lung expansion therapy.pptx

METHODS OF LUNG EXPANSION THERAPY IN PHYSIOTHERAPY
METHODS OF AIRWAY CLEARANCE

1. LUNG EXPANSION THERAPY PREMKUMAR .K

2. Lung Expansion Therapy Group of medical treatment modalities (I.S, IPPB, CPAP or EzPAP ) designed to prevent or treat pulmonary atelectasis and associated problems caused from post-op thoracic or abdominal surgery, heavy sedation, neuromuscular diseases, weaken breathing muscles, chest trauma or chest wall injury . 3/27/2023 PK 2

3. INDICATIONS Postoperative patients (highest risk) -Upper abdominal, thoracic, cardiac surgery Acute respiratory failure due to pneumonia Post traumatic ARF: Pulmonary contusions, Flail chest Neuro -compromised patients -Heavily sedated patients ,Spinal cord injury Patients with reduced lung volumes and ineffective cough resulting from chest wall deformity, such as Scoliosis Respiratory muscle weakness or prolonged immobility Patients unable to take a deep breath 3/27/2023 PK 3

4. M odalities used to administer lung expansion therapy to increase the patient's lung volume by increasing the transpulmonary pressure gradient (the difference between the alveolar pressure and the pleural pressure). T he transpulmonary pressure gradient results alveoli expand. 3/27/2023 PK 4

5. Contraindications Pneumothorax ICP >15mmHg Active haemophytsis Haemodynamic instability Recent esophageal surgery & fistula Hiccups & air swallowing Nausea 3/27/2023 PK 5

6. 3/27/2023 6 MECHANISAM OF LUNG EXPANSION THERAPY 1)Increasing trans pulmonary pressure gradient Trans pulmonary Pressure gradient -1 -2 -6 +1 Intrapulmonary pressure Intra alveolar pressure

7. To increase the transpulmonary pressure gradient : 1.By decreasing the surrounding pleural pressure (A spontaneous deep inspiration increases the transpulmonary pressure gradient by decreasing the pleural pressure.) 2.By increasing the alveolar pressure (Positive pressure increases the transpulmonary pressure gradient by raising the pressure inside the alveoli.) 3/27/2023 PK 7

8. INSPIRATION EXPIRATION +1 -1 -2 -6 Trans Pulmonary Pressure Gradient 3/27/2023 8

9. 3/27/2023 9 2)Addition of inspiratory hold to breathing exercise will improve collateral ventilation of alveoli Interbronchial Channels of martini Bronchoalveolar Channels of lambert Interalveolar Pores of kohn

10. 3/27/2023 10 Mucous plug alternate route for gas flow when peripheral airways obstructed

11. 3/27/2023 11 3)Interdependence- If a group of alveoli have a tendency to collapse, the adjacent expanded alveoli produces forces that tend to prevent collapse

12. 3/27/2023 12 TECHNIQUES Controlled mobilization Position Breathing exercise Neuro physiological facilitation of respiration Incentive spirometry Intermittent positive pressure breathing(IPPB) Positive pressure therapy(PEP) Continuous positive airway pressure(CPAP)

13. 3/27/2023 13 CONTROLLED MOBILIZATION Reduces pressure on the diaphragm and encourages basal distribution of air,with natural deep breathing

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17. 3/27/2023 17 Therapeutic Positioning Functional resudal capacity (FRC) decreases from standing to slumped sitting Lung compliance decrease and work of breathing increases progressively from standing, to sitting ,to supine Increase shunt Arterial oxygenation is usually higher in side lying postion than supine Supine is unhelpful for lung volume

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19. Effect of positioning Improve 02 transport in acute/ chronic cardiopulmonary dysfunction Prevent the – ve effect of restricted che wall mobility Application of positioning to optimize 02 transport , primary by manipulation effects of gravity on cardiopulmonary mobilization and exercise further enhances 02 transport Note- therapeutic positioning for PD are based on anatomy of lung and tracheobronchial tree 3/27/2023 19

20. 3/27/2023 20 Time should be spent in side lying, well forward so that the diaphragm is free from abdominal pressure Positioning also affects the V/Q ratio Lying with the affected lung uppermost means that the better ventilation of the dependent normal lung is matched with better perfusion

21. Incentive spirometry Incentive spirometry (IS) enhances lung expansion through a spontaneous and sustained decrease in pleural pressure. IS designed to mimic natural sighing or yawning by encouraging the patient to take long, slow, deep breaths. This is accomplished by using a device that provides patients with visual or other positive feedback when they inhale at a predetermined flow rate or volume and sustain the inflation for a minimum of 3 seconds. 3/27/2023 PK 21

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23. 3/27/2023 23 Spontaneous breathing Incentive spirometer inspiration expiration inspiration expiration

24. Intermittent Positive Pressure Breathing (IPPB) Intermittent positive pressure breathing (IPPB) is a technique used to provide short-term or intermittent mechanical ventilation for the purpose of augmenting lung expansion, delivering aerosol medication, or assisting ventilation 3/27/2023 PK 24

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26. 3/27/2023 26 IPPB increase alveolar pressure during inspiration or expiration PEP and EPAP IPPB

27. Continuous positive airway pressure Continuous Positive Airway Pressure (CPAP) is a simple approach using a device which maintains some positive pressure in the airway at the end of exhalation to keep the airways continuously open Indications for CPAP: - Mild to moderate RDS - After extubation - Alternative to mechanical ventilation 3/27/2023 PK 27

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29. 3/27/2023 29 CPAP during both inspiration and expiration CPAP

30. Positive Airway Pressure System ( EzPAP ) Positive Airway Pressure System ( EzPAP ) is the easy option for the prevention and treatment of atelectasis and a medical need for lung expansion therapy. 3/27/2023 PK 30

31. AMBU BAG / SELF INFLATING BAG I nstruments used to provide oxygen during intermittent positive pressure respiration (IPPR) via an endotracheal tube or a facemask. Used in emergencies when somebody is facing breathing difficulties to provide artificial ventilation. 3/27/2023 PK 31

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33. It is a compressible, self-inflating, non-rebreathing silicon bag, which has an inlet through which air and additional O2 is supplied and an outlet through this can be transferred to the patient The gas enters in the self-expanding bag through one way valve which restricts the flow back from the inlet. When the bag is compressed, the air is pushed forward through the mask in the pharynx or throat which in turn leads to wind pipe and then in the lungs, hence assisting in artificial ventilation. 3/27/2023 PK 33

34. There are other valves which prevent rebreathing of the expired air and excessive pressure from developing. It basically increases the FIO 2 of the inspired O2 from 40% to almost 90% (if used with a reservoir). Some of these self-inflating bags come with pressure restrictor or manometer tube connector or pressure gauge connector . The manometer connector (or the pressure gauge connector) can be used to connect manometer tube (or pressure gauge) to monitor the airway pressure. It is strongly recommended to have one of these safety features in self-inflating bags when they are used in pediatric cases. 3/27/2023 PK 34

35. various sizes as per the age group: - - Neonate: - 250ml - Pediatric: - 500ml - Adults: - 1600 ml 3/27/2023 PK 35

36. 3/27/2023 36 Technique administered LET D epends on level of consciousness If patient unconscious-PNF respiration If patient not alert-IPPB therapy If patient having problem with excess secretions-PEP therapy If patient conscious and cooperative-incentive spirometer If problem still not resolved-intermittent CPAP

37. OUTCOME LET Prevents or reverses atelectasis Aides in the mobilization of secretions Reduces air-trapping in asthma and COPD patients Optimizes the delivery of bronchodilator therapy Decreases work of breathing Improves inspiratory muscle strength Increases lung volumes Recruitment of collapsed alveoli by increasing FRC Creates a positive airway pressure gradient that will prevent premature airway closure and expand collapsed lung regions. 3/27/2023 PK 37

38. 3/27/2023 38 Summary LET Evidence shown that breathing exercises is always beneficial than any other mechanical aids Deep breathing Localized breathing exercises End- inspiratory hold Abdominal breathing Sniff Stacked inspiration Rib springing

39. 3/27/2023 PK 39 Neuro physiological facilitation of respiration Externally applied proprioceptive and tactile stimuli produce reflex respiratory movement response and that appear to alter the rate and depth of breathing

40. Rationale Shallow respiration leads to inadequate ventilation Which leads to atelectasis and retention of secretions Lack of muscle tone leads to instability of chest wall which leads to deranged mechanical respiratory dysfunction 3/27/2023 PK 40

41. Perioral pressure Stimulus Applying firm maintined pressure to the patients on upper lip Response 5 second apnea followed by epi gastric excursion ,deep breathing mouth closure, swallowing snout phenomena Suggested mechanism Primitive reflex response related to sucking breathing and swallowing 3/27/2023 PK 41

42. Intercostal stretch Stimulus applying pressure to upper border of rib inorder to stretch the intercostals muscle in downward direction Response gradual increase in respiratory movements in area under and around stretch Suggested mechanism intercostals stretch receptors 3/27/2023 PK 42

43. Manual vertebral pressure (High) Stimulus manual pressure to thoracic vertebral region of T2 – T5 Response: Increased epigastric excursion Deep breathing Suggested mechanism Dorsal root mediated inter segmental reflex 3/27/2023 PK 43

44. Manual vertebral pressure(low) Stimulus Manual pressure to thoracic vertebral region of T 7– T10 Response Increased respiratory movements of apical thorax Suggested mechanism Dorsal root mediated inter segmental reflex 3/27/2023 PK 44

45. Co contraction of abdomen Stimulus Therapist placing one hand on patients lower ribs and one pelvis on same side and pushing with moderate pressure so that force is applied right angle to the patient Response Increased epigastric excursion Increased muscle contraction – rectus abdominis Decrease girth in obese Increase firmness to palpation Coughing Suggested mechanism Stretch receptors of abdominal muscles Intercostal to phrenic reflexes 3/27/2023 PK 45

46. Anterior stretch basal lift Stimulus Procedure is performed by placing hands under posterior ribs of supine patient and lifting gently upwards Response Increased expansion of posterior basal area Suggested mechanism Dorsal root mediated inter segmental reflex stretch receptors in intercostals and back muscles 3/27/2023 PK 46

47. Maintained moderate manual pressure Stimulus Mild pressure of open hands is maintained over the area in which expansion is desired Response gradually increased excursion on area of contact Suggested mechanism Cutaneous afferent 3/27/2023 PK 47

48. Factors that that alter response Patients pre existing muscle tone Level of consciousness Adequacy of ventilation Obesity 3/27/2023 PK 48

49. General effects of all the procedure Changes in breath sound as determined by auscultation have been noted with all procedure Some patients appear to become improved from level of unconscious during respiratory facilitation Response such as fluttering eye lids , head movements, spontaneous movements , opening of eyes 3/27/2023 PK 49

50. Contra indications Abdominal co-contractions is avoided in patients with decerebrate rigidity, young children Inter costal stretch in fractured rib In children except peri oral stimulation all others procedures are contraindicated 3/27/2023 PK 50

51. Incentive Spirometry (IS) or Sustained Maximal Inspiration (SMI) Most widely used form of lung expansion therapy. Mimics a natural sigh by encouraging the patient to take a deep breath. Helps avoid atelectasis and pneumonia. 3/27/2023 PK 51

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53. Incentive spirometry is to facilitate a sustained slow deep breath involves the patient take a sustained maximal inspiration (SMI). An SMI is a slow, deep inspiration from the Functional Residual Capacity up to the total lung capacity followed by ≥5 seconds breath hold. 3/27/2023 PK 53

54. Types Flow oriented – mediflow & triflow Volume oriented – cough spirometer & volydyme Volume calculation by flow spirometer Flow= volume/time Volume= flow * time Eg - rising 1 ball for 1sec Volume = 600* 1 = 600 ml Rising 1st ball upon half in the 1st column for 1 sec Volume = 600/2* 1= 300 ml Raising 11/2 ball for 2 sec ( 900/1.5 *2= 450 3/27/2023 PK 54

55. Guideline Therapist demonstrates prescription of uses and cleaning advice based on manufacturers instructions. Patient should be in a relaxed position suitable for deep breathing (e.g. sitting upright in a chair or side lying if extra volume is required in one lung due to ventilation perfusion matching). 3/27/2023 PK 55

56. Patient creates a tight seal around the mouthpiece and inhales deeply and slowly. The patient watches the flow meter for visual feedback. If possible the patient sustains the inhalation to create an end-inspiratory hold. Ideally, the inhalation is sustained for 4-5 seconds. Patient relaxes seal around the mouthpiece and exhales; normal breathing is resumed with relaxed shoulder girdle. 3/27/2023 PK 56

57. Indications Pre-operative screening of patients at risk of postoperative complications to obtain a baseline of inspiratory flow and volume Presence of pulmonary atelectasis Conditions predisposing to atelectasis such as: Abdominal or thoracic surgery [ Prolonged bed rest Surgery in patients with COPD Presence thoracic or Abdominal binders Lack of pain control Restrictive lung disease associated with a dysfunctional diaphragm or involving respiratory musculature Patients with inspiratory capacity less than 2.5 liters Patients with neuromuscular disease or spinal cord injury 3/27/2023 PK 57

58. Contraindications Patients who cannot use the device appropriately or require supervision at all times Patients uncooperative pediatrics with developmental delay Hyperventilation Hypoxaemia secondary to interruption of oxygen therapy Fatigue Patients unable to take deep breathe effectively due to pain, diaphragmatic dysfunction, or opiate analgesia. Patients who are heavily sedated or comatose The device is not suitable for people with severe dyspnoea 3/27/2023 PK 58

59. Precautions The technique is inappropriate major lung collapse or consolidation. Hyperventilation barotrauma in emphysematous lung secondary to uncontrolled pain. bronchospasm 3/27/2023 PK 59

60. IPPB Therapeutic application, usually via a mask or mouthpiece of inspiratory positive pressure to the airway of a spontaneously breathing patient on an intermittent Short-term use is for purposes of assisting ventilation 3/27/2023 PK 60

61. IPPB intermittent positive pressure breathing / ventilation Non invasive, Pneumatic devices that involves the patient triggering the delivery of a positive inspiratory pressure breath during inspiration & expiration . Once triggered, the IPPB machine will deliver a positive inspiratory breath to the patient based on the set peak airway pressure intermittent treatments usually last 15 to 20 minutes given several times each day. 3/27/2023 PK 61

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63. Physiologic effects of IPPB An increase in mean airway pressure A decrease in the work of breathing (WOB) Manipulation of the inspiratory-expiratory ratio Increase in tidal volume (VT) Correct atelectasis 3/27/2023 PK 63

64. Indications Removal secretions ( IPPB) To improve lung expansion (IPPV) To provide short-term ventilatory support To aid in the delivery of aerosolized drugs 3/27/2023 PK 64

65. Contraindications Tension pneumothorax Subcutaneous or mediastinal emphysema Active untreated tuberculosis Intracranial pressure 3/27/2023 PK 65

66. Precautions Decrease pleural pressure and raise alveolar pressure. Positive pressure can compress the lung's vascular beds increase pulmonary vascular resistance, impede venous return and decrease cardiac output 3/27/2023 PK 66

67. Hazards Increased intracranial pressure Impeded venous return Increased airway resistance Pulmonary barotrauma Nosocomial infection Hemoptysis Hypocapnia and respiratory alkalosis Hypoventilation, hyperoxia , and respiratory acidosis Gastric distention Air trapping, auto-PEEP, overdistention Psychological dependence 3/27/2023 PK 67

68. OUTCOMES Improved VC Improved FEV1 Cough & secretion cleaner Improved CXY & breath sound Improved oxygenation 3/27/2023 PK 68

69. CPAP Continuous positive airway pressure Non invansive Positive pressure is given during both inspiration & expiration Ip = Ep , CPAP is given spontaneously breathing patients who cannot perform incentive spirometry Cpap given through face mask Flow constant inspiration and expirations 3/27/2023 PK 69

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71. Effects Increased FRC Improve gas exchange Delay the need of intubation Prevention of atectasis Re-expansion of collapsed alveoli 3/27/2023 PK 71

72. Complications Aspiration Abdominal distension Noisy sound Decreased venous return Coughing with mask produce ear damage Contraindications Untrained pneumothorax Emphysema sx & bullae 3/27/2023 PK 72

73. BIPAP Bi level positive airway pressure, non invasive + ve pressure in both inspiration & expiration Inspiratory pressure > expiratory pressure Inspiratory pressure – 10- 14 cm H2o Expiratory pressure- 2- 4 cm H2o Setting IP = EP acts as CPAP Flow triggered pressure control flow cycle 3/27/2023 PK 73

74. Effects Improves sleep Reduces breathlessness 3/27/2023 PK 74

75. PEEP Defined as that positive pressure which is applied during the end of expiration – which increases the end expiratory pressure to more than atmospheric pressure. Often used to improve patient’s oxygen status especially in patients with refractory hypoxemia. 3/27/2023 PK 75

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77. Indications of PEEP : Refractory hypoxemia to any cause Intra pulmonary shunts Decreased FRC & lung compliance 3/27/2023 77 PREMKUMAR

78. Refractory hypoxemia: Hypoxemia which responds poorly to moderate to high levels of oxygen (FiO2 = 1) Useful clinical guide is a PaO2 -60mm Hg or less at FiO2 = > 0.5 3/27/2023 78 PREMKUMAR

79. Intrapulmonary Shunts & hypoxemia : Caused by decreased FRC, atelectasis , V/Q mismatch. Decreased FRC & lung compliance: PEEP, here increases FRC and decreases the work of breathing, hence improves the symptoms. 3/27/2023 PK 79

80. PHYSIOLOGY OF PEEP: Positive pressure at the end of expiration -> reinflates the collapsed alveoli -> maintains the alveolar inflation even during expiration -> increases FRC -> improves ventilation. Once the recruitment of these alveoli has occurred, PEEP lowers the alveolar distending pressure and facilitates the gas diffusion and oxygenation. 3/27/2023 PK 80

81. Auto PEEP: Incomplete expiration prior to the initiation of the next breath causes progressive air trapping ( hyperinflation ). This accumulation of air increases alveolar pressure at the end of expiration which is referred to as auto-PEEP or intrinsic PEEP. 3/27/2023 PK 81

82. Auto-PEEP develops commonly in high minute ventilation(hyperventilation), expiratory flow limitation (obstructed airway) and expiratory resistance (narrow airway). The PEEP value range commonly used ranges from 5-10 cm H2O, though the upper limit has been posted at 20 cm H2O. Levels above that is associated with increased incidence of complications especially barotrauma . PEEP is increased at the rate of 2-3cm H2O depending on the clinical condition of the patient. 3/27/2023 PK 82

83. Complications of PEEP Decreases venous return Decreased cardiac output Barotrauma Increased intra cranial pressure Alters renal metabolism and water balance 3/27/2023 PK 83

84. Lung Expansion Modalities Positive Expiratory Pressure (PEP) Fixed orifice flow resistors 3/27/2023 PK 84

85. Fixed orifice flow resistor PEP therapy Patients exhales through a fixed orifice flow resistor. The patient is taught to exhale actively but not forcefully through the flow resistor. This positive expiratory pressure (5-25 cmH20) helps to keep the airways open through exhalation, thus lengthening the expiratory phase. 3/27/2023 PK 85

86. Positive expiratory pressure 3/27/2023 PK 86

87. Mechanism Administration of + ve pressure allows air to enter behind the area of mucus obstruction and keep the airways open during exhalation PEP therapy does not utilize a pressurized gas source, it is dependant upon the expiratory flow rate of the patient. Can accommodate virtually any patient’s lung capacity. May be used with a mask or mouthpiece with a nebulizer for bronchodilator therapy. 3/27/2023 PK 87

88. Techniques Patient sitting leaning forward with elbow supported on table Exhalation through mouth piece / mask Breathing cycle rapid 10-20 times , instruct at end to do huff limitation is patient cooperation and ability to follow directions 3/27/2023 PK 88

89. FLUTTER MECHANISM Vibration applied to the airways facilitates the losing secretion Increase bronchial pressure and avoid air trapping , expiratory airflow facilitates upward movements of mucus 3/27/2023 PK 89

90. Stages of flutter Stage1- mucus mobilization & loosening Stage 2- mucus elimination by cough or huff 3/27/2023 PK 90

91. Acapella Principal of PEP & FLUTTER delivered with nebuliser 2 types * green 15 l/m for > 3 sec Blue 15l/m min 3 sec 3/27/2023 PK 91

92. Patient position – Patient sitting instructed to breath out 3-4 sec perform breath then ask pt to cough /huff 3/27/2023 PK 92

93. Other Devices pk 93 Aerobika Quake

94. Indication PEP, FLUTTER& ACAPELLA To reduce air trapping in asthma& copd To Aid mobilize retrained secretion To Prevent or reverse atlectasis To optimize deliver of bronchodilator Contraindication & hazards - same to IS& IPPB 3/27/2023 PK 94

95. Techniques of chest physiotherapy PREMKUMAR

96. Chest physiotherapy CPT is a form of bronchial hygiene which includes postural drainage ,autogenic drainage, deep breathing exercises, manual chest percussion and active cycle breathing techniques 3/27/2023 PK 96

97. Chest Physiotherapy techniques Airway clearance techniques Facilitating airway clearance technique with effective coughing techniques Technique to facilitate ventilation pattern Mobilization and Exercises 3/27/2023 PK 97

98. Airway Clearance Techniques Chest Physiotherapy or CPT Postural Drainage Chest Percussion Chest Vibration Turning/Positioning Deep Breathing Exercises Active cycle of breathing technique Autogenic drainage Positive expiratory pressure High frequency chest compression Coughing CPT consists of 2 separate mechanisms Mucociliary Clearance Cough Clearance 3/27/2023 PK 98

99. Postural Drainage PDis a technique in which different positions are assumed to facilitate the drainage of secretions from the bronchial airways. Gravity helps to move the secretions to the trachea to be coughed up easily. The goal of postural drainage is to help drain mucus from the affected lobes into the larger airways of the lungs so it can be coughed up more readily. 3/27/2023 PK 99

100. Postural drainage 3/27/2023 PK 100

101. … Postural drainage All the patients do not require postural drainage for all the lung segments. So the procedure must be based on the clinical findings. In postural drainage, the person is tilted or propped at an angle to help drain secretions from the lungs. 3/27/2023 PK 101

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103. … Postural Drainage Postural drainage treatments are scheduled two or three times daily, depending on the degree of lung congestion. The best times include before breakfast, before lunch, in the late afternoon, and before bedtime. It is best to avoid hours shortly after meals because postural drainage at these times can be tiring and can induce vomiting 3/27/2023 PK 103

104. … Postural Drainage Help the patient assume the appropriate position, based on the lung field that requires drainage. 3/27/2023 PK 104

105. …. Postural Drainage After positioning the client Have the patient remain in the desired position for 10 to 15 minutes, if tolerated. Perform percussion and vibration by keeping the client in position. The sequence for chest physiotherapy is usually as follows: Positioning, percussion, vibration, and removal of secretions by coughing or suction 3/27/2023 PK 105

106. Chest percussion Chest percussion involves rhythmically clapping on the chest wall over the area being drained to force secretions into larger airways for expectoration. Position the hand so the fingers and thumb touch and the hands are cupped 3/27/2023 PK 106

107. …..Percussion Perform chest percussion by vigorously striking the chest wall alternately with cupped hands. begin with non dominant hand The procedure should produce a hollow sound and should not be painful. Perform percussion over a single layer of clothing, not over buttons or zippers. 3/27/2023 PK 107

108. Percussion is contraindicated - patients with bleeding disorders, osteoporosis, fractured ribs and open& unhealed wounds . Precautions over the spine, sternum, stomach or lower back as trauma can occur to the spleen, liver, or kidneys. Typically, each area is percussed for 30 to 60 seconds several times a day. If the patient has tenacious secretions, the area must be percussed for 3-5 minutes several times per day. 3/27/2023 PK 108

109. Percussion 3/27/2023 PK 109

110. Vibration/shaking 3/27/2023 PK 110

111. Vibration Vibration is a gentle, shaking pressure applied to the chest wall to move secretions into larger airways. The uses rhythmic contractions and relaxations of arm and shoulder muscles over the patient’s chest. During vibration, place your flat hand firmly against the chest wall, on the appropriate lung segment to be drained.  Vibrate the chest wall as the patient exhales slowly through the pursed lips. 3/27/2023 PK 111

112. …..Vibration After each vibration, encourage the client to cough and expectorate secretions into the sputum container. 3/27/2023 PK 112

113. Manual hyperinflation 3/27/2023 PK 113

114. AMBU- Air Mask Bag Unit A bag valve mask , abbreviated to BVM and sometimes known by the proprietary name Ambu bag or generically as a manual resuscitator or "self-inflating bag", is a hand-held device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately 3/27/2023 PK 114

115. Inflating the lung with oxygen and manual compression to total volume ( Vt ) of liter requiring a peak inspiratory pressure of b/n 20 and 40 cmH20 Providing a larger Vt than baseline Vt to the patient and using a Vt which is 50% greater than that delivered by the ventilator 3/27/2023 PK 115

116. Manual ventilation Squeezing gas into the patients lungs at tidal volume For eg when changing ventilator tubing Manual hyper ventilation Delivers rapid breaths For eg if patient is hypercapnic 3/27/2023 PK 116

117. Indication To help clinical assessment of air entry into lungs To improve oxygenation pre and post suctioning To mobilize excess bronchial secreation To re-inflate areas of collapsed lungs To maintain ventilation when mechanical is interupted 3/27/2023 PK 117

118. Techniques Mapleson circuit-absence of valves to direct from or to the patient When inspiratory gas flow exceeds fresh gas flow rebreathing occurs Self inflating bag-has inbuilt valve that’s prevent rebreathing 3/27/2023 PK 118

119. Feedback Manual hyper inflation may increase the risk of trauma if high peak airway pressure and volumes are delivered It should be >20 cmH2o to be clinically effective and < 40 cm H2o to prevent baro -trauma 3/27/2023 PK 119

120. Effects BENEFICIAL EFFECTS Increase static compliance Increase removal of secretion ADVERSE EFFECTS Decrease cardiac output – increase intrathoracic volume causes decrease venous return by compression great veins Increase intracranial pressure - increase intrathoracic volume causes decrease venous return – cause increases stasis in brain 3/27/2023 PK 120

121. Precaution & CI PC- Fall CO, Barotrauma , severe bronchospasm CI- Unstable cvs , pneumothorax , hypoxia 3/27/2023 PK 121

122. Ventilator sign mode vs MH A sign mode is perferred in a ventilated patient instead of AMBU bag To get better result 1- PT will do AMBU & 1 – PT will do chest physio & suctioning To expand the lung –slow inspiration hold To remove secretion – faster expiratory flow with short inspiratory time 3/27/2023 PK 122

123. Documentation Following chest physiotherapy , the should auscultation the client’s lungs, compare the findings to the baseline data, and document the amount, color, and character of expectorated secretions. 3/27/2023 PK 123

124. ACBT ACBT are a specific set of breathing exercises designed to remove excess bronchial secretions Combinations of breathing control, thoracic expansion control and FET 3/27/2023 PK 124

125. Active cycle of breathing technique 3/27/2023 PK 125 Breathing control Thoracic expansion FET

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128. Breathing control relaxed breathing between manoeuvre efforts Shoulders relaxed, gentle breathing with lower chest Abdomen should move slightly 3/27/2023 PK 128

129. Thoracic expansion * Deep breaths in. use a three-second breath-hold to get more air behind the mucus. This may be done with chest clapping or vibrating, followed by breathing control * Typically limited to 3-4 deep breaths Larger lung volume increases airflow through peripheral airways and collateral ventilation channels, which increases the gas volume available to mobilize secretions during expiration. Avoid fatigue and hyperventilation. 3/27/2023 PK 129

130. FET Combination of manoeuvres described as a ‘milking action’ Directed Cough Forced Huff Exhalation 3/27/2023 PK 130

131. Directed Cough Standard procedure Deep breath Hold, using abdominal muscles to force air against a closed glottis Cough with single exertion Several relaxed breaths before next effort 3/27/2023 PK 131

132. 3-5 slow, deep breaths, inhaling through nose, exhaling through pursed lips, using diaphragmatic breathing. Deep breath and hold for 1-3 seconds Exhale from mid-to-low lung volume. Normal breath in squeeze it out by contracting the abdominal and chest wall muscles with the mouth open while whispering the word ‘huff’ during exhalation. Repeat several times. When secretions enter larger airways, exhale from high-to-mid lung volume to clear secretions Repeat process 2-3 times. Take relaxed breaths before next efforts 3/27/2023 PK 132

133. ACBT – A High volumes of mucus production pk 133 Forced Expiration Technique Fink, J.B. (2007). Forced Expiratory Technique, Directed Cough and Autogenic Drainage. Respiratory Care, 52(9), p. 1216, Fig. 6.

134. ACBT– B ( Bronchospastic ) pk 134 Fink, J.B. (2007). Forced Expiratory Technique, Directed Cough and Autogenic Drainage. Respiratory Care, 52(9), p. 1216, Fig. 6. Forced Expiratory Technique

135. ACBT – C airway collapse & mucus plugging pk 135 Fink, J.B. (2007). Forced Expiratory Technique, Directed Cough and Autogenic Drainage. Respiratory Care, 52(9), p. 1216, Fig 6. Repeat Forced Expiratory Technqiue

136. Equipment Patient or care givers hands to percuss or shake vibrate the chest wall during thoracic expansion used. - Mechanical percussors or vibrations may be required - If PD positions are used equipment for positioning will be required - To teach huffing maneuver Peak flow meter mouth piece may be used – game of huffing at the cotton balls ‘ Chicken breath’ 3/27/2023 PK 136

137. Advantages 1.Patient can actively participate in secretion moblisation 2. Independently managing airway clearance 3. Technique may be adapted for patients with gastro oesophagial reflex, bronchospasm and acute exacerbation of pulmonary disease 4 . Decrease in oxygen saturation caused by chest percussion can be avoided by ACBT 5. Cost of ACBT is minimal. 3/27/2023 PK 137

138. Disadvantages young children and extremely ill adults a care giver will be necessary to assist the patient this technique care must be taken to adapt technique in patient with hyperactive airways 3/27/2023 PK 138

139. Autogenic drainage 3/27/2023 PK 139

140. Autogenic Drainage It’s an airway clearance technique characterized by breathing control, where the person adjusts the rate, depth, and location of respiration to clear chest secretions independently. Aim of breathing is to achieve highest possible expiratory flow simultaneously in different generations of the bronchi, keeping bronchial resistance low, and avoiding bronchospasm and dynamic airway collapse. 3/27/2023 PK 140

141. Important to note, this technique requires a great deal of patient cooperation, and is recommended for patients >8yrs old who have a good sense of their own breathing, and can actively participate in the process. Very difficult clearance technique to master, but well worth the time and effort to learn. 3/27/2023 PK 141

142. Preparation & Position Clear upper airways, ie , nose & throat – huffing or coughing Take prescribed nebulizers or inhalers Find comfortable, unrestricted position pk 142

143. Inspiration Performed slowly, through the nose Held for 2-4 seconds Up to twice the size of normal tidal breath pk 143

144. Expiration Active, silent sigh At least as long as inspiration, but exhaling a little longer helps to achieve low lung volume stage Urge to cough should be suppressed until secretions are high enough to expectorate successfully Utilize controlled cough or huff for expectoration pk 144

145. The process ‘unstick’ – low volume breathing ‘collect’ – breathe based on frequency vibrations ‘evacuate’ – only when secretions have made their way to upper/central airways or mouth pk 145 Agostini , P. & Knowles, N. (2007) Autogenic drainage: the technique, physiological basis and evidence. Physiotherapy, 93, p. 159.

146. COLLECT EVACUATE pk 146 UNSTICK

147. High frequency chest compression 3/27/2023 PK 147

148. Exercises for airway clearance 6- 7-very very light 8- 9- very light 10- 11- fairly light 12- 13- somewhat hard 14- 15- hard 16- 17- very hard 18- 19- very very hard 20- extremely hard Brog scale 3/27/2023 PK 148

149. Indications and cautions Cystic fibrosis Atelectasis Asthama Respiratpry muscle weakness Bronchiectasis Mechanical ventilation Neonatal respiratory distress syndrome 3/27/2023 PK 149

150. Contraindications Intracranial pressure (ICP) > 20 mm Hg Head and neck injury until stabilized Active hemorrhage with hemodynamic instability Recent spinal surgery ( e.g .• laminectomy ) or acute spinal injury Active hemoptysis Empyema Bronchopleural fistula Large pleural effusions Pulmonary embolism Aged, confused, or anxious patients Rib fracture. with or without flail chest Surgical wound or healing tissue 3/27/2023 PK 150

151. Trendelenburg Position is Contraindicated Patients in whom increased ICP is to be avoided Uncontrolled hypertension Distended abdomen Esophageal surgery Recent gross hemoptysis related to recent lung carcinoma Uncontrolled airway at risk for aspiration 3/27/2023 PK 151

152. Subcutaneous emphysema Recent epidural spinal infusion or spinal anesthesia Recent skin grafts, or flaps, on the thorax Burns. open wounds. and skin infections of the thorax Recently placed pacemaker Suspected pulmonary tuberculosis Lung contusion Bronchospasm Osteomyelitis of the ribs Osteoporosis Coagulopathy Complaint of chest-wall pain 3/27/2023 PK 152

153. Treatment prescription. Motivation Patient’s goals Physician/caregiver’s goals Effectiveness ( of considered technique Patient’s age Ease (of learning and of teaching) Skill of therapist/teachers Fatigue or work required Need for assistants or equipment Limitations of technique based on disease type and severity Costs (direct and indirect) Desirability of combing methods 3/27/2023 PK 153

154. Facilitating airway clearance with effective coughing technique What is cough….??? Stages of cough Techniques of teaching effective coughing self assisted coughing manual coughing 3/27/2023 PK 154

155. Self assisted coughing technique 3/27/2023 PK 155

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157. Manual coughing technique 3/27/2023 PK 157

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160. Technique to facilitate ventilation pattern Body positioning Breathing technique Mobilizing the thorax Facilitating the accessory muscles of respiration 3/27/2023 PK 160

161. Body positioning Standing upright position Erect sitting (self supported or with assist) with feet moving (e.g., active, active assisted or passive cycling motion) Erect silting (self-supported or with assist) with feet dependent Lean forward sitting with arms supported and feet dependent 24S degree sitting with legs dependent Erect long sitting (legs non dependent) < 4S degrees sitting (legs non dependenl ) Prone and semi prone/side lying Supine 3/27/2023 PK 161

162. Breathing exercise BE also called as ventilatory training. Levenson classified breathing exercise into 3 categories: 1 . BE includes to increase lung volume& capacities ( FRC), redistribute ventilation& gas exchange Outcomes Improve ventilation& gas exchange Decrease work of breathing Maintain or improve chestwall mobility Prevent pulmonary compromise 3/27/2023 PK 162

163. 2 nd category BE includes improve strength, endurance& efficiency of ventilatory muscle 3 rd category of BE includes to decrease the work of breathing and facilitation of relaxation 3/27/2023 PK 163

164. Breathing techniques Diaphragmatic breathing pattern Segmental expansion Glossopharyngeal breathing technique Pursed lip breathing Paced breathing 3/27/2023 PK 164

165. Diaphragmatic breathing 3/27/2023 PK 165

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167. Segmental breathing 3/27/2023 PK 167

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169. Pursed lip breathing 3/27/2023 PK 169

170. Facilitating the accessory muscles of respiration 3/27/2023 PK 170 Pectoralis Major Sternocleido mastoid Trapezius Serratus anterior

171. Indications To increase ventilation Respiratory muscle weakness 3/27/2023 PK 171

172. Mobilization and exercises Mobilization is defined as the therapeutic and prescriptive application of low-intensity exercise in the management of cardiopulmonary dysfunction usually in acutely ill patients. Primarily, the goal of mobilization is to exploit the acute effects of exercise to optimize oxygen transport. Even a relatively low intensity mobilization stimulus can impose considerable metabolic demand on the patient with cardiopulmonary compromise. 3/27/2023 PK 172

173. In addition, mobilization is performed in the upright position, that is the physiologic position, whenever possible, to optimize the effects of being upright on central and peripheral hemodynamics and fluid shifts. Thus mobilization is prescribed to elicit both a gravitational stimulus and an exercise stimulus 3/27/2023 PK 173

174. exercise What are the exercises given-Exercise is the term used to describe the therapeutic and prescriptive application of exercise in the management of subacute and chronic cardiopulmonary and cardiovascular dysfunction. Primarily, the goal of exercise is to exploit the cumulative effects of and adaptation to long-term exercise and thereby optimize the function of all steps in the oxygen transport pathway. 3/27/2023 PK 174

175. Treatment prescription for mobilization and exercises It depends on the patient’s condition Whether the patient is in patient or in out patient department Also it depends on the functionality of the patient at the present stage It is decided on the basis of the exercise testing protocol Also on the basis of METs 3/27/2023 PK 175

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177. Step 1 Identify all the factors underlying the pathology causing deficits in oxygen supply. Step 2 Determine whether mobilization and exercise are indicated and if so, which form of either will specifically address the oxygen transport deficits identified in Step I. 3/27/2023 PK 177

178. 3/27/2023 PK 178 Step 3 Match the appropriate mobilization or exercise stimulus to patient's oxygen transport capacity. Step 4 Set the intensity within therapeutic and safe limits of the patient's oxygen transport capacity. Step 5 Combine the various body positions especially in the erect position with the following maneuvers :

179. Step 6 Set the duration of the mobilization sessions based on the patient's responses (i.e., changes in measures and indices of oxygen transport) rather than time. Step 7 Repeat the mobilization session as often as possible based on its beneficial effects and on is being safely tolerated by the patient. Step 8 Increase the intensity of the mobilization stimulus. duration of the session, or both comml!l1surate with the patient's capacity to maintain optimal oxygen transport when confronted with an increased mobilization stressor, and in the absence of distress; monitored variables to remain within predetermined threshold range. 3/27/2023 PK 179

180. Heiarchy of treatment for oxygen supply treatment PREMISE: Position of optimal physiological function is being upright and moving. Mobilization and Exercise Body Positioning Breathing Control Maneuvers Coughing Maneuvers To minimize the work of breathing. of the heart. and oxygen demand overall ROM Exercises (Cardiopulmonary indications) Postural Drainage Positioning Manual Technique Suctioning 3/27/2023 PK 180

181. Parameters for treatment prescription in the management of cardiopulmonary patients Define parameters of treatment based on history, laboratory investigations, tests, and assessment Treatment type Intensity (if applicable) Duration Frequency Instruct patient in "between treatment" treatment, and if applicable the nurse. a family member. or both Reassessment every treatment Modify as necessary within each treatment Progress between treatments as indicated 3/27/2023 PK 181

182. Define treatment outcomes Determine when treatment is to be discontinued Request for additional supportive information. tests, and investigations as indicated Predict time course for optimal effects and course of treatment to determine treatment efficacy; modify as necessary In conjunction with other interventions (e.g., medical, surgical, nursing, respiratory therapy (weaning oxygen supplementation. sympathomimetic drugs, ADLs, balance with sleep and rest periods. peak of nutrition and feeds. Peak energy times. peak of drug potency and effects (e.g., pain, reduced sedation. reduced neuromuscular blockade) 3/27/2023 PK 182

183. references Principles and practice of cardiopulmomary physical therapy 3 rd edition Donna Frownfelter Tidy’s physiotherapy Physiotherapy for respiratory and cardiac problems 3 rd edition by Jenifer A Pryor 3/27/2023 PK 183

184. Thank you 3/27/2023 PK 184