COPD
Table of content1- Definition 2- General aim of treatment 3- Treatment in the early stages a- Increasing exercise tolerance b- Inspiratory muscle training c- Removal of secretions d- Improving the breathing pattern 4- Treatment in the late stage a- Non-invasive positive pressure ventilation b- Invasive positive pressure ventilation 5- Terminal care |
Definition:-
Pulmonary rehabilitation is evidence based,multidisplinary , and comprenhensive intervention for ptients with Chronic respiratory disease who are symptomatic and often have decresed daily life activities.
COPD affected cells
The physiotherapy management for all diseases should be aimed at symptoms management once symptoms have been identified during physiotherapy assessment.
General Aims of Treatment:-
•To improve exercise tolerance and ensure a long-term commitment to exercise.
•To give advice about self-management in activities of daily living.
•To increase knowledge of the patient's lung condition and control of the symptoms.
•To relieve any bronchospasm , facilitate the removal of secretions and optimise gaseous exchange.
•To improve the pattern of breathing , breathing control and the control of dyspnoea.
•To teach local relaxation, improve posture and help allay fear and anxiety.
Treatment in the early stages :-
Increasing/Maintaining exercise tolerance :-
The patient may be treated as an impatient or as an outpatient in a health center or at home by community physiotherapist. It is important to see the patient regularly.Advice should be given on taking regular exercises,for example a short walk every day.
Maintaining exercise tolerance
There are three important features of successful rehabilitation:-
1- A multi-disciplinary approach , which may include respiratory physicians, physiotherapist, occupational therapist, dietitians , nurses, psychologist and therapy assistants.
2- Attention to physical and social function through exercise training , education , nutritional , psychological ,social and behaviour interventions.
3- Individualized to meet each patient's needs.
Inspiratory muscle training:-
Muscles became fatigue and fatigue may be caused by ;
•Increase mechanical load on the respiratory muscles
•Reduced muscle strength
•Reduced energy supply to the respiratory muscles
muscle training exercise
Muscle weakness, which may be a predisposition to muscle fatigue, is present in patients with COPD. It therefore follows that training techniques ;
Removal of secretions :-
The Active Cycle of Breathing Techniques (ACBT):-
This is a cycle of breathing control thoracic expansion exercises and the forced exspiratory technique(FET) and has been shown to be effective in the clearance of bronchial secretion and to improve lung function.
Thoracic expansion exercises are deep breathing exercises which may be combined with the 3 second hold off inspiration (unless the patient is very Breathless when this may not be tolerated).
ACBT
This increase in lung volume allows air to flow via Collateral channels and may assist in mobilizing the secretions as air in able to to get behind the secretions.
The FET man-oeuvre is a combination of one or two force expressions against open glottis.
Postural drainage/positioning:-
This may also aid sputum removal and may be combined with ACBT technique the. optimal position for effectiveness must be stabilized with each individual although, postural drainage for the lower lobe segment may be difficult as some patient may not tolerate the head -down position or even lying flat.
postural drainage
In the lateral position the lower lung is always better ventilated regardless of the side on which the subject is lying although there is still remains a bias in favor of right side because of its larger size when compared with the left lung.
postural drainage
Perfusion is also preferential to the lower lung in the lateral position in the spontaneously breathing person, although if pathology exist within the lower most lungs gaseous exchange may be compromised because of presence of Pulmonary hypoxic vasoconstriction which can't be overcome by Gravity.
Humidification :-
if secretions are very thick and tenacious the patient may be given humidification by a Nebulizer usually nebulized saline.
Humidification
Improving the breathing pattern:-
The patient is taught how to relax the shoulder girdle in a supported post you really correct position as such Crook half lying breathing control is start following clearance of secretions if the patient is previous respiratory control is very gained starting with short respiratory phases and allowing the rate to slow as patients breathing pattern improves.
Treatment in the later stages :-
It is imperative that patient with property are able to maintain as much Independence and maximum function as it possible through a support from the hospital or Community Health Care team .
COPD stages
During acute exacerbation ,the ACBT may be continued to assist clearance of secretion. breathing control should be emphasized so that the patient can walk or climb stairs with confidence.
Relaxation position should be taught for regaining breathing control after activity has made the patient with less if the patient become very disabled walking frame may help to retain some degree of Independence as the arms are fixed and accessory muscle of inspiration may be used.
Non invasive position pressure ventilation :-
Tracheal intubation and mechanical ventilation providing intermittent positive pressure ventilation (IPPV) is used in Intensive Care Unit for high dependency unit to manage patient with deteriorating respiratory failure .
NIPPV
Howere, tracheal intubation may result in complications including tracheal injury and infection.
furthermore it may be difficult to win this patient of IPV resulting in a prolonged stay in ICU.
Non invasive position pressure ventilation (NIPPV) is therefore indicated for the delivery of intermittent positive pressure and may be applied via the nose or mouth using a silicone mask attached to a beside ventilator.
Unlike(IPPV) and (NIPPV) can be administered on a General ward for patient in respiratory failure.
the ventilator is programmed to supplement the patients on respiratory effect effort and,if required ,oxygen therapy may be given in conjunction with NIPPV.
NIPPV can be used during an acute exacerbation and has been shown to improve quality of life and arterial blood pressure and to reduce mortality in patient with COPD.
Physiotherapy will be required for short spells but frequently throughout the day and sometime at night .
NIV may be used to assist sputum clearance because if unavailable intermittent positive pressure breathing may also be given to assist sport immobilization using a mass if the the patient is too Drowsy to use the mouthpiece.
postural drainage may be necessary if tolerated, together with rigorous is taking applied during the expiratory phase of ventilator.
suction wire and Airway on other section may have to be used as a last resort to remove secretion if patient is unable to cut spontaneously or effectively.
If paco2 is high and pao2 is low the patient should not be given and high concentration of oxygen drugs such as mucolytic agent or bronchodilator may be provided through a Nebulizer attached to ventilator.
The patient should be encouraged to save drinks because dehydration make the secretion viscid.
Terminal care :-
The main theme is to keep the patient as comfortable as possible treatment need to be short and frequent. non-invasive natural ventilation may be provided for home use in addition may be used to loosen the qualify secretions.