Statistical modeling in pharmaceutical research and development.
Physiotherapy
1.
2. 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)
3. 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
4. • 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)
5. 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
6. 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.
7. 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
9. 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
10.
11. 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)
12. 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
13.
14. 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
15.
16. 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
17. Pursed lip breathing –Indication
COPD
Emphysema leads to Hyperinflation by two mechanism
a)Passive hyperinflation
b)Dynamic hyperinflation
18. Passive hyperinflation
Is caused by reduced elastic recoil which allows the
airway to collapse on expiration
19. 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)
20. 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
21. 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
22. 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.
23.
24. 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
25. 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).
27. Advantages of segmental
breathing(indication)
Prevent accumulation of pleural fluid
Prevent accumulation of secretions
Decreases paradoxical breathing
Decrease panic
Improve chest mobility
28. 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”
29. 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
30. Self resistance technique
When using this
technique patient should
not elevate his shoulder
or achieve costal
expansion by side flexion
of spine
31. 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
32. 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
33. 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
34. 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 )
35. 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
36. 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
37. 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
38. Exception to the bad lung up rule
Recent pneumonectomy
Large pleural effusion
Broncho pleural fistula
40. 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
41. 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
42. 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
43. 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
44. 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)
45. 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
46. 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)
47. 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
48. Cont..
At high lung volume the EPP is more proximal because
pleural pressure decreases and alveolar elastic recoil
increases
49. 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)
50. FEM in Low lung volume
EPP
+
++
+
Alveoli
Upper respiratory
way
+ +
+
+ +
51. FEM in Mid lung volume
EPP
+ +
Alveoli + + +
+ +
+
+
Upper respiratory
way
52. FEM in High lung volume
+
+ +
+
+ +
+
+ +
EPP
Alveoli
Upper respiratory
way
53. 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
56. 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
59. 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
61. 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
63. 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
64. 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
65. 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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Physiotherapist plays important role in effective clearance,Increase the volume of inspired air, Augment the compression force , or elicit a cough reflex
Pt inspire maximally ,close glottis bear down by tightening abdominal, perineal gluteal, and shoulder depressor muscle and cuff no more than two times during each expulsive expiratory phase ,proper cuff technique after surgery additionally requires incisional splinting
Phases of cuffing are Irritation ,inspiration, compression and expulsion.
Compression begins with closure of glottis ,intra thoracic pressure and abdominal pressure is built with contraction of expiratory respiratory muscles –expulsion phase begins with opening of glottis and expulsion of trapped air occurs