Basic techniques of pulmonary physical therapy (I)
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Evaluation of breathing function
• Chart review
– History
– Chest X‐ray – Blood test
• Observation/palpation
– Chest mobility
– Shape of chest wall – Accessory muscle
firing
– Respiratory rate – Posture
• Physical
examination
– Breathe sound – Dyspnea index – Cough ability – Functional
capacity
Evaluation of breathing pattern
• Breathing pattern (I)
– 2C2D – 3C1D
• Breathing pattern (II)
– Upper chest paradox – Abdominal paradox
– Excessive accessory muscle use
• Breathing pattern (III)
– Paradoxical
– Rapid and shallow
– Prolong expiration, and etc.
Breathing retraining
• Active expiration
• Pursed lips breathing
• Specific body positions
• Diaphragmatic breathing
• Accessory muscle stretch
• Breathing control
• Relaxation breathing
• Incentive spirometry (IS)
Active expiration
• Contraction of the abdominal muscles during expiration
• Lengthens the diaphragm
– Improve the length‐tension relationship or
geometry of the respiratory muscle (diaphragm) – Assist the next inspiration
• ↑transdiaphragmatic pressure
• The efficacy of the contraction in moving the rib cage improves
• ↑strength and endurance of inspiratory
muscle
Length‐tension relationship
In same neural input,
↑length, ↑output of muscle
Pursed lips breathing
• Effects
– 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
• Active and prolonged expiration through half‐opened lips
Pursed lips breathing
Body position
• Upright position
– Oxygen transport is optimized to the
greatest degree (ventilation vs perfusion) – Maximize lung volume and capacities (Fig) – Anteroposterior dimension of chest wall is
the greatest, and compression of the heart and lung is minimized
– Maximal expiratory pressure is greatest
(cough, huffing, etc.)
To optimize thoraco‐abdominal movements
• Segmental breathing
Segmental breathing
Diaphragm breathing
• Move the abdominal wall
predominantly during inspiration and to reduce upper rib cage motion
– Improve chest wall motion
– Improve distribution of ventilation – ↓ the energy cost of breathing
– ↓ the contribution of rib cage muscle – ↓ dyspnoea
– ↑ exercise performance
Diaphragm breathing
Accessory muscle stretch
• Accessory muscle
– sternocleidomastoid (elevated sternum) – scalene muscles (anterior, middle and
posterior scalene)
– serratus anterior, pectoralis major &
minor, upper trapezius, latissimus dorsi, erector spinae (thoracic), iliocostalis
lumborum, quadratus lumborum,
serratus posterior superior and inferior,
levatores costarum, transversus thoracis,
subclavius
Accessory muscle stretch
Accessory muscle stretch
• Sidelying, with the upper arm elevated to stretch the intercostal muscles or in sitting, using active shoulder abduction combined with lateral flexion
• Active or passive bilateral arm flexion and spine extension may be combined with deep inspiration
Manual therapy techniques
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Breathing control
• Respiratory ratio
– Inhalation: exhalation= 1:2
Relaxation breathing
• When hyperinflation caused by an ↑ activity of the inspiratory muscles during expiration
• Hyperinflation is due to altered lung mechanics (COPD)
– Loss of elastic recoil pressure – air trapping
• Forward leaning→ COPD
– Relief hyperinflation and paradoxical abdominal movement
– ↓EMG activity of the scalene and sternomastoid muscles
– ↑transdiaphragmatic pressure, ↑thoraco‐
abdominal movements
Relaxation breathing
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• Mechanical devices introduced in surgical patients
• Attempt to reduce postoperative
complications by increasing inspiratory capacity
• Activated by the patient’s inspiratory effort
– Slow, deep inspiration – Mouthpiece
– Visual feedback
– Preset volume and hold at full inspiration for 2‐3 secs
Incentive spirometry
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Incentive spirometry
Manual therapy techniques
• Subjective assessment
– Musculoskeletal dysfunction
• Postural and skeletal changes over time
– Overuse of upper chest breathing patterns – Lack of lower rib expansion
– Chronic hyperinflation typically leads to the development of a barrel‐shaped chest
• Physical assessment: posture
– The relaxed posture of the pelvis, lumbar, thoracic and cervical spines
– The position of the scapulae and the location of the humeral head within the glenoid
– The posture of the neck and head and alignment with the trunk and pelvis
– The point of maximal curve of each of these segments – Whether the spinal posture is fixed or able to be
corrected
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Manual therapy techniques
• Physiotherapy management
– Postural correction and motor control training
• Educating awareness
• Use visual, auditory and sensory feedback
• Motor learning with training the holding ability of the postural stabilizers‐ frequent gentle repetitions of the corrected
movement or position
• Initial focus: correct any posterior pelvic rotation in sitting and on reducing the lumbar and thoracic kyphosis
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Manual therapy techniques
– Mobilization techniques
• Focus:
– improving the range and quality of thoracic extension and rotation
– Increasing the mobility of the ribs
– Muscle‐lengthening techniques – Taping
– Muscle retraining
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