Emphysema (Respiratory Pathologies )

Question 1

What is Emphysema?

Answer 1

A disease that causes enlargement of air spaces distal to the terminal bronchioles and destruction (sự phá hủy) of the alveolar walls

Question 2

Most Common Forms of Emphysema

Answer 2

1. Centrilobular (trung tâm tiểu thùy):

• Destroys the central portion of the lung and is the form most associated with smoking
• Abnormal, enlarged air spaces are surrounded by normal tissue
• Most frequently found in the upper lobes

2. Panlobular (toàn cầu):

• Destroys the lobules uniformly throughout the lungs
• Most associated with an inherited enzyme deficiency disorder
• An irregular form that is associated with a previous lung pathology such as TB (tuberculosis)
• Enlarged air spaces are formed due to the fibrosis and scarring that follow the healing process

Question 3

Disease Process

Answer 3

1. In all forms of emphysema, the alveolar walls are destructed, leaving large air spaces-the largest of these are called “bullae” mụn nước
2. These air spaces cause inefficient gas exchange due to the reduced surface areas
3. The normal elastic recoil (giật lại) of the lungs is lost as the elastic tissue in the alveolar walls is destroyed
4. The loss of elasticity contributes to early airway collapse on exhalation and air trapping. Over time emphysema can lead to congestive (sung huyết) heart failure and death

The air collect in the lung and can’t get out (L)

Question 4

Causes of Emphysema

Answer 4

1. An overabundance of proteolytic enzymes (phân giải)
2. Caused by an inflammatory response to an airway irritant Chất kích thích
3. The irritant is most commonly cigarette smoke
4. Once neutrophils and basophils have finished participating in the inflammatory response in the airway walls, they necrose which release proteolytic enzymes that digest the lung tissue
5. An inherited lack of proteolytic enzyme inhibitors
6. This allows naturally occurring enzymes to destroy elastic tissue in alveolar walls which causes larger than normal air spaces

Question 5

Symptom Picture

Answer 5

1. Dyspnea on exertion in the early stages of the disease and in the later stages, dyspnea at rest
2. Cough wheezing prolonged expiration and physical inactivity leading to deconditioning
3. Hyperinflation of the lungs leads to an increased anteroposterior dimension of the thorax called “barrel chest”. The ribs and muscles of inspiration are in a constant position of maximum inspiration. The diaphragm is flattened and the accessory muscles of respiration are overused
   The person often assumes a seated position, leaning forward on the arms to give the accessory muscles of respiration mechanical advantage

***Intercostal lenthen; scm, scalene, pec overwork

4. Even though hypoxia occurs, people are able to struggle and over ventilate, maintaining blood gas levels until later in the disease. The term “pink puffer” or “fighter” may be used
5. People with emphysema are usually thin
6. Tachypnea (rapid, shallow breathing) is present and the person exhales through pursed lips
7. As the disease progresses, pulmonary hypertension is followed by enlargement of the right ventricle, right-sided heart failure (cor pulmonale) and death

Question 6

COPD (Chronic Obstructive Pulmonary Disease)

Answer 6

1. COPD describes a spectrum of diseases, most commonly a combination of emphysema and chronic bronchitis. Cystic fibrosis (Bệnh xơ nang) (CF) is also a COPD, although asthma due to its episodic nature is not a classic chronic obstructive disease
2. CF is a genetic disorder of the apocrine glands.
3. There is an increase in the size and number of bronchial mucous glands which secrete copious amounts of mucus that is exceedingly sticky. There are increased secretions from the salivary, sweat and pancreatic glands.

Question 7

Health History Questions

Answer 7

1. When was the onset and what was the cause of the emphysema?
2. Do you have dyspnea? If so, when does it happen?
3. What medication are you taking? Have you ever been hospitalized for this and/or required oxygen?
   What are your functional abilities? Do you fatigue easily?
4. Do you smoke?
5. Do you eat well?
6. Are you depressed?
7. Do you have severe cardiopulmonary conditions, indicating the client should not take very hot showers or bath?
8. Are you doing any other parallel threapies?

Question 8

Observations

Answer 8

1. A postural assessment may reveal elevated shoulders, a barrel chest, horizontal ribs and head-forward posture
2. Exhalation is prolonged and the client may lean on their elbows so the shoulder girdle muscles can work as accessory muscles of respiration
3. Pursed lip breathing may be used on expiration
4. Accessory muscles of respiration are prominent
5. The client is likely thin and fatigued looking, with skin being rosy or pink
6. Fingertips may be clubbed or enlarged

Question 9

Palpation & Testing

Answer 9

1. Thoracic rigidity occurs with emphysema
2. Muscles of respiration are hypertonic, including the diaphragm, intercostals, scalenes and SCM
3. AF and PR ROM are reduced in the thoracic and cervical spine
4. AR strength testing of the shoulder girdle may reveal weaker and overused muscles
5. Vocal fremitus and mediate percussion tests will either be very hollow-sounding (more air) with emphysema alone or positive for areas of congestion with associated chronic bronchitis

Question 10

Contraindications

Answer 10

1. Do not exhaust the client with overtreatment or prolonged painful techniques
2. Avoid placing the client with severe emphysema in a supine or prone position
3. Postural drainage is CI’d with severe hemoptysis (copious amount of blood in sputum), severe pulmonary edema, congestive heart failure, pulmonary embolism, hyper and hypotension, recent myocardial infarction
4. Do not use postural drainage directly after the client has eaten
5. Tapotement is CI’d over bony prominences, floating ribs and breast tissue
   Prolonged tapotement that accompanies postural drainage is CI’d 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
6. Joint play for the ribs and rib springing are CI’d with rib hypermobility and a history of rib subluxation
   A client with cardiac or renal disorders should not increase the daily intake of water as is sometimes recommended as self care
7. Chronic airflow obstruction may lead to pulmonary hypertension and right sided heart failure

Question 11

Treatment Considerations

Answer 11

1. It must be taken into account the severity of the client’s symptoms when treating a client with emphysema
2. A milder presentation may allow for more vigorous techniques such as fascial work and mobilizations of the thorax
3. A more severe presentation is likely limited to promoting relaxation and encouraging improved breathing patterns
4. A reduced treatment to half an hour may be appropriate
5. Cardiac pathologies will require treatment modifications is terms of positioning and the use of segmental petrissage
6. If the therapist is in doubt, contact the client’s physician

Question 12

Treatment Goals

Answer 12

1. The primary goals of the massage are to:

a. reduce SNS firing

b. promote relaxation of accessory muscles of respiration

c. encourage diaphragmatic breathing to minimize shortness of breath

d. mobilize the thorax

2. Other goals for the massage are to:

a. Remove accumulated mucus, if chronic bronchitis is present

b. Treat any postural dysfunctions such as hyperkyphosis

3. Because there is a potential of hypertension with emphysema, the client’s blood pressure should be taken before and after treatment

Question 13

Treatment Positioning & Hydrotherapy

Answer 13

• Positioning:

1. A semi-supine position is optimal for relaxation
2. If the client has severe emphysema, treatment in a propped-up position, side-lying or seated, leaning forward are best

• Hydrotherapy:

1. Heat applications may need to be avoided with hypertension
2. Facial steams that help to mobilize secretions may be appropriate

Question 14

Treatment

Answer 14

1. The treatment should be performed in the context of a relaxation massage
2. With mild to moderate severe emphysema, muscle stripping and fascial techniques for the upper and lower intercostals are performed within the client’s pain tolerance ( they already stretch , we should stimulate them)
3. Mobilization of the thorax if indicated, is done gently, especially with debilitated clients
4. Swedish techniques are used on muscles of respiration. The techniques should be light, soothing and repetitive
5. Trigger points can be addressed with muscle stripping and intermittent ischemic compressions
6. Postural drainage, breathing exercises and tapotement are used to remove mucus secretions with associated chronic bronchitis

Question 15

Self-care

Answer 15

1. Client’s with moderate to severe emphysema have remedial exercise and hydrotherapy plans cleared by their physician before commencing
2. Goals of self care are to decrease or moderate the severity and frequency of the symptoms through correct breathing patterns, pursed-lip breathing and productive coughing
3. If client’s experience shortness of breath, showing them the correct position of leaning forward with elbows on their knees while seated or while standing, placing both hands on a table, then leaning forward. The client can then practice relaxed exhalation or pursed-lip breathing
4. If not CI’d, postural drainage combined with diaphragmatic breathing
   Self-massage to scalenes, intercostals and costal margin
5. Stretching for the shoulder girdle and accessory muscles of inhalation
6. Exercise tolerance is gradually increased with mild to moderate emphysema clients
7. If the client smokes, they are encouraged to stop