Asthma (Respiratory Pathologies )

Question 1

What is Asthma?

Answer 1

A chronic inflammatory disorder characterized by bronchospasm (co thắt phế quản) (narrowing of the airways in the lungs), which is reversible over time either spontaneously (một cách tự phát ) or following treatment

Question 2

Causes of Asthma

Answer 2

1. Underlying airway inflammation and an abnormal bronchospasm response to triggers that would not normally provoke such a response
2. Asthma is more common in urban than in rural areas suggesting environmental factors override genetic factors predisposing to asthma
3. Exposure to dust mites present in bedding and house dust. An allergen is found in the fecal pellets những viên phân of the house dust mite
4. Bronchoconstriction is provoked by cigarette smoking
5. Occupational factors such as repeated exposure to chemicals
6. Can be a result from food allergies
7. Exercise induced asthma can be triggered by the cooling and drying effect of inhaled air

Question 3

Types of Asthma

Answer 3

*** Extrinsic:

1. Irritating substances from outside the body cause an immune system or allergic response ( smoke, allergen)
2. A release of inflammatory mediators from mast cells within the airways occurs
   The immune system responds to irritating agents such as pollens, animal dander, foods and cigarette smoke
3. Attacks are related to exposure to irritating substances
4. Skin tests for allergens are positive
5. Most childhood onset is extrinsic

*** Intrinsic:

1. Characterized by a lack of clearly defined precipitating factors such as an allergic response
2. Skin tests are negative
3. Factors within the body, such as respiratory infections may cause an attack.
4. Also, weather changes, emotional stress and bronchial irritants
5. Adult-onset asthma is usually intrinsic
6. There is less reversibility and more long standing airflow obstruction

Question 4

Terms Associated with Asthma

Answer 4

1. Inducers:

Act by causing airway inflammation such as allergies, genetic factors, infections and occupational and environmental influences

2. Triggers:

Factors that cause airway smooth muscle contraction in conjunction with pre-existing airway inflammation and airway hyperresponsiveness

3. Triggering Factors:

Inhaled allergens, cigarette smoke, respiratory infections, environmental pollution, exercise, food intolerances, drugs, occupational, psychological and hormonal factors

Question 5

Anatomy of Respiration in Asthma

Answer 5

1. With asthma, there is an abnormal response of the airways or bronchospasm
2. A hyperresponsiveness occurs as a consequence of chronic underlying inflammation
3. With extrinsic asthma:

a. an immune response occurs to the irritating stimuli

b. Histamines are released from mast cells in the airways

c. A chain of inflammatory events occur, leading to edema of the airways and thickening of the bronchial walls

d. Eosinophils, inflammatory cells, invade the walls, which results in edema

e. Between attacks, these changes are reversible, but over time, goblet cells enlarge and the bronchial smooth muscles may become thickened

4. There is increased mucus production which is abnormally sticky and inhibits ciliary action in the airways, leading to mucus retention and plug formation
5. Air trapping occurs when mucus plugs trap air in the lungs, which over time, causes increased lung volume
6. During forced inspiration, the diaphragm, external intercostals and scalenes are assisted by numerous muscles which become shortened due to air trapping and increased lung volume
7. During forced exhalation, the internal intercostals, the abdominals and QL are recruited which are shortened and tight
8. Control of the bronchial airways is by the autonomic nervous system, through the vagus nerve and fibers from the thoracic ganglia

Question 6

Symptom Picture

Answer 6

1. Mild Asthma:

Indicated by occasional wheezing or coughing that does not cause major impairment of physical activity, by sensitivity to triggers including allergens and cold air and by symptoms that restrict activity two or three times a week

2. Moderate Asthma:

Indicated by daily symptoms, occasional (sometimes) nocturnal symptoms and avoidance of exercise

3. Severe Asthma:

Indicated by daily wheezing, severe nocturnal symptoms, absence from work several times a year or more, poor quality of life and occasional hospital admissions

• Nocturnal symptoms of breathlessness and coughing are usually at their worst several hours after the person has gone to bed and has been lying down, which narrows the airways and allows mucus secretions to build up
  With exercise-induced asthma, a cough is noticed about 5-10 mins after exercise begins and peaks 3-15 mins after the exercise ceases
• Airway obstruction in all types of asthma is reversible, especially with the use of bronchodilator medication, but over time, airway obstruction can become irreversible
  With chronic uncontrolled asthma, air trapping eventually leads to lung hyperinflation and changes in the shape of the thorax
• In children, asthma is initially characterized by paroxysmal coughing, especially at night. Chest tightness, wheezing and breathlessness occur in mid-childhood
• Warning signs of an acute asthma attack are:
  a. Sleep disturbances

b. Increase in symptoms

c. Increasing need for bronchodilator treatment combined with decreasing medication effectiveness

d. A fall in the peak air-flow

Question 7

During an Attack (for rmt)

Answer 7

1. Expiration becomes prolonged due to the airway obstruction and the amount of air that can be exhaled forcefully from the lungs with each breath decreases
2. Air that can’t be exhaled becomes trapped in the lungs, resulting in hyperinflation
3. The diaphragm becomes flattened due to hyperinflation, preventing the lower ribs from moving up and out
4. Coughing to clear the mucus becomes unproductive during the attack and productive afterwards
5. Wheezing is audible on both inhalation and exhalation
6. The person is visibly anxious and may be sweating
7. The most comfortable position is sitting upright
8. Dyspnea or distressed, laboured breathing and tachypnea or rapid, shallow breathing may be severe
9. Acute severe asthma occurs when an attack becomes persistent and intractable
   Immediate emergency medical attention is required
10. The person cannot complete a sentence in one breath
11. Respiration is more than 25 breaths per minute and their pulse is more than 110 beats per minute

Question 8

Health History Questions

Answer 8

1. When was the onset of the asthma? (childhood, aldults). Has it been diagnosed by a physician?
2. Do you have any other respiratory conditions?
3. Does anyone else in your family have asthma, hay fever or eczema?
4. Have you ever been hospitalized for asthma?
5. What kind of asthma do you have? (ex, in trinsict)
6. What triggers an attack for you?
7. Are you under continuous stress or increased amounts of stress at home or work?
8. Do you have any pets that could trigger the attacks?
9. Is your living space insulated, sealed or dusty?
10. Do you have immediate symptoms on exposure to smoke (second hand) , cold air, exercise or dust?
11. Do you have nocturnal symptoms of cough or waking with shortness of breath?
12. Are you taking any medications? Is it effective?
13. What colour is your sputum?
14. What are your activity levels like?
15. If the client has an inhaler, where is it?
16. What should the therapist do if an acute attack happens during treatment?
17. Are you doing other parallel therapies?

Question 9

Observations

Answer 9

1. Accessory muscles of respiration are likely hypertrophied
2. There may be dyspnea or tachypnea and the breathing pattern may be apical
3. Hyperkyphosis, head-forward posture or scoliosis may be present
4. A barrel chest may be present with chronic, poorly controlled asthma
5. During an attack, the seated client may lean forward, stabilizing the shoulder girdle to assist with inhalation
6. Exhalation is rapid, laboured and incomplete and there may be signs of anxiety

Question 10

Palpation & Testing

Answer 10

1. Muscles of respiration and accessory muscles are tender and hypertonic
2. Axillary attachments of pectoralis major and latissimus dorsi and the costal margins are usually tender
3. Trigger points are likely present in the same above muscles and they may feel ropey and fibrosed
4. AF ROM of the thoracic and cervical spine and shoulder girdle reveals reduced ROM
   PR ROM of the thoracic and cervical spine show areas of hypomobility
5. AR strength testing for muscles of the shoulder girdle and the abdominals may be performed to assess for weakness

Question 11

Special Tests

Answer 11

1. Vocal fremitus and mediate percussion tests will be positive for areas of congestion due to mucus
2. Measurement of the thoracic circumference at full inspiration and full expiration is taken with a tape measure at the axilla and at the xiphoid process. The measurement at exhalation is subtracted from the measurement at inhalation to give the amount of thoracic expansion with normal differences in adults between 3-7.5cm
3. Rib motion test is positive with larger areas of restricted motion

Question 12

Contraindications

Answer 12

1. After determining the client’s asthma triggers, if they are allergens such as dust or mould spores, these may exist in the treatment room
2. Do not exhaust the client with over treatment or prolonged painful techniques
3. Avoid direct compression on the xiphoid process and the floating ribs
4. Treatment is CI’d during an acute attack
5. Postural drainage is CI’d with severe hemoptysis (copious amounts of blood in sputum), severe pulmonary edema, congestive heart failure, pulmonary embolism, severe hypertension or hypotension, recent myocardial infarction and recent neurosurgery
6. Tapotement is CI’d over bony prominences, floating ribs and breast tissue
7. Bronchodilator medication taken recently may indicate treatment modifications. Long term steroid use may lead to osteoporosis
8. Chronic airflow obstruction may lead to pulmonary hypertension and in occasional cases, right-sided heart failure or cor pulmonale
9. Avoid an increase in daily water intake self-care if the client has cardiac or renal disorders

Question 13

General Treatment Considerations

Answer 13

1. The general focus of the treatment is to reduce stress and mobilize the thorax
2. If the client has frequent asthma attacks, they should bring their inhaler to the treatment
3. Positioning will depend on the structures being treated and the client’s general health. Positioning is more important with more chronic, severe cases
4. In general, the prone position has shown to improve ventilation and oxygenation
5. The time the client is in supine position can be reduced or they can be placed in sidelying, avoiding supine entirely
6. Hydrotherapy of a facial steam for 5 mins prior to the massage can help to thin mucus

Question 14

Treatment

Answer 14

1. For a moderate asthma presentation where modifications for hypertension or ventilation are not needed, the following is a general guideline:
2. Hydrotherapy of heat to the back and chest can be used
3. Diaphragmatic breathing to help decrease SNS firing
4. Reduce fascial restrictions over the posterior thorax. (they are lengthened so we don’t need to stretch them )
5. Swedish techniques to the back and trigger point therapy are beneficial to reduce hypertonicity and increase circulation
6. Mobilize the thorax using anterior and lateral challenges to hypomobile thoracic vertebrae
7. Thoracic mobilizations and rib springing are indicated for hypomobility

*** In supine:

1. Decreasing fascial restrictions to the pectoral and sternum area are beneficial
2. Diaphragm attachments are treated
   Swedish techniques are used on the chest and neck muscles, intercostals and abdominals to reduce hypertonicity, trigger points and pain
3. Joint play are indicated to treat areas of hypomobility on the sternum and ribs
   Stretch shortened muscles in the neck and accessory muscles of breathing
4. If postural drainage is required, the client is place in the appropriate postural drainage position

Question 15

Self-Care

Answer 15

1. Relaxation techniques for the muscles of the neck and shoulder girdle are important
   Breathing techniques to strengthen weakened muscles
2. Reduce or eliminate triggering factors (dust mites, pollens and spores, occupational-related asthma triggers, exercise-induced asthma triggers), ( change their filter often if the dust in the house bother them)
3. Stretch short muscles
4. Self massage
5. Mobilize the thorax
6. Thin secretions