STRATEG I ES FOR REDUCED OF BREATHLESS

1. STRATEGIESFOR REDUCED OF BREATHLESS Sevgi Ozalevli, PhD, PT, Assoc.Prof. School of Physical Therapy and Rehabilitation, Dokuz Eylul University, Izmir.

2. Content of the presentation • Breathlessness = Dyspnea, Definition, Causes Of Dyspnea • Treatment Of Dyspnea, Non-pharmacologic Methods • Patients And Familiy Education • Strategies For Reducing Work Of Breathing And Consumption Of Oxygen • Tecniques For Regulating Breathing And increasing Capacity Of Pulmonary Relaxation Exercise And Positions Forward Leaning Pursed Lips Breathing Regulation in Breathing Pattern And Active Expiratory Tecnique Diaphragmatic Breathing Exercises • Exercise Training • Respiratory Muscle Training • Oxygen Therapy • Rest Of Respiratory Muscles And Mechanic Ventilation • Conductive Addition Therapies

3. Breathless – Dyspnea, Definition • The sensation of difficulty in breathing • Breathing discomfort • Inability to breathe deeply enough • Increased respiratory effort that is unpleasant and regarded as inappropriate by the patient • Awareness of respiratory distress • Feeling breathless, suffocated • Experiencing air hunger Richards, 1935 Mahler, 1984

4. Dyspnea - Definition The experience derives from interactions among multiple physiological, psychological, social, and environmental factors, and may induce secondary physiological and behavioral responses. American Thoracic Society. Dyspnea: mechanisms, assessment and management-a consensus statement. Am J Respir Crit Care Med 1999

5. Reduced elastic lung recoil Increased airway resistance Expiratory flow limitation Acute dynamic lung hyperinflation Dyspnea O’Donnell, 2007

6. Airway disease Parenchymal lung disease Pneumonia Pleural disease Pulmonary vascular disease Chest wall disease Respiratory muscle dysfunction Cardiovascular Anemia Decondition Psychological factors CausesofChronic Dyspnea

7. Jones PW, 1998

8. Possible mechanism contributing to dyspnea in COPD 1. Increased ventilatory demand a. Increased physiological dead space b. hypoxemia c. Early onset of lactic acidosis d. Limp muscle weakness due to deconditioning, systemic effects of COPD, and/or poor nutrition. 2. Dinamic airway compression 3. Dynamic hyperinflation a. Increase in elastic loading b. Shortening of the vertical muscle fibers of the diaphragm (functional weakness) 4. Respiratory muscle weakness

9. Treatment of Dyspnea • Pharmacologic treatment • Treatment with non-pharmacologic methods

10. Non-pharmacologic Strategies 1. Patient/Family Education 2. Strategies for reducing work of breathing and consumption of oxygen 3.Tecniques For Regulation Breathing And increasing Capacity Of Pulmonary Relaxation Exercise And Positions Forward Leaning Pursed-lip Breathing Regulation in Breathing Pattern And Active Expiratory Tecnique Dyaphragmatic Breathing Exercise 4. Exercise Training 5. Respiratory Muscle Training 6. Oxygen Therapy 7. Noninvasive Positive Pressure Ventilation 8. Conductive Addition Therapies Yoga Walking Aids Walking And Exercise With Music Hypnosis Acupuncture-acupressır Biofeedback Neuromusculer Electric Stimulation (NMES) Use Cool Air To Face Organisation Of Environment Air And Conditions Psychological Support Nutritional Support

11. Patient/Family Education • in education program for reducing breathlessness • It should be included • control of breathing • organization of home and environment • To limit number of people in room • regulation of temperature and humidity • strategies for coping with stress, anxiety and depression • developing self care coping strategies AMA:EPEC 1999

12. Patient/Family Education The “coaching” of nebulized bronchodilator therapy should be included on patients and familly education. During the therapy, unsupported seated and prolonged use of upper limbs, and rapid and shallow breathing pattern should be keep down.

13. Strategies for reducing work of breathing and consumption of oxygen • It is important to teach breathing with normal tidal volume and lower chest wall by relaxation to upper chest wall and shoulder and neck muscles Effects of this strategies Quality of sleep Functional activities Quality of life Work of breathing Heart rate Perception of dyspnea

14. Strategies for reducing work of breathing and consumption of oxygen Aims • Reduce unsupportive body positions • Reduce works which is doing against gravity • Reduce change positions • Reduce speed and deep of ventilation • Reduce activity of accessory respiratory muscles • Use advantage body positions (forward leaning) • Use breathing control during the daily living activities • Use relaxation in daily life • Improve strategies for cope with stress Mahler, 1990

15. Christenbery, 2005

16. The effects of education on the dyspnea perception? It has been determined that the patient education reduces dyspnea, increases quality of life, improves life style adaptations, which include the use of inhaler, relaxation tecniques, energy conservation techniques, and strategies for coping with stress. Hunter & Hall, 1989. Howland, 1986.

17. Tecniques For Regulating Breathing And increasing Capacity Of Pulmonary

18. Relaxation Exercise and Positions Efficacy Ensure breathing control Regularize breathing rate Increase tidal volume Reduce severity of anxiety Reduce working of breathing Reduce heart rate Improve quality of sleep Reduce accessory muscles activities Reduce perception of dyspnea

19. High side lie Supin position with high head lie Forward leaning with supported upper extremities Forward leaning with supported by table Supported forward and rearward standing Relaxation Positions

20. Progressive muscle relaxation This is important strategy of breathing which is teaching to patient, inspiration with contraction of all muscles groups during 5-10 sec and expiration with relaxation. Patients with chronic heart failure, n=158 Study group, 14 wks, progressive muscle relaxation by home program and workshop Control group, relaxation education, 45min According to the control group, in study group; psyhologial stress, severity of dyspnea and fatigue were reduce. . Breathing rate Anxiety Dyspnea Yu, J Psychosom Res, 2007

21. Progressive muscle relaxation

22. Forward leaning

23. Forward Leaning • Reduces scalen and sternomastoid muscles activities • Increases transdiaphragmatic pressure • Regulatesthoracoabdominal motions • Pectoral muscles by aid of supported upper extremities elevate upper ribcage • Regulates and increased diaphragm function • Increases Pimax 20-45° Barach, 1974 Sharp, 1980 Druz, 1982 Delgato, 1982 O’Neil, 1983 Diaphragm function Dyspnea ? Hyperinflation

24. Pursed-lips Breathing • Reduces FRC by increase bronchial diameter • Delayes air way collaps by increased end expiratory lung volume • Reduces dinamic hyperinflation Conclusion; It was determined that the PLBE was increased SaO2 and PaO2, alveolar ventilation, reduced PaCO2, breathing rate, minute ventilation by İmproved pulmonary gas change and reduced dyspnea by increased tidal volume, İmproved deep and slow breathing and increased exercise capacity. PLBE, a simple-easy technic, no need device, useable during the walking and other activities Puente-Maestu, 2006 Gigliotti, 2003 Collins, 2001 Spahija, 2005

25. 12 wks, 1st wk-10 min, 4th wk- 25 min in PLBE group, according to the expiratory muscle training and control group, Severity of dyspnea reduced Inspiratory muscle strength and physical functional capacity increased

26. Regulation in Breathing Pattern And Active Expiratory Tecnique There is a positive correlation between the accessory respiratory muscles activity and severity of dyspnea Breslin, Chest, 1990 Reduced breathing frequence, increased tidal volume and PaO2 improve alveolar ventilation, functional status and reduce perception of dyspnea. Slow and Deep Breathing (lower frequency, higher tidal volume breathing) Use for; improves of abnormal chest wall motions, reduces working of breathing, reduces activities of accessory respiratory muscles and dyspnea

27. Diaphragmatic Breathing Increases abdominal motions and reduces upper rib cage motions No changes ventilation distribution Reduces working of breathing Reduces severity of dyspnea Sackner, 1984 Grimby, 1975 Diaphragmatic breathing increases work of breathing in patients with severe COPD Gosselink, 1995

28. Ventilatory limitation Deconditioning Dyspnea Loss of physical performance Exercise Training Exercise training for reduce dyspnea; • Interval training • Upper extremities exercise • Exercises must done with breathing control • Aerobic + strength exercises • Respiratory muscle training • Minimum 4 wks • Patients education Gigliotti, 2003, Ambrosino, 2004 Reardon, 2005, Porta, 2005 O’Donnell,2005, Lacasse, 2006 Georgiadou, 2007

30. Respiratory Muscle Training In COPD patients, hastenes respiratory muscles adaptation • ↑ respiratory muscle strength and endurance • ↓ nocturnal desaturation • ↑ exercise capacity • ↑ tidal volume without changed minute ventilation • ↓ breathing frequence (by increases expiration time and tidal volume) • Reduces dyspnea Gosselink, 2006 Ries, 2007 Geddes, 2008 Shahin, 2008

31. Respiratory Muscle Training In generally, respiratory muscle training was programmed with; • Pimax 25-35 % • 15 -30 min, 3-5 day/wk, • 6-8 wks Gosselink, 2006 Ries, 2007 Geddes, 2008 Shahin, 2008

32. Oxygen Therapy Oxygen; Obtaines bronchodilatation Reduces ventilatory demand Reduces lung hyperinflation ALLEVIATES DYSPNEA This effect is independent from oxygen desaturation at rest. Fujimoto, Chest, 2002

33. Oxygen Therapy in COPD • IC ↑, EELV ↓ • Dyspnea and leg fatigue ↓ and exercise time ↑ • Relief not always correlated to degree of hypoxemia O’Donnell, 2001 Alvis, 2003 Wouters, 2006 Peters, Thorax 2006 There was a low-grade scientific evidence that oxygen improves dyspnea in some patients with advanced pulmonary disease at rest. Gallagher, J Pain Palliat Care Pharmacother, 2004 Low-density oxygen = heliox 72 % + O2, 28 % or Heliox 79 % + O2, 21% in COPD patients; Dynamic hyperinflation ↓ Severity of dyspnea ↓ exercise capacity ↑ Chiappa, 2009 Barclay, 2006

34. Ambulatory oxygen is useful. Eaton, 2002 Ozalevli, 2007 6-minute walking tests performed in room-air conditions (A6MWT) and with supplemental oxygen (O6MWT) in patients with chronic obstructive pulmonary disease (COPD) and exercise-induced oxygen desaturation. Walking distance was longer with the O6MWT than with the A6MWT (p=0.001). The O6MWT resulted in a smaller increase in dyspnea, leg fatigue, and heart rate and a smaller drop in pulsed saturation than the A6MWT (p<0.05).

35. not chronically hypoxic COPD patients, exertional desaturation  88% (n=41), 4L.min O2

36. Rest of Respiratory Muscles and Mechanic Ventilation Noninvasive Positive Pressure Ventilation CPAP With nasal mask, 30-60 min, 7.5-8 cmH2O CPAP reduces dyspnea, improves QOL • CPAP; • Reduces inspiratory muscles effort • Reduces inspiratory breathing work • Improves diaphragmatic activity • Improves quality of sleep Severe COPD, acute exacerbations COPD, severe congestive heart diseases, severe interstitial lung disease, sleep-apnea and neuromuscular disease • Chest 2000; 118:1582-90

37. * * MRC dyspnea Stable hypercapnic COPD patients 6 months LTOT (n=47) NPPV + LTOT (n=43) Compared with long-term oxygen therapy alone, the addition of noninvasive positivepressureventilation to long-term oxygen therapy in stable chronic obstructive pulmonarydisease patients with chronic ventilatory failure improved dyspnoea.

38. Six minute walking test suppl. O2 (2.3 L/min) + NPPV (29±4 mbar, 20/min) suppl. O2 (2.3 L/min) 20, COPD, FEV1 %27

39. Dyspnea 6↓4 (M.Borg Scl) Walking distance 209↑252m In chronic hypercapnic chronic obstructive pulmonary disease, high-intensity noninvasive positive-pressure ventilation can administered during walking programs Dreher, 2007

40. Conductive addition therapies • Yoga • Walking aids • Walking and exercise with music • Hypnosis • Acupuncture-Acupressır • Biofeedback • Neuromusculer Electric Stimulation (NMES) • Organisation of Environment air and conditions • Use cool air to face • Nutritional support • Psychological support

41. Yoga Yoga = Deep breathing + Relaxation improves control of breathing by teaching deep and effective breathing and breathing awareness COPD patients, 12 wks, 2 sessions/wk, yoga Severity of Dyspnea ↓ *** Health-related quality of life → Functional capacity → Donesky-Cuenco, 2009

42. Walking Aids (Rollators) Improve forward leaning support upper extremities position stabilization to upper rib cage Increase maximal volounter ventilation Decrease perception of dyspnea and leg fatigue Increase functional capacity and status in daily living activities Improve courage and morale Solway, 2002 Probst, 2004 Gupta, 2006 Crisafuli, 2007

43. Walking Aids Forty, stable, severe COPD patients, One 6MWT was performed unaided, and the other was performed with a rollator Use of the rollator & reduction in dyspnea (p < 0.001) Conclusion: Use of a rollator was effective in improving functional exercise capacity by reducing dyspnea and rest duration.

44. Walking And Exercise With Music In COPD patients, walking with music; • Not changes severity of dyspnea. Brooks, 2003 Pfiste, 1998 • Decreases anxiety, fear of activity and dyspnea Bauldoff, 2002 Sidani, 2004 Exercise with music is a important strategy which make possible doing exercises with longer time and higher severity De Peuter, 2004 Need more research

45. Hypnosis Hipnoz Pediatrics 2001;107(2). 17 asthma and allergy patients (mean age 13.4) Hypnosis for relaxation and symptom control 1 month follow Dyspnea reduced in child specially which teaching self-hypnosis There is not enough research about this issue

46. Acupuncture&Acupressure Acupuncture in COPD patients, No change in dyspnea Lewith, 2004 Vicker, 2005 reduces dyspnea severity Jobst, 1986 Maa, 1997 44 COPD patients, 7 sessions/week, 6 wks, acupressure Severity of Dyspnea ↓ (p<0.05) Wu, J Adv Nurs, 2004 Acupressure is a non-invasive method which can used at home. need to research of it’s effects

47. Biofeedback Used with aim of improving breathing control developing functional statu regulating breathing pattern increasing tidal volume developing relaxation decreasing stress It was found that biofeedback with breathing voice was reduced bronchospasm according to the control group in mild-modarate asthma patients in study

48. Biofeedback • Incentive spirometry • Pulse Oksimetry • PEF meter EMG Biyofeedback

49. Patients with COPD, n=20, Biofeedback with pulse oxymeter (with follow heart rate and peripheral saturation) + Walking program 10 wks, Increase walking distance Reduce dyspnea Improve quality of life

50. Neuromuscular Electrical Stimulation • Severe COPD patients (n=15) • Home based NMES • 6 wks • Peripheral muscle strength, maximal exercise capacity were increase. • Severity of Dyspnea (CRDQ) was reduce (p<0.05) • Performance of daily life activities was improve. Neder, Thorax, 2002