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A M Yohannes, Manchester Metropolitan University, Manchester, UK
& 2006 Elsevier Ltd. All rights reserved.

Physiotherapy has long been utilized in the treatment of patients with respiratory problems. In the late 1950s, breathing exercises were recommended as a treatment for patients with chronic chest diseases but this suggestion was short-lived, as the efficacy of these exercises was inconclusive. Until the late 1970s, chest physiotherapy was a passive treatment on the part of the patient and the physiotherapist carried out manual chest physiotherapy techniques including percussion, vibrations, and shaking with gravity-assisted positions. The development of the active cycle of breathing technique (breathing control, lower thoracic expansion exercises, and forced expiratory technique), autogenic drainage, and adjunct physiotherapy aids in the removal of secretions. Procedures such as intermittent positive breathing techniques, have enhanced the treatment of chest clearance for patients with acute or chronic respiratory problems. Chest physiotherapy is routinely employed as a prophylactic measure prior to major surgery and postoperatively to prevent respiratory complications such as atelactasis and pneumonia. However, most of the systematic reviews that examined these techniques were inconclusive in their findings. To ascertain the benefits of these techniques in terms of reducing respiratory morbidity and healthcare usage and to improve the quality of life for patients with chronic respiratory problems, well-controlled clinical trials are needed.

Respiratory disease has a substantial impact on the health of the population at all ages and every level of

morbidity. Acute upper respiratory tract infections, including chronic lung diseases, are common causes of visits to general practitioners; they are a common cause of hospital admissions during the winter months, particularly in the elderly. Physiotherapy is the art and science of utilizing a variety of modalities to treat by using hands in order to maximize physical function. Chest physiotherapy assists the clearance of secretions and reduces breathlessness to improve lung function and reduce morbidity and mortality. Excessive bronchial secretion retention may contribute to the development of symptoms such as airflow obstruction, wheeze, shortness of breath, fatigue, and cough. Chest physiotherapy is defined as a combination of several mucus-clearance techniques to treat patients with acute or chronic respiratory problems by assisting mucus transport in order to improve lung function. These techniques can be used in a hospital ward setting, either in isolation or with mechanical devices, to treat patients with acute exacerbations, including those on life support machines in critical situations in the intensive care unit. Impaired clearance of the airways may lead to the development of respiratory infection, leading to acute infective bronchitis or, in more severe cases, the development of atelactasis and consolidation (pneumonia). These factors may contribute to poor gaseous exchange, decrease in ventilation perfusion, and breathlessness due to airflow limitation. If they


are not adequately treated and managed, persistent infection may lead to chronic lung disease, for example, bronchiectasis. The aims of chest physiotherapy are
* * * * * *


to reduce breathlessness, to remove excess bronchial mucus secretions, to increase exercise tolerance, to prevent respiratory complications postsurgery, to improve general fitness, to enhance gaseous exchange and reduce the work of breathing, and to encourage self-management for those with chronic respiratory problems.

exercises after abdominal surgery showed that breathing exercises have some benefits in reducing respiratory complications. However, other systematic reviews have reported conflicting findings. Indeed, no significant difference was reported in those studies that compared deep breathing exercises and incentive spirometry or continuous positive airway pressure or intermittent positive pressure breathing. Thus the usefulness of chest physiotherapy in the prevention of pulmonary complications after cardiothoracic surgery remains inconclusive.

Postoperative Physiotherapy
The effects of anesthesia may compromise the mucociliary clearance system, which is a physical defense mechanism protecting the lungs from damage. In addition, the patient’s fear of pain and rupture of the incision, especially a high incision on the upper abdomen, may compromise the function of the diaphragm. For those patients with routine abdominal surgery, the treatment should focus on breathing exercises to remove excess sputum secretions, encourage effective coughing with or without support, and lower thoracic-expansion exercises to increase ventilation and perfusion in the bases of the lung in order to prevent atelectasis and pneumonia. Early ambulation with the support and encouragement of the physiotherapist may assist in the prevention of deep vein thrombosis. The various chest physiotherapy techniques are discussed in terms of their efficacy, indications, contraindications, and evidence from systematic reviews. An essential requirement for any of the techniques described below, if the patient is in pain, is administration of adequate analgesia prior to chest physiotherapy treatment.

Preoperative Physiotherapy
It has been reported that pulmonary complications are common after cardiothoracic surgery and may increase the length of hospital stay, resulting in increased healthcare expenditure. The most common complications may include atelactasis (collapse of an area of lung) and pneumonia. Chest physiotherapy is, generally, prescribed as a prophylactic measure for patients admitted for major surgery, to ensure that the lung fields are clear prior to surgery. It also enables the therapist to assess the patient’s respiratory effort, to teach the patient chest clearance and effective coughing techniques, and also determine exercise tolerance. Indeed, performing an appropriate chest assessment will help the therapist to design and implement appropriate treatment strategies postoperatively (see Table 1). Systematic reviews that investigated the benefits of preoperative conventional chest physiotherapy techniques versus other adjunct chest physiotherapy aids have reported conflicting findings. Studies that compared incentive spirometry versus deep breathing
Table 1 Pre- and postoperative physiotherapy treatment Respiratory system

Circulatory system Check the patient for circulatory problems including deep vein thrombosis Teach ankle exercises – dorsal flexion, plantar flexion

Preoperative physiotherapy Assess the lung fields which are clear and free from excess sputum retention and crackles Teach the patient breathing exercises and effective coughing techniques Prepare the patient physically and psychologically for the operation Assess both upper and lower limb strength and mobility Postoperative physiotherapy Assess the chest for sputum retention Check for drains and tubes Monitor the arterial blood gases and oxygen saturation Teach breathing exercises routinely two to three times per day to keep the airways clear For those with sputum retention, encourage effective coughing techniques supporting the wound

Advice on posture and positioning Instruct and monitor ankle exercises Bed mobility Encourage walking at the bedside and within the ward


Active Cycle Breathing Techniques
Active cycle breathing techniques (ACBT) is a cycle of techniques of breathing control, lower thoracicexpansion exercises, and the forced expiration technique, modifiable to each individual patient. Indications. ACBT is appropriate for mobilizing and removing excess bronchial secretions in order to improve lung function without inducing hypoxemia.
Breathing Control

Breathing control (BC) is normal tidal breathing using the lower part of the chest with relaxation of the upper chest and shoulders. The aims of this technique are to encourage relaxation, ease breathlessness, and enhance the normal breathing pattern. The patient should be comfortable and well supported in an upright sitting or half-lying position. However, this can be modified according to the patient’s needs. The technique requires minimal effort from the patient. The therapist may place one hand lightly on the upper abdomen and encourage breathing through the nose, so that the air is warmed and filtered. As the patient breathes in, the hand should be felt to rise up and out; as the patient breathes out, the hand sinks down and in. The technique should be performed at the patient’s own pace. BC technique can be used as many times as possible on its own or as part of ACBT to encourage normal breathing. This technique is indicated for a patient with shortness of breath, hyperinflation, and those experiencing panic attacks/anxiety or for a patient who has had abdominal surgery and is unable to use the lower part of the chest due to pain. No contraindications for usage of this technique have been reported so far.
Lower Thoracic-Expansion Exercises

chest. The technique can be performed two to three times and interspersed with breathing control and rest. This technique can be combined with a 3-second ‘inspiratory hold’ after full inspiration before the passive relaxed expiration. The benefit of a 3-second hold at full inspiration has been claimed to decrease collapse of lung tissue. Care has to be taken for a patient with severe dyspnea. Further additional lung volume can be achieved by using a ‘sniff’ maneuver at the end of a deep inspiration with the purpose of recruiting collateral ventilation. Customarily, the therapists have employed these techniques two or three times per session; however, evidence of their efficacy is lacking. Precautions are required for a patient with severe shortness of breath. No more than three or four deep breaths should be performed at a time, otherwise it may lead to dizziness. However, the technique can be interspersed with rest and in conjunction with breathing control. Additional techniques such as chest percussion and vibration can be incorporated during chest-expansion exercises to mobilize secretions.
Forced Expiratory Technique

Lower thoracic-expansion exercises (LTEE) are indicated for patients with poor expansion of the lungs due to collapse of a particular segment of the lung (atelectasis), possibly due to fear of pain and copious sputum retention. LTEE helps to increase collateral ventilation so that the air behind the secretions may help to mobilize secretions from the periphery of the lung to the central airways. Thoracic-expansion exercises are deep breathing exercises emphasizing inspiration. Patients should be comfortably supported with pillows in order to relax the upper chest. The technique can be applied singlehanded at the affected lobe where the movement of the chest is to be encouraged or by placing both hands bilaterally at the lower bases of the lung, approximately at the level of the eighth ribs. Instructions include breathing in slowly and deeply and filling up the lungs with air and expanding the lower

Forced expiratory technique (FET) is indicated for patients with excessive sputum retention. The technique comprises one or two forced expirations (huffs) and breathing control. There are two types of huffs. (1) A huff using a mid-to-low lung volume (‘small breath in’) helps to move peripherally situated secretions to proximal larger airways. It is performed from mid-lung with a medium-sized breath and with the mouth and glottis open. (2) A huff employing higher lung volumes (‘a deep breath in’) can be used to clear secretions from the larger airways. However, FET is a difficult technique for some patients to grasp so patients should be taught in a simplified manner, for example, blowing in a tube or cottonwool ball in order to learn the correct FET technique. A reasonable amount of time needs to be spent with the adult patient to execute the technique effectively. Teaching children the FET technique using a peak flow mouthpiece or blowing games is useful. Normally, two or three FETs are adequate within a session interspersed with breathing control. The advantage of this technique is that it can be used at different levels of lung volumes and may assist the patients who produce large amounts of sputum. Excessive use of FET may, however, lead to bronchospasm. The FET technique uses the principle of the equal pressure point, which is the point where the pressure within the airways is equal to the pleural pressure.


The downstream of the equal pressure point towards the mouth, and the dynamic squeezing of airways allows secretions to be mobilized to the upper airways and is cleared by a huff from high lung volumes. This technique can be repeated a couple of times. The cough is a natural protection mechanism for airway clearance. It comprises of deep inspiration followed by short and sharp expiration that leads to closure of the glottis. When the expiratory muscles contract, causing a high increase in intrapulmonary and abdominal pressure, there is a sudden expulsion of air as the glottis open rapidly. This helps to expectorate the sputum from the airways. Excessive continuous coughing may induce bronchospasm so care is needed. ACBT is a successful, comfortable, and safe method of bronchial chest clearance technique for the expectoration of secretions and is widely used by physiotherapists to treat patients with respiratory problems. The whole ACBT cycle should be performed two or three times depending on the amount and the location of secretions. There are no contraindications for this technique. The ACBT cycle sequence may be employed in different combinations. For example, for a patient who is anxious and with overinflation, emphasis will be on breathing control, whereas for a patient with sputum retention, treatment may focus on lower thoracic-expansion exercises and forced expiratory technique, interspersed with breathing control (see Figure 1).



BC TEE Huff (c) FET BC

Figure 1 Examples to demonstrate the flexibility of the active cycle of breathing techniques. BC, breathing control; FET, forced expiratory technique; TEE, thoracic-expansion exercises.

Autogenic Drainage Technique
Autogenic drainage (AD) aims to maximize airflow within the airways to enhance the clearance of mucus and improve ventilation. The AD technique is not used as widely as the active breathing cycle technique and is mostly employed in Germany, Netherlands, and Belgium. It has been claimed that AD improves mucus clearance from peripheral to central airways due to changes in airway caliber and breathing at different lung volumes during expiration. Chevaillier originally described the three phases of AD as ‘unstick’, ‘collect’, and ‘evacuate’. Breathing at low lung volume may aid in the mobilization of secretions (‘unstick’) from the periphery to the central airways, breathing at mid-lung volume tends to collect the mucus in the middle range, and breathing at high lung volume may assist in the expectoration of sputum (‘evacuate’) from the larger airways. Several studies have commented that it is difficult for a patient to learn autogenic drainage and it requires a considerable amount of effort and cooperation from

the patient to participate in the treatment. The longterm benefits and its usage in clinical practice require further investigation.

Postural Drainage
Postural drainage is indicated when the volume of secretions is greater than 30 ml day À 1, when the patient is facing difficulty actively removing secretions, and conditions with excess sputum production prior to utilizing chest-clearance techniques. Technique. Secretions can be drained, as part of self-management, from the affected part of the lobe or segment using gravity-assisted drainage positions. The gravity-assisted drainage positions are based on the anatomy of the bronchial tree (see Table 2). However, in a patient with severe chronic obstructive pulmonary disease, these positions may not be tolerable and should be tailored and modified to the individual lobe in a way the patient can tolerate. The duration of treatment may range from 10 to 20 min. The affected area of the lung should be positioned in an uppermost position with or without a head-down

Table 2 Gravity-assisted drainage positions Lobe Upper lobe 1 2 Apical bronchus Posterior bronchus (a) Right Position 2 3 Sitting upright Lying on the left side horizontally turned 451 on to the face, resting against a pillow, with another supporting the head Lying on the right side turned 451 on the face, with three pillows arranged to lift the shoulders 30 cm from the horizontal Lying supine with the knees flexed Lying supine with the body a quarter turned to the right maintained by a pillow under the left side from shoulder to hip. The chest is tilted downwards to an angle of 151 Lying supine with the body a quarter turned to the left maintained by a pillow under the right side from shoulder to hip. The chest is tilted downwards to an angle of 151 Lying prone with a pillow under the abdomen Lying on the right side with the chest titled downwards to an angle of 201 Lying supine with the knees flexed and the chest tilted downwards to an angle of 201 Lying on the opposite side with the chest tilted downwards to an angle of 201 Lying prone with a pillow under the hips and the chest tilted downwards to an angle of 201

(b) Left


3 Lingula 4 5

Anterior bronchus Superior bronchus Inferior bronchus

5 7 7

Middle lobe

4 5

Lateral bronchus Medial bronchus

9 9

Lower lobe

6 7 8 9 10

Apical bronchus Medial basal (cardiac) bronchus Anterior basal bronchus Lateral basal bronchus Posterior basal bronchus

6 8 10 11 12

tip for drainage of secretions. During this time, other techniques such as percussion, vibration, and shaking can be incorporated as part of the treatment to loosen sticky secretions. For different gravity-assisted positions (see Figures 2–14). Contraindications to the head-down position may include:
* * * * * * * * * * * * * *

including heart rate, respiratory rate, blood pressure, and oxygen saturation measured with oximetry. Postural drainage immediately after meals should be avoided. The patient’s condition pre- and posttreatment should be monitored with a stethoscope to ensure that the affected area is clear.

Hypertension Severe dyspnea Recent surgery Severe hemoptysis Nose bleeds Advanced pregnancy Esophagus hiatus hernia Cardiac failure Cerebral edema Aortic aneurysm Head or neck trauma/surgery Mechanical ventilation Epileptic seizure Desaturation observed (whatever the reason) when the procedure is performed.

Relaxed Positions
Patients with severe dyspnea expend more energy and effort in daily activities. They may derive some benefit by adopting relaxed positions so that the abdominal content is not pressing on the diaphragm resulting in apical breathing with excessive usage of the accessory breathing muscles, especially at rest or after mild exercise. These positions may optimize the length and tension status of the diaphragm to improve its function, and also assist relaxation of the accessory muscles to reduce breathlessness. These relaxed positions may be helpful as selfmanagement for the patient (by performing breathing control to ease relaxation of the accessory muscles and allow movement of the lower chest). They may assist to overcome the impact of breathlessness

During head-down position, it is important to monitor cardiovascular and respiratory parameters


Figure 4 Posterior segment left upper lobe.

Figure 2 Apical segments upper lobes.

Figure 5 Anterior segments upper lobes.

Figure 3 Posterior segment right upper lobe.

Figure 6 Apical segments lower lobes.

in daily activities (see Figures 15–19): 1. Upright sitting or relaxed sitting with forward leaning (Figures 15(a) and 15(b)) 2. Forward lean standing (Figure 16) 3. Relaxed standing (Figures 17(a) and 17(b)) 4. Forward lean sitting (Figure 18) 5. Forward kneeling (Figure 19) The therapists have prescribed these positions as a part of chest physiotherapy treatment for patients with chronic chest diseases. However, to date,

the effects of these positions to improve functional activities or quality of life have not been conclusively proved in controlled clinical trials.

Manual Hyperinflation in Airway Clearance
Manual hyperinflation is one of the chest physiotherapy techniques that is used in intensive care in intubated patients. It involves using an ambu bag in order to produce a slow deep inspiration, inspiratory


Figure 10 Anterior basal segments. Figure 7 Lingula.

Figure 11 Lateral basal segment right lower lobe. Figure 8 Right medial basal and left lateral basal segments lower lobes.

Figure 12 Posterial basal segments lower lobes. Figure 9 Right middle lobe.

pause, and unobstructed expiration. The goals of physiotherapy treatment are to remove secretions, resolve atelectasis, and improve ventilation. Contraindications may include cardiovascular instability, barotraumas, severe bronchospasm, undrained pneumothorax, raised intracranial pressure,

and a high level of positive end expiratory pressure 410 cmH2O. A recent review of the usage of manual hyperinflation in airway clearance remains inconclusive. These techniques, however, have been used widely in intensive care units for many years. Future studies are needed to evaluate the correct dosage, patient position, and level of pressures and volumes.


Manual Chest Physiotherapy

Figure 13 Assisted treatment in high side lying.

Percussion or clapping is a synonymous term to describe the rhythmic clapping on the chest wall with relaxed wrist and cupped hand, creating an energy wave that is transmitted to the airways. Indications. Tenacious secretions, when the patient is unable to expectorate on their own. Technique. It is performed using a cupped hand with a rhythmical flexion and extension action of the wrist. It requires usage of both hands. Depending on the area of the chest, it may be more appropriate to use one hand to treat a specific lobe. For the infant,

Figure 14 Positioning: (a) sitting upright; (b) slumped sitting.

Figure 15 Relaxed sitting.


chest clapping is performed using two or three fingers of one hand. Chest clapping should be performed over a layer of clothing to avoid sensory stimulation of the skin. To

reduce any adverse consequence, the technique should be performed for 30 s, and interspersed with 3–4 lower thoracic-expansion exercises. It is essential to be cautious of vigorous and rapid chest clapping as this could lead to breath-holding and may induce bronchospasm in a patient with hyperreactive airways. Contraindications. Severe osteoporosis and hemoptysis.

Shaking is the use of coarse oscillations produced by the therapist’s hands compressing and releasing the chest wall and applied during expiration phase only.

Figure 16 Forward lean standing.

Figure 18 Forward lean sitting.

Figure 17 Relaxed standing.


secretions and using mechanical aids to stimulate lung function.

Figure 19 Forward kneeling.

Indication. Sputum retention. Technique. It should be performed following ‘a deep breath in’, during the expiratory phase. The hands are placed on the affected lobe in the directions of the ribs to mobilize secretions. Care must be taken for patients using long-term steroids and patients with osteoporosis, bony metastasis, and severebronchospasm. Shaking is contraindicated over a recent rib fracture or surgical incision. Evidence for its clinical use is sparse.

Vibrations are fine oscillations applied to the chest wall by the therapist’s hands and carried out during expiration after a deep breath in. The therapist should keep firm contact and direct the force inwards towards the center of the patient’s chest. Indication. Sputum retention. Contraindications. A recent rib fracture or surgical incision. Anecdotal evidence suggests that vibration has some benefit in the short term but there is a lack of evidence of the long-term benefits of this technique. A recent Cochrane review that investigated the benefits to bronchial hygiene of the use of percussion, vibration, and shaking concluded that there is not enough evidence to refute or support the efficacy of these techniques in treating patients with COPD and bronchiectasis. As most of the studies were small in sample size, had poor methodological designs, and a lack of sensitive outcome measures, it would be difficult to generalize the findings. Future studies should focus on larger sample sizes, with controlled randomized clinical trials being the best way forward.

Indication. Excessive sputum production (plugging), inability to cough effectively. Technique. Suction catheter should be sterile to prevent cross-infection. In practice, disposable catheters are used. It is good clinical practice to explain the procedure to the patient, if conscious, before carrying out the suction. Ensure the catheter is positioned so as not to damage the airway mucosa. The duration of treatment should be limited to 10–15 s. Suction should be applied constantly while removing the catheter. Saline can be used as an aid to suctioning to assist in the clearing of secretions. The extracted sputum should be sent to the laboratory for microbiological assessment in order to prescribe appropriate antibiotics. Contraindication. Severe hemoptysis, severe bronchospasm, and undrained pneumothorax. The physiotherapist may also be involved in the treatment of this patient group to maintain full range of movements of both upper and lower limb extremities by performing passive and active assisted exercises in order to maintain soft tissue length and function and also to reduce risks of developing edema and deep vein thrombosis in the lower limbs. However, the evidence of preventing or reducing deep vein thrombosis requires further investigation.

Exercise Therapy
Exercise therapy is a fundamental part of chest physiotherapy. Patients with chronic chest diseases should be encouraged routinely to be involved in an aerobic exercise program in order to improve general fitness, and increase exercise tolerance and functional activities. Physiotherapists are in a unique position to prescribe appropriate exercise programs as part of medical treatment for patients admitted in hospital with acute exacerbations of chronic lung diseases. The exercise regime should be tailored to the individual patient’s hobbies (if possible) and to baseline functional abilities. The purpose of the physiotherapy treatment is to maximize the patient’s independent function and increase walking endurance. The exercise program will need to determine the intensity, type of exercise, setting, and patient compliance in order to monitor the efficacy of the program.

Intensive Care Unit
The role of the physiotherapist in the intensive care unit is to treat intubated patients by clearing chest

342 PHYSIOTHERAPY Ground-Based Walking Exercise

Walking improves both cardiovascular fitness, increases exercise tolerance, and stimulates psychological well-being. It is simple to perform, safe, and able to be incorporated into the daily routine of the patient. The exercise can be done at home and does not require special equipment. In simplistic terms, patients with chronic chest problems can monitor their own progress by, for example, monitoring how many meters or miles they have covered or for how long they have walked per session. There is no clinical guideline as to how many times per week ground-based walking exercises will be required in order to produce a significant improvement in the patient’s functional activities and quality of life. Current customary clinical practice in the prescription of ground-based exercise by physiotherapists is two to three times per week for a duration of approximately 30 min. This self-management exercise program requires future investigation to find out if it has any benefits in terms of reducing exacerbations of chronic respiratory disease.
Upper Limb Aerobic Exercise Training

limb muscles, for example, reduced strength and endurance of the quadriceps muscle. Quadricepsstrengthening exercise should then be incorporated with the treatment program. Step aerobics have been shown to improve general fitness. For those with severe chest diseases, graduated stair-climbing several times a day may improve general fitness and quadriceps function. The home exercise program can be devised using the bottom of the step and climbing up and down by holding a banister or stair rail. The intensity and duration of the exercise program should be determined by the patient’s exercise tolerance and fatigability. However, patients should be assessed prior to the exercise program for other medical problems such as dizziness. If the patient is unable to perform the exercise mentioned above, this can be substituted by unweighted straight-leg raising when lying and knee extension when sitting.
Stationary Cycling

Dyspnea on exertion is a primary problem for patients with chronic chest problems. Patients very often have difficulties in performing overhead activities, for example, lifting light objects from a shelf or dusting. This often leads to fear and avoidance of these activities and in turn to atrophy by disuse and weakness of muscles in the upper limbs. This exacerbates and promotes inactivity which may lead to a ‘vicious circle’. Studies have reported that aerobic exercise training in patients with chronic chest problems improves exercise tolerance and reduces metabolic and ventilatory requirement. The following exercises can be prescribed by the therapists after discharge (for home ‘use’). Unweighted arm exercise with repetitive bilateral shoulder flexion and abduction from neutral position synchronized with breathing. The level of intensity of the exercise program can be determined by assessing the patient to see how many times he/she can perform the exercise. The frequency and intensity of the exercise program can be increased over time. For those who are capable of weight-lifting, the exercise can be prescribed using light weights that can be increased suitably.
Lower Limb Aerobic Exercise Training

Stationary cycle can be used at home or in a local gymnasium. This may provide more controlled exercise than ground-based walking. This form of exercise is helpful in determining the level of exercise intensity achievable. Hence it can be used as a selfmonitored objective measure to determine the progress of exercise capacity. All these exercise training modalities should be considered both in the clinical setting and as a selfmanagement program at home to improve cardiorespiratory function and exercise tolerance for this patient group.

Several chest physiotherapy techniques and adjunct modalities are available in current clinical practice to treat patients with acute and chronic chest diseases. Chest physiotherapy may be effective in improving mucus transport. Whether it has any benefits on pulmonary function in the long term is not clear. In addition, evidence from systematic reviews suggests no single technique is superior than the other. The findings from research studies are inconclusive. Treatment for individual patients has to be ‘tailormade’ in light of the patient’s clinical findings, for example, arterial blood gases and oxygen saturation, in order to be effective. Further studies are required to determine the efficacy and benefits of these physiotherapy techniques and modalities in short, medium, and long term in reducing length of hospital stay, healthcare utilization, and impact on quality of life and self-management programs.

Patients with chronic chest problems, especially older patients, spend substantial amount of their time indoors leading a sedentary lifestyle. This may lead to physical deconditioning and weakness of the lower

PLATELET-DERIVED GROWTH FACTOR 343 See also: Atelectasis. Exercise Physiology. Symptoms of Respiratory Disease: Cough and Other Symptoms. Ventilation: Control.
Lapin CD (2002) Airway physiology, autogenic drainage and active cycle of breathing. Respiratory Care 47: 778–785. Pasquina P, Tramer MR, and Walder B (2003) Prophylactic respiratory physiotherapy after cardiac surgery: systemic review. British Medical Journal 327: 1379–1381. Pryor JA (1999) Physiotherapy for airway clearance in adults. European Respiratory Journal 14: 1418–1424. Pryor JA and Prasad SA (eds.) (2002) Physiotherapy for respiratory and cardiac problems. In: Adults and Paediatrics, 3rd edn. London: Churchill Livingstone. van der Schans CP, Postma DS, Koeter GH, and Rubin BK (1999) Physiotherapy and mucus transport. European Respiratory Journal 13: 1477–1486. West JB (2001) Pulmonary Physiology and Pathophysiology. An Integrated Case-Based Approach. Philadelphia: Lippincott Williams & Wilkins. Yohannes AM (2001) Pulmonary rehabilitation and outcome measures in elderly patients with chronic obstructive pulmonary disease. Gerontology 47: 241–245.

Further Reading
Denehy L (1999) The use of manual hyperinflation in airway clearance. European Respiratory Journal 14: 958–965. Harden B (2004) Emergency Physiotherapy. London: Church Livingstone. Hough A (2001) Physiotherapy in Respiratory Care. An EvidenceBased Approach to Respiratory and Cardiac Management, 3rd edn. Chelthenham: Nelson Thornes. Jones AP and Rowe BH (2000) Bronchopulmonary hygiene physical therapy for chronic obstructive pulmonary disease and bronchiectasis (Cochrane Review). Cochrane Database of systematic Reviews (2): CD000-045.

Plasminogen Activator and Plasmin

see Fibrinolysis: Plasminogen Activator and Plasmin.

J C Bonner, CIIT Centers for Health Research, Research Triangle Park, NC, USA
& 2006 Elsevier Ltd. All rights reserved.

Platelet-derived growth factor (PDGF) isoforms are polypeptide mediators that play a major role in stimulating the replication, survival, and migration of mesenchymal cells during the pathogenesis of fibrotic diseases. PDGF is secreted by a variety of cell types including epithelial cells, macrophages, and fibroblasts as a response to injury, and many proinflammatory cytokines mediate their mitogenic effects via the autocrine release of PDGF. PDGF-A and PDGF-B chain dimeric isoforms (PDGF-AA, PDGF-AB, and PDGF-BB) play important roles in the pathogenesis of fibrosis. These isoforms promote myofibroblast proliferation and chemotaxis, but also serve other functions including stimulation of collagen production and promotion of cell adhesion. Less is known regarding the significance of the more recently discovered PDGF-C and PDGF-D chain isoforms. The biological activity of PDGF is determined by the relative expression of PDGF a-receptors and b-receptors on the cell surface. These receptors are induced during lung fibrogenesis, thereby amplifying biological responses to PDGF isoforms. PDGF action is further modulated in the extracellular milleau by binding proteins, matrix molecules, and proteases.

serum factor that stimulated the growth of arterial smooth muscle cells during the pathogenesis of atherosclerosis. Several groups subsequently purified this major PDGF on the basis of its ability to stimulate the growth of smooth muscle cells and other mesenchymal cells. In the late 1980s, the genes encoding the classical PDGFs (PDGF-A and PDGF-B) along with two receptor genes (PDGF a-receptor – PDGFRa and PDGFb-receptor – PDGFRb) were cloned. More recently, two novel PDGFs (PDGF-C and PDGF-D) were discovered that are proteolytically activated in the extracellular microenvironment. PDGF and its receptors have been shown to play critical roles in the normal processes of development and tissue repair as well as in the pathogenesis of diseases such as cancer, atherosclerosis, and fibrotic diseases.

The genes encoding the four PDGF polypeptide chains are located on four different chromosomes. The human PDGF-A and PDGF-B genes are located on chromosomes 7 and 22, whereas the PDGF-C and PDGF-D genes are located on chromosomes 4 and 11, respectively. All four PDGFs are synthesized and assembled as disulfide-linked dimeric polypeptides in the endoplasmic reticulum (ER) as inactive precursors, which are then proteolytically processed

In the 1970s, Ross and colleagues discovered platelet-derived growth factor (PDGF) in the search for a

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