Managing Respiratory Conditions by Physiotherapy
Physiotherapists see a very wide spectrum of respiratory conditions in primary and secondary care, learning to manage the assessment and treatment of many chest diseases. Typical conditions seen include cystic fibrosis, asthma, chronic bronchitis, pneumonia, bronchiectasis, chronic obstructive pulmonary disease and hyperventilation. Physiotherapy training in respiratory disease is intensive and detailed, allowing physios to assess and advise on the treatment of most respiratory problems. Respiratory assessment and treatment is difficult to learn and is complicated by the often severely unwell status of the patient, making the physiotherapists take significant responsibility for the care of such patients.
The patient's notes and observation charts are first reviewed by the physiotherapist before going to see the patient, so as to be clear about the medical diagnosis, opinion and treatment. The blood test results will be important and the physiotherapist should have a good understanding of these. The physiotherapist will introduce themselves to the patient and whilst questioning the patient about their illness will be observing their condition at the same time, looking for the rate of respiration, hand, nose and lip colour, oxygen or nebuliser treatments, the overall wellness of the patient, their weight, the effort of breathing they are making and if they are using arm and neck muscles to help breathing.
The observation of the patient allows the physiotherapist to gather a lot of valuable information very quickly and points them to where they should continue their objective examination. The efficiency of air entry into the lungs and the ability to expand the chest are assessed initially by feeling the chest expansion for depth and symmetry. Then the physiotherapist will listen to the chest with a stethoscope, assessing the air entry into the airways, any areas of blocked passages, areas of consolidated lung, any areas of collapse and wheezy air entry. Once assessed, this will point towards further investigation needed and to appropriate treatments.
The physiotherapist initially looks at the patient's oxygen concentration as the correct level is critical for the patient's respiratory and overall status. If the blood oxygen saturations are below normal then the doctors will prescribe oxygen at a specific percentage such as 24 percent or 28 percent via a venturi type administration device which maintains a constant oxygen concentration as variations in concentration would be damaging. Continuous gas delivery can dry the airways and the secretions, making treatments more difficult, so oxygen should always be administered humidified and heated to body temperature by the appropriate gas delivery circuit.
The physiotherapist will then move on to the efficiency of air entry into the lung peripheral airways, as the airways can become blocked by sputum from infections or may collapse down. This compromises air entry and reduces the patient's ability to maintain blood oxygen levels. Breathing exercises are taught initially by the physiotherapist to attempt clearance and re-inflation of the collapsed airways and if that is not successful then IPPB (Intermittent Positive Pressure Breathing) can be used. IPPB uses a machine to force air at a controlled volume into the patient's lungs at a greater volume than they can do themselves.
Sputum retention in the lungs occurs when the patient is unable to expectorate the secretions which are formed by infections and worsened by lying in bed in hospital. Active cycle of breathing is a typical physiotherapy technique taught to patients, allowing them to move secretions from peripheral airways to the central airways where they can be removed by huffing or coughing. The technique involves steadily increasing depth of inspiration with longer expirations under slight pressure, avoiding the tendency to increase the bronchospasm of the airways. Patients can become very good at practicing this technique, allowing them to self treat effectively.
Manual techniques which physiotherapists use are vibrations and clapping to the chest wall to loosen the sputum and promote expectoration. An inspiratory flutter device can also be used which vibrates the incoming air and disturbs the secretions in the airways, again encouraging coughing and removal of sputum. If the patient has fractured ribs or a surgical wound, painkillers are very important and the physiotherapist will teach the patient to self splint the injured area to allow more effective deep breathing and coughing.