physio in lung disease

1. Physiotherapy in lung disease -
top tips for clinicians
Sita Kansagra
Specialist Outpatient Physiotherapist

2. Aims:
• Run through current physiotherapy practice
– Airway clearance
– Pulmonary rehabilitation
– Dysfunctional breathing
• What information to provide when referring a
patient in an acute situation as well as a general
inpatient/outpatient referral
• If time try some of the airway clearance adjuncts

3. Pathophysiology of Mucociliary clearance
• MCC – critical host defence
mechanism of upper & lower
airways
– Incl Cough
– Anatomical barriers
• Mucus transport – dependent on:
– Integrity & function of ciliated
epithelium
– Periciliary fluid
– Mucus properties (volume, rheology,
viscosity)
• Aerodynamic changes
– Shear forces, alterations in airflow

4. Impact of abnormal muco-ciliary clearance
 Sputum plugging
 Pain, hypoxia, alveolar collapse
 Bacterial binding facilitates
bacterial growth
 Vicious cycle hypothesis
 Impact of lung disease
 Ion transport (eg CF)
 Cilia dysfunction
 NMD- impaired cough
 Airway damage

5. Airway Clearance Techniques
 Short-term aims:
-  airway obstruction
-  airway resistance
-  ventilation
-  airflow
- Mucus viscosity
 Long-term aims:
- to delay progression
of disease
- maintain optimal
respiratory function
Clinical status/Social circumstances/
Personal preference

6. A summary of current techniques used for
airway clearance
Independent Techniques ACBT- Active cycle of breathing
AD – Autogenic drainage
Device dependent techniques PEP- Positive Expiratory pressure
OPEP – oscillating positive expiratory pressure.
Intrathoracic: Flutter/acapella
Extrathoracic: High frequency chest wall oscillations
IPPB: Intermittent positive pressure
NIV: non invasive ventilation
Assistive components to techniques Manual techniques
Chest percussion
Chest wall vibrations
Overpressure
Gravity assisted positioning
Modified postural drainage
Adjunction to assist techniques Humidification
Nebulised therapy
Mucolytics
Saline (0.9%)
Hypertonic saline 7%
Mannitol

7. Evidence and Guidelines
Very brief synopsis: key points
 All patients producing daily mucus +/- evidence of mucus
plugging on HRCT should be taught an airway clearance
technique
 Airways humidification +/- hypertonic saline should be
considered for patients with daily sputum
 Positive pressure may augment airway clearance in selected
patients
 Exercise may benefit patients with COPD/Bx/CF/Asthma
 Cough augmentation is important to consider in patients with
neuromuscular disease

8. ACT evidence discussions
• Very difficult to plan future ACT research
– Inadequate research design/S-T studies/Powering studies
• ST studies 1-14 days. 6 x Cochrane reviews 2011-2014
– Airway clearance techniques have short-term effects
in the terms of increasing mucus transport
– No evidence was found on which to draw conclusions
concerning the long-term effects; quality of life or
survival with chest physiotherapy.
• Other guidelines offer ‘Good practice points’

9. Why is exercise important?
“Those who do not make time for
exercise will eventually have to make
time for illness”
Earl of Derby (1863)

10. Pulmonary Rehabilitation
AIMS:
• Improve symptoms of breathlessness
• Increase physical function
• Reduce reliance on healthcare providers
• Support secondary pathophysiology
• Help the patient take responsibility for their own health
• Allow the patient to regain or maintain independence
• Improve health enhancing behaviors

11. Typical Programme
• Outpatient based
• Twice weekly supervised exercise
sessions (aerobic, specific training)
• Education session(s)
• Multidisciplinary
• 6-8 weeks duration

12. Recommendation and Guidelines
BTS Guidelines and ACPRC/BTS Guidelines
• PR should be offered to individuals who have
breathlessness affecting their activities of
daily living with an Medical Research Council
Dyspnea score :
– MRC 3-5 for COPD patients
– MRC 2 or above for patients with confirmed
respiratory diagnosis affecting function

13. BTS PR Guidelines
COPD
• Pulmonary rehabilitation should be offered to patients with chronic obstructive pulmonary disease (COPD) with a view to
improving exercise capacity by a clinically important amount. (Grade A)
NON CF Bronchiectasis
• Patients with non-CF bronchiectasis who have breathlessness affecting their ADL should have access to and be considered for
pulmonary rehabilitation. (Grade D)
• No evidence to have concerns re: cross infection unlike in CF (PSA/nTM)
ILD
• ▸ If healthcare professionals consider referring certain patients with stable ILD who are limited by breathlessness in ADL to
pulmonary rehabilitation, they should discuss with the patient the likely benefits. (√)
• ▸ Patients with idiopathic pulmonary fibrosis (IPF) have a potential for significant desaturation during exercise related activities.
(√)
Asthma
• Routine referral of patients with asthma to pulmonary rehabilitation is not recommended. (Grade D)
– Patients with severe asthma: considerations of age/working status/likelihood of completing the course.
– The benefits of exercise and the recommendation of incorporating exercise activities into a healthy lifestyle should be
discussed with all patients with asthma. (√)
– If healthcare professionals consider referring certain patients with stable asthma who are limited by breathlessness in
ADL to pulmonary rehabilitation when on optimal therapy, they should discuss with the patient the likely benefits. (√)
 ACPRC/BTS Guidelines recommend
 Physical training should be advised for improvements in fitness and cardio respiratory performance in patients with
asthma. (Grade B)
 Physical training should be advised to help reduce breathlessness and improve health-related quality of life in people
with asthma. (Grade B)
 Physical training programmes should aim to reach a minimum of activity as per the American College of Sports Medicine
guidelines. (Grade A)

14. POLO –
Periodic
occurrence
of laryngeal
obstruction
Upper airway
irritation/ Chronic
cough
Dysfunctional Breathing
EILO – Exercise
induced laryngeal
obstruction
ILO – induced
laryngeal
obstruction

15. Breathing control: key
messages
• Can co-exist with disease
– Symptoms tend to be disproportionate to disease severity
• Essential to identify trigger.
• Nose breathing at rest and low level exertion with appropriate
response during exercise.
• Nasal Hygiene
• Hydration
• Over breathing: ‘box breathing’
• Not all over breathers have a high respiratory rate
• Difficult to capture symptoms e.g. high level athletes need the
adrenaline of a race environment. If patient consents, ask
coach or parent to video symptoms.

16. Physiotherapy referrals: what
physiotherapists need to know from
the referral
• Acute
– PMH
– What condition is currently being treated?
– What has acutely occurred: all observations/recent CXR, ABG’s
– What they have already tried
• Patients may have strategies that need encouragement
– Nebs
– Airway clearance
– Changed position
– Breathing control techniques
– Give us a means of contacting you back after we have seen the patient. Bleep/mobile/ext
• Standard referral
– Detailed relevant PMH/ last clinic note
– What you would like us to particularly assess:
• Airway clearance
• Ex Tolerance/ functionality
• Breathing pattern
• Remember to tell the patient for what reason you are referring them to a respiratory
physiotherapist.

17. References
• M C Pasteur, D Bilton, A T Hill3, on behalf of the British Thoracic Society
Bronchiectasis (non-CF) Guideline Group ‘British Thoracic Society non-CF Bx
guidelines 2010’ Thorax, 65: 1-58
• Charlotte E Bolton, Elaine F Bevan-Smith,John D Blakey, Patrick Crowe, Sarah L
Elkin, Rachel Garrod, Neil J Greening, Karen Heslop, James H Hull,William D-C
Man,1 Michael D Morgan, David Proud,C Michael Roberts,Louise Sewell, Sally J
Singh, Paul P Walker, Sandy Walmsley, British Thoracic Society Pulmonary
Rehabilitation Guideline Development Group,on behalf of the British Thoracic Society
Standards of Care Committee, British thoracic society Pulmonary rehabilitation
guidelines Thorax 68 1-30,2013
• Barker NJ, Jones M, O’Connell NE, Everard ML. 2013 ‘Breathing exercises for
dysfunctional breathing/hyperventilation in children’ Cochrane Database Systematic
Review 18;12:CD010376
• Bott J, Blumenthal S, Buxton M, Ellum S, Falconer C, Garrod R, Harvey A, Hughes T,
Lincoln M, Mikelsons C, Potter C, Pryor J, Rimington L, Sinfield F, Thompson C,
Vaughn P, White J. 2009 ‘Guidelines for the management of the adult, medical,
sponteously breathing patient’ Thorax, 64: 1-52
• Nielsen EW, Hull JH, Backer V. 2013 ‘High prevalence of exercise-induced laryngeal
obstruction in athletes’, Medical Science Sports Exercise, 45 (11): 2030-2035

18. Thank you for listening…
• Any questions?