Breathing exercises

Introduction,Goals,Muscles of ventilation,Inspiration,Expiration ,Mechanics of ventilation,Lungs and pleurae,Lobes of lungs,Lung volumes and capacities,Total lung capacity,Analysis of chest shape,Barrel chest ,Pectus excavatum (funnel chest),Chest mobility,Palpation,Mediastinal shift,Auscultation of breath sounds,Normal Breath sound,Adventitious Breath sound.

1. Breathing exercises Dr. Bhawna

2. Introduction Cardiovascular and pulmonary physical therapy is a multifaceted area of professional practice that deals with the management of patients of all age with acute and chronic, primary or secondary cardiovascular and pulmonary disorders.

3. Goals Prevent airways obstruction Prevent excess accumulation of secretions Improve airways clearance Improve endurance Improve general exercise tolerance Prevent or correct postural deformities associated with pulmonary or extra pulmonary disorders Maintain or improve chest mobility

4. Muscles of ventilation Ventilatory muscles, also referred to as respiratory muscles, are classified as primary or accessory. Primary muscles of ventilation are recruited during quiet (tidal) breathing. Accessory muscles of ventilation are only recruited during deep, forced or labored breathing.

5. Inspiration Primary muscles – diaphragm, scalenes , parasternals . Accessory muscles– sternocleidomastoid , upper trapezius , pectoralis major and minor, subclavius and external intercostals

6. Expiration Primary muscles – none active during tidal (resting) expiration Accessory muscles – abdominal muscles (rectus abdominis, transverse abdominis, internal and external obliques), pectoralis major and internal costal.

7. Mechanics of ventilation

8. Lungs and pleurae

9. Lobes of lungs

10. Lung volumes and capacities Pulmonary function tests that measure lung volumes and capacities are performed to evaluate the mechanical function of the lungs. Lungs volumes and capacities are related to a person’s age, weight, sex and body position and are altered by disease.

11. Total lung capacity TLC is the total amount of air contained in the lungs after a maximum inspiration. TLC can be subdivided into four volumes : tidal volume inspiratory reserve volume expiratory reserve volume residual volume TLC = 6000 ml (approximately)

12. Tidal volume The amount of air exchanged during a relaxed inspiration followed by a relaxed expiration is called the tidal volume (TV) TV = 500 ml (approximately) Approximately 350 ml of the tidal volume reaches the alveoli and participates in gas exchange (respiration)

13. Inspiratory Reserve Volume IRV is the amount of air a person can breathe in after a resting inspiration. IRV = 3000 ml (approximately)

14. Expiratory reserve volume ERV is the amount of air a person can exhale after a normal resting expiration. ERV = 1000 ml (approximately)

15. Residual volume RV is the amount of air left in the lungs after a maximum expiration. RV = 1500 ml (approximation) RV increases with age and with restrictive and obstructive pulmonary diseases.

16. Inspiratory capacity IC is the maximum amount of air a person can breathe in after a resting expiration. IC = 3500 ml (approximately)

17. Functional Residual Capacity FRC is the amount of air remaining in the lungs after a resting (tidal) expiration. FRC = 2500 ml (approximately)

18. Vital capacity VC is the sum of the TV, IRV and ERV. It is measured by a maximum inspiration followed by a maximum expiration. VC = 4500 ml (approximately) Vital capacity decreased with age and is less in the supine position than in an erect posture (sitting or standing)

19. Analysis of chest shape

20. Symmetry of the chest and trunk Observe anteriorly , posteriorly and laterally The thoracic cage should be symmetrical.

21. Mobility of the trunk Check active movements in all directions and identify any restricted spinal motions, Particularly in the thoracic spine.

22. Shape and dimension of the chest The anteroposterior (AP) and lateral dimensions are usually 1:2 Common chest deformities include: Barrel chest Pectus excavatum (funnel chest) Pectus carinatum (pigeon chest)

23. Barrel chest The circumference of the upper chest appears larger than that of the lower chest. The sternum appears prominent and the AP diameter of the chest is greater than normal. Many patients with chronic obstructive pulmonary disorders , who are usually upper chest breathers, develop a barrel chest.

24. Pectus excavatum (funnel chest) The lower part of the sternum is depressed and the lower ribs flare out. Patients with this deformity are diaphragmatic breathers, excessive abdominal protrusion and little upper chest movement occur during breathing.

25. Pectus carinatum (pigeon chest) The sternum is prominent and protrudes anteriorly .

26. Chest mobility

27. Symmetry of chest movement Analysis of the symmetry of the moving chest during breathing gives the therapist information about the mobility of the thorax and indicates indirectly what areas of the lungs may or may not be responding.

28. Procedure Place your hands on the patient’s chest and assess the excursion of each side of the thorax during inspiration and expiration.

29. To check upper lobe expansion Face the patient Place the tips of your thumbs at the midsternal line at the sternal notch. Extend your fingers above the clavicles. The patient fully exhale and then inhale deeply.

30. To check middle lobe expansion Face the patient Place the tips of your thumbs at the xiphoid process Extend your fingers laterally around the ribs. Ask the patient to breath in deeply.

31. To check lower lobe expansion Place the tips of your thumbs along the patient’s back at the spinous processes (lower thoracic level) Extend your fingers around the ribs Ask the patient to breath in deeply

32. Palpation Palpation of the thorax provides evidence of dysfunction of the underlying tissues including the lungs chest wall and mediastinum.

33. Tactile (Vocal) fremitus Tactile fremitus is the vibration felt while palpating over the chest wall as a patient speaks. Procedure: place the palms of your hands lightly on the chest wall and ask the patient to speak a few words or repeat “99” several times. Fremitus is increased in the presence of secretions in the airways and decreased or absent when air is trapped as the result of obstructed airways.

34. Mediastinal shift The trachea normally is oriented centrally in relation to suprasternal notch indicating symmetry of the mediastinum. The position of the trachea shifts as the result of asymmetrical intrathoracic pressures or lung volumes. Eg . 1. If the patient has a removal of lung (pneumonectomy), the lung volume on the operated side decreases and the trachea shifts toward the side. 2.if the patient has a blood in thorax (hemothorax), intrathoracic pressure on the side of the hemothorax increases and mediastinum shifts away from the affected side.

35. Procedure Patient sit facing you with the head in midline and the neck slightly flexed to relax the sternocleidomastoid muscles. With your index finger, gently palpate the soft tissue space on either side of the trachea at the suprasternal notch. Determine whether the trachea is palpable at the midline or has shifted to the left or right.

36. Mediate percussion Mediate percussion is an examination technique designed to assess lung density, the air to solid ratio in lung.

37. Procedure Place the middle finger of the nondominant hand along the chest wall in intercostal space. The tip of the middle finger of the opposite hand firmly tap on the finger. Repeat the procedure several times.

38. Indicates The sound is dull and flat if there is greater amount of solid matter. The sound is hyperresonant if there is a greater amount of air. If asymmetrical or abnormal findings are noted, the patient should be referred to the physician for additional objective test.

39. Auscultation of breath sounds Auscultation is a general term that refers to the process of listening to sounds within the body. Breath sounds occurs because of movement of air in the airways during inspiration and expiration. A stethoscope is used to magnify this sounds

40. Procedure Setting is quiet Comfortable, relaxed, sitting position Place the diaphragm of the stethoscope directly against the patient’s skin along the anterior and posterior chest wall. Ask the patient to breath in deeply and out quickly through the mouth as you move the stethoscope from point to point.

41. Normal Breath sound

42. Tracheal Breath sounds are heard over the trachea. These sounds are harsh and sound like air is being blown through a pipe.

43. Bronchial   Bronchial  sounds are present over the second and third intercostal spaces Bronchial sounds are loud, hollow or tubular high pitched sound but not as harsh as tracheal breath sounds. Heard over the mainstem bronchi and trachea Bronchial sounds heard equally during inspiration and expiration A slight pause in the sound occurs between inspiration and expiration,

44. Bronchovesicular Bronchovesicular  sounds are heard in the supraclavicular , suprascapular , and parasternal region anteriorly and between the scapulae posteriorly . Bronchovesicular sounds are softer than bronchial sounds, but have a tubular quality. Bronchovesicular sounds are about equal during inspiration and expiration; differences in pitch and intensity are often more easily detected during expiration.

45. Vesicular Vesicular  sounds are soft, low pitched but faint sounds heard over most of the chest except near the trachea and mainstem bronchi and between the scapulae. Vesicular sounds are normally heard throughout inspiration, continue without pause through expiration, and then fade away about one third of the way through expiration.

46. Adventitious Breath sound

47. Crackles Fine, discontinuous sounds ( similar to the sound of bubbles popping or the sound of hairs being rubbed between your fingers next to your ear) Crackles sound heard primarily during inspiration as the result of secretion moving in the airways or in closed airways Rales

48. Wheezes Continuous high or low pitched sounds Sometimes musical tones heard during exhalations Occasionally audible during inspiration Bronchospasm or secretions that narrow the lumen of the airways causes wheezes Rhonchi

49. C:\Users\Administrator\Desktop\md\BE\Essential Lung Sounds.mp4 C:\Users\Administrator\Desktop\md\BE\videoplayback (1).mp4