Physio Professionals Newsletter July 2012
this issue P ro f e ssi o n a l D e ve l o p me n t
P.1&2 What is Respiratory Physiotherapy?
Physio Professionals prides itself in its continuing staff education initiatives.
What is respiratory physiotherapy?
Michelle Crew (nee: Peauril) Masters of Physiotherapy Level 3 Sports Physio AIS MAPA
Respiratory physiotherapy involves a thorough assessment, identification of the problem and a variety of treatment and management techniques including education, exercises and controlled activity, and adjuncts such as intermittent positive pressure breathing (IPPB), continuous positive airway pressure (CPAP), non-invasive ventilation, suction, flutter device, and positive expiratory pressure mask. In general, however, physiotherapists focus on three main areas - decreased lung volumes, increased work of breathing and retained secretions.
Andy Magill B.Sc. Physiotherapy (Hons) MAPA
Andrew Crew Remedial/Sports Massage Performance Bike Fit
Lung volume Lung volume may be reduced as a result of, for example, atelectasis (common in postoperative patients), consolidation, pleural effusions or pneumothorax. The latter two may respond simply to insertion of an intercostal chest drain.
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Reduced lung volumes respond well to increasing patient mobility. This may consist of upper limb exercise in bed for the immobile patient, transferring patients to chairs, walking on the spot or climbing a flight of stairs. It is a simple yet effective treatment technique. For patients who are unable to sit out of bed, lower thoracic
expansion/deep breathing exercises may be taught instead, in conjunction with good positioning . Changing a patient's position can increase lung volumes by choosing one that will allow better excursion (movement) of the diaphragm. Lying supine or slumped in bed will decrease lung volumes by pushing the abdominal contents up against the diaphragm, limiting movement. For patients with a unilateral problem, such as a chest infection, consolidation should lie with the affected lung uppermost, as optimal ventilation and perfusion will occur in the dependent (lower area) lung. If poor lung volumes begin to compromise the patient's gas exchange, CPAP may be used to splint airways open and thus allow alveolar ventilation. This should be done in a closely monitored environment since there is a risk of haemodynamic instability with CPAP. There should be recognition that the patient is acutely unwell and may need urgent intervention if CPAP does not improve the situation.
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Sputum retention Clearance of sputum is commonly seen as a cornerstone of physiotherapy practice. Sputum may not be a problem if it is not compromising a patient's oxygen saturations or respiratory rate and he or she is able to expectorate it independently - for example, some patients with COPD. However, if the cough is weak or ineffective or there is an overwhelming volume or tenacity of sputum ventilation may deteriorate, leading to respiratory failure. Sputum may be easily cleared by mobilisation and breathing exercises. By increasing lung volumes (specifically tidal volumes) sputum can be loosened by air turbulence in bronchioles and moved to larger airways from where it can be coughed up. This can be facilitated by a series of breathing exercises known as the active cycle of breathing techniques which, when taught correctly, help clear secretions with minimal effort. Tidal volumes can be increased with the use of intermittent positive pressure breathing (IPPB) in patients who are unable, due to pathology or exhaustion, to take sufficiently deep breaths independently. Additional manual techniques, such as shaking or percussion, may help, but only in specific circumstances assessed and suggested by a respiratory physiotherapist. They can have serious side-effects, including bronchospasm, when used or performed incorrectly. Positioning to clear secretions can be used by identifying the lobe(s) affected and using a position where gravity will help to drain sputum towards the trachea, from where it can be coughed up. This is known as postural drainage. Such positions may also alter the ventilation-perfusion quotient ratio by changing the dependent area of the lung. It needs careful assessment in order to select the appropriate position and to modify it in the presence of various precautions.
Management of breathlessness Breathlessness is a subjective and frightening experience for patients, and they need to be given techniques to manage this. There is little relationship between blood gases and breathlessness (Hough, 1997), so patients can be profoundly hypoxic with minimal breathlessness or very short of breath with little change to their oxygen saturations. As a result, telling patients to 'just relax' or 'just breathe slowly' is rarely effective. Rather, they need to be shown positions that decrease breathlessness and advised on how to cope with breathlessness on exercise. Changing the position of a patient can have a profound effect on respiratory rate and breathlessness. Most patients will automatically adopt a position that relieves their shortness of breath. If they cannot do so, sitting them upright in bed, or out in a chair, can increase their lung volumes considerably - this is related to the displacement of the diaphragm by the abdominal contents. This is especially effective with obese patients or those with a large abdomen (for example, patients with ascites). Supine or slumped lying in bed is the least helpful position for patients with respiratory distress (Hough, 1996). Some patients may benefit from leaning forward on to a table with their arms supported on pillows. Pulmonary rehabilitation treatments have proved invaluable in managing patients with breathlessness. Techniques used in pulmonary rehabilitation include educating patients in controlling their own breathing, improving their exercise tolerance, returning their confidence and managing their lung disease. Shop 27 â€œCENTREPOINT PLAZAâ€? Cnr Minchinton St & Leeding Tce Caloundra Qld 4551
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