localized breathing exs.pptx

segmental breathing exercise is one of the deep breathing exercises, which improve individual lobe function.
It reduces post-surgical Pulmonary complications and improves Chest wall mobility

1. Localised basal expansion Dr. T Sunil Kumar Dept. of Physiotherapy

2. INTRODUCTION Localised breathing exercises are useful for assisting in the removal of secretions and improving movement of the thoracic cage. It is unlikely that individual lobes of the lung are ventilated by these exercises. They should not be performed during attacks of breathlessness. It has been stated that localised basal expansion utilises the ‘ bucket-handle ’ movement of th e ribs.

3. Although there is a certain amount of controversy about this, it seems to be agreed that the movement is caused by the contraction of the outer fibres of the diaphragm when the central tendon is fixed. When treating most conditions it is preferable to teach unilateral basal expansion , otherwise the patient is unable to relax the shoulder girdle adequately and this tends to exaggerate the movement of the upper chest.

4. POSITION OF THE PATIENT The patient should be in a half-lyin g position with the knees flexed over a pillow, or sitting in an upright chair. TECHNIQUE The physiotherapist places the palm of the hand in the mid-axillary line over the 7th and 8th ribs; fingers should be relaxed and well round the posterior aspect of the thorax. The patient is instructed to relax and breathe out, allowing the lower ribs to sink down and in: this movement must not be forced.

5. At the end of expiration the physiotherapist should apply firm pressure against the chest and instruct the patient with the next inspiration to expand the lower ribs against therapist’s hands. Pressure should be released at the end of inspiration and the weight of the hands follow the chest back to rest. Pressure is re-applied when the patient is ready to breathe in again.

6. If the aim of the treatment is to expand lung tissue, the emphasis should be on holding the maximum inspiration for 3 seconds (Ward, 1966) and then ‘sniff in a little more air. Where there is a region of lung which has partially obstructed airways or decreased compliance, the alveoli will fill at a slower rate than the unaffected areas (i.e. increased time constant). Patients with airways disease or scattered areas of atelectasis have local variations of time constants.

7. These areas need more time to expand than unaffected areas, therefore slow deep breathing with a hold on inspiration allows them more chance of gaining ventilation. Holding the breath also allows time for the air to diffuse through the pores of Kohn. There is collateral air drift at alveolar level and hence a ‘sniff will provide a little more expansion. Once the patient has learned the correct technique, he is taught to give pressure himself.

8. Some patients who have limited wrist extension will find it easier to apply pressure with the back of the fingers or the palm of the opposite hand. WHEN USING ANY OF THESE METHODS THE PATIENT SHOULD NOT ELEVATE HIS SHOULDER GIRDLE, OR ACHIEVE COSTAL EXPANSION BY SIDE FLEXION OF THE SPINE. THE USE OF A WIDE BELT MADE OF WEBBING OR SOME OTHER STRONG, NON-EXTENSIBLE MATERIAL MAY BE HELPFUL.

9. When helping to remove secretions from the lungs, or when trying to stimulate increased ventilation in a chronic condition or after abdominal or thoracic surgery, it is often helpful to concentrate on one phase of breathing at a time, as full range costal exercises may be tiring. Full inspiration can be encouraged verbally and manual resistance given to encourage expansion. Full inspiration is held for about 3 seconds, the expiratory phase is naturally passive in this exercise.

10. Expiratory costal exercises may be practised to encourage maximum costal movement and to stimulate coughing. The patient gently breathes out fully, actively contracting the expiratory muscles. The physiotherapist may assist with increased gentle pressure at full expiration. The inspiration will not be emphasised in this exercise.

11. As full expiration narrows the airways, this exercise should be avoided if bronchospasm is present. Care must be taken to give enough rests between the efforts of the breathing exercises. Each deep breath should be done slowly and paced for the individual, to prevent breathlessness or dizziness.

12. Apical expansion It is necessary to teach apical expansion exercises if there is underlying disease in the upper lobe. When there is involvement of the upper lobes, as in cystic fibrosis or emphysema, the patient is already over-inflating the upper chest and needs to concentrate on relaxed diaphragmatic breathing and localised basal expansion.

13. In certain cases after thoracic surgery, for example residual apical pneumothorax following lobectomy, or when there is restricted movement and deformity of the chest wall caused by extensive pleural thickening, apical expansion exercises are useful. They should be taught unilaterally.

14. TECHNIQUE Pressure is applied below the clavicle using the tips of the fingers. The patient is instructed to breathe in and expand the chest upwards against the pressure of the fingers. Full inspiration may be held for a moment but the shoulders must remain relaxed . The patient should be in a well supported half-lying or sitting position and can be taught to give pressure himself with the opposite hand.

15. Posterior basal expansion This exercise is useful if movement is restricted in this area. Pressure is given unilaterally over the posterior aspect of the lower ribs and the patient can be taught to apply this pressure himself.

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