Chronic Bronchitis (Respiratory Pathologies )

Question 1

What is Chronic Bronchitis?

Answer 1

A condition that results in the production of purulent sputum for at least 3 months in a row over two consecutive years

Question 2

Bronchial Mucus

Answer 2

1. There are two sources of bronchial mucus: the bronchial glands and the epithelial goblet cells which line the bronchial walls
2. In chronic bronchitis, there is an enlargement of the mucus-secreting bronchial glands and an increase in the number of epithelial goblet cells.
3. There is also a decrease in the number of ciliated epithelial cells which help to mobilize and remove mucus

Question 3

Disease process

Answer 3

1. Airways become chronically inflamed from ongoing irritation which leads to edema and thickening or hyperplasia of the bronchial walls
2. There is a decrease in expiratory airflow rates and prolonged expiration due to airways being obstructed from an increase in bronchial mucus
3. The person can experience wheezing with a severe productive cough, dyspnea (laboured, distressed breathing) and bouts of respiratory infection. –> This leads to less tolerance for exercise and eventually no physical reserves left for times of stress
4. Blockage of the airways leads to insufficient oxygenation in the alveoli which causes cyanosis (bluish tinge to skin) and general peripheral edema results from ventricular failure
5. People with chronic bronchitis tend to retain weight
6. A person with combined cyanosis, edema and weight retention is called a “blue bloater”
7. Over time, severe chronic bronchitis can lead to pulmonary hypertension, right-sided heart failure and death

Question 4

Chronic Obstructive Pulmonary Disease (COPD)

Answer 4

1. A combination of chronic bronchitis and emphysema
2. This most commonly occurs in people who smoke

Question 5

Causes of Chronic Bronchitis

Answer 5

1. Smoking-results in airway inflammation that is thought to trigger the specific pathological changes seen in the airway goblet cells and epithelium
2. Environmental factors including air pollution and occupational exposure to inhaled particles or fumes

Question 6

The Respiratory Tract and Lungs

Answer 6

1. In the upper respiratory tract, air flows through the nasal cavity and pharynx where it is warmed and humidified
2. The air is filtered and particles are removed by mucosa and cilia
3. In the lower respiratory tract, air is transported to the alveoli where gas exchange takes place
4. Ventilation is the air exchange from atmosphere to alveoli (opposite to respiration which is the blood transport and exchange of gases at the alveolar capillary membrane
5. The trachea branches into left and right main bronchi at the level of the 2nd rib anteriorly and T5 posteriorly
6. The bronchi supply the left and right lungs through a further division into lobar and segmental bronchi
7. The bronchi further divide into bronchioles, then into terminal bronchioles, respiratory bronchioles and finally alveoli
8. The trachea and alveoli are supplied with lots of mucus-producing cells and ciliated cells which line the airways
9. The left lung is divided into two lobes and is divided obliquely by a fissure between the left upper and lower lobes from the 5th rib anteriorly to T3 posteriorly
10. The right lung is divided into three lobes, upper, middle and lower. The fissure between the upper and middle lobes runs obliquely from the 3rd rib anteriorly to T3 posteriorly. The fissure between the middle and lower lobe runs obliquely from the 6th rib anteriorly to the 5th rib at the level of the lateral border of the scapula

Question 7

Muscles of Respiration

Answer 7

1. Resting Inhalation:

Ta. he diaphragm contracts and flattens
The external intercostals contract, lifting the ribs (increases the anterior/posterior and transverse dimensions of the thorax)

b. The thorax volume increases and the pressure in the lungs decreases

c. Air moves into the lungs

d. The scalenes elevate the first two ribs, becoming active

e. The average adult breathes 10-12 times per minute at rest

2. Forced Inhalation:
3. The diaphragm descends at least 3-4 intercostal spaces
4. The accessory muscles of inhalation are recruited
5. SCM’s lift the sternum only when the head and neck are upright or hyperextended
6. Subclavius elevates the first rib when the clavicle is fixed
7. Levator costarum lifts the ribs posteriorly and superiorly
8. Serratus posterior superior raise the 2nd-5th ribs
9. Latissimus dorsi raise ribs 9-12
10. Pectoralis major raises the sternum and 2nd-6th ribs
11. Pectoralis minor lifts the 3rd-5th ribs
12. With activity, the average adult breathes 50 times per minute
13. Relaxed Exhalation:

a. A passive process

b. The diaphragm relaxes upward into a domed shape

c. The external intercostals and scalenes relax, allowing the ribs to drop

d. The thoracic volume decreases

e. The pressure in the lungs increases, pushing air out of the lungs

4. Forced Exhalation:

a. The internal intercostals contract, pulling the ribs downward
b. Rectus abdominis, internal and external obliques and quadratus lumborum are also recruited

Question 8

Symptom Picture

Answer 8

1. Increase in mucus production from the bronchial glands and an increase in the number of goblet cells due to chronic irritation
2. Airways are narrow due to chronic inflammation, thickening of the bronchial airways and accumulated mucus
3. Decreased mobility of the thoracic joints
4. Respiratory infections may be present
5. Chronic productive cough which worsens in the morning and evening and in the winter months.
6. Mucus is purulent
7. Over time, cyanosis occurs, the finger ends are clubbed or bulbous, the person tends to retain weight and peripheral edema results

Question 9

Health History Questions

Answer 9

1. When was the onset of the bronchitis?
2. Are there any other respiratory conditions?
3. What is their occupation and recreational activities?
4. Do they smoke? If so, how frequently?
5. Do they know what lobes are affected?

6.Do they have dyspnea? Is sleep disrupted because of this?

7. Is the cough productive? Is it severe? What time of day is the cough worse?
8. What is the colour of the sputum?
   a. Clear or whitish is common
   b. Yellow or green indicated infection
   c. Blood streaked may be present
   d. If it severe, postural drainage is CI’d
9. What is the quantity of the sputum?
10. Have they been hospitalized for chronic bronchitis? When and how long?
11. Do they have a fever? If so, massage is CI’d
12. Are they taking any medication?
13. Are they doing any other modalities?

Question 10

Observations

Answer 10

1. The client may lean forward while sitting to stabilize the shoulder girdle to assist with inhalation
2. The accessory muscles of respiration are likely hypertrophied
3. The client may have dyspnea or tachypnea (rapid, shallow breathing)
4. The client may have apical breathing (using the upper chest only)
5. A barrel chest may be present (increased anteroposterior thoracic dimensions)
6. Hyperkyphosis, hyperlordosis or scoliosis may be present
7. In severe cases, the client may breathe through pursed lips
8. Cyanosis may be observed at the nail beds or the lips
9. Clubbing of the fingers, weight retention and peripheral edema may be present

Question 11

Palpation

Answer 11

1. The muscles of respiration and the accessory muscles are tender and hypertonic (diaphragm, intercostals, scalenes, SCM, pectoralis major and minor and abdominals)
2. Trigger points are likely present in the above muscles and they may feel ropey and fibrosed
3. In advanced cases, peripheral edema is palpated

Question 12

Testing

Answer 12

1. AF ROM of the thoracic and cervical spine and the shoulder girdle reveals reduced ranges
2. PR ROM including static and motion palpation of the thoracic and cervical spine reveal areas of hypermobility
3. AR strength testing for muscles of the shoulder girdle and the abdominals may be performed, assessing for possible weakness

Question 13

Special Tests:

Answer 13

1. Vocal fremitus test:

a. To assess for areas of bronchial congestion, due to emphysema or chronic bronchitis

b. Place client in a prone position

c. Place relaxed hands on the client’s thorax and move them over the various aspects of the thorax

d. While doing this, have the clint repeat words containing nasal sounds (“ninety-nine”) which will cause the thorax to vibrate in a palpable manner.

e. The vibrations will be the most noticeable over the lungs and bronchi

f. Repeat in the supine position
g. Positive: if the vibrations are decreased over the lungs and bronchi. Indicative of congestion due to infected mucus, serum or lymph, indicating which pleural lobe is affected

2. Mediate percussion test:

a. To assess the lung density, specifically for the presence of mucus congestion in specific lobes as in chronic bronchitis or hyperinflation in emphysema

b. Place client in the prone position, and then in supine

c. Place the middle finger of the non-dominant hand flat on the thorax along an intercostal space

d. With the tips of the 1st and 2nd fingers of the dominant hand, tap firmly on the finger positioned on the thorax

e. Repeat tapping over various aspects of the thorax

f. The sound is duller over areas of congestion and more resonant over hyperinflated lungs. The sound is also duller over solid areas, such as the heart and abdomen

Question 14

Contraindications

Answer 14

1. Do not exhaust client with overtreatment or prolonged painful techniques
2. Joint play techniques to the ribs with rib hypermobility and a history of subluxation
3. Postural drainage with severe hemoptysis (lots of blood in sputum) severe pulmonary edema, congestive heart failure, pulmonary embolism, severe hypertension or hypotension, recent myocardial infarction
4. Do not use postural drainage directly after the client has eaten
5. Tapotement over bony prominences
6. Prolonged tapotement that accompanies postural drainage with chest wall pain unstable angina, anticoagulation therapy, osteoporosis, rib fracture, prolonged steroid therapy, hemoptysis, untreated lung abscesses, pulmonary embolism and open thoracic wounds or burns
7. A client with cardiac or renal disorders should not increase the daily intake of water to thin mucus secretions

Question 15

General Treatment Considerations

Answer 15

1. In the client has long standing severe chronic bronchitis where there is a possibility of hypertension, the therapist should monitor the client’s blood pressure before and after the treatment
2. Positioning of the client depends on the structures to be treated, the location of the affected lobes and the client’s general health
3. Positioning during the massage is increasingly important with more severe cases of bronchitis. The time that the client spends in the supine position is reduced or the client is placed only in a side lying position avoiding supine entirely
4. The prone position has shown to improve ventilation and oxygenation, while supine does the opposite
5. With unilateral lung diseases, lying on the unaffected side increases oxygenation than lying supine
6. When the disease is bilateral, lying on the right side increases oxygenation
7. Hydrotherapy such as a facial steam for 5 mins prior to the massage will help to thin the mucus

Question 16

General Treatment

Answer 16

1. The treatment should be performed in the context of a relaxation massage including diaphragmatic breathing
2. Treatment can start in supine:

a. Address fascial restrictions through the anterior chest, intercostals and abdomen

b. Stretching can be applied to the shortened cervical muscles

c. Decrease hypertonicity, trigger points and pain through the neck and chest muscles, intercostals and abdominals

d. Mobilize the thorax by placing both hands on the restricted ribs and have the client breathe diaphragmatically. As the client inhales apply gentle resistance to the ribs

e. Joint play techniques are used on the thorax to create movement at the costal articulations

3. Turn the client into the prone position:

a. Decrease fascial restrictions on the lower intercostals and low back

b. Decrease hypertonicity, trigger points and pain through the back muscles

c. Encourage circulation in the overused structures

d. Mobilize the thorax

Question 17

Postural Drainage

Answer 17

1. Remove secretions using postural drainage. The client should practice diaphragmatic breathing and productive coughing if copious amounts of mucus are being produced
   Have tissues and a wastebasket available for the client
   The positioning of postural drainage is based on the location of the affected lobe and bronchi
   Gravity drains the mucus into the main bronchi where it can be more easily expectorated by coughing
   These positions can be maintained for 3-5 mins or longer if the client can tolerate it
   Although the client can be left in these positions while resting and some drainage will occur, the addition of tapotement makes the drainage more efficient
2. Lower lobes:

The client’s hips must be elevated above the head
A wedge of pillows is created so the client’s thorax is placed at an angle between 30-45 degrees

3. Right Middle Lobe:

The client lies one quarter turn from supine on the left side, supported on the right side posteriorly by pillows

4. Upper Lobes:

Most commonly affected if the person is bedridden
The client is seated

5. Finishing Treatment:

a. Tapotement is performed at a slower rather than a faster rate to achieve maximum relaxation and to avoid possible bronchospasm

b. The treatment is ended with soothing effleurage and stroking to the back to decrease SNS firing

Question 18

Self-Care

Answer 18

1. Practice breathing exercises:

a. Pursed lip breathing
b. Productive coughing
c. Diaphragmatic breathing
d. Postural drainage with breathing and productive coughing

2. Encourage relaxation strategies:

Relaxation techniques for the neck, shoulder muscles

3. Thin secretions:

a. Inhalation of steam in a hot shower helps to thin secretions
b. Drinking 6-8 glasses of water per day

4. Mobilize the thorax:
   Refer to Rattray pg 887
5. Stretch short muscles:

a. Stretch the muscles of the shoulder girdle and neck

Self massage to the costal margins, intercostals and scalenes

6. Strengthen weak muscles:
   Breathing exercises will strengthen the muscles of respiration
7. Reduce or eliminate perpetuating factors:
   a. Encourage client to stop smoking if that is a factor
   b. Airborne pollutants in the home can be reduced
   c. Avoidance of people with respiratory infections is also helpful