Chest Physical Therapy and Breathing Techniques - Literature review Example

Literature review on the Chest physical therapy and breathing techniques focus on the relevance for pulmonary rehabilitation rather than COPD in general. Chest physical therapy (CPT) is essential to the management of several respiratory diseases. CPT considered one of the elements of pulmonary rehabilitation program. There are a lot of techniques, which can be modified according to the patient’s symptoms and convenience. CPT is carried out in the hope that the removal of secretions will improve the respiratory function of the lung and prevent its collapse (Palmer, 1953). An uncontrolled study recording subjective impressions about the recovery of patients appeared in 1915 as one of the earliest papers advocating the technique of CPT (MacMahon, 1915). CPT is usually conducted on patients who produce excessive sputum, more than 30 ml a day. However, several studies have shown that the technique has either been useless or harmful in patients who did not produce excessive sputum. This paper will focus on how CPT can contribute greatly in pulmonary rehabilitation, which works to reduce symptoms of respiratory diseases and restoring independent function. Our lungs have a protective lining with mucus which catches any dirt, dust or other particles in the air that we might have inhaled. If they stayed in the lungs, they would irritate the lungs and cause infections. The Cilia, tiny hair lined on the air passages, carry the mucus up to be coughed out. When the lungs are working extra hard to remove an infection, extra mucus develops slowing down the cilia from working which is why CPT is used to get the mucus out. Extra mucus is harmful as it can block the air passages hampering the entire process. The blood does not get enough oxygen and the carbon dioxide is not removed if the air passages are blocked. CPT consists of postural drainage, chest percussion, chest vibration and breathing exercises (Van, 2007). CPT can contribute greatly in pulmonary rehabilitation, which works to reduce symptoms of respiratory diseases and restoring independent function. Education, exercise and psychological interventions are all involved in rehabilitating the patient medically. This also helps lowering the health-care and utilization costs. The benefits of pulmonary rehabilitation have been recognized by most commercial insurers and Medicare for almost 3 decades (Griffiths, 2000). One of the most important elements of pulmonary rehabilitation is the respiratory therapy services and the techniques used in CPT. CPT in particular aims is reducing airway obstruction by an improvement of the clearance of secretions; it reduces the severity of the infection through the clearance of infection material. It also seeks at maintaining optimal respiratory function and exercising tolerance. (International Physiotherapy Group for Cystic Fibrosis booklet, 1995). Moreover, CPT is utilized to loosen mucus in the lungs making the patients cough it up. Certain techniques like percussion and body positions are used to loosen the mucus; it helps expand the collapsed areas in the lung. CPT should be administered with care. People with oxygen deficiency, increased intracranial pressure, temporary low blood pressure, bleeding in the lungs, pain or injury to the ribs, muscles or spine, vomiting and heart regularities should not be given CPT (Kristine & Gale, 2002). In these cases CPT can affect the medical process adversely, hindering the process of pulmonary rehabilitation. In order to achieve that pulmonary rehabilitation is unhindered certain precautions should be taken regarding CPT and it should not be administered to people who just ate or vomited, with asthma or tuberculosis, with brittle bones or broken ribs, who are coughing blood or have bleeding pains, experiencing extreme pain, have head or neck injuries or skull damage, collapsed or damaged lungs and heart diseases. CPT for pulmonary rehabilitation can be divided into 4 steps for convenience. 1. Positioning The patient should be positioned in a way to make sure the part of the lung which is to be drained is higher than any other part. The patient and the person performing it should both be in a comfortable position because that makes treatment easier. The patient’s knees and hips should be bent to make coughing easier. 2. Clapping The fingers should be brought together in a cupped position for the clapping procedure. The hands should be bent at the knuckles and the thumb should be held against the index finger. In the case of little children, two or three fingers can be used to tap the chest. It is usually performed at a fairly fast rate. The skin should be covered with a towel or a sheet. Clap the hands, one after the other, on the chest or the back. It should be performed in a regular rhythm and at a fast rate but make sure it is comfortable and not tiring. In order for the mucus to move clapping should be normal. Make sure the person is breathing normally throughout. When clapping is performed in the right way, it does not hurt. 3. Vibrating Vibrating is performed on the same area of the lung as clapping, placing your hand flat over the area stiffening your shoulder and arm so that it all vibrates together. The fingertips should not be used and the entire arm should shiver. Start it at the outside edges and slowly move it towards the center, slowly applying downward pressure. Breathing should be normal and vibration should be done as he/she exhales. 4. Coughing Clapping and vibration should have managed to loosen up the mucus, now it should be coughed and spat out. The patient should be encouraged to cough and spit out as much as possible. It can start in the same position in which the patient was and then moved to other positions encouraging coughing in each position. If there is any blood being coughed up then it should be reported to a respiratory therapist or nurse. CPT should be effective, efficient and flexible. The active cycle of breathing techniques (ACBT) is a method of physiotherapy which has been rigorously evaluated and meets these requirements (Shuldham, 1998). ACBT consists of breathing control, thoracic expansion exercise and the forced expiration technique (webber, 1990). A CPT cycle starts with breathing control, which is gentle breathing at a standard rate and rhythm using the lower chest, with the upper chest and shoulders relaxed (Shuldham, 1998). The next step is thoracic expansion exercise where the patient has to take three to four deep breaths with the emphasis on inspiration via nose. Expiration via mouth is passive and relaxed (Shuldham, 1998). The final step is forced expiration technique that consists of huff along with breathing control. A huff is produced by the patient breathing out forcefully with an open mouth and simultaneously contracting the abdomen muscle, the force used should not be violent (Shuldham, 1998). Many other procedures are applied and techniques are used according to the patient. In hospitals patiently are routinely monitored and treated according to their condition and health. Patients receiving long term therapy are revaluated regularly. Turning is one of the methods employed by hospitals, it permits lung expansion. Patients who are critically ill who are dependent on mechanical respiration are overlooked by staff who turn them once every couple of hours. Deep breathing also helps expands the lungs and air is better distributed throughout the lungs. Deep breathing exercises done regularly prove to be very successful. Postural drainage is aided by gravity in the drainage of secretions from the lungs after which they can be coughed out or suctioned out. The patient is kept in a particular position with his head or chest down and kept in this position for up to 15 minutes. Critically ill patients are provided this therapy 4-6 times daily. The technique can be performed in conjunction with percussion and vibration. Percussion simply refers to clapping; the chest wall is rhythmically struck by cupped hands. The thick secretions are broken up this way making them easier to remove. The purpose of vibration is the same. Breathing exercises are commonly administered to improve the condition of people suffering from lung diseases, breathing exercises do not improve the functioning of the lungs directly but they can reduce the risk of complications in the lungs after surgery. Often, hospitals use an incentive spirometer, allowing the patient to breathe deeply through a tube attached to a chamber with a ball in it. However, the artificial method may not be as effective as deep breathing exercises encouraged by respiratory therapists or nurses. People undergoing pulmonary rehabilitation are administered another type of breathing pattern as well called Pursed-lip breathing, patients are taught to exhale against partially closed lips like they are about to whistle. The exercise helps increasing pressure in the airways and preventing collapse. It is advisable for the patient to bend over while performing the exercise. The position improves the functioning of the diaphragm and reduces shortness of breath. The techniques should be used in conjunction with other treatments like the inclusion of physical activities greatly strengthens the effects of the treatment (Andreasson et al., 1987). CPT has proved successful in removing cough and the production of extra sputum. After a daily session of postural drainage with an active cycle of breathing techniques most adults produce sputum (Webber, 1990). Evidence suggests that even in patients who have mild chest involvement, regular daily physiotherapy helps keep the chest in better condition as compared to when the treatment is omitted (Reisman et al., 1988). Patients requiring PR commonly complain of a productive cough and/or shortness of breath. Assessment and Intervention by an experienced therapist plays a crucial role in relieving these symptoms. The intensity of the therapy will depend on the patient and the health of the patient. It is essential that the patient is monitored by a therapist who has great experience (Morton et al., 1996). Supportive respiratory therapy, which includes CPT, can be used in conjunction with pulmonary rehabilitation. Supportive therapy can be used for people who have chronic lung disorders (such as cystic fibrosis or bronchiectasis) or acute lung conditions (such as pneumonia). References 1- Andreasson B, Jonson B, Kornfalt R, Nordmark E, Sangstrom S.(1987) Long term effects of physical exercise on working capacity and pulmonary function in CF. Acta Paediatr Scand 1987; 76: 70-75 2- Cystic Fibrosis trust,(1995), International Physiotherapy Group for Cystic Fibrosis booklet 'Physiotherapy in the Treatment of Cystic Fibrosis', 2nd Edition, 1995. 3- Kristine Krapp. Gale Cengage, (2002) Chest Physical Therapy." Encyclopedia of Nursing & Allied Health. Ed. eNotes.com. 2006. 21 May, 2009 from http://www.enotes.com/nursing-encyclopedia/chest-physical-therapy 4- Morton A, Wolfe S, Conway SP.(1996) Dietetic intervention in pregnancy in women with CF -the importance of pre-conceptional counselling. Israel J Med Sci 1996; 32 (suppl): S271 5- Nationwide Children’s Hospital, Children’s Hospital, Inc., Columbus Ohio (Copyright 1977-2004) from http://www.pediatricassociates.info/documents/ChestPhysicalTherapy-ChildrenandAdults.pdf 6- Palmer KNV, Sellick BA.(1953) The prevention of postoperative pulmonarv atelectasis. Lancet 1953;i: 164-8. 7- Reisman JJ, Rivington-Law B, Corey M, Marcotte J, Wannamaker E, Harcourt D et al.(1988) Role of conventional physiotherapy in cystic fibrosis. J Pediatr 1988; 113: 632-636 8- van der Schans, CP. (2007). Conventional Chest Physical Therapy for Obstructive Lung Disease. RESPIRATORY CARE 52, (9) Retrieved April 15, 2009 from http://www.hanze.nl/NR/rdonlyres/FB7CB7A0-0043-4024-8D43-916785C2F7F5/0/09071198. 9- Webber BA (1996). The active cycle of breathing exercises. Cystic Fibrosis News. 1990; Aug/Sept: pp10-11 Worthington D, Kelman BA. Current physiotherapy practice of new referrals to a regional paediatric cystic fibrosis service. Physiotherapy 1996; 82: 253-257 10- MacMahon C. Breathing and physical exercises for use in cases of wounds in the pleura, lung and diaphragm. Lancet 1915; ii: 769-70.) Read More