Netraya Nimpitakpong MD., C.Ped.
Physical Medicine & Rehabilitation Department,
Faculty of Medicine, Thammasat University
What is Pulmonary Rehabilitation
•
•
•
•
Chest physical therapy
Home base exercise
Recreation activity
even Playing…
?
What is Pulmonary Rehabilitation
•
•
•
•
Chest physical therapy
Home base exercise
Recreation activity
even Playing…
But need to
be aim to
“GOAL”
?
GOALS of Pulmonary Rehabilitation
for COPD & Asthma patient
• Prevent airway obstruction
• Improve airway clearance + ventilation
• Reduce energy costs during respiration
• Teach the patient how to deal with
short-of-breath attacks
• Improve endurance
• Prevent accumulation of secretion &
Increase the effectiveness of the cough
mechanism
Improve a patient’s
overall functional capacity
Normal
Breathing
• Deep & slow rate
• Quiet breathing &
relax
• Use normal
respiratory muscles
COPD & Asthma
attack
• Short shallow &
rapid rate
• Wheezing & restless!
• Use respiratory
muscles + Accessory
muscles
How they feel when being
breathlessness!!
Increase respiratory rate
lower alveoli ventilation &
increase work load
How they feel when being
breathlessness!!
Breath in-breath out through mouse
(instead of nose)
Cold air cold airway increase
bronchospasm
Breath out …faster than normal 
collapse small airway & increase air
trapping
Normal
Breathing
• Normal airway
diameter
• Optimal secretion
• Effective cough
COPD & Asthma
attack
• Collapse airway
diameter
• Excessive and sticky
secretion
• Not enough
breathing in Poor
cough
Airway collapse
Airway collapse
Collapse small airway
then air was trapped
in alveoli
How
?????
Same
principle as
given
medication
Positioning
Pursed lip
Diaphragmatic
breathing
Improve secretion
drainage: cough, postural
drainage, percussion
Chest mobilization
Aerobic exercise
How do I stop my
breathlessness?
Learn to teach the patient how to deal
with short-of-breath attacks
• ACUTE EXACERBATION!!!
ACUTE EXACERBATION!!!
• When short of breath start….patient can feel
scary. It helps the patient know what to do
their can stay calm even they're short of
breath. Pursed-lip breathing and
diaphragmatic breathing will both help. These
breathing methods prevent or reduce the
trapped air in lungs, and allow patient to
breathe in more fresh air. Thus teach them as
the following;
ACUTE EXACERBATION!!!
• Stop and rest in comfortable position, lower
his/her head and shoulders Breathe in through
the nose, and blow out through the mouth,
breathe in and blow out just as fast as is
necessary
• Begin to blow out more slowly and for a longer
time. Don't force it. Use pursed lip breathing,
then slow rate of breathing down
• Begin breathing through the nose
• Begin doing diaphragmatic breathing and stay in
this position for 5 minutes longer
Comfortable positions when patient
has short of breath
• Sitting:
1. Sit with back against the
back of the chair. Head and
shoulders should be rolled
forward and relaxed
downwards. Rest the hands
and forearms on thighs,
palms turned upwards.
Don’t teach them to lean on
their hands (นัง่ เท้ าคาง) in this
position. Their feet should
be on the floor, knees rolled
slightly outwards.
• Sitting:
2. Lean back into the chair in
a slouched position, Head
rolled forward, shoulders
relaxed downward. Rest
the hands gently on
stomach. Keep the feet on
floor, knees rolled
outward
3. Place a pillow on a table
and sit down, arms folded
and resting on the pillow.
Keep the feet on the floor
or a stool, and rest head
on your arms.
• Standing:
1. The same manner as the
sitting can be used while
Sitting:
standing, arms resting on
– Lean back into the chair in a
kitchenposition,
counterHead
or back of
slouched
rolled
forward,
shoulders
chair,
not leaning,
knees
relaxed downward. Rest the
bentgently
slightly,
one foot in
hands
on stomach.
Keep
theof
feet
floor, knees
front
theonother.
rolled outward
2. Lean with back to the wall,
– Place a pillow on a table and
pole,arms
etc. folded
Place feet
sitadown,
and
resting
on the
pillow.
slightly
apart
andKeep
at a
the feet on the floor or a
comfortable
distance
stool,
and rest head
on yourfrom
arms.
the wall, head and
shoulders relaxed.
Let the air escape naturally- don't force
the air out of lungs
• “Keep doing pursed lip breathing until no
longer short of breath”
• ACUTE EXACERBATION!!!
• Breathe in slowly through the nose for 1 count
• Purse lips as if you were going to whistle (แบบ
ผิวปาก, เป่ าเทียนเบาๆ)
• Breathe out gently through pursed lips for 2
slow counts, breathe out twice as slowly as
the breathed in (ให้ ง่ายหายใจเข้ านับ หนึ่ง...สอง... หายใจ
ออก นับ หนึ่ง..สอง...สาม...สี่)
Diaphragmatic Breathing
Accessory
muscle
tr
• Let the patient sit and relax
shoulders in a comfortable
chair slightly lean backward
for easy to breathing
training.
• 1st step: Put one of patient’s
hand on his/her upper
chest, and the other on
belly just above waist for
monitor the movement of
chest and belly while
breathing.
• 2nd step:
Let them breathe
in slowly through nose –
instruct the patient that they should be able
to feel the hand on their belly moving out but
the hand on chest shouldn't move.
• 3rd step:
Breathe out slowly
through pursed lips
– instruct the patient that they should be able
to feel the hand on the belly moving in as
they breathe out.
Want to be stronger!
Learn to improve pulmonary fitness
and also effective coughing
Maintenance: Cough Training
• Sit down, head slightly lean forward, place
both feet firmly on the ground.
• Demonstrate a sharp, deep, double cough to
the patient
• place the patient’s hands on his/her
abdomen, let them try to making ”k” sound
this manner make the vocal cord tightening,
closure glottis, abdominal contraction then
patient can detect the feeling when vocal cord
closing.
Maintenance: Cough Training
• Breathe in deeply using diaphragmatic
breathing & try to hold the breath for three
seconds.
• While keeping mouth slightly open, cough out
twice.
• The first cough should bring up the phlegm,
and the second cough should move it towards
the throat.
• Take a break and repeat these steps once or
twice if necessary
Chest mobilization
• Limb & body movement synchronized with
breath in and breath out
• Improve chest expansion better ventilation
& gas exchange
Chest
mobilization
• ท่ าที่ 1 กางแขนขึ้นเป็ นรู ปตัววี (V) ยืดอก หายใจเข้าลึก จากนั้นลดแขนลงมา
อยูร่ ะหว่างขาสองข้าง ก้มตัวพร้อมๆกับหายใจออก
Chest
mobilization
• ท่ าที่ 2 ยกมือสองข้างขึ้นแตะบริ เวณท้ายทอย แอ่นยืดแขนและอก หายใจเข้า
ลึก จากนั้นหุบแขนเข้า โน้มศีรษะและก้มตัวลงพร้อมๆกับหายใจออก
Chest
mobilization
• ท่ าที่ 3
มือสองข้างประสานกัน เหยียด
แขนขึ้นไปด้านข้างและเอี้ยว
บิดตัว หายใจเข้าลึก จากนั้น
ลดแขนลงมาที่ขาด้านตรงข้าม
ก้มตัวพร้อมกับหายใจออก ทา
จนครบ 6-10 ครั้ง แล้วบิดไป
อีกด้านด้วย
Chest
mobilization
• ท่ าที่ 4
ยกมือขึ้นข้างหนึ่งขึ้นเหนือ
ศีรษะ แล้วเอนตัวไปด้านตรง
ข้าม หายใจเข้าลึก จากนั้นลด
แขนลงวางข้างตัว พร้อมกับ
หายใจออก จนครบ 6-10 ครั้ง
แล้วสลับเอนตัวไปอีกข้าง
Aerobic Exercise
: 30 minute/day, 3 days/week
How do I stop my
breathlessness?
Learn to relax by use the proper position &
pursed lip breathing when breathlessness
Learn to use Diaphragmatic breathing &
segmental breathing technique
Learn to do the effective coughing