Pulmonary rehabilitation in a patient with disturbed airway clearance

1. Pulmonary rehabilitation in a patient with disturbed airway clearance Sema Savcı PT, PhD, Prof H.U. School of Physical Therapy Rehabilitation

2. Respiratory mechanics • Air flow • Airway resistance • Elastic recoil pressure • Bronchial wall stability • Mucus reology • Ciliary beat and frequency • Dynamic compression • Respiratory muscles • Collateral ventilation

3. Airway clearance disorders • Altered mucus rheology (cystic fibrosis) • Altered mucociliary clearance (primer ciliar dyskinesia) • Structural defects (bronchiectasis) • Abnormal cough mechanisms (muscle weakness)

4. Goals of airway clearance • Maintainance of airway patency •  V/Q matching •  work of breathing •  oxygenation

5. Airway clearance techniques Postural drainage and positioning Percussion, vibration and shaking Huffing, cough, forced expiration technique Active cycle of breathing techniques Autogenic drainage Positive expiratory pressure (PEP) therapy High frequency chest wall oscillations (VEST, Hayek) Intrapulmonary percussive ventilation (IPV) Exercise (aerobic, peripheral & respiratory muscle training)

6. Postural drainage • Use of gravitational forces to promote mucus transport to central airways • 12 positions: 5-10 min each • Modify positions to optimize patient tolerance & comfort • Never head down: ICP > 20, GER, risk of aspiration, orthopnea, hemodynamic instability

7. Percussion (clapping) • Clapping external thorax directly over lung segment being drained • Transmission of oscillatory forces to bronchi

8. Vibration & shaking • Manual oscillatory actions on expiration only in the direction of normal movement of the ribs • Fine movement: vibration • Coarse movement: shaking

9. Huffing & cough • Huffing: modified forced expiratory breaths-open glottis • Coughing: controlled cough-closed glottis • Equal pressure points • Forced expiration technique

10. Active cycle of breathing techniques • Breathing control: stabilizes airways • Thoracic expansion exercises (TEE): collateral ventilation • Forced expiration techniques: helps mobilize secretions

11. ACBT+NIMV,  lenght of MV (1,7 days) •  length of stay in ICU (1,3 days) • PaCO2 more stable Austr J Physiother 2004.

12. Autogenic drainage • Utilizes expiratory air flow at various lung volumes to mobilize secretions • Three stages: • Unstick • Collect • Evacuate

13. COPD(n= 30) • 20 days, ACBT and AD •  Pulmonary function •  Secretion mobilization

14. Positive expiratory pressure (PEP) • Clears secretions in occluded airways by increasing collateral ventilation • Utilizes airway stabilization • Allows air to get behind secretions

15. Flutter ve Acapella • Utilizes internal expiratory vibrations • Oscillating endobronchial pressure clears mucus from small airways

16. PEP • To compare short-term effects of flow dependent PEP, flow independent PEP and ACBT • Stable cystic fibrosis patients(n=25, 6-17years) • PFT, SaO2 dyspnea and fatigue perception were evaluated • Flow independent threshold PEP improved large and middle airway function

17. To compare the short – term effects of PEP, CPAP and NPPV in cystic fibrosis patients with severe airway obstruction. • Wet and dry sputum weight, SaO2 andPFT were evaluated. Each patient received each treatment twice a day for consecutive days. • The highest sputum wet weight was produced with PEP treatment. • After mask PEP these patients felt more tired than after CPAP or NPPV.

18. To evaluate the acute efficacy and tolerability of Flutter, ACBT ve ACBT + PD in bronchiectatic patients (n=36) • Sputum wet weight for ACBT+PD was twice that either ACBT or flutter • Patient preference was • 44% for Flutter, 22% ACBT, 33%ACBT+ PD • ACBT was superior in terms of acute efficacy.

19. High frequency chest wall oscillations (Hayek oscillator & VEST) • Generates increased airflow velocities via oscillation of chest wall • High airflow velocities create repetitive cough like shear forces • Shear forces decrease viscosity of secretions • Expensive • Prefer mentally retarded patients

20. Intrapulmonary percussive ventilation • Inhalation therapy • High frequency puff open atelectatic alveoli

21. Respiratory muscle training •  Respiratory muscle endurance and strenght •  Cough efficiency • Intensity: Pımax  30% Duration : 30 min/day Frequency: 5 days/week

22. Mekanical IN-EXSUFFLATION •  inhalation volume. •  lung recoil pressure • Use in patients with respiratory muscle weakness

23. DMD patients, Peak cough flow rate < 160 L/min Mechanical IN-EXSUFFLATION • Prevent hospitalization •  need for tracheostomy

24. Exercise training • Essential component. •  exercise capacity. •  oxidative capacity in peripheral muscle • Mediator release in the airway •  ventilation

25. To investigate the effects of heavy resistance training (RT) in the elderly males with COPD (n=18, 65-80 years) • Cross sectional area of quadriceps asssessed by MRI • Isometric-isokinetic knee extension, isometric trunk strength, leg extension power, stair climbing time, normal and max gait speed on a 30 m track. • RT performed twice a week for 12 weeks. • Significant improvements in muscle size, knee extension strength, leg extension power and functional performance in elderly male COPD patients.

26. ES • To evaluate whether ES was a beneficial tecnique in the rehabilitation programs for severely deconditioned COPD patients after acute exacerbation. • 17 COPD patient participated in this study (FEV1, 30  3% pred, BMI 18  2.5 kg/m2) • usual rehab (UR) (n=8) , UR +ES (n=9) program for 4 weeks • QMS, exercise capacity and HRQoL were measured before and after rehabilitation. Chest 2006; 129:1540-1548.

28. Conclusion • Airway clearance techniques should be used in patients with disturbed airway clearance. • Patients’ age, cooperation, social status, and compliance should be considered when choosing the method. • Exercise training is essential component of PR. • Aerobic exercise training, peripheral and respiratory muscle training should be included in PR program.

29. Sonuçlar • Number of patients • Controlled study • Different pathologies • Patient preference

30. THANK YOU