Increased WOB Treatment HB (1)

Question 1

How does increased WOB occur

Answer 1

When there is a mismatch between the demand and supply of the respiration

Question 2

Aim for physiotherapy in WOB

Answer 2

reduce the work of breathing and reduce sensation of dyspnoea

Question 3

what will adapting patient positioning do

Answer 3

help them feel less breathless

Question 4

Positions of ease

Answer 4

Upright supported positions:

Relaxation of upper chest and shoulders which allow movement of the lower chest and abdomen

1/2 lying

Side lying - elbows rested on knees

High side lying- forward lean sitting

Standing leaning back with hands in pockets

Standing leaning forward onto wall zimmer etc

Question 5

What do positions of ease aim to do

x4

Answer 5

• Position the respiratory muscles to work properly
• Reduce extraneous muscle work (which reduces demand on the respiratory system)
• Support the shoulder girdle to allow the accessory muscles to work more efficiently
• Forward leaning can improve the length-tension relationship of the diaphragm and reduces hyperinflation.

Question 6

What does forward leaning do to the abdominal contents

Answer 6

When leaning forwards (in sitting or standing), the abdominal contents raise the anterior part of the diaphragm, doming it which is thought to facilitate its contraction during inspiration. A similar effect can be seen in side lying and high side lying where the curvature of the dependent (lower) part of the diaphragm increased.

Question 7

Diagram stress position

Answer 7

Supine, sunbathers’ position (both hands behind head) =

used to dome the diaphragm and minimise the use of upper accessory muscles.

A book placed over the upper abdomen which provide ps proprioceptive feedback to the patient
about their breathing pattern.

In this position effective use of the diaphragm is
essential.

Position not tolerable for people with severe cardio respiratory problems

Patients with hyperventilation disorder or well-
controlled asthma = helpful for diaphragm and
breathing pattern training

Question 8

Breathing control definition

Answer 8

Normal tidal volume using lower chest with relaxation of the upper chest and shoulder

Question 9

What is breathing control and how does it benefit the patient

Answer 9

It is an abdominal or diaphragmatic breathing technique used for normalising the breathing pattern and giving the patient a sense of control over their breathlessness

relax the airways and relieve the symptoms of wheezing and tightness which normally occur after coughing or breathlessness

Question 10

What is the overall aim and outcome of breathing control

5

Answer 10

• reduce the work of breathing
• help relieve breathlessness at rest or on exertion
• encourage a normal, efficient breathing pattern
• improve ventilation of lung bases, therefore increasing gaseous exchange
• encourage relaxation

Question 11

When is breathing control taught and how is it practiced

Answer 11

It is taught and practised at rest then used to recover from acute breathlessness following exertion

Patient should practice technique at rest which will give them confidence to use it when exerted

Question 12

Teaching breathing control

Answer 12

Position patient to ensure they are supported comfortable and relaxed 1/2 lying or sitting is easiest to teach breathing control

Place one hand across upper abdomen between the bottom of the ribs and belly button ask patient to breathe in and out at their own pace in through their nose to filter and humidify air

As patient inspires encourage relaxed upward movement of abdomen under your hand “feel your tummy rise up as your breathing” then relaxed expiration

Upper chest and shoulder girdle should show minimal activity it’s helpful to place the other hand on the upper chest to assess where movement is coming from and provide patient feedback about their technique

Question 13

Why should prolonged expiration be avoided

Answer 13

Attend to encourage uncontrolled inspiritory effort using accessory muscles

Some patients may have pursed lip breathing this may be important to continue with in some very breathless patients

Question 14

Why should the patient use their own hand and avoid active contraction of abs

Answer 14

Patient should use their own hands for proprioception and feedback

Active contraction of abdominals should be avoided as this increases the work of breathing and is not part of the normal breathing pattern at rest

Question 15

Why should you give feedback to the patient

Answer 15

Constructive feedback is important as this can ensure they are doing the technique correctly and avoid bad habits forming

Question 16

What can Breathing pattern Re-training be used for

Answer 16

This can be used for patient to have a stable long-term condition here not particularly breathless at rest e.g. asthma or hyperventilation

Question 17

What is the aim of Breathing pattern Re-training

Answer 17

Minimise over breathing and normalise breathing pattern which involves very slow rhythmical breathing timed to an external stimulus such as a ticking clock or metronome

Question 18

What should be done throughout Breathing pattern Re-training

Answer 18

Natural pause between exhalation and inhalation is emphasised and a treatment program may involve breath holding

Relaxed diaphragmatic nasal breathing should be demonstrated throughout

Question 19

How does Breathing pattern Re-training differ from Breathing control

Answer 19

Requires patient to breath slowly which is not appropriate for more acutely unwell or chronically breathless patients

Question 20

Buteyko Breathing Technique

Answer 20

A type of breathing retraining used in the management of asthma.

Developed in the 1950s by Professor Konstantin Buteyko

breathing techniques that include:

• nose breathing
• very slow breathing
• extended breath holding.

Some evidence to support the use of this technique for patients with asthma.

Specialised physiotherapists may be trained additionally in the use of Buteyko.

Question 21

Relaxation techniques

Physical and mental dimension

Answer 21

physical dimension =relaxation
relates to a reduction in muscular tension

mental dimension= a feeling of well-being freeing the individual from uncomfortable thoughts

During stress or anxiety, the body responds to stress by the ‘fight or flight’ mechanism and initiation of the autonomic nervous system.

There is an increased heart rate, blood pressure, respiratory rate, blood glucose levels and 
sweating increases (all associated with increased metabolic rate)

Question 22

What happens in individuals with sever stress

Answer 22

adopt particular postures:

such as raised shoulder girdles, flexed
elbows and flexed torsos.

Both the postural manifestations and the increased
metabolic rate can add to the overall work of breathing, which can lead to a vicious
cycle of stress, anxiety and breathlessness.

Question 23

What is the aim of relaxation

Answer 23

• reduce muscular tension
• improve the feeling of wellbeing
• improve the patient’s ability to cope with certain situations
• Reduce the sensation of breathlessness
• Reduce heart rate, respiratory rate and blood pressure
• Reduce anxiety and improve sleep

Question 24

General principles relaxation

Answer 24

• Restful atmosphere – room quiet but not silent, +/- music, subtle lighting,free
from interruptions, privacy

• Support – consider position of individual (chose a supported position of ease).

• Comfort –need sufficient pillows to support the upper limb; room should be warm but not hot with some fresh air; patient should remove or loosen
restrictive clothing; patient should have an empty bladder

• Therapist – professional; clearly explains method and what is to be expected; calm, restful manner; soft tone of voice; volume and pace should gradually be reduced; clear instructions; allows time for instructions to be carried out; gradual end to the session

Question 25

How often should relaxation be used

Answer 25

Could be a one off then the patient continues to do this at home or more than once with gradual refuction of therapist input

Question 26

Contrast method

Answer 26

This method is based on the physiological principle that a strong contraction of a
muscle will be followed by equal relaxation of that muscle.

Many individuals struggle to appreciate the sensation of relaxation, as very often they are unaware that they
are tense.

The individual is led through a series of instructions that encourage a strong contraction of a muscle group and then the subsequent contrast
in sensation of relaxation that follows.

The sequence of instructions is from distal to
proximal.

It can be helpful to start with the instructions for breathing control, work distally to proximally along the limbs, then return to breathing control at the end of the relaxation

Question 27

Guided imagery

Answer 27

People are taught to focus on pleasant images to replace negative or stressful feelings.

Guided imagery may be self-directed or led by a practitioner or a recording.

For example, guided imagery to accompany breathing control techniques could use a metaphor of the ebb and flow of a tide gently lapping at the shore to encourage relaxed inhalation and passive exhalation.

Question 28

Advice and education

Answer 28

It is important that techniques to reduce work of breathing and dyspnoea are carried
out regularly.

Breathing control and breathing pattern retraining require ongoing practice and a level of commitment.

Teach the use of positions of ease and breathing control during an attack of acute dyspnoea.

If the patient can recognise that positioning and breathing control reduce dyspnoea in the safe, supported hospital environment, they are more likely to be confident to try these techniques at home.

Appropriate positions of ease can be
taught and practiced prior to discharge.

It is important to stress that the rate of breathing does not matter, as the patient gains control of their breathing, the rate will slow down of its own accord

Question 29

Pacing during exercise

Answer 29

Once a patient can control their breathing in a position of ease, progression can be made to controlling the breathing while walking on the level, on an incline and upstairs.

Question 30

What do patients do during exercise

Answer 30

The tendency is for patients to hold their breath when carrying out any activity which increases the feeling of breathlessness.

Question 31

How can you stop a patient holding their breath during exercise

Answer 31

This can be overcome by breathing in rhythm with steps, for example, breathing out 2:1 2 steps and in for 1.

blow out on most strenuous activity e.g expire when standing from sitting

The pattern will vary between individuals. The physiotherapist can walk with the patient, initially counting the synchronised walking/breathing pattern.

It may be helpful for the patient to “chop up” any activity into small steps, using their
breathing control to recover in-between these stages.

For example when ascending the stairs, they could be advised to stop after every 2-3 steps, lean against the bannister, practice breathing control then continue once they have recovered control of their breathing.

Desensitizing the patient to breathlessness during exercise is a key goal of physiotherapy as this can help to prevent the vicious cycle of breathlessness and inactivity

Question 32

Oxygen therapy

Answer 32

Hypoxic (Sa02 <90%) patients may require a portable oxygen cylinder or oxygen
concentrator to allow some degree of mobility, however the majority of patients’
breathlessness is unrelieved by oxygen because the mechanisms which cause
increased work of breathing are rarely directly due to lack of oxygen. Patients who
are hypoxic during exercise will be referred to specialist clinics (often run by
Respiratory Physiotherapists) and an individual oxygen prescription is produced.

Question 33

Fan therapy

Answer 33

Some patients with breathlessness may benefit from a hand held fan. This stimulates
the trigeminal nerve and can reduce the sensation of breathlessness. It is often used
in palliative care. It may be used in combination with positions of ease and breathing
control

Question 34

Purses lip breathing

Answer 34

Patients may breathe out through pursed lips automatically or this may be a technique that is advised by a physiotherapist. It involves gentle, prolonged, active exhalation through pursed lips. Patients who have increased airways resistance (acute asthma or COPD) may benefit from the longer duration for exhalation.

Patients with emphysema have “floppy” airways which have reduced elastic recoil.

Breathing out through pursed lips creates a small back-pressure which can help to keep the airways open during exhalation, reducing hyperinflation.

Question 35

Inhaler technique

Answer 35

Many conditions associated with increased work of breathing are improved with
inhaled medication such as salbutamol. An important part of the physiotherapeutic
advice and education for these patients involves optimising their inhaler technique.
The delivery and therefore effectiveness of the inhaled medication can vary
significantly depending upon the appropriateness of the technique used.