See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/327919926

Physiotherapy for Respiratory conditions.

Article · September 2018

CITATIONS READS
3 4,343

1 author:

Lalit Gupta
Maulana Azad Medical College
87 PUBLICATIONS   33 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Text Book View project

All content following this page was uploaded by Lalit Gupta on 27 September 2018.

The user has requested enhancement of the downloaded file.

 Advanced Nursing & Patient Care International Journal

Review Article Volume 1; Issue 1

Physiotherapy for Respiratory Conditions

Lalit Gupta1* and Himani Gupta2

1Department of Anesthesia, Maulana Azad Medical College, India
2Department of Musculoskeletal, Adhunik Institute of Education and Research, India

*Corresponding author: Dr. Lalit Gupta, Department of Anesthesia, Maulana Azad Medical College & Associated
Hospitals New Delhi, India, Tel no: 09868092739, 8588862786; Email: [email protected]

Received Date: May 30, 2018; Published Date: July 11, 2018

Abstract
Physiotherapists are important clinical team members in intensive care units, respiratory wards, outpatient clinics and
palliative care services [1]. In recent years, the evidence base for the use of physiotherapy in the form of appropriate
exercises has grown in many areas, ranging from intensive care to chronic respiratory conditions [2,3]. Respiratory
physiotherapy is not a new concept. Deep breathing exercises have been practiced for over a century to strengthen the
chest, lungs, and stomach. Respiratory physiotherapy is primarily concerned with maintaining and restoring an
individual’s maximum respiratory functional ability [4]. It involves examination/assessment, planning and execution of
treatment in form of respiratory exercises with step by step intervention and re-assessment.

Keywords: Physiotherapy; Respiratory Conditions; Breathing

Abbreviations: IPPV: Intermittent Positive-Pressure i. Mobilizing secretions leading to effective coughing

Ventilation; CPAP: Continuous Positive Airway Pressure; and removal of secretions.
COPD: Chronic Obstructive Pulmonary Disease. ii. To teach appropriate breathing patterns and control.
iii. To mobilize thorax and shoulder girdle with proper
Introduction postural awareness.
iv. Reduce breathlessness and the work of breathing
Respiratory conditions are most common cause of
v. Improve the efficiency of ventilation
prolonged stay in hospital settings, with a vast variety of
clinical diagnosis being assessed and need physiotherapy vi. Support weaning from ventilators and support
contribution along with medical treatment. Conditions further noninvasive mechanical ventilation
which necessitate a must physiotherapy involvement vii. Improve functional abilities and exercise tolerance
include pneumonia, chronic bronchitis, asthma, (i.e. carrying out daily tasks)
bronchiectasis, cystic fibrosis, hyperventilation and viii. Home management advice.
chronic obstructive pulmonary disease [5]. The
physiotherapist’s role in patient care includes assessment, A physiotherapist should achieve the above aims with the
advice, education and active hands-on intervention. goal of evidence-based practice in mind, i.e. [7] they
Traditionally, respiratory physiotherapists aid the should know the most effective intervention, based on the
mobilization and removal of secretions [6]. However, evidence, and integrate this knowledge and its application
their scope extends to an array of measures for further with clinical judgment and patient preference.
betterment of patients like:

Citation: Lalit Gupta and Himani Gupta. Physiotherapy for Respiratory Conditions. Adv Copyright © 2018 Lalit Gupta and Himani Gupta.
Nursing Patient Care Int J 2018, 1(1): 180003.
 2 Advanced Nursing & Patient Care International Journal

Methods of Treatment programme of acute and chronic pulmonary disorders.

They are basically designed
Physiotherapists often use mechanical devices, such as a. To retrain respiratory Muscles
intermittent positive-pressure (IPPV) and CPAP b. To improve ventilation
equipment; tools that have been used in the profession c. To decrease work of breathing
since the mid-20th century. With the resurgence of
interest in physiotherapy and knowledge of lung Types of breathing exercises
segments physiotherapists have a greater armory to a. Diaphragmatic breathing
deliver. Many individuals with life-threatening b. Respiratory muscle training
respiratory failure can be successfully managed in this
c. Segmental breathing or local basal expansion exercises
way, avoiding intubation. Similarly, carefully selected
devices can assist in mucus clearance and improvement in i. Apical expansion exercises
respiratory parameters. Exercise equipments have long ii. Upper lateral costal expansion exercises
been used in pulmonary rehabilitation programmes in iii. Lower lateral costal expansion exercises
different forms; however, physiotherapists may also use
iv. Posterior basal expansion exercises
supplementary oxygen, noninvasive mechanical
ventilation, complex training modalities or d. Gloss pharyngeal breathing
neuromuscular electrical stimulation to enhance the e. Purse lip breathing
effectiveness of exercise training in respiratory patients
[8]. Postural drainage: It consists of positioning with the
gravity assistance for draining of a specific area /segment
Some of the commonly used exercises and principles of the involved lung (Figure 1). Positioning is done in such
employed in day to day chest physiotherapy are a way to assist the required bronchus perpendicular to
summarized as: the ground for mobilizing secretions from involved
segment to central airways, which are then suctioned out
For mobilizing secretions or removed by active coughing (Figure 2). Postural
Breathing exercises: Breathing exercises play an drainage technique involved the basic techniques of
important role in overall pulmonary rehabilitation percussion, vibration and shaking [9].

Figure-1: Lung segments.

https://chembioepub.com/ANPCIJ/ Submit Manuscript @ https://chembioepub.com/submit-manuscript.php

 3 Advanced Nursing & Patient Care International Journal

Positions: Many respiratory diseases are characterized common technique. This is where the physiotherapist will
by the continuous production of sputum/mucus in the teach a patient to lie at certain angles or get into certain
lungs. In cases like these, postural drainage is a very positions in order to help drain the lungs of fluid.

Lung segment Position recommended Representation

High Fowler’s position (semi-upright sitting

Both upper lobes Apical position (45-60 º and may have knees either bent
or straight

Sitting on edge of the bed

Left upper lobe-anterior segment

Left upper lobe-posterior Side-lying with elevation of left side of the chest
segment with pillows/support

One fourth turn on right side from supine, with

Lingula pillows behind the back in 20º-300 head down
position

https://chembioepub.com/ANPCIJ/ Submit Manuscript @ https://chembioepub.com/submit-manuscript.php

4 Advanced Nursing & Patient Care International Journal

Right upper lobe-anterior

Supine with head end of the bed raised
segment

Right upper lobe-posterior Side-lying with pillows under the right side of the
segment chest for elevation

One fourth turn on left side from supine, with

Right Middle lobe pillows behind the back in 20º-300 head down
position

Both lower lobes-superior

Prone lying
segment

Both lower lobes-anterior Laid flat on the back (supine position) with foot
segments end of the bed raised

https://chembioepub.com/ANPCIJ/ Submit Manuscript @ https://chembioepub.com/submit-manuscript.php

 5 Advanced Nursing & Patient Care International Journal

Both lower lobes -posterior

Prone with foot end of the bed raised
segment

Left lower lobe lateral position Right side-lying with foot end of the bed raised

Right lower lobe lateral position Left side-lying with foot end of the bed raised

Figure-2: Postural drainage positioning.

Body position has also been shown to affect oxygenation. ii. Make suitable position as per the force of gravity to
Alterations in ventilation–perfusion inequality drain out bronchial secretions from affected lung
have been suggested as the main reason for improved segments to the dependent central airways.
oxygenation in these body positions. iii. The required positions are determined depending on
the location, severity, and duration of mucous
Basic requirements obstruction.
a. Pillows iv. The physiotherapy exercises are performed atleast
b. Tilt table twice or thrice a day before meals and bedtime and
c. Sputum cup each position is done for 5-15 minutes.
d. Paper tissues v. If patients develops signs of hypoxemia (tachycardia,
e. Vibrators / massagers approved for physiotherapy palpitations, dyspnea, or chestpain) the procedure
should be discontinued if occurs. Immediate
Steps discontinue the exercise if hemoptysis occurs.
i. Nebulize the patient with saline / bronchodilator / vi. Comfort of the patient must be of paramount
mucolytic agents before starting any physiotherapy consideration for active participation for positional
exercise to reduce bronchospasm, decrease viscosity physiotherapy exercises.
of mucus and sputum, and thereby liquefying them vii. Must ensure to auscultate the chest before and after
for enhancing secretion removal [10]. the positional exercises to ascertain effectiveness of
exercises and to further determine the areas of
needed drainage.

https://chembioepub.com/ANPCIJ/ Submit Manuscript @ https://chembioepub.com/submit-manuscript.php

 6 Advanced Nursing & Patient Care International Journal

viii. Encourage deep breathing and coughing after energy transfer between the high airflow velocity and the
spending the adequate time in each position. mucus layer thus dislodging the mucus and leading to its
ix. Diaphragmatic breathing should be encouraged removal.
throughout the postural drainage (this helps in
widening of airways foe effective secretions Coughing: It involves a deep breath (full lung volume),
drainage). with the help of abdominal muscles to ensures that the
expiration is sufficient to remove secretions from airways.
Massage manipulations
Huffing: It is a forced expiration again open glottis. It
Manual or mechanical percussion and vibration are based
generates less intrathoracic pressure than coughing. The
on the assumption of transmission of oscillatory forces to
patient is instructed to take a medium size breath in (mid
the bronchi. This helps in mucus transport in addition to
lung volume), involving the abdominal muscles with fast
postural drainage and coughing.
expiration making a strong sighing sound. It is performed
with pursed lips with mouth slightly open.
Vibration: It has mechanical effect in moving secretions
towards the main bronchi and also stimulates cough
Forced Expiratory Technique: It involves taking one or
reflex.
two huffs from mid to low lung volumes, with open glottis.
a. It should ideally be performed during expiratory phase.
Prerequisite for this involves a period of relaxed
b. Vibration is applied either by placing both hands
controlled diaphragmatic breathing before and after the
directly on the ribcage and over the chest wall or
procedure, with deep slow breaths [11].
cupping with some facemask like device/single hand
and gently compressing and rapidly vibrating the chest
wall as patient exhales.
Relaxation
c. After every three or four vibrations, patient should be Relief of dyspnoea is often experienced by patients in
motivated for deep coughing using diaphragm and different body positions. These specific positions will
abdominal muscles. assist relaxation of the upper half of the thorax while
d. Patient must be adequately rested in phases. encouraging controlled diaphragmatic breathing during
e. After each cycle of vibration, chest should be the attack of dyspnoea [12]. Forward leaning has been
auscultated with stethoscope for any new change/ shown to be very effective in COPD and is probably the
improvement in breath sounds. most adopted body position by patients with lung disease.
f. Each cycle of vibration should be decided according to These relaxing positions involve:
the patient’s tolerance and clinical response: usually i. High side lying
10-15 minutes. ii. Relaxed sitting
g. Vibration is to be avoided over the patient’s breasts, iii. Forward kneel sitting
spine, sternum, and rib cage to prevent any discomfort iv. Relaxed standing
to the patient. v. Forward kneel standing
h. Involvement of family members can also be considered
both for motivation as well as for procedural Breathing Control
performance after adequate training to them with
Patients having chronic respiratory disease usually have
mechanical devices.
very high work of breathing and expand too much of
respiratory efforts in this which should ideally be
Shaking: It also transmits mechanical energy like
effortless. Such patients should be treated in relaxed
vibrations to loosen secretions. In supine the hands are
position and taught breathing to establish a controlled
placed on the anterior aspect of chest or one hand
pattern -counting ‘one out -one in’. This is established at
anteriorly or posteriorly. In side laying the hands may be
patient’s own rate which would slow down once control
placed together on the lateral aspect of the thorax
has been gained (Slow and Deep Breathing) [13]. This
anteriorly or posteriorly.
causes a significant drop in respiratory frequency, and a
significant rise in tidal volume and arterial oxygen tension
Removal of secretions at rest in patients with COPD [14,15]. Recruitment of the
Forced maneuvers like coughing and huffing, are basal areas of the lungs is usually done by exercises
considered as the main cornerstone of airway clearance involving ‘tummy out with breathing in, tummy in with
techniques, and, thus, an essential part of every breathing out (Diaphragmatic Breathing).
combination of treatment modalities. The concept is to
enhance mucus transport due to forced maneuvers and

https://chembioepub.com/ANPCIJ/ Submit Manuscript @ https://chembioepub.com/submit-manuscript.php

 7 Advanced Nursing & Patient Care International Journal

Progression is made by altering the phasing to ‘one, two Conclusion

out-one in’ then ‘one, two out-one in’ then ‘one,two,three
out,-one two in’. The patient’s position is then altered to Physiotherapy is cornerstone for non-medical treatment
reduce support until he or she is able to stand, walk and of patients with respiratory disease. In addition to its
go up or down stairs with breathing control. Such patients traditional role in the treatment of airflow obstruction
are taught to breathe out when bending down and to and mucus retention, other aspects of respiratory
breathe in when straightening up during everyday activity disorders such as in ventilatory dysfunction, dyspnoea
(e.g. taking water bottles from refrigerator, mopping the and quality of life are also benefitted by physiotherapy
floor, etc). interventions. Respiratory physiotherapy aims to improve
ventilation in respiratory diseases with a variety of
Postural awareness techniques by improving inspiratory muscle strength and
that also aid in clearance of sputum by bronchopulmonary
Rounded shoulders, kyphosis, lordosis, scoliosis and head
techniques. It involves a variety of strategies aimed at
thrust forward are common postural abnormalities. Such
reducing the work of breathing, improving ventilation,
abnormalities limit thoracic spine mobility and hence
increasing function, and enabling relief of dyspnoea.
decrease chest expansion. Therefore it is essential to
Exercise training, peripheral and respiratory muscle
teach patients to relax the upper tar so, straighten the
training, airway clearance techniques, and breathing
spine and keep the head erect while walking or sitting.
retraining have been shown to be effective treatments in a
This must be applied in positions of work and when
variety of conditions affecting the respiratory system, if
sitting resting, e.g. reading or watching television.
properly employed.
Mobilizing the thorax and shoulder girdle
References
Exercises involving thorax and shoulder are useful in
mobilizing the lower part of the thorax and to encourage 1. Pathmanathan N, Beaumont N, Gratrix A (2015)
basal expansion to prevent atelectasis and improve Respiratory physiotherapy in the critical care unit,
coughing. Continuing Education in Anaesthesia Critical Care &
Examples of such exercises are: Pain 15(1): 20-25.
a. Sitting; trunk turning or bending with arms relaxed.
b. Under bend sitting (first on side of chest wall), trunk 2. Thomas PJ, Paratz JD (2007) Is there evidence to
bending sideways. support the use of lateral positioning in intensive
c. Sitting; shoulder girdle circling backwards. care? A systematic review. Anaesth Intensive
d. Sitting; trunk bending forwards with breathing out and Care 35(2): 239-255.
trunk raising with breathing in.
e. Sitting; arms raising forwards and upwards, and 3. Zeppos L, Patman S, Berney S, Adsett JA, Bridson
lowering sideways. JM, et al. (2007) Physiotherapy in intensive care is
f. Sitting trunk bending forwards and to the left and safe: an observational study. Aust J Physiother 53(4):
stretching upwards backwards and to the right- repeat 279-283.
to the other side.
4. Downie PA, Cash JE (1987) Cash’s textbook of chest
and vascular disorders for physiotherapist. (4th edn),
Home Management Lippincott, Philadelphia, USA, pp. 704.
The physiotherapist must discuss with each patient 5. Oldenburg FA Jr ,Dolovich MB, Montgomery JM,
suffering chronic respiratory disease how treatment is Newhouse MT (1979) Effects of postural drainage,
carried out at home. This will include formal teaching to exercise, and cough on mucus clearance in chronic
the patient and family members’ involved about the bronchitis. Am Rev Respir Dis 120(4): 739-745.
feasibility of postural drainage positions by performing
some commonly used day to day activities. Breathing 6. Judson, MA, Sahn, SA (1994) Mobilization of
exercises with webbing belt helps the patient to practice secretions in ICU patients. Respir Care 39: 213-226.
basal expansion. Methods of safe disposing of sputum
should be discussed. Self percussion and vibration 7. Wallis C, Prasad A (1999) Who needs CPT? Moving
maneuver by commercially available vibrators and from anecdote to evidence. Arch Dis Child 80(4): 393-
massagers along with timely nebulization and steam with 397.
regular exercises have to be fitted in to the patient’s
lifestyle.

https://chembioepub.com/ANPCIJ/ Submit Manuscript @ https://chembioepub.com/submit-manuscript.php

 8 Advanced Nursing & Patient Care International Journal

8. Nici L, Donner C, Wouters E, Zuwallack R ,Ambrosino management of the adult, medical, spontaneously
N, et al. (2006) American Thoracic Society/European breathing patient. Thorax 64(Suppl 1): i1-51.
Respiratory Society statement on pulmonary
rehabilitation. Am J Respir Crit Care Med 173(12): 13. Policy statement (2011) Description of physical
1390-1413. therapy. World Confederation for Physical Therapy,
pp. 1-12.
9. Mc Carren B, Alison JA, Herbert RD (2006) Manual
vibration increases expiratory flow rate via increased 14. Langer D, Hendriks E, Burtin C, Probst V,Van der
intrapleural pressure in healthy adults: an Schans C, et al. (2009) A clinical practice guideline for
experimental study. Aust J Physiother 52(4): 267-271. physiotherapists treating patients with chronic
obstructive pulmonary disease based on a systematic
10. Kisner C, Colby LA (1996) Therapeutic Exercise: review of available evidence. Clin Rehabil 23(5): 445-
Foundations and Technique. (3rd edn), F A Davis, 462.
Philadelphia, USA, pp. 761.
15. Dimitrova A, Izov N, Maznev I, Vasileva D, Nikolova M
11. Fink JB (2007) Forced Expiratory Technique, Directed (2017) Physiotherapy in Patients with Chronic
Cough, and Autogenic Drainage. Respir Care 52(9): Obstructive Pulmonary Disease. Open Access Maced J
1210-1221. Med Sci 5(6): 720-723.

12. Bott J, Blumenthal S, Buxton M, Ellum S, Falconer C, et

al. (2009) Guidelines for the physiotherapy

https://chembioepub.com/ANPCIJ/ Submit Manuscript @ https://chembioepub.com/submit-manuscript.php

View publication stats