature.
are
and
and
the
CYSTIC FIBROSIS
The chronic pulmonary component of CF is
related to the abnormally viscous mucus
secreted in the tracheobronchial tree. The
altered secretions, resulting in airway
obstruction and hyperinflation, impair the
function of the mucociliary transport
system.
Exaggerated
and
sustained
neutrophilic
airway
inflammation
in
response to infection is also a feature of
this disease.24 Partial or complete
obstruction of the airways reduces
ventilation to the alveolar units. Ventilation
and perfusion within the lungs are not
matched. Fibrotic changes are ultimately
found in the lung parenchyma.
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SYMPTOMS
CLINICAL
CHRONIC BRONCHITIS
Clinical Manifestations
Progressive
exertion
dyspnea,
especially
on
with
acute
Clinical Manifestations
Insidious onset of smokers cough, which
progresses to chronic productive cough
Progressive exertional dyspnea, with
possible respiratory distress late in the
disease
ASTHMA
Clinical Manifestations
Recurrent paroxysmal attacks of cough,
chest tightness, and difficult breathing,
often accompanied by audible wheezing
EMPHYSEMA
insufficiency
and
respiratory failure.
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Distant
breath
sounds,
prolonged
expiration; high-pitched expiratory and
possibly inspiratory wheezes throughout
both lungs
Tachypnea, possible signs of respiratory
distress (e.g., increased use of accessory
muscles, intercostal retractions, nasal
flaring)
Markedly reduced FEV1, forced expiratory
flow from 25% to 75% of vital capacity
(FEF25%-75%), and maximal expiratory flow
rate at all lung volumes and increased total
lung capacity (TLC) during acute attacks;
increased airway resistance and reduced
maximal expiratory flow rates during
remissions (patients often monitor their
status via daily peak expiratory flowmeter
readings).
During acute attacks, hypoxemia with
hypocapnia is common; normal or increased
paco2 is a serious sign indicating ventilatory
possible
impending
Clinical Presentation
The clinical symptoms of asthma during an
exacerbation may include cough, dyspnea
on exertion or at rest, and wheezing.
The chest is usually held in an expanded
position, indicating that hyperinflation of the
lungs has occurred. Accessory muscles of
ventilation may be used for breathing, even
at rest. Intercostal, supraclavicular, and
substernal retractions (visible inward motion
of the soft tissue) may be present on
inspiration. While expiratory wheezing is
characteristic of asthma, crackles may also
be present. With severe airway obstruction,
breath sounds may be markedly decreased
owing to poor air movement and wheezing
may be present not only during exhalation,
but may also become present on inspiration.
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BRONCHIECTASIS
Clinical Manifestations
in the levels of
dangerous than
and tend to be
serious clinical
reduced hemoglobin.
Assessment of spo2 is strongly advised for
all patients with an FEV1 less than 50% of
predicted normal or a DLCO less than 60%
of predicted, because of the increased
likelihood of desaturation.
Pulse oximeters tend to have an accuracy
of 2% when resting sao2 is 80% to 100%,
but accuracy may be reduced during
exercise and when oxygen saturation is less
than 70% to 80%.13,22,45 Inaccuracies are
especially likely to occur during rapid or
severe desaturation, in patients requiring
intensive care, and those with poor
peripheral perfusion due to peripheral
arterial disease, vasoconstriction, or low
cardiac output, as well as a number of other
conditions, as listed in Table 2-8 (also refer
to Chapter 6, page 280).
When discrepancies are found between
the spo2 results and the patients clinical
presentation,
blood
gas
analysis
is
indicated.
In infants, transcutaneous oxygen (tcpo2)
electrodes are often used to monitor
ELECTROCARDIOGRAPHY
12-lead electrocardiogram is commonly
obtained to ascertain the presence of right
ventricular hypertrophy (RVH) and/or strain
in patients with chronic lung disease, acute
asthma, and pulmonary embolism.
Specific indicators of RVH and/or strain
include right axis deviation, P pulmonale (a
tall, peaked P wave >2.5 mm in leads II, III,
and avf), and a dominant R wave in leads
avr and V1
Fluoroscopy
offers
a
quick
and
inexpensive method of detecting lesions
that are obscured by ribs or that can be
seen clearly only in an unusual oblique
projection (e.g., some pleural plaques,
retrocardiac nodules), as well as pulsatile
nodules and masses.
COMPUTED TOMOGRAPHY
NUCLEAR MEDICINE/SCINTIGRAPHIC
IMAGING STUDIES
Scintigraphic studies employ radioactive
imaging agents to light up various tissues
during imaging, using a gamma counter.
VENTILATIONPERFUSION SCANNING
Ventilationperfusion ( V/Q ) scans use
radionuclides to evaluate and compare the
distribution of ventilation and perfusion
within the lungs.
Perfusion and ventilation studies are
obtained separately and then the images
are compare
V/_Q scans are used most commonly to
diagnose pulmonary embolism, predict
postoperative
lung
function
after
pneumonectomy, diagnose early airflow
obstruction, and assess the potential benefit
of surgical excision of emphysematous
bullae.
V/Q scans do not confirm or exclude
pulmonary embolism; rather, they give an
estimate of its likelihood, However, a normal
perfusion scan virtually excludes clinically
relevant
pulmonary
embolism.
Parenchymal
lung
diseases,
whether
obstructive or restrictive, usually produce
matched defects in both ventilation and
perfusion or a reverse mismatch in which
ventilation is reduced compared with
perfusion
Abnormal findings indicate that significant
mismatch between ventilation and perfusion
exists and the patient is likely to have
limited tolerance for activity.
SPECT
images
reflect
functional
information, including blood flow, oxygen or
glucose
metabolism,
or
dopamine
transporter concentration.
In pulmonary medicine, SPECT is
commonly used for _ V/Q studies and
produces better characterization of the
lobes and segments than two-dimensional
imaging.
POSITRON EMISSION TOMOGRAPHY
Positron
emission
tomography
(PET)
scanning uses biologically active positron
emission radiopharmaceuticals (i.e., 18Fdeoxyglucose, FDG) to display and quantify
metabolic processes, receptor occupancy,
and blood flow. In pulmonary medicine, PET
is used mostly for evaluating newly
discovered pulmonary nodules, staging of
confirmed nonsmall cell lung cancer, and
sometimes for monitoring response to
therapy.
OTHER
STUDIES
SCINTIGRAPHIC
IMAGING
measure
mucociliary
clearance
(e.g.,
indium-111labeled white blood cells, 111In
wbcs;
technetium
99mlabeled
diethylenetriaminepentaacetic acid, 99mtcDTPA; or thallium.
Pleurocentesis
is
also
performed
therapeutically
to
relieve
respiratory
impairment caused by pleural effusions.
Blind, or closed, needle biopsy is
performed, usually with image guiding,
when tuberculosis, malignant effusion, or
other pleural pathology is suspected.
Rehabilitation
activities
should
be
AND
BIOPSY/EXPLORATIVE
Purposes:
Chest
Shape
and
Procedure:
Place your hands on the patients chest and
assess the excursion of each side of the
thorax during inspiration and expiration.
Each of the three lobar areas can be
checked.
Extent of Excursion
Method 1:
Measure the girth of the chest with a tape
measure at three levels (axilla, xiphoid,
lower costal). Document change in girth
after a maximum inspiration and a
maximum expiration.
Method 2:
Place both hands on the patients chest or
back as previously described. Note the
distance between your thumbs after a
maximum inspiration.
Palpation
Palpation of the thorax provides evidence of
dysfunction of the underlying tissues
including the lungs, chest wall, and
mediastinum.
Procedure:
Firmly press against the chest wall with your
hands to identify any specific areas of pain
potentially of musculoskeletal origin. Ask
the patient to take a deep breath and
identify any painful areas of the chest wall.
Chest wall pain of musculoskeletal origin
often increases with direct point pressure
during palpation and during a deep
inspiration. Pain of pulmonary origin is
usually localized to a region of the chest but
also may be felt in the neck or shoulder
region.
Mediastinal Shift
The position of the trachea shifts as the
result
of
asymmetrical
intrathoracic
pressures or lung volumes. For example, if
the patient has had a pneumonectomy
(removal of a lung), the lung volume on the
operated side decreases, and the trachea
shifts toward that side. Conversely, if the
patient has a hemothorax (blood in the
thorax), intrathoracic pressure on the side of
the
hemothorax
increases,
and
the
mediastinum shifts away from the affected
side of the chest.
Procedure:
Procedure:
Place the palms of your hands lightly on the
chest wall and ask the patient to speak a
few words or repeat 99 several times.
Normally, fremitus is felt uniformly on the
chest wall.
Fremitus is increased in the presence of
secretions in the airways and decreased or
absent when air is trapped as the result of
obstructed airways.
Chest Wall Pain
Procedure:
Place the middle finger of the nondominant
hand flat against the chest wall along an
intercostal space. With the tip of the middle
finger of the opposite hand, firmly tap on
the finger positioned on the chest wall.
Repeat the procedure at several points on
the right and left and anterior and posterior
aspects of the chest wall. This maneuver
produces a resonance; the pitch varies with
the density of the underlying tissue. The
subjective determination of pitch indicates
the following:
-
Auscultation
term that
is
a
general
refers to the
process of
listening
sounds
the body,
to
within
specifically
to
breath
sounds during an examination of the lungs.
A stethoscope is used to magnify these
sounds.
Breath sounds should be assessed to:
Procedure:
Vesicular. Soft, low-pitched, breezy but faint sounds heard over most of the
chest except near the trachea and mainstem bronchi and between the
scapulae. Vesicular sounds are audible considerably longer on inspiration than
expiration (about a 3:1 ratio).
Bronchial. Loud, hollow, or tubular high-pitched sounds heard over the
mainstem bronchi and trachea. Bronchial sounds are heard equally during
inspiration and expiration; a slight pause in the sound occurs between
inspiration and expiration.
Bronchovesicular. Softer than bronchial breath sounds; also heard equally
during inspiration and expiration but without a pause in the sound between the
cycles. The sounds are heard in the supraclavicular, suprascapular, and
parasternal regions anteriorly and between the scapulae posteriorly.
VIII.
Chronic
Bronchiti
s
-
Peripheral
Airway Disease
Emphysema
partridge
paz et. Al
MANAGEMENTS
Kisner
Paz et. Al
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Pharmacological Management
Antihistamines
Antihistamines are used to block histaminemediated
reactions
associated
with
seasonal allergies. They reduce mucosal
congestion, irritation, and discharge caused
by inhaled allergens, and they also reduce
coughing and sneezing associated with the
common cold. They are often combined with
decongestants.
The first-generation antihistamines
readily crossed the bloodbrain barrier to
enter the brain, causing the common side
effects of sedation, fatigue, dizziness, and
blurred
vision.
In
addition,
their
anticholinergic effects may cause drying of
secretions and lead to further airway
obstruction in some patients.
Newer,
second-generation
antihistamines
include
astemizole
(Hismanal), loratadine (Claritin), terfenadine
(Seldane), and fexofenadine (Allegra). They
do not easily cross the blood brain barrier,
so they are far less likely to cause sedation
or other CNS side effects. However, some
may produce cardiotoxicity with serious
arrhythmias.
Antitussives
Antitussives suppress the cough reflex and
are used to treat the irritating, dry, hacking
cough
associated
with
minor
throat
irritations and the common cold. They are
not indicated for productive coughs.
Two main classifications of drugs provide
antitussive effects: nonnarcotic, over-thecounter, cough suppressants (e.g.,
dextromethorphan and
narcotics (e.g., codeine).
benzonate)
and
paz et al
Physiotherapeutic management
Intensity of exercise
Duration Of Exercise
Warm-up= 5- 15 min
HR
decrease
musculoskeletal injuries
incidence
of
allows
body
to
gradually
accommodate the CP demands of exercise
aerobic training
0- nothing at all
0.5- very very week
1- very weak
2- weak
3- moderate
4-somewhat strong
5- strong
6
7- very strong
8
9
19-very, very strong
maximal
Diaphragmatic Breathing
Diaphragmatic
Breathing
When
the
diaphragm is functioning effectively in its
role as the primary muscle of inspiration,
ventilation is efficient and the oxygen
consumption of the muscles of ventilation is
low during relaxed (tidal) breathing.When a
patient relies substantially on the accessory
muscles of inspiration, the mechanical work
of
breathing
(oxygen
consumption)
increases and the efficiency of ventilation
decreases. Although the diaphragm controls
breathing at an involuntary level, a patient
with primary or secondary pulmonary
dysfunction can be taught how to control
breathing by optimal use of the diaphragm
and decreased use of accessory muscles.
Procedure
Pursed-Lip Breathing
Many therapists believe that gentle pursedlip breathing and controlled expiration is a
useful procedure, particularly to relieve
dyspnea if it is performed appropriately. It is
thought to keep airways open by creating
back-pressure in the airways. Studies
suggest that pursed-lip breathing decreases
the respiratory rate and the work of
breathing (oxygen consumption), increases
the tidal volume, and improves exercise
tolerance
Procedure
Have the patient assume a comfortable
position and relax as much as possible.
Have the patient breathe in slowly and
deeply through the nose and then breathe
out gently through lightly pursed lips as if
blowing on and bending the flame of a
candle but not blowing it out.43 Explain to
the patient that expiration must be relaxed
and that contraction of the abdominals must
be avoided. Place your hand over the
patients abdominal muscles to detect any
contraction of the abdominals.
Glossopharyngeal Breathing
it is used primarily by patients who are
ventilator-dependent because of absent or
incomplete innervation of the diaphragm as
the result of a high cervical-level spinal cord
lesion or other neuromuscular disorders.
Procedure
Glossopharyngeal breathing involves taking
several gulps of air, usually 6 to 10 gulps
in series, to pull air into the lungs when
action of the inspiratory muscles is
inadequate. After the patient takes several
gulps of air, the mouth is closed, and the
Self-Assisted Technique
Therapist-Assisted Techniques
Tracheal Stimulation
POSTURAL DRAINAGE
Postural drainage (bronchial drainage),
another intervention for airway clearance, is
a means of mobilizing secretions in one or
more lung segments to the central airways
by placing the patient in various positions so
gravity assists in the drainage process.
When secretions are moved from the
smaller to the larger airways, they are then
cleared by coughing or endotracheal
suctioning. Postural drainage therapy also
includes the use of manual techniques, such
as percussion, shaking, and vibration,
coupled with voluntary coughing.
Percussion
Percussion is used to augment mobilization
of secretions by mechanically dislodging
viscous or adherent mucus from the
airways. Percussion is performed with
cupped hands over the lung segment being
drained. The therapists cupped hands strike
the patients chest wall in an alternating,
rhythmic manner (Fig. 25.24B). The
therapist should try to keep shoulders,
elbows, and wrists loose and mobile during
the maneuver. Mechanical percussion is an
alternative
to
manual
percussion
techniques. Percussion is continued for
several minutes or until the patient needs to
alter position to cough. This procedure
should not be painful or uncomfortable.
Vibration
Vibration, another manual technique, often
is used in conjunction with percussion to
help move secretions to larger airways. It is
Chronic Bronchitis
Specific Treatment
Medications include the following
Anticholinergic
bronchodilators
versus long-acting b-agonists
Inhaled corticosteroids
Supplemental oxygen
Specific Treatment
Medications:
EMPHYSEMIA
ASTHMA
Specific Treatment
Medications
Short-acting b2-agonists as rescue
therapy 4Inhaled corticosteroids
If
unsuccessful,
long-acting
bronchodilators,
leukotriene
modifiers, mast cell stabilizers, or
anticholinergic drugs
Avoidance of asthma triggers
Aerobic
conditioning,
relaxation
techniques, and dyspnea positions
BRONCHIECTASIS
REFERENCES
Specific Treatment
Medications:
4Anticholinergic
bronchodilators versus long-acting bagonists
Inhaled corticosteroids
Supplemental oxygen
Surgical interventions
Bullectomy
Lung volume reduction
Lung transplantation, particularly for
a1-PI deficiency