Pulmonary rehabilitation in a patient with disturbed airway clearance
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Pulmonary rehabilitation in a patient with disturbed airway
clearance
Sema SavcıPT, PhD, Prof
H.U. School of Physical Therapy Rehabilitation
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Respiratory mechanics
Air flow
• Airway resistance
• Elastic recoil pressure
• Bronchial wall stability
• Mucus reology
• Ciliary beat and frequency
• Dynamic compression
Respiratory muscles Collateral ventilation
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Airway clearance disorders
Altered mucus rheology (cystic fibrosis)
Altered mucociliary clearance (primer ciliar dyskinesia)
Structural defects (bronchiectasis)
Abnormal cough mechanisms (muscle weakness)
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Goals of airway clearance
Maintainance of airway patency V/Q matching work of breathing oxygenation
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Airway clearance techniques
Postural drainage and positioning Percussion, vibration and shaking Huffing, cough, forced expiration technique Active cycle of breathing techniques Autogenic drainage Positive expiratory pressure (PEP) therapy High frequency chest wall oscillations (VEST, Hayek) Intrapulmonary percussive ventilation (IPV) Exercise (aerobic, peripheral & respiratory muscle
training)
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Postural drainage Use of gravitational forces
to promote mucus transport to central airways
12 positions: 5-10 min each
Modify positions to optimize patient tolerance & comfort
Never head down: ICP > 20, GER, risk of aspiration, orthopnea, hemodynamic instability
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Percussion (clapping)
Clapping external thorax directly over lung segment being drained
Transmission of oscillatory forces to bronchi
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Vibration & shaking
Manual oscillatory actions on expiration only in the direction of normal movement of the ribs
Fine movement: vibration
Coarse movement: shaking
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Huffing & cough Huffing: modified
forced expiratory breaths-open glottis
Coughing: controlled cough-closed glottis
Equal pressure points
Forced expiration technique
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Active cycle of breathing techniques
Breathing control: stabilizes airways
Thoracic expansion exercises (TEE): collateral ventilation
Forced expiration techniques: helps mobilize secretions
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ACBT+NIMV, lenght of MV (1,7 days) length of stay in ICU (1,3 days) PaCO2 more stable
Austr J Physiother 2004.
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Autogenic drainage
Utilizes expiratory air flow at various lung volumes to mobilize secretions
Three stages:
• Unstick
• Collect
• Evacuate
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COPD(n= 30) 20 days, ACBT and AD Pulmonary function Secretion mobilization
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Positive expiratory pressure (PEP)
Clears secretions in occluded airways by increasing collateral ventilation
Utilizes airway stabilization
Allows air to get behind secretions
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Flutter ve Acapella
Utilizes internal expiratory vibrations
Oscillating endobronchial pressure clears mucus from small airways
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PEP
To compare short-term effects of flow dependent PEP, flow independent PEP and ACBT
Stable cystic fibrosis patients(n=25, 6-17years) PFT, SaO2 dyspnea and fatigue perception were
evaluated Flow independent threshold PEP improved large and
middle airway function
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To compare the short – term effects of PEP, CPAP and NPPV in cystic fibrosis patients with severe airway obstruction.
Wet and dry sputum weight, SaO2 and PFT were evaluated. Each patient received each treatment twice a day for consecutive days.
The highest sputum wet weight was produced with PEP treatment.
After mask PEP these patients felt more tired than after CPAP or NPPV.
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To evaluate the acute efficacy and tolerability of Flutter, ACBT ve ACBT + PD in bronchiectatic patients (n=36)
Sputum wet weight for ACBT+PD was twice that either ACBT or flutter
Patient preference was
• 44% for Flutter, 22% ACBT, 33%ACBT+ PD
ACBT was superior in terms of acute efficacy.
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High frequency chest wall oscillations (Hayek oscillator & VEST)
Generates increased airflow velocities via oscillation of chest wall
High airflow velocities create repetitive cough like shear forces
Shear forces decrease viscosity of secretions
Expensive Prefer mentally retarded
patients
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Intrapulmonary percussive ventilation
Inhalation therapy High frequency puff
open atelectatic alveoli
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Respiratory muscle training
Respiratory muscle endurance and strenght
Cough efficiency
Intensity: Pımax 30%Duration : 30 min/dayFrequency: 5 days/week
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Mekanical IN-EXSUFFLATION
inhalation volume. lung recoil pressure Use in patients with
respiratory muscle weakness
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DMD patients, Peak cough flow rate < 160 L/min Mechanical IN-EXSUFFLATION
• Prevent hospitalization need for tracheostomy
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Exercise training
Essential component. exercise capacity. oxidative capacity in
peripheral muscle Mediator release in the
airway ventilation
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To investigate the effects of heavy resistance training (RT) in the elderly males with COPD (n=18, 65-80 years)
Cross sectional area of quadriceps asssessed by MRI Isometric-isokinetic knee extension, isometric trunk strength, leg
extension power, stair climbing time, normal and max gait speed on a 30 m track.
RT performed twice a week for 12 weeks. Significant improvements in muscle size, knee extension
strength, leg extension power and functional performance in elderly male COPD patients.
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ES
To evaluate whether ES was a beneficial tecnique in the rehabilitation programs for severely deconditioned COPD patients after acute exacerbation.
17 COPD patient participated in this study (FEV1, 30 3% pred, BMI 18 2.5 kg/m2)
usual rehab (UR) (n=8) , UR +ES (n=9) program for 4 weeks QMS, exercise capacity and HRQoL were measured before and
after rehabilitation.
Chest 2006; 129:1540-1548.
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Conclusion
Airway clearance techniques should be used in patients with disturbed airway clearance.
Patients’ age, cooperation, social status, and compliance should be considered when choosing the method.
Exercise training is essential component of PR. Aerobic exercise training, peripheral and respiratory
muscle training should be included in PR program.
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Sonuçlar
Number of patients
Controlled study
Different pathologies
Patient preference
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