Tag: palliative care

A physiotherapist assesses, treats, monitors, follows and cares for patients with lung and heart disorders. Breathing disorders targeted by physiotherapy include asthma, bronchitis, emphysema, cystic fibrosis, pneumonia, chest trauma as well as cardiac-induced respiratory failure. Physiotherapy for respiratory conditions includes basic chest physiotherapy, which aims to provide:

• assistance for airway clearance – using chest physiotherapy
• optimum functional capacity – catering for the patient’s full functioning
• problem oriented care – finding out what the cause of the problem is and then managing the discovered problem
• holistic management – patient is seen as a whole, where not the initial complaint is targeted, but anything else associated with the same patient, thus, a patient requiring basic chest physiotherapy may also be provided with assistance regarding obesity, nutrition and lifestyle changes

Physiotherapy for respiratory conditions challenges include:

• inability to clear chest
• inability to breathe easily
• reduced exercise tolerance
• reduced lung capacity
• reduced functional capacity
• poor self management due to being unable to function normally

Chest Physiotherapy (CPT) provides a method for bronchial hygiene by:

• Turning
• Postural drainage
• Chest percussion and vibration
• Specialised cough techniques a.k.a. directed cough

These strategies help in reducing dyspnoea, improving ventilation and perfusion and increasing respiratory function by causing bronchial secretions to move to the central airway via gravity.

NOTE: CPT is contraindicated for asthma patients. Instead, a different technique is used for asthma where the patient is encouraged to huff instead (as if misting a mirror with their breath).

CPT Indications:

• poor exercise tolerance
• decreased mobility
• potential postural deformities
• mucus plugging causing acute lung or lobar collapse
• increased secretions or secretion retention affecting respiration

Low secretion level should be targeted by gentle methods of excretion; High secretion level should be targeted by tougher methods which provide more efficacy, whilst taking into consideration how frail the patient is.

NOTE: With reference to the above positions, patients who have undergone gastric surgery, facial surgery or cardiac surgery, as well as the elderly or the frail, SHOULD NOT be positioned tipping down.

Vibrations vs Shakings: Vibrations are gentler than shakings; shakings are of high magnitude, thus vibrations are preferred where the patient is frail eg. elderly or has osteoporosis.

Manual Hyperinflation: an ambubag is used to expand lung eg. if lung has collapsed. In case of secretions, the use of an ambubag is combined with shakings to clear secretions.

With reference to the above image:

Breathing Exercises Cycle ACBT helps with reducing heart rate, reducing anxiety and reducing respiratory rate;

Breathing Control: small breaths that are controlled; help expand lungs

Thoracic Expansion: larger breaths; Sitting low limits breathing capacity; breathe deeper to encourage more air into the alveoli…air seeps behind secretions and mobilises them when breathing out

FET Forced Expiratory Technique: completes cycle by facilitating excretion of secretions

Physiotherapy in the ITU Setting

Patients in acute, critical and ITU setting are in poor health conditions. It is indicated that with every day spent in bed, patients lose 30% of their muscle fibers. Physiotherapy for respiratory conditions in such settings is focused on:

• Deconditioning – reversible changes in the body due to lack of physical activity.
• Impaired Airway Clearance – poses risk for the patient to develop an infection, major atelectasis and other related problems such as impaired gas exchange and airflow limitation.
• Atelectasis – a complete or partial collapse of the entire lung or lobe of the lung due to alveoli deflating or possible filling with alveolar fluid; Atelectasis is one of the most common respiratory complications post surgery.
• Intubation avoidance – insertion of an endotracheal tube through the mouth and into the airway for ventilation purposes; assists with breathing during anesthesia, sedation, or severe illness.
• Weaning failure – failure in reducing ventilatory support, where patient is unable to breathe spontaneously and so cannot be extubated.

Physiotherapy for respiratory conditions improves respiration through airway clearance and improvement in gas exchange, as well as muscle function through the prevention of muscle atrophy, loss of strength, loss of muscle fiber, and polyneuropathies (peripheral neuropathy / damage of multiple nerves).

In ITU setting, pulmonary infections can happen due to ventilator acquired pneumonia and through lobar atelectasis. Prevention of lung collapse is also very important in ITU setting. Techniques mentioned further above help increase lung expansion. Upkeep of the respiratory system helps in avoiding late development of complications.

Pulmonary exacerbation can lead to:

• muscle weakness
• haemoglobin reduction
• reduction in testosterone levels in both males and females
• hypoxia
• systemic inflammation
• possible concomitant heart failure

Paediatric Physiotherapy for Respiratory Conditions

Physiotherapy can be initiated from as early as a few days after birth. In intensive care, physiotherapy can reduce the risks associated with endotracheal tube obstruction.

In short term treatment, the main aim is that of eliminating obstructive secretions from the airway, which reduces breathing work, improves efficiency of mechanical ventilation, improves gas exchange, prevents or resolves complications, leading to early weaning from ventilator use.

In long term treatment, the main aim is that of preventing postural deformities, improving tolerance to exercise and providing better quality of life.

A ventilated paediatric patient risks:

• ventilator associated pneumonia
• oxygen toxicity
• hyperinflation
• atelectasis
• impaired mucociliary clearance
• decreased funcitonal residual capacity (FRC)
• endotracheal tube insertion
• inadequate humidification of vent gases leading to increased secretions which then cause obstruction, infection, atelectasis = chronic disease.

Paediatric breathing mechanics are different. Babies are more fragile and need to be treated in a more gentle way. Constant monitoring and lung clearance help in avoiding the development of ventilator associated pneumonia. Oxygen should be monitored frequently as excessive oxygen in babies can cause blindness, mental and brain related problems.

Physiotherapy is contraindicated (unless advised otherwise) in:

• very premature babies
• unstable / severely ill child
• pulmonary haemorrhage
• pulmonary oedema
• pulmonary hypertension
• raised intracranial pressure
• platelet count less than 50 (in less than 100 it may be indicated with extra care)

NOTE: Bronchiolitis is a very common condition affecting babies up to around 4 years of age. Bronchiolitis restricts respiratory function.

Palliative Care

If a patient has no possible treatment option (such as in lung cancer, cystic fibrosis, COPD), quality of life can still be improved through physiotherapy. It helps the patient to cope and live comfortably with his/her condition.

Below you can find a collection of videos that can help provide a more visual approach to physiotherapy for respiratory conditions.

Postural Drainage Technique

Chest Percussion

Percussion and Vibration Technique

Effective Coughing Technique

Manual Hyperinflation

Active Cycle of Breathing Technique (ACBT)

Positive Expiratory Pressure (PEP)

Flutter

Diaphragmatic Breathing

Segmental Expansion

Glossopharyngeal Breathing

Pursed Lip Breathing

COPD Patient Using Accessory Muscles of Respiration

Pulmonary Rehabilitation

Special thanks to the creators of the featured videos on this post, specifically Youtube Channels Metro Physical Therapy, NHS University Hospitals Plymouth Physiotherapy, Physio Keeps You Moving, mmfllws 1, NewYork-Presbyterian Hospital, KP’s OUR HEALTH HELPING YOU TO HELP YOURSELVES, CANVent Ottawa, American Lung Association, Doctors Hub and Ascension Via Christi.

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