respiratory 5

Physical Therapy Intervention
For Pulmonary Diseases
Dr. Mohamed Seyam PhD. PT.
Assistant professor of physical therapy
Physical Therapy Intervention for Pulmonary diseases
Breathing Exercise
Thoracic Mobilization Techniques
Inspiratory Muscle Training
Airway Clearance Techniques
Mechanical Ventilators
1) Improve or redistribute ventilation.
2) Prevent postoperative pulmonary complications.
3) Improve the strength, endurance, and coordination of the
muscles of ventilation.
4) Correct inefficient or abnormal breathing patterns and
decrease the work of breathing.
5) Promote relaxation and relieve stress.
6) Teach the patient how to deal with episodes of Dyspnea.
Types of Breathing Exercises
a. Diaphragmatic breathing exercise
b. Segmental breathing exercise
c. Pursed- lip Breathing exercise
d. Glossopharyngeal breathing
e. Preventing and Relieving Episodes of Dyspnea
a. Diaphragmatic breathing exercise
These are designed to
1. improve the efficiency of ventilation,
2. decrease the work of breathing,
3. increase the excursion (descent or ascent) of the
diaphragm, and
4. improve gas exchange and Oxygenation.
Position: Semi-Fowler’s position (in which gravity
assists the diaphragm), long sitting or supine.
Procedure Of Diaphragmatic breathing exercise
 Start instruction by teaching the patient how to relax the accessory
muscles of inspiration those muscles (shoulder rolls or shoulder shrugs
coupled with relaxation).
 Place your hand on the rectus abdominals just below the anterior costal
margin on the epigastric angle.
 Ask the patient to breathe in slowly and deeply through the nose.
 Have the patient keep the shoulders relaxed and upper chest quiet,
allowing the abdomen to rise slightly.
 Then tell the patient to relax and exhale slowly through the mouth.
After the patient understands and is able to control breathing using a
diaphragmatic pattern, practice diaphragmatic breathing in a variety
of positions (sitting, standing)and during activity(walking, climbing
b. Segmental breathing exercise
 Segmental breathing techniques may need to be directed to the lobes if
there is accumulation of secretions or insufficient lung expansion in these
1.Lateral Costal Expansion
 called lateral basal expansion,
 can be carried out unilaterally or bilaterally.
 Position: Hook-lying position;
 later progress to a sitting position.
 Procedure Place your hands along the lateral aspect of the lower ribs to
direct the patient’s attention to the areas where movement is to occur.
1)Lateral Costal Expansion
 Ask the patient to breathe out, and feel the rib cage move downward and
 As the patient breathes out, place pressure into the ribs with the palms of your
 Just prior to inspiration, apply a quick downward and inward stretch to the
 This places a quick stretch on the external intercostals to facilitate their
 Apply light manual resistance to the lower ribs to increase sensory awareness
as the patient breathes in deeply and the chest expands.
 Teach the patient how to perform the maneuver independently by placing
his or her hand(s) over the ribs or applying resistance with a towel or belt
around the lower ribs
2) Posterior Basal Expansion
 Deep breathing emphasizing posterior basal expansion is important
for the postsurgical patient who is confined to bed in a semi reclining
position for an extended period of time because secretions often
accumulate in the posterior segments of the lower lobes.
 Have the patient sit and lean forward on a pillow, slightly bending the
 Place your hands over the posterior aspect of the lower ribs.
 Follow the same procedure just described for lateral costal expansion.
c. Pursed-Lip Breathing
Pursed-lip breathing is a strategy that involves lightly pursing the lips together during
controlled exhalation.
 p r e c a u t i o n : The use of forceful expiration during pursed-lip breathing must be
avoided because this can cause further restriction of the small bronchioles.
 Position Any comfortable position
 Have the patient breathe in slowly and deeply through the nose and then breathe out
gently through lightly pursed lips as if blowing on and bending the flame of a candle but
not blowing it out.
 Explain to the patient that expiration must be relaxed and that contraction of the
abdominals must be avoided.
 Place your hand over the patient’s abdominal muscles to detect any contraction of the
d. Glossopharyngeal breathing
It is a means of increasing the inspiratory capacity when there is severe weakness of the
respiration muscles.
 It is used primarily by patients who are ventilator-dependent because of absent or
Incomplete innervations of the diaphragm as the result of a high cervical-level spinal
cord lesion or other neuromuscular disorders
 Glossopharyngeal breathing involves taking several “gulps” of air, usually 6 to 10
gulps in series, to pull air into the lungs when action of the inspiratory muscles is
 After the patient takes several gulps of air, the mouth is closed, and the tongue
pushes the air back and traps it in the pharynx. The air is then forced into the lungs
when the glottis is opened. This increases the depth of the inspiration and the
patient’s inspiratory and vital capacities
e. Preventing and Relieving Episodes of Dyspnea
If the patient becomes slightly short of breath, he must learn to stop an
activity and use controlled, pursed-lip breathing until the dyspnea
 Procedure
1. Have the patient assume a relaxed, forward-bent posture. A forward bent position
stimulates diaphragmatic breathing (the viscera drop forward and the diaphragm
descends more easily).
2. Have the patient gain control of his or her breathing and reduce the respiratory rate
by using pursed-lip breathing during expiration.
3. After each pursed-lip expiration, teach the patient to use diaphragmatic breathing
and minimize use of accessory muscles during each inspiration.
2. Thoracic Mobilization Techniques
Chest mobilization exercises are any exercises that
combine active movements of the trunk or extremities
with deep breathing.
They are designed to maintain or improve mobility of the
chest wall, trunk, and shoulder girdles when it affects
ventilation or postural alignment.
Exercises that combine stretching of these muscles with
deep breathing improve ventilation on that side of the
a. Specific Techniques
To Mobilize One Side of the Chest
1. While sitting, have the patient bend away from the tight side to
lengthen hypo mobile structures and expand that side of the chest
during inspiration
2. Then, have the patient push the fisted hand into the lateral aspect of
the chest, bend toward the tight side, and breathe out
3. Progress by having the patient raise the arm overhead on the tight
side of the chest and side-bend away from the tight side. This places an
additional stretch on hypo mobile tissues.
To Mobilize the Upper Chest and Stretch the pectoralis muscle
While the patient is sitting in a chair with hands elongating
the clasped behind the head, horizontally abduct the
arms have him or her Pectoralis major) during a deep
Then instruct the patient to bring the elbows together and
bend forward during expiration.
c. To Mobilize the Upper Chest and Shoulder
While sitting in a chair, have the patient reach with both
arms overhead (180 bilateral shoulder flexion and slight
abduction) during inspiration.
Then bend forward at the hips and reach for the floor
during expiration
3.Respiratory muscle Training (RRT)
 RRT is advocated to improve ventilation in patients with pulmonary
dysfunction associated with weakness, atrophy, or inefficiency of
the muscles of inspiration or to improve the effectiveness of the
cough mechanism in patients with weakness of the abdominal
muscles or other expiratory muscles.
Types of Training
a. Inspiratory Muscle Training (IMT)
b. Incentive Spirometer
a. Inspiratory muscle training
 The patient inhales through a resistive training device placed in the
 These devices are narrow tubes of varying diameters or a
mouthpiece and adapter with an adjustable aperture that provide
resistance to airflow during inspiration and therefore place resistance
on inspiratory muscles.
 The smaller the diameter of the tube and, the greater is the
 The patient inhales through the device for a specified period of time
several times each day.
b. Incentive spirometer
 Incentive spirometer is a form of ventilatory training that emphasizes sustained
maximum inspirations.
 The purpose of incentive spirometer is to increase the volume of air inspired.
 It is used primarily to prevent alveolar collapse and atelectasis in post operative
 Have the patient assume a comfortable position (semi reclining, if possible) and
inhale and exhale three to four times and then exhale maximally with the fourth
 Then have the patient place the spirometer in the mouth, inhale maximally through
the mouthpiece to a target setting and hold the inspiration for several seconds.
 This sequence is repeated five to ten times several times per day.
4. Airway Clearance Techniques
1. Sputum in perspective
7. Hydration and humidification
2. Exercise
8. Postural drainage
3. Manual techniques
9. modified Postural drainage
4. Breathing techniques
10. Mechanical aids
5. Cough
11. Pharyngeal suction
6. Nasopharyngeal airway 12. Minitracheostomy
4. Airway Clearance Techniques
 An effective cough is necessary to eliminate respiratory obstructions
and keep the lungs clear.
 A cough may be reflexive or voluntary.
The Cough Mechanism
1. Deep inspiration occurs.
2. Glottis closes, and vocal cords tighten.
3. Abdominal muscles contract and the diaphragm elevates, causing
an increase in intra thoracic and intra-abdominal pressures.
4. Glottis opens.
5. Explosive expiration of air occurs.
Factors that Decrease the Effectiveness of the
Cough Mechanism and Cough Pump:
1. Decreased inspiratory capacity.
2. Inability to forcibly expel air.
3. Decreased action of the cilia in the bronchial tree.
4. Increase in the amount or thickness of mucus.
Teaching an Effective Cough
1. Assess the patient’s voluntary or reflexive cough.
2. Have the patient assume a relaxed, comfortable position - Sitting or
leaning forward
3. Teach the patient controlled diaphragmatic breathing,
emphasizing deep inspirations.
4. Demonstrate a sharp, deep, double cough.
5. Demonstrate the proper muscle action of coughing (contraction of
the abdominals).
6. Take a deep but relaxed inspiration, followed by a sharp double
cough. The second cough during a single expiration is usually more
Additional Techniques to Facilitate a Cough
1.Manual-Assisted Cough
If a patient has abdominal weakness manual pressure on the abdominal area assists
in developing greater intra-abdominal pressure for a more forceful cough.
a. Therapist-Assisted Techniques
b. Self-Assisted Technique
2. Splinting
If chest wall pain from recent surgery or trauma is restricting the cough, teach the
patient to splint over the painful area during coughing.
3. Tracheal Stimulation The therapist places two fingers at the sternal notch and
applies a circular motion with pressure downward into the trachea to facilitate a
reflexive cough
5. Aerosol therapy
 A therapeutic administration of a drug in the form of an aerosol.
 Indications
1. Bronchospasm
2. Inflammation
3. Mucosal edema
4. Copious secretion
5. For mobilization of secretion
Aerosol drug delivery systems
 Delivery systems:
a) Nebulizer
b) MDI (Metered dose-inhalers)
a) Nebulizer
It is a device used to converting a liquid drug into a fine mist which can then be
inhaled easily.
a) Jet Nebulizer
b) Ultrasonic Nebulizer
 To administer medication directly into the respiratory tract to induce sputum
expectoration in case of sputum induction
 To reduce the difficulty in bringing out the secretions
 To increase Vital capacity
metered-dose inhaler (MDI)
A metered-dose inhaler (MDI) is a device that delivers a specific amount of
medication to the lungs, in the form of a short burst of aerosolized medicine
that is inhaled by the patient.
 It is the most commonly used delivery system for treating asthma, chronic
obstructive pulmonary disease (COPD) and other respiratory diseases.
 The medication in a metered dose inhaler is most commonly
a bronchodilator, corticosteroid or a combination of both for the
treatment of asthma and COPD.
Thank you
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