RESPIRATORTY

TREATMENT By :
Dr: Eman Abd El Halim
• Chest P.T is the area of treatment that deals with evaluation and treatment of patients with
acute and chronic lung disorders.
• Therapeutic measures may be curative or preventive
• Proper management of a patient with respiratory problems requires an understanding of :
• 1- physiological problem present
• 2- The effectiveness of a given treatment must be measured by effective criteria
• e.g.: secretion accumulation
General clinical problems of patient
with pulmonary disorders:
1. impaired ventilation and oxygenation
2. Increased the work of breathing
3. Increased oxygen consumption
4. Impaired cough
5. Impaired airway clearance
6. Musculoskeletal dysfunction and postural abnormalities
7. Decreased exercise tolerance
8. Pain
Goal
s:GOALS IS DIVIDED into sort and long term goal 9. Improve endurance and general exercise
and must be discussed with the patient tolerance
1. Improve ventilation 10. Prevent or correct postural deformities
2. To increase oxygenation associated with respiratory disorders

3. Prevent pulmonary impairment 11. Promote relaxation physically and mentally

4. Improve the strength , endurance, and 12. Maintain or improve chest mobility
coordination of respiratory muscles 13. To decrease oxygen consumption
5. Reduce work of breathing 14. Teach the patient how to deal with
6. Improve cough effectiveness shortness of breath attacks

7. Prevent airway obstruction and 15. Improve a patient overall functional

accumulation of secretions capacity

8. Improve airway clearance 16. Improve quality of life of these patients

I- TTT administered to increase ventilation
and oxygenation:
• Alveolar ventilation depends on the magnitude of :
 Tidal volume
 Dead space
• As : Alveolar ventilation = (VT- DS)* R.R
• During normal breathing: Alveolar ventilation = (500-150) * 12 = 4200 ml/min
• So P.T strategies administered to increase ventilation should:
• Increase Tidal volume
• Decrease Dead space
• Or both
• Decrease the arterial carbon dioxide tension (PaCo2)
• Increase the arterial oxygen tension (PaO2)
• Techniques to increase ventilation and oxygenation:
A. Positioning techniques (TO IMPROVE v/q matching )
B. Breathing exercises
Monitoring of treatment to improve
ventilation and oxygenation :
1. Normalization of respiratory rate
2. Normalization of respiratory pattern
3. Arterial blood gases :
- Increase PaO2
- Decrease PaC02
II- TTT administered to decrease the O2
consumption:
• There are two strategies to reduce the O2 consumption by :
A- Reducing the work of breathing : by breathing exercises and leaning forward postures : to reduce
the rate of breathing and eliminate activity of accessory muscles
B- Reducing the general body work: by:
1- relaxation therapy
2- work adjustment
• All the treatments administered to reduce the O2 consumption working by :
 Reducing the basal metabolic rate
 Minimizing the unsupported body position
 Minimizing the antigravity work
• Benefits of treatment to reduce the O2 consumption:
1. Elevate dyspnea threshold for a given activity
2. Elevate functional activity tolerance
3. Improve quality of life
III. improve secretion clearance:
• cough technique
• postural drainage and its adjuctives
• Active cycle of breathing
• Autogenic drainage
• Devices: ( flutter , …)
IV. prevent shortening of muscles and
postural
problems:
• - stretching ex
• - stretching positioning
V. Improve exercise tolerance
Techniques used with Chest
patients
A. Positioning
techniques
• Supine
• Prone
• Lateral decubitus

• The changes in positions may significantly alter arterial oxygenation

• Changing in patient position depends on ventilation- perfusion (V/Q) ratio
• Ventilation- perfusion (V/Q) ratio:
• At alveolar capillary level , the ventilation (V) perfusion (Q) must be balanced so that
optimal gas exchange occurs.
• Optimal V/Q ratio=1 but this is theoretically as there are regional differences in
ventilation and perfusion along different areas of the lung. ( the actual is 0.8 )
• In general, these differences are due to the effect of gravity and intra-pleural pressure
gradient, which is more negative at the upper part of the lung and less at the lower parts
• On supine position : the posterior aspects of the lungs is the most gravity – dependent
areas and receives the most blood

• On standing : the base of the lungs (gravity – dependent areas ) the greatest amount
blood flow.

• When the position is changed, areas of greatest ventilation also changed.

B- Breathing exercises (retraining )
• Def.: it is a type of exercise that aim to retrain muscles of respiration and improve ventilation & oxygenation, facilitate deep
breathing & often stimulate cough reflex also patients with acute and chronic lung disease are taught controlled breathing

activities to improve the efficiency and lessen the work of breathing. Also can be done connected with active ROM exercise to

the shoulders & trunk that also help expand the chest

• Indications :
1. Acute or chronic lung disease: ( COPD, Pneumonia, Atelectasis & ARDS)
2. Pain in the thoracic or abdominal area because of surgery or trauma
3. Airway obstruction secondary to bronchospasm or retained secretions
4. Deficits in the CNS ( neuromuscular disease) that lead to muscle weakness: ( high spinal cord injury, acute or chronic
myopathic or neuropathic diseases)
5. Sever orthopedic abnormalities, such as scoliosis and kyphosis that affects respiratory function
6. Stress management
7. Old age & prolonged bed rest.
N.B: patients with chronic lung disease is often taught “ breathing control” or “ breathing retraining” exercises
Goals of breathing retraining :
1. Improve ventilation function as it improve tidal volume
2. Improve the strength , endurance, and coordination of respiratory muscles
3. Increase the effectiveness of cough mechanism and so assist removal of secretions
4. Prevent atelectasis
5. Correct ineffective or abnormal breathing pattern
6. Improve the position and function of respiratory muscles
7. Control the respiratory rate and breathing patterns thus decreasing air trapping
8. Maintain or improve chest and thoracic spine mobility
9. Promote relaxation by reducing work of breathing.
10. Teach the patient how to deal with shortness of breath attacks
General principals in teaching
breathing :-
1- if possible, choose a quite area for instruction where you can interact with the patient with a minimum of distractions
2- Explain to the patient the aims and rationale of breathing exercises
3- Place the patient in comfortable, released position and loosen restrictive clothing
a) Initially, a crock lying position in bed, with the head, and trunk elevated approximately 45 degrees, is desirable totally
supporting the head and trunk and by flexing the hips and knees and supporting the legs with a pillow, so the abdominal
muscles remain relaxed.
b)Other positions such as supine , sitting or standing may be used initially or as the patient progresses in treatment
4- observe and evaluate the patient 's natural breathing pattern while at rest and with activity;
a. determine whether retraining is indicated,
b.determine the emphasis, either inspiratory or expiratory, that the breathing exercise program should take,
c-establish a baseline for assessment of change and progress in treatment
• If necessary teach the patient relaxation techniques. This will relax the muscles of the upper thorax, neck and shoulders to
minimize the use of the accessory muscles of respiration. Pay particular attention to relaxation of the sternocledomastoid ,
scalene, upper trapezius and levator scapulae.
5 Demonstrate the desired breathing pattern to the patient
6 Have the patient practices the correct breathing pattern in a variety of positions at rest and with activity
What is the function of the physiotherapist hand during breathing exercise?
▪ Guidance: To stimulate the chest movement “ guide the motion” and prevent trick
movement
▪ Assistance: by giving pressure at the end of expiratory phase.
▪ Mobilizing : Mobilize the thoracic joints by putting the fingers on the ribs and
giving pressure & vibration at the end of expiration on ribs.
▪ Strength: Strength the intercostal muscles by putting your fingers in the intercostal
space, resist the movement of chest by giving pressure (resistance ) at the middle of
inspiration
▪ N.B: patient can apply the exercise by himself after teaching the proper methods for
doing
it
Precautions:
• When teaching breathing exercises, be aware of the following precautions:

1)Never allow the patient to force expiration as it should be relaxed and passive because forced expiration will
increase turbulence in the airways which can lead to bronchospasm & increase airway restrictions due to obstruction.

2) Don’t allow patient to do very prolonged expiration as this will cause patient to gasp with the next inspiration and
so his breathing pattern become irregular and inefficient

3)Don’t allow patient to initiate inspiration with the accessory muscles & upper chest & advise him that upper chest
should be relatively quiet during respiration.

4)Allow the patient to practice deep breathing for only three or four inspirations & expiration at time to avoid
hyperventilation that lead to get rid of all carbon dioxide that is considered the main stimulator for hypothalamus to
initiate signals for respiration.

N.B: all breathing patterns should be deep, voluntarily controlled & relaxed.
 CONTRAINDICATION
Severe pain and discomfort
S Patients with skin grafts or spinal fusions will
A c u t e m e d i c a l o r s u r g i c a l e m e r g e n c y have undue stress placed on areas of repair.
Patients with reduced conscious level Bony metastases, brittle bones, bronchial
hemorrhage, and emphysema are
Increased ICP
contraindications for undue stress to the
Unstable head or neck injury thoracic area.
Active hemorrhage with hemodynamic instability Verify that patient has not eaten for at least one
or hemoptysis hour.
Recent (within one hour) meal or tube feed
Flail chest
Untreated pneumothorax
Uncontrolled hypertensionAnticoagulation
Rib or vertebral fractures or osteoporosis
Acute asthma or tuberculosis
Patients who have recently experienced a heart
attack.
Types of breathing retraining techniques :
Breathing techniques can be divided into normal breathing, known as 'breathing control', where minimal effort is expended, and
breathing exercises where either inspiration is emphasized as in thoracic expansion exercises or expiration is emphasized as in the
huff of the forced expiration technique.

Breathing techniques used to improve ventilation and oxygenation:

1. Diaphragmatic breathing exercise

2. Pursed lips breathing exercise

3. Segmental ( localized ) breathing exercises

4. Belt breathing exercise

5. Sustained maximal breathing exercise

6. Breathing exercise connected wit postural exercise

7. Breathing control techniques ( paced breathing )

Other classifications:
• I- Deep breathing exercise: • Also can be classified into inspiratory and expiratory ex. :
• 1- Diaphragmatic br ex • Inspiratory exercise:
• 2- Pursed lips br ➢ Nose exercise
• II- localized Br.Ex: ➢ Diaphragmatic breathing.
• 1- upper costal ➢ Localized breathing exercise ( Segmental breathing).
• 2- lower costal ➢ Belt exercise.
• 3-Apical ➢Exercises to strengthen the inspiratory muscles & increase the
depth of inspiration.
• 4- sternal
➢ Inspiratory resistance training.
• III- Ex. Connected with respiration
• Expiratory exercise
• Ul&LL
➢ PURSED LIP BREATHING.
• trunk
➢ Buteyko breathing technique.
➢ Active cycle of breathing technique.
➢ Autogenic drainage
➢ Candle blowing.
➢ Talking long sentences.
➢ Forced expiratory technique.
• Postural exercise connected with breathing For both inspiration
& expiration
 1- Nose breathing exercise:
Benefit:
To stimulate and strength of the diaphragm
Graduations:
• Massage for the nose for both sides for stimulation
• Feeling the air on the top of nose.
• Giving him something to smell.
• Vibration of the nose to stimulate the normal airway passage by using the middle & ring finger bilaterally.
• Closure of one opening then by the other opening take inspiration &expiration.
• Then inspire from one opening & expire from the other “alternative opening & closing”.
• Then do snuffing (short interrupted breathing to stimulate diaphragm).
• Then do sniffing (deep long breathing to strength diaphragm).
• Then massage again for nose for relaxation.
2- Diaphragmatic breathing
exercise:
*the diaphragm controls breathing at an involuntary level, but a patient can be taught diaphragmatic breathing by correct use of the
diaphragm and relaxation of the accessory muscles
• Benefits :
• Improve Diaphragmatic excursion
• Improve distribution of ventilation as it improve expansion in lower lung zones
• Increase total ventilation as it increase the depth of inspiration
• Eliminate the activity of accessory muscles as it strengthen respiratory muscles
• Increase rib cage motion
• Its uses are:
A-to control breathing during attacks of dyspnea and during exertion
B-to improve ventilation in the bases of the lungs and improve oxygenation and the excursion ( descent and ascent) of the
diaphragm
C- used to mobilize lung secretions during postural drainage
D- delay the onset of fatigue of the diaphragm by improving strength and metabolic capacity of this major muscle of inspiration.
E- In particular, clinicians suggest that patients with neuromuscular disorders that weaken the diaphragm or other muscles of
inspiration can benefit from strengthening exercises for the diaphragm
Procedure of Diaphragmatic breathing exercise:
• prepare the patient in a relaxed and comfortable position, evaluate his breathing pattern and
demonstrate the correct method of diaphragmatic breathing
•Position patient in long sitting. with his back and head are fully supported and abdominal muscle
relaxed
•Place your hand or patient's hand on his epigastric area .( on rectus abdominis just below the
anterior costal margin
• Ask the patient to breathe in slowly but deeply , keeping his shoulders relaxed and upper chest
quite and allowing his abdomen to rise
• The order you give him is: take a deep inspiration try to make your abdomen as a balloon keeping
your shoulders relaxed & upper chest quiet ;
then till him to slowly let all air out (The order you give him is: breathe out as quietly as possible ).
• This must be made 3 or 4 times only and rest.
• The patient will feel the movement himself by his hands
• When the patient understands and is able to breathe using a diaphragmatic pattern, suggest that he
breath in through nose and out through mouth
• Practice diaphragmatic breathing in a variety of positions( sitting, standing) and during activity (
walking, and climbing stairs)
Don’t allow using of the accessory muscles of inspiration.

• Don’t allow patient to hyperventilation.

Use of weight for strengthening the diaphragm :

1 have the patient assume a supine or slightly head up positioned

2 be sure that the patient knows how to breathe in by primarily using the diaphragm

3 place a small weight such as sandbag (1.30- 2.20 kg or 3-5 ib) over the epigastric region of the patient's abdomen

4tell the patient to breathe in deep while trying to keep the upper chest quiet. The resistance should not interfere, with full excursion of
the diaphragm.

5 gradually increase the time that the patient breathes against the resistance of the weight. The weight can be increased when the patient
can sustain the diaphragmatic breathing pattern for 15 minutes

•Other method by giving resistance by hand in opposite direction of diaphragm movement N.B:

P.T can assist diaphragmatic breathing by his hand in the direction of diaphragm movement

- One hand can be on the chest so fell if the patient start breathing with chest not the abdomen and instruct him/her to do the exercise
correctly
3- Pursed lips breathing
•exercise
Benefits :
• Slow the R.R
• Reduction in airway narrowing during expiration
• Increase tidal volume
• Enhance ventilation in the previous under-ventilated areas.
• Relives dyspnea
• It increase ex tolerance
• Prevent collapse of small airways as it reflects a positive pressure in the small airways at the end of expiration
which will prevent air trap in
• It can be used in COPD during shortness of breath attacks that usually occurs with physical exertion or in contact
with allergen
• Technique :
• Take bronchodilator. (Not common).
• Position the patient is a comfortable, relaxed forward bending position as this position will stimulate diaphragmatic breathing.
• Explain the benefit of the exercise to the patient
• Explain to patient that expiration must be relaxed, passive & that contraction of abdominal muscle must be avoided. Explain
why abdominal muscle contraction is undesirable.
• Place your over the mid-rectus to detect any abdominal muscle contraction.
• Direct the patient to inhale slowly and deeply through nose while mouth is closed
• Instruct the patient to purse the lips before exhalation, control the breathing & decrease respiratory rate.✓ This will make
a backward pressure that will open collapsed alveoli & mobilize secretions.
• Instruct the patient to relax the air out through the pursed lips and without abdominal contraction
• Direct the patient to stop exhalation when abdominal muscle contraction is detected
• Ask the patient to do exercise independent while standing and exercising (walking)
• Orders :
• Sit relaxed
• Inhale slowly and deeply through nose while mouth is closed
• Purse lips
• Breath out through pursed lips (Breath out twice longer as breathing in )
• do not contract abdominal muscles (to Ensure relaxed expiration )
4- Segmental ( localized ) breathing
exercises
Benefits
1. Expand localized areas of the lungs ( isolated lobes )
2. Prevent accumulation of pleural fluid
3. Prevent accumulation of tracheobronchial secretions
4. Improve chest mobility
Types :
1 Apical breathing
2lateral costal ( upper, middle, lower) breathing
3- posterior basal breathing
4- sternal breathing
* can be done unilaterally or bilaterally
* All these exercises can be done with assistance or resistive by using the therapist hands;
- If PT gives the pressure during end of expiration it will be assisted with slight vibration
- If PT gives the pressure in the middle of inspiration it will be resistive which is used to strengthen the respiratory muscles
- pressure is applied to appropriate areas of the chest wall utilizing proprioceptive stimuli so that efficient expansion of these areas
may be obtained
1-apical Br. Ex. :
this is useful when there is restricted upper chest movement or incomplete expansion of lung tissue particularly where
there is an apical pneumothorax e.g. following lobectomy
- the patient breath in, expanding the chest forwards and upwards against the pressure of the fingers and the breath
out, shoulders should be relaxed
Procedure :
•The patient should be in half –lying position with the knees slightly flexed over a pillow OR Long sitting or sitting
with supporting the back & the neck to avoid use of accessory muscle.
• Patient or therapist hand under clavicle bilaterally or unilaterally with wrist at level of suprasternal notch with the
fingers open & hands hooking around both shoulders apply pressure below the clavicle with the fingertips
• Tell patient: try to push my hands upwards filling your chest with air.
• Then tell him to breathe out.

• If the patient is obese knuckles placed under clavicle or by all hands.

2- Upper lateral costal breathing exercise:
• Patient placed in a comfortable position.
• The therapist hand is just below the axilla bilaterally or unilaterally with the knuckles parallel to the anterior
axillary line and the thumbs at level of Luis angle.
• For mobilization hand placed on ribs giving pressure & vibration at end of expiration.
• For strength hand placed on muscles giving resistance at middle of inspiration.
• Ask patient to breathe slowly but deeply making him pushing your hands outward by filling his chest with air.
• Then ask him to breathe out assisting him by gently squeezing the rib cage in a downward &inward direction.
3- Middle lateral costal breathing expansion:
•patient is sitting, The same procedures but with the physiotherapist hand bilateral & unilateral fanning at level of
middle ribs just below axilla
4- Lower lateral costal expansion:
• patient in sitting or crock lying position
• The same procedures but with the physiotherapist hand fanning over lateral Aspect of the lower ribs
(7th, 8th, and 9th ribs) with 2 thumbs at level of epigastric area or angle and , his knuckles parallel to the
anterior axillary line, to make patient attention to the areas where movement is to occur
• therapist applies p. or guidance via his hands
• Ask patient to breathe out, and feel the rib cage move downward and inward
• As the patient breathes out, apply quick downward and inward stretch on the external intercostals to
facilitate their contraction. These muscles move the ribs outward and upward during inspiration
• Tell the patient to expand the lower ribs against your hands as he/she breathe in
• Apply gentle manual resistance to the lower rib area to increase sensory awareness as the patient
breathes in and the chest expands and ribs flare
• Then again, as the patient breathes out, assist him by gently squeezing the rib cage in a downward and
place a quick downward pressure into the ribs
• The patient may then be taught the maneuver himself. He may place his own hand (s) over his rib cage.
5 Posterior basal expansion:
• Have the patient sit & lean forward slightly binding his hips.
•Place the physiotherapist over the posterior aspect of lower ribs with the 2 hands cupping 2 scapula’s with the
same procedure.
•This form of segmental breathing is important for the post-surgical patient who confined to bed in a semi
upright position for an extended period of time as secretions often accumulates in the posterior segments of the
lower ribs.
6- sternal Br. Ex. :
• The patient is in sitting position or in long sitting position in bed with shoulders relaxed.
• The therapist places his hand over the sternum
5- Belt breathing
exercise:
• Belt : -Length :1.5-2 meter -Width: 25- 35 cm
• Used for:
▪ In case of incisions (Postoperative).
▪ Large areas to apply equal pressure.
▪ Obese subjects & Different sex.
▪ As a home program as the patient can do the exercise by
himself.
• Advantage:
• ✓ Used after operation as it is not painful.
• ✓ Give equal pressure in all points.
• ✓ Take large areas.
• ✓ Suitable for fatty, very sensitive patients.
• ✓ Easy to be used by patient himself.
• Disadvantage:
• ✓ Trick movements are difficult to be noted.
6- Sustained maximal breathing
exercise:
• Benefits : slow R.R
• Breathing exercise during which hold for about 3 seconds at maximal inspiration is encouraged

7- Breathing control techniques ( paced breathing ):

Benefits:
• Reduce the work of breathing during activity
• Increase the breathing control
Technique :
• Walking: inhale two steps, and then exhale four steps
• Upstairs : exhale as stepping up, then inhale and rest before the next step
• Pushing or pulling: exhale
• From lying to sitting to standing: exhale
 8 - Breathing exercise connected wit postural
exercise ( exercise connected with
▪breathing) : combine active movement of trunk & extremities with deep breathing.
It is type of exercises that
Benefits :
• Maintain or improve the mobility of the trunks and shoulders when it affects respiration
• Reinforce or emphasize the depth of inspiration or expiration
• Exercises can be: mobilizing, strengthening and /or stretching ex. Connected with respiration (expiration and /or
inspiration )
 For upper limbs and lower limbs do:
• - movement of the limb away from the body with inspiration (e.g; shoulder flexion and abduction, elbow extension,…etc)
• - movement of the limb toward the body with expiration (e.g; shoulder extension and adduction, elbow flexion , ,…etc)
 For trunk do :
• Bending forward (flexion ) with expiration
• Bending backwards (extension) with inspiration
• Turning trunk with expiration
• Examples:
1) Exercise to mobilize one side of shoulder:
• With the patient sitting, have him bend away from the tight side to lengthen tight structures &expand that side of the chest
during inspiration. (Like in scoliosis the tight side is the concave side).
• Then have him push his fisted hand into the lateral of his chest as he bends toward the tight side & breathe out.
• Progress by elevating his arm on the tight side overhead.
2) To mobilize the upper chest & stretch the pectoralis muscles:
• With the patient sitting on a chair & his hands clasped behind head (have horizontally abducted his arms) during inspiration.
• Then have him bring his elbows together & bend forward emphasize expiration.
3) To mobilize upper chest & shoulder:
•With the patient on a chair, have him reach with both arms overhead (180 degree bilateral, shoulder flexion& slight abduction)
during inspiration.
• Bend forward at hips & reach for the floor during expiration.
4) To increase expiration during deep breathing:
• Have the patient breath in a crock lying position.
• Then pull him both knees to his chest during expiration.
N.B: wand exercise emphasizing shoulder flexion during inspiration may also be combined with breathing exercise.
9- The Butekyo breathing technique
(BBT):
• Butekyo breathing technique is a set of breathing exercises developed by the ukranian doctor Konstantin
Pavlovich Butekyo.
• Dr K.F. Butekyo developed the theory that chronic hyperventilation and subsequent depletion of CO2 lead to the
development of defensive reactions of the body which are attempts by the organism to limit the further
exhalation and loss of Co2.
• The Butekyo method assesses the degree of depletion of CO2 by measuring the length of breath holding time (
breathing test )
• Butekyo breathing technique: based on control pause during expiration as to control hyperventilation
• Indications : Asthma, anxiety, bronchitis, emphysema, hyperventilation, persistent cough, snoring, sleep apnea,
sinusitis.
• Contraindications:
▪ Acute stage of emphysema.
▪ Positive TB infection.
▪ DVT.
▪ Cerebral atherosclerosis
Butekyo breathing technique:

1 take pulse at rest by measuring the pulse rate at wrist.

2Control pause (CP): breath in and out normally through nose and then hold breath (e.g. by pinching your nose )
until it becomes uncomfortable- i.e. until you can breathe in without gasping. Note how long CP is.

3 very shallow breathing: breathing in and out through the nose as shallow as possible – do this 3 minutes or as
possible

4relax shoulders: shrug shoulders and relax neck as the previous exercise will probably have made them tense

5- Maximum pause (MP) breath is done by doing CP but by holding breath as long as possible.

6- Repeat the steps again as following.• Repeat step 4 then 2, 3 & note the 2nd CP that must be higher than the 1st
as a result of exercise.• Repeat step 4 then check your pulse.• After 3 days of training patient should be able to do
around 8 to 10 sets a day.

• The main aim is to build CP up to 45, 70, 80 seconds.