Reduced lung volumes Treatment HB (3)

Question 1

what is the aim of physiotheraphy for patients with reduced lung volumes

Answer 1

to increase whichever volume is affected (for example to increase FRC, tidal volume and/or
inspiratory capacity) in order to maximise gas exchange via ventilation and perfusion matching.

Question 2

What are the 3 most common problems which lead to reduced lunch volumes

Answer 2

• Low Functional Residual Capacity (FRC)
• Atelectasis
• Lobar Collapse

This often reduces gaseous exchange

Question 3

what are lung volumes responsive to

Answer 3

positioning

*** functional residual capacity (FRC).

Positions: supine or semi recumbent= reduce in lung volume as a reduced FRC contributes to the closure of airways during the respiratory cycle.

These positions = avoided when possible.

Question 4

common people with difficulties

Answer 4

This effect is accentuated in older people, patients with cardiopulmonary disease, smokers, obese individuals and during the post-operative period.

Question 5

Positions that should be encouraged are:

Answer 5

• Sitting upright
• Standing
• Side lying inclined towards prone

Question 6

what do recommend positions depend on

Answer 6

The reason for reduced expansion,

if it is caused by unilateral lung disease e.g

pneumonia=side lying for ventilation/perfusion (V/Q) purposes

Question 7

Thoracic Expansion Exercises

Answer 7

The ACBT including thoracic expansion exercises is fully explained in Treatment Handbook 2 (Impaired Airway Clearance).

For patients whose primary problem is
reduce lung volume, TEEs can be progressed using the following techniques

Question 8

end inspiratory holds

Answer 8

The patient is asked to breathe in as deeply as they can and hold for 3 seconds on full inspiration.

This hold can be carried out on every breath or every few deep breaths depending on the patient.

This procedure utilises the collateral ventilation channels to open adjacent alveoli.

used at the end of deep breathing to compensate asynchronous ventilation that may happen due to sputum retention or atelectasis in some respiratory conditions

Question 9

sniff

Answer 9

Even after a full inspiration, a sniff will further increase expansion which increases collateral ventilation.

This can be combined with an inspiratory hold whereby the patient breathes in maximally, holds for 3 seconds then sniffs before exhaling.

It tends to be more effective when the therapist gives the command to sniff (“deep breath in, then hold, hold, hold - now sniff!”

Question 10

resistance

Answer 10

Application of pressure by the therapist’s hand/s throughout inspiration may assist the increase in expansion.

The resistance should be sufficient to offer proprioceptive incentive to increase expansion but should not restrict movement.

As such, the appropriate level of pressure will vary between patients. A patient may use their own
hand to offer resistance to increase expansion.

If the patient experiences difficulty with this then the use of a wide belt made of webbing or a towel may be useful to offer resistance on inspiration

Question 11

over pressure

Answer 11

This involves the application of pressure by the therapist’s hands at the beginning of inspiration, to act as a stimulus to increase inspiration.

The patient is instructed to breathe deeply whilst the pressure is applied to the ribcage during the initial part of inspiration but then released to allow a deeper inspiration than would have occurred otherwise

Question 12

incentive spirometer

Answer 12

This is a mechanical device used primarily by surgical patients to encourage regular and effective thoracic expansion exercises.

The patient seals their lips around the mouthpiece and takes as deep an inspiration as they can. Whilst they are inhaling, the device will offer visual feedback on the volume of their breath and/or the flow rate
they have achieved (depending on the particular design).

Question 13

the complete active cycle of breathing

Answer 13

The cycle can be individualised so patients with reduced lung volume may revisit thoracic expansion exercises multiple times before moving on to the FET.

NOTE: patients with reduced lung volume may be prone to breathlessness and may well have sputum stuck in the collapsed airways (particularly with atelectasis and lobar collapse) = incorporate the breathing control and FET elements with the TEEs is recommended.

Question 14

Adjuncts

Answer 14

Inspiratory Muscle Training (IMT)
Intermittent Positive Pressure Breathing (IPPB)
Continuous Positive Airways Pressure (CPAP)
Non-Invasive Ventilation (NIV)
High Flow Nasal Oxygen

Question 15

Inspiratory Muscle Training (IMT)

Answer 15

As with any skeletal muscles, the inspiratory muscles
(predominantly the diaphragm and intercostal muscles) can
be strengthened and will undergo a hypertrophic response
to training. There are various IMT devices available but they
all provide resistance to inspiration which increases the load on the inspiratory muscles. The usual principles of overload are applied and a regime related to the patient’s 1-rep-max (1RM) can be produced. When using the Threshold IMT ® the resistance can be gradually increased until the patient’s 1RM is discovered. They are then instructed to train regularly at 60% 1RM (by reducing the resistance back to 60% of 1RM). This type of treatment is particularly appropriate for severely deconditioned patients with specific respiratory muscle weakness, for
example those recovering from a prolonged period on a ventilator in intensive care.

Question 16

Intermittent Positive Pressure Breathing (IPPB)

Answer 16

This device (also known as the Bird respirator)
maintains positive pressure throughout inspiration,
with airway pressure returning to atmospheric
pressure during expiration. It is delivered to the
patient either via a mouthpiece or a tight-seal face
mask.

It can be used improve lung volume, mobilise sputum and improve cough strength.

The patient typically performs 3-4 breaths as part of the ACBT. It augments thoracic expansion exercises by providing an additional inspiratory force (like blowing up a balloon) to inflate the lungs further than with the patient’s effort alone (see graph).

Question 17

Continuous Positive Airways Pressure (CPAP)

Answer 17

As the term implies, this is the application of positive pressure to the airways throughout the breath cycle, usually via a tight seal facemask.

Application of CPAP increases FRC (see graph),
reduces atelectasis and improves alveolar ventilation.

Provides a distending pressure which splints the airways open and prevents airway collapse, particularly during exhalation.

This increases surface area for gas exchange and therefore improves oxygenation.

Because the airways are open, inspiration becomes easier (see V/Q podcast for mechanism)

Question 18

Non-Invasive Ventilation (NIV)

Answer 18

Non-Invasive Ventilation is a form of mechanical support for the respiratory system.

Combines the additional pressure during inspiration provided by IPPB with the airways splinting of CPAP (see graph).

For this reason it is also referred to as Bi-Level
Positive Airways Pressure (BiPAP). NIV is used for patients experiencing actual or imminent ventilatory failure in acute care settings such as Emergency Departments,

High Dependency Units and Intensive Care. Similar to CPAP, a tight-seal face mask is used in order to transmit pressure to the patient’s lungs

Question 19

High Flow Nasal Oxygen

Answer 19

This is a system of oxygen delivery that is superior to standard oxygen delivery in the following ways:

• Heated humidification – improves mucociliary clearance
• High oxygen concentrations –systems deliver up to 100% oxygen – improves gas exchange for moderate hypoxaemia.
• High flow rate of up to 60 litres/minute flow – reduces work of breathing, especially for patients with rapid respiratory rate.
• Has a low-level CPAP effect at high flow rates (≥40 litres/minute)
• Nasal cannulae are generally well-tolerated by the patient compared with mask oxygen or CPAP/NIV

Most patients who require high flow nasal cannulae will be cared for in a High Dependency or Critical Care environment.

Question 20

Advice and Education

Answer 20

The patient should be advised to continue with appropriate positioning and thoracic expansion exercises independently.

Thoracic expansion exercises should be
completed at least 10 times every waking hour to be effective.

Advice about avoiding recumbent (lying down) positioning wherever possible should
be reinforced and some strategies to address this could be suggested.

For example if a patient is on a hospital ward, sitting out of bed for every meal might be an achievable goal and would break up long periods of lying in bed.

Question 21

Exercise

Answer 21

Mobilisation is an excellent technique for increasing lung volume as it combines the upright posture (which encourages the distribution of air to dependent regions) with natural deep breathing. Wherever possible, mobilisation should be the first line
approach to increasing lung volume.

When mobilising to achieve increased lung volumes, an exercise response should be elicited – i.e. the rate and particularly depth of breathing should increase.

The level of mobilisation required to elicit an exercise response will vary from patient to patient, so this should be gradual, progressive and appropriate for the individual’s functional capability.

Question 22

Additional brething techniques: breathing stacking

Answer 22

This technique can be used to increase the inspiratory capacity for patients with reduced lung volumes due to neuro-muscular disorders. It is usually combined with expiratory coughing techniques to aid airway clearance as well as improving lung volumes.

Patients who can control their glottic function are taught to breath in maximally, close the glottis then breath in maximally again usually 3-4 times before exhaling.

Patients who have lost bulbar function and are therefore unable to close their glottis are assisted with breath-stacking using a mask, ambu-bag and one-way valve