PULMONARY REHABILITATION/
CHEST PHYSICAL THERAPY
References :
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Caroline Kisner
Jackson Tan
Brompton Hospital Chest Physioterapy
Somers MF, 2010. Spinal Cord Injury Functional Rehabilitation. 3rd edition
Garrett B, Shatzer H, Bach JR. 2009. In Sisto SA, Druin E, Sliwinski MM (Eds). Spinal Cord
Injuries Management and Rehabilitation.
Normal Value in Healthy Young Adult
TV (Tidal Volume)
IRV (Inspiratory Reserve Volume)
ERV (Expiratory Reserve Volume)
500 ml
3000 ml
1000 ml
RV (Residual Volume)
1500 ml
IC (Inspiratory Capacity) = 3500ml TV + IRV
FRC (Functional Residual
ERV + RV
Capacity) = 2500ml
VC (Vital Capacity) = 4500ml
TLC (Total Lung Capacity) = 6000
ml
TV + IRV +
ERV
TV + IRV +
ERV + RV
PULMONARY REHABILITATION / CHEST PHYSICAL THERAPY
I.
Secret Removal
1.
Secretion Mobilization
a.
b.
c.
2.
Airways Clearance
a.
b.
c.
d.
3.
Postural Drainage
Manual Tech (Percussion/Clapping, Shaking,
Vibration, use vibrator)
Adjuvant (Nebul w/ bronchodilator/normal
saline, humidifier, mucolytic, enough hydration)
Cough Maneuver/Effective Cough
Huffing
Suctioning
Mechanical Insufflation-Exufflation (MIE)
Strengthening muscle (inspiration &
abdominal)
III. Relaxation Technique
1.
2.
3.
Breathing Control
Relaxation Position
Cognitive Relaxation
II. Breathing Exc/Controlled Breathing Technique (CBT)
1. CBT to improve Pulmo Func Test (PFT) Parameter
a. Diaphragm Breathing
b. Segmental breathing/chest expansion exc
c. Incentive spirometer (triflowmeter)
d. Glosopharyngeal breathing
2. CBT to reduce dyspnea & work of breathing
a. Breathing control
b. Pursed lip breathing (PLB)
c. Pacing activity
3. Muscle ventilation strength & endurance exc
4. Chest Mobilization
IV. Abdominal Muscle Strengthening & Support
V.
General Reconditioning Program/Aerobic Exc
VI. Energy Conservation Tech
VII. Give Adequate Ventilation
I.1. Secret Mobilization Technique
1. a. Postural Drainage
• Use gravity-assisted positions to improve mobilization of secretions
from individual lung lobes & segments.
• Affected lung segment is positioned upper most for drainage as well
as oxygenation.
• Can be done in modified position if px cant tolerate the position.
• Time : after awakening in the morning, prior sleeping. Don’t do
after or before meal
Kontraindikasi Postural Darinage :
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Kondisi kardiovaskular yang tidak stabil
Tension pneumothorax yang tidak teratasi
Emboli paru
Efusi pleura berat
Cedera vertebra yang tidak stabil
Post operasi bedah saraf dengan
kontraindikasi peningkatan tekanan
intrakranial
• Kondisi orthopedi atau patah tulang yang
membatasi posisi
• Hemoptisis akut
1. b. Percussion/Clapping, Shaking, Vibration
Kontraindikasi :
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TB aktif
Hemoptisis
Emfisema subkutan
Pasien dengan anestesia spinal
Pasien dengan skin graft atau flap pada thoraks
Kondisi kulit lainnya seperti luka bakar, luka terbuka, dan infeksi
Osteoporosis lanjut
Kanker dengan metastasis tulang
Patah tulang kosta
Kondisi yang rentan terjadi pendarahan
Nyeri dada akut saat dilakukan intervensi ini
1.b Manual Technique
• Percussion/Clapping
- Applied throughout entire respiratory cycle by cupped the hand or using
finger tips in small infants for 1-5 minutes rhythmically
- Should performed over the clothes or towel
- Mechanical energy is transmitted through the chest wall to the airway &
loosen the mucus.
- For px w/ bronchospasm  slower rate (60 beat/minute) is more relaxing
• Shaking
• Vibration
- There is little or no pressure to the thorax, may be used when
percussion/shaking is contraindicated.
- Should performed during expiratory phase of breathing.
- Can be done by hand or use vibrator.
I.2 Airway Clearance Technique
a. Cough Maneuver/Effective Cough
a.1 Effective cough/Controlled cough
• Deep breath  hold breath several second (to closed glottis)  contract abdominal
muscles  open glottis & expel the air rapidly 2-3 times while contracting abdomen
& lean slighty forward
• Then rest & control breathing  repeating effective cough
a.2 Tracheal stimulation cough
• Quick inward & downward pressure
on trachea (above the suprasternal
notch) to elicit cough reflex.
a.3 Active-assisted cough
• Manual-assisted
• Self-assisted
Manual-assisted Cough
Heimlich-assisted cough atau
abdominal trust assist
Costophrenic-assisted
cough
Anterior chest
compression
Long-sit Self-assisted
Self-assisted Cough
Prone-on-elbows Self-assisted
Self-assist in Quadruped
Short-sit Self-assisted
2.b Huffing
• Same with effective cough but glottis remain open.
• Deep breath  immediately expel the air while contracting abdomen & saying “Haaa”
2.c Suctioning :
2.d MIE :
• Preoksigenasi  Gunakan ukuran kateter
& tekanan sesuai, suction ≤ 10dtk
• Oksigenasi kembali sebelum mengulang.
• Memasukkan tekanan (+) ke airway slm 12 dtk  eksuflasi/tekanan (-) slm 2-3 dtk.
• Dilakukan 4-5 x dng jeda.
Example Secret Removal Program :
1. Nebulizer w/ bronchodilator/normal saline or Humidification w/ normal saline.
2. Set the patient in postural drainage position.
3. Do clapping/shaking/vibration 1-5 minutes.
4. Pause for relaxation or breathing control.
5. Cough maneuvers/huffing, 1-2 times followed by breathing control.
6. Repeat the procedure until lung lobe/segment clear.
7. With active treatment an area usually cleared in 10-20 minutes.
8. Treatment shouldn’t exceed 45-60 minutes.
9. May required 2-4 times a day.
10. If px can’t do voluntary cough, airway clearance can be done by suctioning or
use MIE
II. Breathing Exc/Controlled Breathing Technique (CBT)
II.1 CBT to improve Pulmo Func Test (PFT) Parameter
a. Diaphragm Breathing/Deep breathing
• Start in semireclining/semifowler position & flex hip-knee.
• Inhale slowly & deeply through nose, abdomen rise & upper chest
quite, hold 3 second  exhale slowly through mouth.
• If difficult, start w/ exhale with depressed the abdomen or stimulate
diaphragm by press epigastrium cranially before inspiration.
• Do 3-4 times  rest (prevent hyperventilation)
• Practice in variety positions (sitting, standing, during activity)
b. Segmental breathing/chest expansion exc
• Px inspire against light resistance in specific lung segments & release it to
allow full inspiration or give resistance in the end of inspiration.
• Do 3-4 times  rest (prevent hyperventilation)
c. Incentive spirometer (triflowmeter)
• Inhale slowly through mouth piece, hold 3’,
exhale passively (balls give visual feedback)
d. Glosopharyngeal breathing
d. Glosopharyngeal Breathing
• Diberikan pd Px dng kelemahan berat otot ventilasi.
• Cara :
• Mengumpulkan udara di dalam mulut
• Menutup bibir
• Mendorong udara dng otot lidah & faring (meneguk) secara cepat bbrp kali.
• Px yg sudah mahir dpt bernafas 8-9x/menit, @ nafas perlu 12-15 tegukan.
• Memerlukan kemampuan spesialisasi tinggi (terapis handal).
II.2. CBT to reduce dyspnea & work of breathing
a. Breathing control
• Same with diaphragm breathing, but just to stimulate diaphragm breathing
pattern, px doesn’t need to hold breath.
b. Pursed lip breathing (PLB)
• Purpose : Keep airways open to prevent air trapping by creating back-pressure
in the airways.
• Avoid : forceful expiration  increase turbulence airways  restrict bronchiole
• Technique : inhale slowly several second through nose  exhale slowly 4-6’
through lips. Abdomen should relax
c. Pacing-activity
• Stop activity (walking, stair climbing, etc) when feel dyspnea, do relaxation
positon (forward bent position) & pursed lips breathing until dyspnea subside,
continue the activity.
II.3. Muscle ventilation strength & endurance
a. Latihan nafas dalam (penguatan diafragma)
• Memberikan tahanan pd epigastrium saat nafas dalam.
• Dilakukan pada posisi yg berbeda-beda.
• Dengan alat : meniup balon atau incentive inspirometer
b. Latihan penguatan otot trunk & AGA.
c. Latihan aerobik
d. Latihan kontrol eksentrik ekspirasi
• Inspirasi maksimal  Menghitung / mengucapkan “ah”/“oh”
• Memberikan vibrasi / tahanan dada saat ekspirasi.
II.4. Chest Mobilization
 Peregangan pasif
• Inspirasi : bahu abd-flx,
scapula add, trunk ext
• Ekspirasi : sebaliknya
 Latihan nafas dalam
 Mobilisasi sendi (manipulasi
manual) : menggerakkan kosta
ke inferior-superior
III. Relaxation Technique
1. Breathing Control Relaxation
a. One breathing technique
• Diaphragm breathing w/ saying “one” every exhalation
b. Eye-movement breathing technique
Lean forward position
correlate with length
tension of diaphragm &
make viscera drop forward
so diaphragm move easily
• Diaphragm breathing w/ looking up eyebrows while inhalation, hold 2’, looking down
while exhalation.
2. Relaxation Position (supine is uncomfort for dyspnea px)
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High-side lying
Sitting lean-forward on a pillow
Sitting lean-forward w/ elbow on knee
Standing lean-forward support hand on table
Standing on wall and lean-foward
3. Progressive muscle relaxation exc
• Systematically learning to tense muscle groups for 10’ followed by active relaxation
for 10-15’
4. Cognitive Relaxation
IV.Abdominal Muscle Strengthening & Support
V. General Reconditioning Program/Aerobic Exc
VI.Energy Conservation Technique
VII.Adequate ventilation
a. Ventilator
Program penyapihan ventilator menggunakan pendekatan
progressive ventilator-free breathing  ventilator dilepaskan
dalam durasi tertentu, durasi & frekuensi kemudian ditingkatkan
bertahap.
b. Intermittent abdominal pressure ventilator (IAPV)
Memberikan tekanan eksternal abdomen secara intermitten,
dng menggunakan sabuk / korset abdomen
c. Stimulator nervus phrenikus (Elektroda & receiver
diimplantasikan dng operasi)