Role of Physiotherapy in

respiratory conditions
 Treatment administered to increase Ventilation &
Oxygenation
 Treatment administered to reduce O2 consumption
 Treatment administered to improve secretion
clearance
 Treatment administered to improve exercise tolerance
(endurance exercise)
 Treatment administered to reduce pain(Pain relieving
electrotherapy modalities)
 Treatment administered to increase Ventilation &
Oxygenation
a)Breathing exercise
b)Positioning technique
• Treatment administered to reduce O2 consumption
a)To reduce work of breathing
b)To reduce general body work
• Treatment administered to improve secretion
clearance
a)To enhance muco-ciliary transport(Postural drainage)
b)To enhance cough( techniques to improve cough)
c) Bronchial hygiene techniques ACB,(FET)Autogenic
drainage),PEP, Flutter, Acapella, High frequency chest
wall oscillations
 Treatment administered to improve exercise tolerance
(endurance exercise)
 Treatment administered to reduce pain(Pain relieving
electrotherapy modalities)
Treatment administered to
increase ventilation & Oxygenation
 Alveolar ventilation depends on the magnitude of tidal
volume and dead space
 Decrease in alveolar ventilation are the result of
decreased tidal volume or increased dead space
 Physiotherapist aim is to increase tidal volume or
decrease dead space(physiological) or both
 Tidal volume can be increased by Breathing exercise
 Dead space can be decreased by proper positioning
technique
Breathing exercise
 Inspiration is done through nose and expiration
through mouth
 Inspiration through nose has four advantage
a)It acts as a filter to prevent dust and other particles
from getting into the lungs,
b) It warms the air
c) It prevents gas from getting into the stomach
d) It naturally controls the intensity of breathing by
controlling the correct balance of oxygen and carbon
dioxide.
 Afferent stimuli from the nerves that regulate
breathing are in the nasal passages. The inhaled air
passing through the nasal mucosa carries the stimuli
to the reflex nerves that control breathing. Mouth
breathing bypasses the nasal mucosa and makes
regular breathing difficult.
 Patient is asked to exhale through mouth with
whistling sound to identify the expiration phase as he
has to perform the chest manipulations
Types of Breathing exercise
 Relaxed Diaphragmatic breathing
 Pursed lip breathing
 Segmental breathing(costal expansion exercise)
a)Apical breathing
b)lateral costal expansion
c)Posterior basal expansion
• Sustained maximal inspiration (deep breathing)
Technique
 Starting position is Half lying (Explain)
 Diaphragmatic breathing enhance diaphragmatic
descent during inspiration and diaphragmatic ascent
during expiration
 Physiotherapist assist diaphragmatic ascent by
directing the patient to allow the abdomen to retract
gradually during exhalation or by contracting
abdominal muscles actively
 Diaphragmatic descent is assisted by directing the
patient to protract the abdomen gradually during
inhalation
 Dominant hand is placed on abdomen and non
dominant hand is placed on the chest
 Instruct the patient to move the dominant hand and
not to move the non- dominant hand so that patient
concentrates on diaphragm and not the external inter-
costal muscles or accessory muscles
 When subjects inhale diaphragmatically after maximal
expiration increases Lower lung zone ventilation
(Cottle, 1972:Rohrer, 1915)
Re education of diaphragm
 As other skeletal muscles, diaphragm also shares the
property of skeletal muscle
 Place the index and middle finger below the lower
costal margin anteriorly in half lying position over the
insertion of diaphragm (central tendon)
 At the end of expiration when diaphragm is relaxed,
stretch stimulus is given to the diaphragm to elicit
Stretch reflex of the diaphragm and patient is
instructed to take breath in
Resisted diaphragmatic breathing

 Manual resistance by therapist over the abdomen

 Placing appropriate weight over abdomen in
 By slightly elevating the foot end of the bed
Physiological outcomes of Diaphragmatic breathing

 Reduces work of breathing

 Reduces the incidence of post operative pulmonary
complications
 Improve ventilation and oxygenation
 Eliminates accessory muscle activity
 Decrease respiratory rate
 Increase tidal ventilation
 Improve distribution of ventilation
Pursed lip breathing –Indication
 COPD
Emphysema leads to Hyperinflation by two mechanism
a)Passive hyperinflation
b)Dynamic hyperinflation
Passive hyperinflation

 Is caused by reduced elastic recoil which allows the

airway to collapse on expiration
Dynamic hyperinflation
 Is caused by the patient having to actively sustain
inspiratory muscle contraction in order to hold open
the airway ,this unfortunate but necessary process is
achieved at the cost of excess work of breathing
 Intrinsic PEEP : airway obstruction reduces expiratory
flow which prevents expired air from being expelled
before next inspiration starts causing air trapping
which creates positive pressure in the chest known as
PEEP(Intrinsic PEEP)
 An average positive pressure is 2cmH2o which imposes
an extra threshold load at the start of inspiration
because inspiratory muscle have to offset this positive
pressure before inspiration can begin
 Distended airway require a grater than normal
pressure for inflation
In Emphysema excess WOB is required to
 Overcome the resistance of obstructed airway
 Assist expiration (active instead of passive )
 Sustain inspiratory muscle action through out
respiratory cycle so that high lung volume are
maintained
 Overcome threshold resistance at the start of
inspiration ,caused by Intrinsic PEEP
Pursed lip breathing -Technique
 1. Relax neck and shoulder muscles.
2. Breathe in (inhale) slowly through nose for two
counts, keeping your mouth closed. Don't take a deep
breath; a normal breath will do.
 Breathe out (exhale) slowly and gently through your
pursed lips while counting to four.
 Note that exhalation should not be too hard.
Hyperventilation will worsen the symptoms. Blow out
with the about same force that you would use to cool
hot soup on a spoon so that you do not blow it off the
spoon.
Uses of pursed lip breathing
 Improves ventilation
 Releases trapped air in the lungs
 Keeps the airways open longer and decreases the work
of breathing
 Prolongs exhalation to slow the breathing rate
 Improves breathing patterns by moving old air out of
the lungs and allowing for new air to enter the lungs
 Relieves shortness of breath
 Causes general relaxation
 It can be applied:
- as a 3-5 minutes “rescue exercise” or an Emergency
Procedure to counteract acute exacerbations or
dyspnea (shortage of air or breathlessness) in COPD
and asthma (Nield et al, 2007; Puente-Maestu &
Stringer, 2006; Garrod et al, 2005;
 Pursed-lip breathing reduces hyperventilation-induced
broncho-constriction (Wardlaw et al, 1987).
Segmental breathing (costal expansion
exercise)

 Apical costal expansion (for

apical lobes)
 Lateral costal expansion (for
middle and lingular lobes)
 Posterior basal expansion(for
lower lobes)
 Advantages of segmental
breathing(indication)

 Prevent accumulation of pleural fluid

 Prevent accumulation of secretions
 Decreases paradoxical breathing
 Decrease panic
 Improve chest mobility
Technique
 The technique uses manual counter pressure to
encourage the expansion of specific part of the lung
 Identify the surface landmark and place hand on the
chest wall overlying the bronco-pulmonary segment
requiring treatment
 Apply firm pressure to that area at the end of patients
expiratory maneuver
 Instruct the patient to inspire attempting to direct the
inspired air toward the therapist hand saying “breath
into my hand”
 Reduce the hand pressure at the end of inspiration and
repeat the procedure
 If the aim of the treatment is to expand the lung tissue
the emphasis should be on holding the maximum
inspiration for 3 sec and then sniff little more air
 Holding the breath also allows time for the air to
diffuse through the pores of Khon and sniff will
provide a little more expansion
 Once the patient has learned correct technique he is
taught to give pressure himself
Self resistance technique

 When using this

technique patient should
not elevate his shoulder
or achieve costal
expansion by side flexion
of spine
Positioning technique-Effect of body
position on perfusion
 Pulmonary pressure system is low pressure system
than systemic circulation
 Pulmonary artery pressure is 25/10mmhg
 Gravity affects the low pressure pulmonary vascular
system than systemic high pressure system
(120/80mmhg)
 Eg: when a person is standing the gravity dependent
areas of the lungs receive the greatest amount of blood
flow and apices are gravity independent lobes and
receive least amount of perfusion
Effect of body position on ventilation
 Regional differences are found in the ventilatory aspect
of lung which is caused by the intra-pleural pressure
gradient
 Intra-pleural pressure gradient is more negative at the
upper part of the lung(apices) & less negative at the
lower part of the lung (base)
 Eg : in standing this pressure gradient result in the
greater resting expansion in apical areas of lung than
in the basal region
 When the air is inhaled the apices being almost full at
the onset of inhalation receive very little of the new
volume of air
 The bases however being almost empty receive most of
the inhaled volume of air ,hence more ventilation in
the basal area &less ventilation in apical area
 When position is changed the areas of greatest
ventilation also changed
 Ventilation perfusion inequality occurs in diseased
states
 Three examples of possible relation are
a)Physiologic dead space (normally aerated alveoli with
no capillary perfusion)
b)physiologic shunt(normally perfuced capillary with
no alveolar aeration )
c)silent unit (non aerated alveoli next to a non perfused
capillary )
Positioning technique
 Lung volume is related to displacement of diaphragm
and abdominal contents
 Lung compliance decreases and work of breathing
increases progressively from standing to supine lying
 Position affects VA/Q ratio ,VA & Q is greater in
dependent lungs
Bad lung up rule
 It promotes comfort following thoracotomy or chest
drain placement
 Facilitates postural drainage
 Helps to improve lung volume when atelectatic lung is
positioned upper most to encourage expansion
 With atelectasis the uppermost areas are stretched and
better expanded
 To optimize gases exchange a person with moderate
unilateral effusion may benefit from side lying with
affected side uppermost because both ventilation and
perfusion are greater in lower lobe
 Large effusion are more likely to show improved Pao2
with the effusion downwards to minimize compression
of unaffected lung
Exception to the bad lung up rule

 Recent pneumonectomy
 Large pleural effusion
 Broncho pleural fistula
Treatment administered to improve
chest clearance – coughing
Techniques to improve cuff

 Positioning for cough

 Forced expiration stimulates cough
 Pressure over extra thoracic trachea
(supra sternal notch) elicit reflex cuff
 Nuero muscular facilitation –intermittent
application of ice over paraspinal muscle 3-5 sec of
thoracic spine
 Reflex cuff are stronger than voluntarily produced
Cont..

 Therapist should determine the phase or phases of

cuffing are reducing its effectiveness ,when inspiration
is too shallow, deep breathing or lateral costal
expansion exercise is taught to patient
Bronchial hygiene technique-ACBT
 Active cycle of breathing originally called Forced
expiratory technique(FET)
 It was renamed to emphasize all of its components
 It is a combination of breathing control ,thoracic
expansion and Forced expiratory technique
 This combination is performed in cycle which is
repeated until the huff is clear and dry
Forced expiratory technique
 Is popularly known as “huff” is forced exhalation
through an open mouth and glottis
 Properly performed this technique maximizes airflow
and minimizes airway collapse
 Huffing prior to coughing will optimize airway
clearance by moving secretions further up the airway
 FET is recommended with all of the airway clearance
technique
 Gravity assisted position will be more effective
 Percussion and vibration can be applied if desired
 ACBT uses the concept of Equal pressure point
theory(EPP)
Bronchial hygiene technique-Autogenic
drainage
 Autogenic drainage is a technique designed to
mobilize secretions by breathing control rather
than postural drainage
 The goal of therapy is to reach the highest
possible airflow in different generations of
bronchi
 This is achieved by breathing at three different
levels and adjusting expiratory flow rates to avoid
airway collapse
 Mechanism

 It consist of a cycle of huff from mid to low lung

volume with deep breathing and relaxed
abdominal breathing
 During huffing or forced expiration the pleural
pressure becomes positive and equals the alveolar
pressure at a point along the airway called Equal
pressure Point(EPP)
 Towards the mouth from this point the
transmural pressure gradient is reversed so that
pressure outside the airway is higher than inside
thus squeezing the air way by the process called
Dynamic compression

 Squeezing of airways mouth wards from this

point mobilizes secretions
Cont..

 At high lung volume the EPP is more proximal because

pleural pressure decreases and alveolar elastic recoil
increases
 Location of EPP
 Forced expiratory maneuver (huff or cuff)at low
lung volume mobilizes secretions from alveoli
 Forced expiratory maneuver at mid lung volume
mobilizes secretion from lobar and segmental
bronchi
 Forced expiratory maneuver at high lung volume
mobilizes secretions from larger airways ( trachea
and main bronchi)
FEM in Low lung volume

Upper respiratory
way
++
+ EPP
Alveoli ++ +
+
++
FEM in Mid lung volume

Upper respiratory
way
++
+ EPP

Alveoli ++ +

+ ++
FEM in High lung volume

Upper respiratory
way
++
+ EPP

Alveoli ++ +

+
++
Treatment administered to improve exercise
tolerance –Raising resting respiratory level
 Resting respiratory level is the point at which the tidal
volume rests within the vital capacity
 It is the point at which the elasticity or recoil of the rib
cage is in balance with the elasticity of the lung tissue
 In emphysema portion of the lung shut down sooner
than others , gross expiration obstruction occours at
late expiration
 Continuing expiration only increases muscle work
while an ever decreasing amount of air is being moved
Positive Expiratory Pressure
Flutter valve therapy
 Flutter is an expiratory device that ,in addition to
positive pressure ,creates vibrations of the airways as a
result of oscillating airflow and pressure ,these
vibrations are thought to further aid in the loosening
of mucus
Flutter
Flutter valve therapy
Acapella
 It is new generation of vibratory PEP therapy ,which is
similar to flutter with the benefits of PEP therapy and
vibrations ,but is different as we can adjust the
frequency and resistance by simply turning a dial
 This unique feature makes it more user –friendly
Acapella
High frequency chest wall oscillations
 High frequency chest wall oscillations utilizes a
mechanical device called the vest
 This system is an air –pulse generator connected to an
inflatable vest worn by the patient
 The vest oscillates the chest wall creating vibrations
and air movement throughout the airways
 This movement is described as “mini- coughs” and this
action helps to loosen and move secretions
High frequency chest wall oscillations
Treatment administered to improve exercise
tolerance –Raising resting respiratory level
 Resting respiratory level is the point at which the tidal
volume rests within the vital capacity
 It is the point at which the elasticity or recoil of the rib
cage is in balance with the elasticity of the lung tissue
 In emphysema portion of the lung shut down sooner
than others , gross expiration obstruction occours at
late expiration
 Continuing expiration only increases muscle work
while an ever decreasing amount of air is being moved
 Breathing cycle is lifted between 200-300 ml from the
obstructed point the ventilation will be more effective
(greater airflow for less work)
 Improved function & exercise tolerance can be
achieved without altering the course of the disease
 The relaxed expiratory phase is watched by the
physiotherapist who directs the patient to begin the
inspiration a little sooner in the respiratory cycle ,thus
avoiding prolong expiration

 The tidal volume is maintained ,thus it is not just the
expiratory level which is raised but the whole
respiratory level
 This technique is designed to help the patients with
airway obstruction due to emphysema ,it is also useful
in helping to improve airflow during an episode of
reversible airway obstruction
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