This document presents an overview of physiotherapy management for chronic obstructive pulmonary disease (COPD). It discusses the epidemiology, pathophysiology, clinical features, diagnosis, stages, and medical management of COPD. It then describes the role of physiotherapy during acute exacerbations, including techniques to reduce work of breathing and secretion removal. Physiotherapy is also involved in pulmonary rehabilitation to improve patient function and management through exercise training and education. Physiotherapy aims to prevent exacerbations and optimize lung function in stable COPD patients.

1. PHYSIOTHERAPY MANAGEMENT OF CHRONIC
OBSTRUCTIVE PULMONARY DISEASE
PRESENTED
BY
OLUWADAMILARE JOSHUA AKINWANDE (PT)
AT
PHYSIOTHERAPY DEPARTMENT
IN
STATE HOSPITAL, ABEOKUTA

2. OUTLINES
• INTRODUCTION
• EPIDEMIOLOGY
• PATHOPHYSIOLOGY
• RISK FACTORS
• CLINICAL FEATURES
• PHYSICAL EXAMINATION,IMAGING, LAB TESTS AND DIAGNOSIS
• STAGES
• DIFFERENTIAL DIAGNOSIS
• MEDICAL MANAGEMENT
• PHYSIOTHERAPY MANAGEMENT/PULMONARY REHABILITATION
• SURGICAL MANAGEMENT
• CONCLUSION
• REFERENCES

3. INTRODUCTION
• Chronic obstructive pulmonary disease (COPD) is an umbrella term which is used
to describe a group of airways diseases (chronic bronchitis and emphysema) that
are not fully reversible (Khachi, Barnes & Antoniou, 2010) . It is a progressive
disease (Khachi et al., 2010).
• Chronic bronchitis is defined as the presence of chronic productive cough for at
least 3 months in each of two consecutive years in a patient in whom other causes
of chronic cough have been excluded (American Thoracic Society [ATS], 1995).
• Emphysema is a pulmonary disease defined as abnormal permanent enlargement
of the airspaces distal to the terminal bronchioles, accompanied by destruction of
their walls and without obvious fibrosis (ATS, 1995).

4. EPIDEMIOLOGY
• COPD is a common pulmonary disease worldwide.
• Globally, COPD is a major cause of chronic morbidity and mortality.
• Its economic and social burden is substantial (Schermer et al., 2008).

5. PATHOPHYSIOLOGY
• An inflammatory process tends to occur in the bronchi in response to inhaled
irritants. This usually results in accumulation and hypersecretion of mucous-
secreting glands in the bronchial tree. This results in chronic bronchitis, provided
it occurs for a minimum of 3 months in each of two successive years (Khachi et
al., 2010).
• A pathological process that involves progressive and destructive enlargement of
the bronchioles, alveolar ducts and the alveoli usually results in emphysema
(Khachi et al., 2010).
• In summary, the classic airflow obstruction in COPD is caused by disease of the
small airways. This is partly due to the effects of inflammation in those airways
and in part to the loss of alveolar attachment to the bronchioles that accompanies
the destructive changes of emphysema (ATS, 1995).

6. RISK FACTORS
The risk factors for COPD are ;
• Tobacco smoking
• Indoor air pollution
• Occupational dusts and chemicals
• Genetics and
• Socioeconomic status (ATS, 1995 ; Khachi et al., 2010 ; Schermer et al., 2008).

7. CLINICAL FEATURES
• COPD is characterized basically by the presence of breathlessness(dyspnea),
chronic cough and sputum production (Khachi et al., 2010 ).
• It is worth noting that the early stages of COPD are commonly asymptomatic and
it is not until affected individuals experience significant limitation that they seek
medical advice (Khachi et al., 2010 ).
• In the later stages of COPD, the impairment of gas diffusion can result in
hypoxemia, hypercapnia and pulmonary hypertension with resultant increased
right-ventricular pressure and subsequent cor pulmonale.
• Other symptoms of COPD include wheeze and chest tightness which can occur at
any stage of COPD, though they tend to occur in severe COPD (Khachi et al.,
2010 ).

8. PICTORIAL REPRESENTATION OF COPD CLINICAL FEATURES

9. PHYSICAL EXAMINATION
This involves checking for the following;
• airflow obstruction which is evidenced by wheezes during auscultation on slow or
forced breathing likewise prolongation of forced expiratory time.
• emphysema which is indicated by hyperinflation of the lungs, increase in
anteroposterior diameter of the chest, limited diaphragmatic motion and decreased
intensity of heart and breath sounds.
• compensatory breathing mechanisms such as the use of accessory respiratory
muscles, assuming an unusual position to relieve breathlessness, exhaling through
a pursed lip likewise indrawing of the lower interspaces (ATS, 1995).

10. IMAGING AND LABORATORY TESTS
• Chest radiography help in the detection of severe emphysema and essentially help
to rule out other lung diseases.
• Spirometry is important to ascertain the presence and the severity of airflow
obstruction along the airways.
• Lung volumes and arterial blood gases measurements (ATS, 1995).

11. DIAGNOSIS
The diagnosis of COPD usually take into account the following factors;
• age
• affected individual’s medical history and manifestation of the features of COPD
• exposure to risk factors
• result of chest examination
• result of spirometry with reverence to the forced expiratory volume in one
second(FEV1), forced vital capacity (FVC) and the ratio of FEV1 to FVC.
A post-bronchodilator FEV1 / FVC ratio <0.7 confirms the presence of COPD
(Khachi et al., 2010 ).

12. STAGES OF COPD
According to the National Institute for Health and Clinical Excellence [NICE] and
the Global Initiative for Chronic Obstructive Lung Disease [GOLD] , patients with a
post-bronchodilator FEV1 / FVC ratio < 0.7 can be classified as follows;
• FEV1 ≥ 80% ; Stage 1(Mild)
• FEV1 50-79% ; Stage 2 (Moderate)
• FEV1 30-49% ; Stage 3 (Severe)
• FEV1 <30% ; Stage 4 (Very Severe) (GOLD, 2020 ; NICE, 2010).

13. DIFFERENTIAL DIAGNOSIS
• Asthma: Though COPD and asthma may present with some overlapping
symptoms, they can be distinguished from one another based on the patient’s
history, exposure to risk factors and spirometry results. Reversibility testing using
an inhaled bronchodilator can help to distinguish between COPD and asthma
(Khachi et al., 2010 ).

14. MEDICAL MANAGEMENT
• This encompasses the use of inhaled bronchodilators and corticosteroids to
manage COPD symptomatically.
• It also incorporates vaccination (such as pneumococcal and influenza) to alleviate
severe illness and reduce mortality in COPD patients (Schermer et al., 2008).

15. PHYSIOTHERAPY MANAGEMENT
This is involved during the acute exacerbation of COPD. The aims of physiotherapy
for acute exacerbation are;
• to reduce work of breathing
• to control shortness of breath
• to assist in the reduction of viscosity and removal of secretions
• to facilitate accessory muscles of respiration (Holland, 2014 ; Mikelsons, 2008 ;
Solomen, 2019).

16. These aims can be achieved via;
• positioning
• oxygen therapy
• pursed lip breathing
• electrical stimulation
• hydration, humidification and nebulization
• modified postural drainage, huffing and active cycle of breathing techniques
• supported arm exercise, forward leaning and anterior pelvic tilt (Holland, 2014 ;
Mikelsons, 2008 ; Solomen, 2019).

17. Physiotherapy management is involved at the time of discharge of a COPD patient
to minimize the future risk of disease progression. This aim can be achieved via;
• exercise prescription for home exercise programme
• smoking cessation programme (Solomen, 2019).

18. Physiotherapy management is also involved in the stable phase of a COPD patient.
The aims are;
• to inhibit accessory respiratory muscles
• to strengthen the inspiratory muscles
• to increase chest expansion and thorax mobility
• to improve the patient breathing pattern
• to prevent exacerbation and
• to reduce energy demand (Solomen, 2019).

19. These aims can be achieved through;
• positioning
• unsupported arm exercise
• inspiratory muscle training
• diaphragmatic breathing
• incentive spirometry
• pursed lip breathing
• Innocenti technique
• endurance training
• strength training and
• flexibility training and
• postural correction exercise (Solomen, 2019).

20. PHYSIOTHERAPY AS A COMPONENT OF PULMONARY
REHABILITATION
• Pulmonary rehabilitation is defined as a “comprehensive intervention based on a
thorough patient assessment followed by patient-tailored therapies that include,
but are not limited to, exercise training, education and behaviour change, designed
to improve the physical and psychological condition of people with chronic
respiratory disease and to promote the long-term adherence to health-enhancing
behaviors,” (Zeng, Jiang, Chen, Chen & Cai, 2018).
• It is a multidisciplinary approach that aims to optimize COPD patients’ functional
capacity and empower management and coping strategies (Mikelsons, 2008).

21. • Ample bodies of evidence currently support the use of pulmonary rehabilitation in
the treatment of patients with COPD, with many randomised controlled trials
describing its potential benefits which include: improved exercise capacity,
increased quality of life, enhanced patients’ sense of control over their condition,
improved emotional function, improved dyspnea and fatigue, increased functional
outcomes, reduced length of hospital stay and number of hospitalizations,
reduction in primary care consultations and survival benefit (Mikelsons, 2008 ;
Zeng et al., 2018).
• Pulmonary rehabilitation is indicated in all stages of COPD.

22. • Physiotherapists play an integral role in the assessment, exercise and education
components of pulmonary rehabilitation (Mikelsons, 2008).
• The assessment of all body systems by a physiotherapist will help to identify key
priorities for treatment. These may include airway clearance in the presence of
sputum and determine the type and level of physical activity appropriate, given the
clinical picture of the patient (Mikelsons, 2008).
• Exercise training (which can be prescribed by physiotherapists) is regarded as the
cornerstone of pulmonary rehabilitation (Zeng, et al., 2018).

23. SURGICAL MANAGEMENT
This may be necessary in severe conditions where symptoms are not controlled by
the aforesaid managements/interventions. It can also be necessitated when it may
improve a COPD patient’s quality of life. This may be achieved via;
• bullectomy
• lung volume reduction surgery or
• lung transplantation (Rees, 2020).

24. CONCLUSION
• COPD is a progressive and an incurable respiratory disease which can be managed
symptomatically via pharmacological and non-pharmacological approaches.
• The role of physiotherapy management cuts across all aspects of the care of
COPD patients in both primary and acute care settings.
• Pulmonary rehabilitation is helpful in the enhancement of the physical and
psychological conditions of COPD patients.

25. REFERENCES
 American Thoracic Society. (1995). COPD: Definitions, epidemiology,
pathophysiology, diagnosis and staging. American Journal of Respiratory and Critical
Care Medicine, 152.
 Global Initiative for Chronic Obstructive Lung Disease. (2020). Global strategy for
the diagnosis, management and prevention of chronic obstructive pulmonary disease.
Retrieved from https://goldcopd.org/
 Holland, A. E. (2014). Physiotherapy management of acute exacerbations of chronic
obstructive pulmonary disease. Journal of Physiotherapy, 60, 181–188.
 Khachi, H., Barnes, N., & Antoniou, S. (2010). COPD clinical features and diagnosis.
Clinical Pharmacist, 2.
 Mikelsons, C. (2008). The role of physiotherapy in the management of COPD.
Respiratory Medicine, 4, 2–7.

26.  National Institute for Health and Clinical Excellence. (2010). Management of chronic
obstructive pulmonary disease in adults in primary and secondary care. Retrieved from
https://www.nice.org.uk
 Rees, M. (2020). COPD stages and their symptoms. Retrieved from
https://www.medicalnewstoday.com/articles/copd-stages
 Schermer, T., van Weel, C., Barten, F., Buffels, J., Chavannes, N., Kardas, P., … Yaman,
H. (2008). Prevention and management of chronic obstructive pulmonary disease
(COPD) in primary care: Position paper of the European Forum for Primary Care.
Quality in Primary Care, 16, 363–77.
 Solomen, S. (2019). Guidelines for the physiotherapy management of chronic
obstructive pulmonary disease. Physiother - J Indian Assoc Physiother, 13, 66-72.
 Zeng, Y., Jiang, F., Chen, Y., Chen, P., & Cai, S. (2018). Exercise assessments and
trainings of pulmonary rehabilitation in COPD: A literature review. International
Journal of COPD, 13, 2013–2023.