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Guidelines for the physiotherapy
management of chronic
obstructive pulmonary disease
Subin Solomen
Website:
www.pjiap.org
Abstract:
DOI:
10.4103/PJIAP.PJIAP_46_18 The purpose of the article is to provide guidelines for the physiotherapy management of patients
with chronic obstructive pulmonary disease (COPD). The various publications on the same topic
were brought together with input from several textbooks in the field of cardiorespiratory
physiotherapy and translated into clinical practice. This article briefs with definition, risk factors,
prevalence, clinical features, investigations, differential diagnosis, and management of COPD
patient. Then, information on physiotherapy management during acute exacerbation phase and
during stable phase is detailed. The article provides specific details on the rationale of why and
especially how to implement exercise training in patients with COPD.
Keywords:
Chronic obstructive pulmonary disease, exercise training, guidelines, physiotherapy, pulmonary
rehabilitation

Introduction rehabilitation are improved exercise

C hronic obstructive pulmonary disease

(COPD) is a common, preventable lung
capacity, reduced perceived sensitivity of
breathlessness, improved health -related
quality of life (HRQOL), reduced number
disorder characterized by progressive, of hospitalisation, and improved arm
poorly reversible airflow limitation often with function.[5]
systemic manifestations, in response to
tobacco smoke and/or other harmful A diagnosis of COPD should be considered
inhalational exposures. The established risk in persons having chronic symptoms of
factors for COPD are tobacco smoking, cough, sputum production, shortness of
exposure to biomass fuel smoke, breath, and/or wheezing, especially among
occupational exposure, and alpha- 1 those with prolonged exposure to risk factors
antitrypsin deficiency.[1] The prevalence of for the disease. COPD patients may
Department of COPD in India according to previous studies demonstrate various physical signs that may
Physical Medicine
was 4.46% in males and 2.86% in females. either be due to the primary disease or an
and Rehabilitation,
Government Medical [2,3] Chronic obstructive pulmonary disease associated complication.[1] The signs elicited
College, Kottayam, is a major cause of morbidity and mortality in in inspection are shortened inspiratory to
Kerala, India India. Drug treatment alone does not expiratory (I: E) ratio, pursed lip breathing
optimize therapy. Pulmonary rehabilitation (PLB), use of accessory muscles, jugular
Address for
correspondence: has been found to improve the physical venous distension, labored breathing signs,
Dr. Subin Solomen, efficiency of COPD patients.[4] The benefits pulsus paradoxus, barrel-shaped chest,
Department of PMR, of pulmonary peripheral edema, dyspnea relieving posture
Government
and muscle wasting and during palpation
Medical College,
Kottayam - 686 008, subxiphoid shift of apex beat, restricted
This is an open access journal, and articles are distributed chest expansion. The findings seen
Kerala, India. E-mail:
under the terms of the Creative Commons
subins2001@
Attribution-NonCommercial-ShareAlike 4.0 License, which
rediffmail.com
allows others to remix, tweak, and build upon the work
How to cite this article: Solomen S. Guidelines for
Submission: 19-10-2018 non-commercially, as long as appropriate credit is given and
the physiotherapy management of chronic obstructive
Revision: 09-01-2019 the new creations are licensed under the identical terms.
pulmonary disease. Physiother - J Indian Assoc
Accepted: 21-05-2019
Published: 07-10-2019 Physiother 2019;13:66-72.
For reprints contact: [email protected]

66 © 2019 Physiotherapy - The Journal of Indian Association of Physiotherapists | Published by Wolters Kluwer - Medknow
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Solomen: Physiotherapy management of COPD

in percussion are hyperresonant in lung field, obliteration were included in this review. The author concluded with
of cardiac dullness, lower level of liver dullness, and moderate level of evidence as pulmonary rehabilitation,
lower diaphragmatic levels. The auscultatory findings including at least 4 weeks of exercise training leads to
seen are diminished breath sound, early inspiratory clinically and statistically significant improvements in
crackles, loud pulmonic component in the second heart health-HRQOL in patients with COPD. Pulmonary
sound and rhonchi or wheeze in expiration. [6-8] Special rehabilitation also leads to a clinically and statistically
maneuvers such as forced expiratory time and snider significant improvement in functional exercise capacity.
match test was also done in COPD patients. A forced Five randomized controlled trials on the effect of
expiratory technique (FET) of more than 6 s suggests pulmonary rehabilitation on outcomes following an acute
airway obstruction.[9] In the snider match test, where the exacerbation of COPD, which met the inclusion criteria
patient attempts to blow out a lighted match held 15 cm and are included in this review. The author concluded
from the mouth and if the patient were unable to do so that pulmonary rehabilitation (within 1 month of hospital
indicates severe ventilatory dysfunction.[10] discharge) after acute exacerbation significantly reduces
hospital readmissions (relative risk, 0.50; 95% confidence
Pulmonary function test is a simple and accurate tool interval, 0.33–0.77; P = 0.001) and leads to a statistically
to assess airflow obstruction. In COPD patients, forced and clinically significant improvement in HRQOL. [5]
expiratory volume in 1 s (FEV 1)/forced vital capacity
ratio is reduced, and FEV1 is reduced. A reversibility Physiotherapy Management of Acute
testing differentiates COPD from asthma as in COPD
Exacerbation of Chronic Obstructive
patients do not show reversibility in airflow obstruction
after administration of bronchodilators. As peak Pulmonary Disease
expiratory flow meter instrument is inexpensive,
An exacerbation of COPD is an acute event characterized by
portable, and easy to operate and maintain, it has
sustained worsening of any of the patient’s respiratory
often been advocated as a surrogate measure for
symptoms (cough, sputum quantity and/or character,
FEV1. The radiological abnormalities associated with
dyspnea) that is beyond normal day-to-day variation and
COPD are flattened diaphragm, hyperinflated lung
leads to a change in medication, and where other causes of
fields, widened intercostal spaces, and tubular or
acute breathlessness have been clinically excluded. The
boot-shaped heart. The differential diagnoses of
precipitants of acute exacerbations of COPD (AECOPD)
COPD include asthma, congestive heart failure,
bronchiectasis, tuberculosis, constrictive bronchiolitis, include infections, nonadherence to medication, or inhalation
and diffuse panbronchiolitis.[1,11] of irritants such as tobacco smoke or particles, and air
pollution. Clinical features of exacerbation of COPD are
Severity staging of COPD is important for disease characterized by symptoms such as reduction in activities of
prognostication as well as for treatment. GOLD guidelines daily living and altered sensorium, labored breathing signs
classify COPD into mild (FEV1 ≥80% predicted), such as intercostal indrawing, Hoover’s sign, supraclavicular
moderate (50% ≤ FEV1 < 80%), severe (30% ≤ FEV1 indrawing and paradoxical chest wall movement, increase in
<50%), and very severe (FEV1 <30%) disease.[12] heart rate (HR) and respiratory rate (RR), marked central
Body-mass, airflow Obstruction, Dyspnea, and Exercise cyanosis, reduced systolic blood pressure (BP), reduction in
(BODE) index is also used for severity staging in COPD saturation needs the patient to be hospitalized. While
patients, but it is not known whether treatment can be elevated blood urea nitrogen, altered mental status, pulse
tailored according to the BODE index. [13] Bhattacharjee et >109 beats/min, age >65 years) score may help in deciding
al.[14] conducted a study to find out the susceptibility of patients who need management in an intensive care unit.
chronic obstructive pulmonary disease among bike riders The differential diagnosis of AECOPD includes the 6Ps;
in Bangalore using BODE index and concluded that more pneumonia, pulmonary embolism, pneumothorax, pleural
than 4 h of bike riding is associated with the chances of effusion, pulmonary edema (heart failure), and paroxysmal
developing COPD even in nonsmokers; therefore, there atrial tachycardia (arrhythmias). Medical management of
is significant susceptibility of COPD among bike riders in exacerbation of COPD includes short-acting bronchodilators
Bangalore. through inhaled route, oral glucocorticoids, antibiotics, and
noninvasive ventilation (NIV). NIV should be used early in
An evidence-based review conducted in 2012 the management of respiratory failure due to AECOPD, in
determined the effectiveness and cost-effectiveness of weaning from invasive mechanical ventilation, used even in
pulmonary rehabilitation in the management of chronic settings where arterial blood gas monitoring is not routinely
obstructive pulmonary disease during acute exacerbation available. Continuous positive airway pressure, Bi-level
and stable phase. Seventeen randomized controlled trials positive airway pressure, and
on the effect of pulmonary rehabilitation on outcomes in
stable COPD which met the inclusion criteria and
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Solomen: Physiotherapy management of COPD

intermittent positive airway pressure are the common tissue hypoxia and preserve cellular oxygenation. Venturi
mode used for noninvasive ventilation.[1] mask is the oxygen delivery device of choice in AECOPD.
The nasal cannula delivers a variable FIO 2 depending on
Aims of physiotherapy for acute exacerbation of COPD the minute ventilation; the lower the minute volume, the
are to reduce work of breathing (WOB), to control higher the FIO2. The nasal cannula can be used in
breathlessness, to assist in the removal of secretions, to AECOPD in those intolerant to Venturi mask, and after
reduce the amount and viscosity of secretions, and to the acute phase of the exacerbation.[1,6,16]
facilitate accessory muscles. Amount and viscosity of
secretions can be reduced by hydration, humidification, Arm exercise
and nebulization. To reduce WOB, strategies such as Supported arm exercise training is given during acute
positioning and oxygen therapy are administered. exacerbation of COPD. During supported arm training
Breathing techniques such as breathing control, (the distal end of the extremity is fixed) this muscle can
Innocenti, and PLB control the breathlessness. To work as accessory muscles, and hence, there is less
facilitate accessory muscles, supported arm exercise can load on diaphragm muscles and hence less dyspnea.
be given. To remove the excess secretions modified Supported arm training is commonly done with arm
postural drainage, active cycle breathing technique ergometer with training done at 60% of maximal work
(ACBT), and huffing techniques are administered.[15] capacity, increase workload every
5th session as tolerated. The patient should do the
Hydration exercise for 30 min.[16,18]
Dehydration reduces mucus transport by 25%. If a
patient is well hydrated, the secretions will be easily Modified postural drainage
loosened up so it is better to advice the patient to drink Sometimes true postural drainage cannot be given in
warm water before chest physiotherapy.[8,16] some conditions because they may desaturate or may
develop orthopnea. In this case, modified postural
Nebulization drainage is adopted. For draining lower lobes, a pillow
It is done to generate aerosol particles (suspension of under the pelvis in supine may drain anterior basal
liquid particles in a gaseous state) . It is of two types: segments, and a pillow under the pelvis in prone lying
bland aerosol and therapeutic aerosol. The bland may drain posterior basal etc.[16,19]
aerosol is the administration of saline which is
commonly done to loosen the secretions before Huffing
postural drainage. The therapeutic aerosol is the Huffing techniques are preferred compared to
administration of the therapeutic dose of selected coughing techniques as coughing may further
agents such as bronchodilators and mucolytics.[6,8,10,16] aggravate bronchospasm. Always huffing technique is
interspersed with breathing control technique. One of
Humidification the active coughing techniques such as pump
It is the method by which humidified (warming and coughing is also used as it facilitates secretion
moistening) air can be introduced into the respiratory clearance in patients with air trapping.[16,20]
system. In a COPD patient, humidification is done to
humidify Oxygen while administering through cannula Electrical stimulation for peripheral muscle
or through mask, to treat bronchospasm caused by dysfunction
cold air and to overcome humidity deficit when the Weakness, atrophy, structural, and metabolic changes
upper airway is bypassed as in case of intubation.[6,8,16] have been observed in limb muscles, which, in turn, can
have a negative impact on exercise tolerance. This may
Facilitation of accessory muscles initiate dyspnea deconditioning cycle. To break this,
During acute exacerbation of asthma or COPD, the electrical stimulation can be applied. Studies have shown
patient’s accessory muscles should be facilitated. An that electrical stimulation improves muscle function,
anterior pelvic tilt facilitates accessory muscle use. exercise performance (increased walking distance and
This can be achieved by placing a towel roll vertically increased time to exhaustion in a constant work rate
along the spine in supine. Keeping hands on cycling test) and muscle size peak torque. [16,21,22]
outstretched position in sitting also relieves
breathlessness as it facilitates accessory muscles.[16,17] TENS to reduce breathlessness
Studies have shown that the effect of single session of
Oxygen therapy bilateral application of TENS for 45 min in patients with
Oxygen therapy is administered in case of documented COPD showed increase in FEV 1, 6-min walk distance
hypoxemia. The goal of inpatient oxygen therapy is to and decrease in dyspnea. An improvement in FEV 1 and
maintain PaO2 ≥60 mmHg or SpO2 ≥90% to prevent dyspnea score at the end of Acu-TENS treatment was
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Solomen: Physiotherapy management of COPD

associated with a concurrent increase in b-endorphin BP, RR, Borg  rate of perceived exertion (RPE) scale
level in patients with COPD.[16,23,24] for breathlessness and fatigue has to be checked
prior, immediately, and after 3 min of exercise testing.
At the Time of Discharge Commonly, these tests are performed at the time of
discharge.[16]
An exercise testing is done at the time of discharge to
prescribe exercise for the patient to perform in the home. Other airway clearance technique
A history of smoking history is noted, and smoking Either ACBT or autogenic drainage (AD) is taught to the
cessation therapy is administered at this time. This can patient as home exercise at the time of discharge. ACBT
minimize the future risk of disease progression. consists of three phases breathing control, thoracic
expansion, and FET. FET consists of low huffs and high
Pacing huffs interspersed with breathing control. AD is a method
Pacing can be taught to get control of breathing during of controlled breathing in which the patient adjust the rate
exercise. This is normally taught to patients at the time location and depth of respiration. It is divided into three
of discharge. This can decrease WOB and relieve phases such as unsticky phase, collecting phase, and
dyspnea during activity. Subject and therapist simply evacuating phase, whereas German approach has only
test different I:E ratios with various activities such as one phase.[16,25]
cycling, walking, stair climbing until they find the rate
and pattern that lower RR, relieves dyspnea, and
Physiotherapy Management in Stable Phase
possibly improves SaO2. For example, while walking;
for every two steps patient should exhale followed by The goals in managing stable COPD include
the next step with patients inspiration.[16,25] techniques to inhibit accessory muscles, to strengthen
inspiratory muscles, to improve posture, to increase
Smoking cessation chest expansion, to improve the mobility of thorax, to
A smoking history, including pack-years or smoking improve the patients breathing pattern, prevention of
index (number of bidis/cigarettes smoked per day
exacerbations, and to reduce energy demand.[15]
multiplied by number of years smoked; mild, moderate,
and heavy smokers are defined as having a smoking Diaphragmatic breathing and incentive spirometry
index of <100, 100–300, and >300, respectively should
Diaphragmatic breathing exercise and incentive
be documented for all patients with COPD. Smoking
spirometry are only given during stable phase not in
cessation is the most effective method to prevent
the acute exacerbation as it may provoke the
COPD. The 5A strategy: ask (about tobacco use),
symptoms. Care should be taken that an inspiratory
assess the status and severity of use advice to stop,
hold should not be given, as bullae may open up with
assist in smoking cessation, and arrange follow-up
inspiratory hold which can result in pneumothorax.
program should be adopted. In addition to a reduction
in the rate of decline of FEV 1 in stable COPD, smoking
Other breathing techniques
cessation is also associated with a reduction in the
Breathing control is synonymous with diaphragmatic
frequency of exacerbations. Nicotine replacement
breathing. However, the only difference is that in
therapies; forms such as gums, tablets, patches, and
diaphragmatic breathing, it is done with maximal inspiration
inhalers, drugs (varenicline or bupropion), are
whereas in breathing control technique is performed at
administered by physician to people who are planning
normal tidal volume. PLB exercise stresses on expiration,
to stop smoking.[26]
therefore, it can be used to control breathlessness and to
reduce WOB. It keeps airways open by creating back
Exercise testing
The parameters of exercise prescription for the patient pressure in the airways. The procedure is such that subject
with chronic cardiopulmonary dysfunction are loosely purse the lips and exhale (like blowing out a match
determined from a clinical exercise test. The purpose stick or candle). PLB decrease RR, increase tidal volume,
of this test is to determine how a patient exercise improves exercises tolerance. Innocenti technique aimed to
response differs from the normal and to diagnose the prevent forceful expiration thereby reduction of excess
specific limitations to exercise. Exercise testing has to energy consumption and improves expiratory flow. The
be done for both the upper limb and lower limb. In the procedure is that at each breath instructs the subject to
lower limb, most commonly a 6-min walk test or inhale just before abdominal muscle recruitment. This allows
shuttle walk test is preferred. However, in case of the a smooth transition from inspiration to expiration practice first
upper limb, a supported upper limb exercise test with with physiotherapist’s voice then without. It helps to prevent
bicycle ergometer or unsupported upper limb airway shutdown consumes less energy than PLB, thereby
endurance test to be performed. Whatever the tests improving PaO2.[16,25]
administered, HR,
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Solomen: Physiotherapy management of COPD

Techniques to inhibit accessory muscles rate they can manage for 15–30 min. High-pressure low
One of the techniques to inhibit the accessory muscle is flow loading can be of two types; inspiratory resistive
that to give the accessory muscle its primary action rather training or inspiratory threshold training. Studies have
than assisting in respiration. Hence that these muscles shown that it can decrease breathlessness, increase
cannot take part in respiration and there will be shift of exercise tolerance, and increase nocturnal saturation.
the respiratory work toward the diaphragm. For example, Even diaphragmatic training using weights can help in
keeping the hand elevated overhead while breathing. ventilatory muscle training.[16-18]
Another way to inhibit accessory muscle is to keep the
muscle either in fully lengthened or fully shortened Endurance training
position. Keeping the muscle in these positions cannot Aerobic endurance training can be performed at high or low
effectively actively part in respiration. For example, intensity. High-intensity training (70%–85% of maximal work
perform breathing with the neck in an elevated position. rate) improves aerobic fitness such as VO2 max, delays
While performing breathing, give facilitatory techniques anaerobic threshold, decreased HR for a given workload,
for lower thorax and inhibitory techniques for the upper increases oxidative enzyme capacity, and more
thorax. This also inhibits the accessory muscle use. capillarization of the muscle. It also improves exercise
Applying the Myofascial release to accessory muscle also endurance. Low-intensity training improves the exercise
inhibits the muscle use. Positioning and unsupported arm
endurance, but it does not improve aerobic fitness.[16,18]
exercises are the other ways to inhibit the accessory
muscle, which is described below.
Strength training
Strength training in stable phase of COPD leads to
Positioning
improvements in muscle strength, increased exercise
During the stable phase, the pelvis should be posteriorly
endurance, and fewer symptoms during ADL.
tilted pelvis to facilitate diaphragmatic muscle. This can
Lower-extremity strengthening may be augmented through
be achieved by placing a pillow under the knees.[17,20]
aerobic training itself. Upper limb strengthening can be done
Arm exercise with low resistance of light weights (dumbbells, pulleys, and
Unsupported arm training is given during the stable elastic bands) and progressed first by increasing repetitions
phase. During unsupported arm exercise, (the distal end (starting with 10–20) before adding additional weight. During
is not fixed) the participation of the accessory muscles in training physical therapist should monitor breathing pattern
ventilation decreases, and there is a shift of respiratory and pulse oximetry.[16,18]
work to the diaphragm. This is associated with
thoracoabdominal dyssynchrony, severe dyspnea, and Flexibility training
termination of exercise at low workloads, especially in Patients with progressive chronic respiratory disease loose
patients with more severe bronchial obstruction. Studies range of motion (ROM) of the shoulder, rib cage, and rib
have shown that that upper limb exercise training for cage. This results in significant changes in posture and
patients with COPD increases upper limb work capacity, reduced mobility. Flexibility exercise can also be given in
improves strength and endurance, and reduces oxygen stable phase as it improves posture, increases ROM,
consumption at a given workload. The most common decreases stiffness and prevents injury. Gentle stretching
types of upper limb exercises are throwing a ball against with body movements should be coordinated with breathing
the wall with arms above horizontal in sitting position, exercises. For example, movements that bring full shoulder
passing a beanbag over the head in sitting position, flexion, back extension, and inspiration should be performed
Exercises on overhead pulleys in sitting position, moving with trunk flexibility. Exercise with forward reaching and trunk
a ring across a wire without touching the wire, while the flexion or with unilateral or bilateral hip flexion should be
arm was above horizontal. Each exercise should be combined with expiration. Flexibility exercise is also
performed for 40 s followed by 20 s rest. Exercises have incorporated in warm up and cool down period in the aerobic
to be repeated four times in 4 min.[16,18] exercise to relieve muscle tension and anxiety.[16,18]

Inspiratory muscle training

Inspiratory muscle training can be done by either through Buteyko technique
inspiratory threshold training or inspiratory resistive The Buteyko technique is performed by slowing RR with
training. Inspiratory muscle training can be classified as breath counting and at night, lying on the left side and
low-pressure high flow loading or high-pressure low flow taping mouth closed. The hold at the end of expiration
loading. In low-pressure high flow loading also called as elevates PaCO2 which helps in bronchodilatation during
normocapneic hyperpenic training increase the rate of stable phase. This technique reverses the symptoms,
breathing without altering PaCO 2 value. In this technique, lessens the need for medication, and prevents attack on
subjects were asked to breath at the highest acute exacerbation.[8,16]
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Solomen: Physiotherapy management of COPD

Postural correction exercise Financial support and sponsorship

A COPD patient typically exhibits a poked chin posture Nil.
(flexion of the lower cervical column with the extension
of the upper cervical column), rounded shoulder with Conflicts of interest
kyphosis and sitting on an outstretched hand. There are no conflicts of interest.
Exercises such as chin tuck, neck extension, shoulder
retraction, and back extension are prescribed for these References
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72 Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 13, Issue 2, July-December 2019