RESTRICTIVE LUNG
DISEASES
DR. MOHAMED SEYAM PHT.PT.
ASSISTANT PROFESSOR OF PHYSICAL THERAPY
• Definition

Restrictive lung disease (RDL) is a chronic
disorder that causes a decrease in the ability to
expand the lung (breathe in).
 Disorders that inhibit normal lung excursion.
1- Pulmonary Causes of Restrictive Lung Disease
1.
Idiopathic Pulmonary Fibrosis
2.
Coal Workers' Pneumoconiosis
3.
Silicosis
4.
Asbestosis
5.
Broncho pulmonary Dysplasia
6.
Bronchogenic Carcinoma
7.
Pleural Effusions
8.
Pneumonia
2-Neuromuscular Causes of RLD
1.
Spinal Cord Injury
2.
Amyotrophic Lateral Sclerosis
3.
Poliomyelitis
4.
Guillain-Barre Syndrome
5.
Myasthenia Gravis
6.
Duchenne Muscular Dystrophy
7.
Other Muscular Dystrophies
3- Cardiovascular Causes
1.
Pulmonary Edema
2.
Pulmonary Emboli
4- Musculoskeletal Causes
1.
Diaphragmatic Paralysis or Paresis
2.
Kyphoscoliosis
3.
Ankylosing Spondylitis
4.
Pectus Excavaturn
5.
Pectus Carinatum
5- Connective Tissue Causes
1.
Rheumatoid Arthritis
2.
SystemIc Lupus Erythematosus
6- Immunologic Causes
1.
Goodpasture‘s Syndrome
2.
Wegeners Granulomatosis
7-Pregnancy as a- Cause of 10- Therapeutic Causes
Restrictive Lung.
1. Surgical Therapy
8- Nutritional and
Metabolic Causes
1.
obesity
2.
Diabetes Mellitus
9- Traumatfc causes
1.
Crush Injuries
2.
Penetrating Wounds
2.
Lung Transplantation
3.
Drug Therapy
4.
Radiation Therapy
Pleural diseases
1.
Dry pleurisy and Pleural effusion.
2.
Heamothorax
3.
Empyema
4.
Pneumothorax
PLEURAL EFFUSION
•
The pleural space normally contains less than 20 mL of fluid.
•
Pleural effusion occurs when there is excess fluid in the pleural cavity.
• caused by
1.
disturbed osmotic or hydrostatic pressure in the plasma,
2.
changes in membrane permeability.
3.
Malignancy causes 25% of pleural effusions .
4.
Other causes are heart, kidney or liver failure,
5.
abdominal or cardiac surgery,
6.
pneumonia or TB.
Types of Pleural effusion
Transudates
Exudates
cloudy,
• clear
•
• low-protein,
• high-protein effusions
• caused by
• caused by
1.
liver or kidney problems,
1.
associated with malignancy,
2.
heart failure,
2.
trauma
3.
malnutrition or fluid imbalance.
3.
infection.
Clinical features
• a stony dull percussion
• decreased breath sounds over the affected area, with bronchial
breathing
•
A small effusion of less than 500 mL creates few or no symptoms.
•
A large effusion displaces the mediastinum and causes breathlessness.
• Radiologically there is a fluid line, occurs when fluid accumulates in
pockets.
Medical treatment
• treatment the cause
• symptomatic relief of breathlessness by
• needle aspiration (thoracocentesis), performed slowly to avoid
ere-expansion pulmonaryoedema‘ .
• Surgery
• may be needed for a thickened restrictive pleura.
• The symptoms of malignant invasion of the pleura
Bilateral pleural effusions.
• The right side
shows a dense opacity
with a smooth horizontal
border and
meniscal edge.
• The left shows
a small effusion
obliterating
the costophrenic angle.
Physiotherapy
• Deep breathing exercises.
• Positioning can be used to optimize gas exchange.
• People with moderate unilateral effusion may benefit from side-lying
with the affected side uppermost because both ventilation and perfusion
are greater in the lower lung.
• Large effusions are more likely to show improved Pa02 with the effusion
downwards to minimize compression of the unaffected lung .
• Some patients require assistance with mobilization.
2- HEAMOTHORAX
• Heamothorax is blood in the pleura as a result of
malignancy or trauma,
• managed by treating the cause, plus tube
drainage if necessary.
3- EMPYEMA
• It is pus in the pleural cavity following localized infection.
• It can complicate pneumonia, bronchiectasis, chronic
aspiration, abscess or chest surgery, especially
oesophageal surgery.
• The patient may be asymptomatic or toxic, depending on
the organism and volume of pus.
TREATMENT OF EMPYEMA
1.
Local and systemic antibiotics.
2.
Needle aspiration,
3.
Tube drainage either into a bag or with strong suction
4.
An underwater seal system,
5.
Lavage,
6.
Debridement via thoracoscopy,
7.
Open drainage with rib resection, or thoracotomy with decortication.
8.
Surgery is required if pus fills more than 40% of the hemithorax Surgical
patients are debilitated and need attention to mobility.
4- PNEUMOTHORAX
• Definition
Air collects between the visceral and parietal pleura.
• Types
1. Spontaneous pneumothorax
2. Traumatic pneumothorax
Types
1.Spontaneous pneumothorax: It may be secondary to an underlying disease.
Causes
a. Asthma or bullous emphysema
b. Infections (e.g. Staphylococcal pneumonia, tuberculosis)
c. Cystic fibrosis
d. Marfan's syndrome.
2.Traumatic pneumothorax
Causes:
•
Penetrating injury to the chest (e.g. by stab wound or a
bullet)
• Non-penetrating injury to the chest wall (e.g. Rib fracture)
•
During the insertion of an intravenous (e.g. subclavian) line
• During surgery to the chest wall
• During pleural aspiration or biopsy.
Pathological changes
•
As air escapes into the pleural cavity and reduces the sub atmospheric pressure (i.e.
less negative)causes the lung collapse.
•
Air then enters the pleural cavity on inspiration but cannot escape during expiration.
•
The lung remains collapsed and, as air accumulates in the pleural cavity and the
pressure increases, there is displacement of the heart together with compression of
the other lung and great vessels.
•
This is termed a tension pneumothorax
Clinical features
•
Increased respiratory rate
•
Dyspnea
•
Chest pain that worsens with a deep breath
•
Fatigue and weakness
•
Tachycardia
•
Cyanosis
•
Hypotension
•
Decreased or absent lung sounds on affected side
Investigations
The chest X-ray shows
absence of lung markings
and the edge of the
collapsed lung can be seen.
This will confirm the
diagnosis
Medical Management
A) small pneumothorax
Requires no treatment apart from a few days bed rest until it resolves.
B) large pneumothorax (i.e. more than 25% of the pleural space is filled with air)
It is treated by needle aspiration or by an intercostal drain which connects the
pleural cavity to a drainage bottle creating an underwater seal.
SURGERY: is indicated for a recurrent pneumothorax.
- PLEURODESIS: comprises the insertion of a powder into the pleural cavity to
adhere both the pleura together.
- PLEURECTOMY: is the removal of the parietal pleura from the chest wall leaving
a raw surface to which the visceral layer sticks.
CHEST DEFORMITIES
1.
2.
3.
4.
5.
Pectus carinatum,
Pectus Excavatum,
Scoliosis,
Kyphosis and
Kyphoscoliosis
1- Pectus Carinatum
• Pectus Carinatum (pigeon chest)
• It is a Structural abnormality characterized by the sternum
protruding anteriorly.
• Fifty percent of patients with atrial or ventricular septal
defects have Pectus carinatum.
• It also has been associa1ed with severe prolonged childhood
asthma.
2- PECTUS EXCAVATUM (funnel chest)
• It is a congenital abnormality characterized by sternal depression
and decreased anteroposterior diameter.
• The lower portion of the sternum is displaced posteriorly, and the
anterior rib5 are bowed markedly.
• If the deformity is very severe, the patient may have
decreased TLC, VC and maximum voluntary ventilation and
may complain of dyspnea on exertion, precordial pain, palpitation,
and dizziness.
3- scoliosis
• This is characterized by lateral deviation of the spine on either side,
mainly in thoracic or lumbar or both region.
• Structural scoliosis involves an irreversible lateral deviation of the
spine.
• Nonstructural scoliosis is reversible and also called postural scoliosis.
4- Kyphosis
• Kyphosis may cause restrictive lung defects
secondary to musculoskeletal deformity and
subsequent compression of the alveoli
5- Kyphoscoliosis
• It is a combination of excessive anter0posterior and lateral
curvature of the thoracic spine .
• A distorted spine increases the work of breathing because of
1. Reduced chest wall compliance
2. Micro atelectasis
3. Altered alveolar surface tension .
• The configuration of the chest wall forces the diaphragm to work
inefficiently.
• Surgery is sometimes undertaken to prevent progression of
scoliosis or improve body image and improve pulmonary function .
PT program in RLD depends on
• The problem and manifestation of the pt.
• The pathological changes of the disease
• The duration and progression of the disease
• The associated condition and complications
Goals
• Maintain and restore adequate
ventilation
• Re-expand affected lung
• Prevent permanent or recurrent
atelectasis
• Assist and control drainage by under
water seal
• Maintain adequate peripheral
circulation
• Improve exercise tolerance and
endurance
• Adequate ROM in upper limps and trunk
• Relieve pain and anxiety
• Prevent deformity and maintain
good posture
• Help in reducing dyspnea and
breathing rate
• Assist the removal of secretions if
present
• Break down any adhesion
Respiratory exercise
• Nose training
• Segmental breathing
• Diaphragmatic breathing
• Exercise connected with breathing
• Belt breathing exercise
• Breathing training with devices
Mobilizing exercise
• Active free exercise
• Gymnastic exercise
• Swimming
• Shoulder wheel and raw machine
• Supported and unsupported exercise
Clearing lung fields
- Humidification
-
Clapping, shaking and percussion
-
breathing exercises may all be necessary in a
-
postural drainage position to the area of the lung affected.
-
Modified postural drainage
-
Suctioning
-
Cough and huff
-
Autogenic drainage