Aerobic Capacity/Endurance Conditioning
Aerobic or endurance exercise has multiple benefits. It enhances physical function and health status, improves physiologic response to increased oxygen demand, and may shorten recovery from infection.3,15,17 Aerobic exercise is characterized by the use of large muscle groups, activated in a rhythmic fashion over time. Walking, bicycling, swimming, dancing, stair climbing, and jogging are examples of aerobic exercises.
Many systems of the body will be affected by aerobic training: cardiovascular, pulmonary, immune, metabolic, musculoskeletal, and neurologic.15,44,45 The heart and lungs become more efficient at gas exchange and oxygen delivery to the tissues, the muscles become stronger and more effective at utilizing oxygen delivered to the tissues, there is a reduction in bone loss during weight-bearing exercises, skill and coordination are enhanced, and there is a sense of well-being. Metabolically, the processing of free fatty acids and glucose is enhanced along with utilization of insulin, the immune system is positively affected, motility of the GI system is improved, and in some cases, recovery from infections is enhanced.45
Julia's exercise prescription (Box 17-2) includes frequency of the aerobic exercise, intensity duration, and mode. In addition, strength training and flexibility exercises are included. The exercise prescription should also address precautions for implementing the exercise program. The prescription is developed once examination, systems review, and tests and measures are completed (see Chapter 3).
Box 17-2 Julia's Exercise Prescription ||Download (.pdf)
Box 17-2 Julia's Exercise Prescription
70%–85% heart rate range from peak 6MW
Resting heart rate plus 10 (low level)
RPE scale 11–15/20 or 3–5/10 (see Box 14-2)
0–1 ventilatory scale (number of breaths to count to 15 in an 8-second period; highest level 4)
Resting respiratory rate plus 4–10 (depending on severity of illness)
Stationary cycle (home program)
Walking in the house or outside on level surface (could be at a mall)
Treadmill (when admitted to hospital)
Goal of 20–30 continuous minutes of exercise in target intensity range
Interval training for initial program: build up to 2–4 intervals of 5–10 min/d; progress to continuous level when time >10 min/interval
If continuous program, 4–5 times per week
If unable to do continuous program, 6–7 times per week
With severe disease, 2–3 times per week
Flexibility and posture
Warm up—5 minutes of low-level cycling without resistance
Cool down—5 minutes of low-level cycling without resistance
ROM exercises: pick three exercises and rotate each session (can also be part of warm-up and/or cool-down; exercises to be combined with controlled breathing to incorporate chest wall mobility and relaxed breathing pattern)
Cervical extension (turtle necks) 3 × 5 sets
Bilateral shoulder flexion with elbows extended 3 × 5 sets
Standing against a wall: heels about 1 ft from wall, buttocks, head, and shoulders against wall, feet shoulder-width apart: elbows at 90 degrees and shoulders at 90 degrees for scapular retraction 3 × 5 sets
Knees bent slightly (stand clear of any objects), feet are shoulder-width apart; hold a towel or a dowel stick in hands with elbows extended; raise arms to shoulder height; slowly rotate arms with towel or dowel horizontal; hold count at each end of the rotation for at least 5–10 seconds; 3 × 5 sets
Calf stretches: stand on a step holding the rail; balls of the feet on the edge of the step; slowly lower 1 heel down and hold for 5–10 seconds; 2 × 2 sets on each leg
Hamstring stretch: stand or sit for comfort; back as straight as possible; place a bath towel around the ball of the foot; other leg should be bent; leg with towel should be fully extended; lean forward until pull is felt behind knee; do not hyperextend knee; 2 × 2 sets on each leg
Quadriceps stretch: hold onto couch back, chair, railing; keep your thighs parallel and stand as straight as possible; cradle your leg with a towel; now stand on one leg while raising the cradled leg to at least 90 degrees or more of knee flexion; keep your trunk as straight as possible so the pull is in the upper part of the thigh lifted by the towel; 2 × 2 sets on each leg
General instructions: do every other day or rotate muscle group (pick at least one exercise from each area of the body and rotate that exercise each time you do strength training; exercises to be combined with controlled breathing to incorporate chest wall mobility and relaxed breathing pattern)
Bicep curls (seated or standing) 3 × 10 with 1–5 lb weight
Triceps extension (seated or standing) 3 × 10 with 1–5 lb weight
Abduction (seated or standing; singles or bilateral depending on breathing) 3 × 10 with 1–5 lb weight
Shoulder flexion (seated or standing; singles or bilateral depending on breathing) 3 × 10 with 1–5 lb weight
Shoulder extension (seated or standing; singles or bilateral depending on breathing) 3 × 10 with 1–5 lb weight
Abdominal curls (supine, knees bent, and feet flat on floor): (1) progress from pelvic tilts to single leg lift to 4 in. holding pelvic tilt and then adding 1–3 lb leg weight as tolerated); (2) practice pelvic tilt and progress to abdominal curl with maintaining pelvic tilt; (3) progress to obliques/rotation when above levels tolerated with maintaining pelvic tilt (3 × 12 sets with each level of progression)
Standing lunges: start without weights and progress up to 5 lb weights after 15 on each leg without balance loss and maintaining upright trunk extension and appropriate pelvic tilt
Hip abduction/adduction (standing/supine/or sidelying): begin with 3 × 10 on each leg and maintain pelvic tilt and trunk extension for alignment; progress to add 1–5 lb weights for each leg
Hip extension (standing or prone): avoid any rotation and keep knee extended; lift the leg up approximately 4 in. off the surface-hold for 5 seconds; progress from 0 to 5 lb; 3 × 10 sets
Hip extension (standing or prone): avoid any rotation and keep knee flexed to 90 degrees; lift the leg up approximately 4 in off the surface-hold for 5 seconds; progress from 0 to 5 lb; 3 × 10 sets
Evaluation prior to starting an exercise program (oxygen saturation at rest and with activity)
Use bronchodilator prior to exercise to prevent bronchospasm
Avoid strenuous exercise with an exacerbation/fever/hemoptysis/untreated pneumothorax
Precautions for osteopenia/osteoporosis
Proper hydration and calorie intake
Avoid poorly controlled climate conditions (hot, humid, freezing, high levels of pollution, windy, etc)
Watch for signs of decompensation: color, breathing pattern, increase in dyspnea, etc.
Watch for sudden chest pain or any type of pain (musculoskeletal)
When indwelling venous catheter in place, avoid resistance exercise with affected upper extremity
Exercise with a buddy if possible; carry identification
Evaluate best time for airway clearance and timing of exercise
Be aware of any declines in activity level; keep a diary of exercise program/progression
Reevaluate exercise program in a timely manner (3–6 months depending on the level of illness and frequency of return visits to clinic)
Nixon and colleagues found that higher aerobic fitness levels in patients with CF were related to improved survival.38 In other words, the more fit and active a patient's lifestyle, obtained through regular aerobic exercise, the better the chance of living longer. Julia should stay as active as possible while awaiting her lung transplant for two primary reasons: her capacity to tolerate the surgery will improve and her recovery following lung transplantation may be shortened.
Flexibility is another important component of an exercise prescription. A commonly used phrase among physical therapists is “the position of comfort is a position of muscle shortening.” Flexibility is key in preventing injury, enhancing chest wall expansion, and promoting healthy postures. Most patients with CF similar in age to Julia present with distinct shortening of the anterior chest muscles, overstretched posterior upper thoracic muscles, and shortening of the hip and knee flexors. Weakness in the lower abdominal region and pelvic floor is not uncommon as is weakness and loss of range of motion in the cervical and thoracic spine. Usually the lumbar spine assumes a flexed position.
Stretching of target areas is vital for ease of chest wall movement. Proximal muscles of the upper and lower extremities as well as trunk musculature play a role in inhibition of chest wall movement if muscle shortening has occurred from poor posture, weak muscles, and muscle imbalances.46 It is important to stabilize the proximal segments to assess shortening of muscles, which cross two joints and influence movement of the chest wall. Instruction in corrective postures and integration of breathing strategies with flexibility exercises reinforce and encourage proper control of airflow while limiting discomfort and bronchospasm with exercise.
Strength, Power, and Endurance Training for Head and Neck, Limb, Pelvic Floor, Trunk, and Ventilatory Muscles27,28,47–53
Strength Training is also an important component of a therapeutic exercise intervention. Strength training will improve muscle tone and BMD, and in some cases, pulmonary function.15,46 Low weight and higher repetitions should be incorporated into a normal exercise routine. The exercises can be performed with dumbbells, soup cans, or resistance equipment. Breathing exercises should be utilized to decrease dyspnea and fear or anxiety that may occur with participation in this type of exercise. Exhalation on the “work” or “lift” part of the exercise will encourage good airflow, lessen the chance of a Valsalva maneuver, and improve strength and coordination of extremities and respiratory muscles. In addition, teaching patients to “brace” the pelvic floor by tightening the muscles before a lifting maneuver may prevent further stress on these muscles. Every other day, strength training in addition to rotation of targeted body segments is recommended to decrease the chance of musculoskeletal injury.
Breathing and movement strategies are important components of relaxation and energy conservation for patients with pulmonary disease. Although not intuitively included in the realm of relaxation, energy conservation techniques are probably best incorporated in this section, which includes breathing and movement strategies. Instruction in conservation techniques to promote a decrease in energy expenditure during daily activities will give the patient a sense of independence, decrease the fear of shortness of breath, and promote an increase in activity.
First pick simple activities like walking on level ground, getting out of a chair, or putting on a shirt before the patient/client is progressed to more energy-consuming and fearful activities like tying one's shoes, climbing stairs, or carrying objects while ascending stairs. Planning out the day or even just an hour at a time will help lessen the fear and anxiety of rushing to do a task. If the patient knows he or she will be spending the majority of the day on the first floor of the house and the bronchodilators are kept on the second floor by the bed, a mental note or an actual list should be made of what the patient needs to bring before he or she moves down to the first floor. Planning ahead for bathroom needs is also important. Rushing up a flight of stairs to get to the bathroom is a task that makes many patients feel short of breath and anxious. If the patient is on a diuretic, steps should be taken to plan when the medication is taken, limit the distance to the bathroom after the medication is taken, and eliminate obstacles on the way to the bathroom, all of which may decrease the energy cost of getting to the bathroom. A final area for improving the ease of ADL should be the process of showering. One suggestion is to bring a chair into the shower or have a chair just outside the shower so the patient/client can be sitting during the shower or immediately after the shower. In addition, if a terry-cloth robe is donned after a shower, the energy-consuming task of drying the patient's backside is eliminated. Pursed-lip breathing, planning ahead, and decreasing anxiety and fear are keys to conservation techniques and give the patient/client a sense of accomplishment. Relaxation techniques are very important for energy conservation, and are described elsewhere. They can be incorporated into daily activities or airway clearance techniques to decrease bronchospasm, control paroxysmal coughing, decrease metabolic demand or energy expenditure, enhance airflow, and promote a sense of well-being. The exercises or techniques can be performed in any position or location.
Functional Training in Self-Care and Home Management
An evaluation of the home environment should include a review of daily activities. For example, on which level are bathrooms and bedrooms located, how many stairs are there in order to enter the house, are there handrails accompanying the stairs, where are the laundry facilities located, how accessible is the kitchen for demands on breathing, is there a gas stove versus electric (Julia uses oxygen), and how will she get her groceries? Julia presently functions independently at home, but she is finding it more difficult to carry out her day-to-day treatment regime and ADL. Education on ways to conserve energy (work of breathing), reduction of cough during ADL, and devices that may assist her to continue to live independently at home should be incorporated into the treatment (see sections on Breathing Strategies).
Functional Training in Work (Job/School/Play), Community, and Leisure Integration or Reintegration
Julia is no longer working and is on disability due to her illness. She does not have any hobbies besides reading and primarily focuses on her daily maintenance treatments. This topic should be examined in order to prepare Julia for discharge from the hospital. Julia may choose to visit with family and friends either at her home or away from her home. Evaluation of situations with which Julia may be presented during these times should be addressed by careful planning and assessment. A mockup of situations may be practiced in the hospital setting prior to discharge in order to evaluate hemodynamic responses and other challenges.
Once she receives the lung transplant, her functional training will have to be reassessed to see if she will be able to return to employment as a teacher. This evaluation should include examining the risk of infection, injury prevention and reduction, and safety awareness training during work, community, and leisure. Musculoskeletal components include assessment of osteoporotic changes, decreased activity, and falls from muscle weakness. Additional factors to consider are the ease of bruising, pain, and the physical side effects of the posttransplant medication including self-perception in the workplace as well as self-confidence related to these side effects. Finally, the evaluation should address the level of endurance related to work demands, hemodynamic challenges to the work area (stairs, inclines, uneven surfaces as on a playground), and other environmental considerations (smog, pollen, dust).
Manual Therapy Techniques
Techniques for mobilization of the rib cage, thorax, pelvic and shoulder girdle have been described to enhance ventilation and improve respiration. A working clinician can easily document the relationship between improvements in range of motion of the shoulder girdle, anterior chest wall, neck and upper thorax with improvements in relaxation, breathing pattern, perception of work of breathing (RPE), RR, level of anxiety, and in some cases, oxygen saturation. Applying the principles of proprioceptive neuromuscular techniques to the chest wall (musculoskeletal pump) can enhance relaxation, stimulate enhanced tidal volume or inspiratory capacity, and, as a result, may improve mucus mobilization and clearance.
Massage can be used to decrease muscle tension, anxiety, and work of breathing and enhance comfort. Massage of the upper posterior thorax and neck area may be beneficial following paradoxical coughing, vomiting initiated by coughing, or positioning, and to decrease musculoskeletal pain related to coughing and poor posture. Ventilation may be enhanced by utilizing massage in conjunction with manual techniques in order to provide relaxation of shortened accessory muscles.
Prescription Application and, as Appropriate, Fabrication of Devices and Equipment
In the case of most individuals with CF, assistive or orthotic type devices are not indicated unless there is another superimposed pathology that would affect neuromuscular control. In the case of Julia, she had an indwelling venous catheter placed at age 26. If Julia and her care team decide that high-frequency chest wall oscillation (HFCWO) is the best form of airway clearance for her, fabrication of a device to offer relief around the catheter site may be necessary for comfort and safety reasons. The vest should be fit to Julia, and then the catheter area can be measured to have an appropriately sized padded device fabricated to prevent discomfort. This same type of device may also be utilized around gastric or jejunal tubes and chest tubes.54–56
Airway Clearance Techniques
When prescribing airway clearance techniques, many factors should be considered including the severity of disease, the patient's lifestyle, and factors affecting adherence (Table 17-5). Goals for airway clearance should be measurable and time oriented. Measuring sputum production, monitoring changes in color or viscosity, and measuring hemodynamic changes (Spo2, HR, RR, and BP) allow appropriate goals to be set. Specific examples of goals included in this section are improvements in breath sounds, PFTs, chest radiography, subjective measurements, and treatment adherence. These goals may be obtained by performing the airway clearance interventions outlined in Box 17-3 and described in the following section.
Table 17-5 Decision Making for Airway Clearance Techniques ||Download (.pdf)
Table 17-5 Decision Making for Airway Clearance Techniques
Considerations When Recommending Airway Clearance Techniques 5,27,42–44
History of esophageal reflux
Cost of device or technique
Osteopenia or osteoporosis
Severity of exacerbation
Comprehension (ease of learning, ease of teaching)
Box 17-3 Airway Clearance Techniques ||Download (.pdf)
Box 17-3 Airway Clearance Techniques
Active cycle of breathing
Techniques to maximize ventilation
Assistive Devices (positive expiratory pressure (PEP), including oscillatory PEP, high-frequency chest wall oscillation, intrapulmonary percussive ventilation)
Chest percussion, vibration, shaking
Chest wall manipulation
To alter the work of breathing
To maximize ventilation and perfusion
Pulmonary postural drainage
Aerobic or endurance exercise
Breathing Strategies: Active Cycle of Breathing or Forced Expiratory Technique10,43,57–59
The forced expiratory technique is based on optimal airflow and avoidance of a cough to prevent premature airway collapse to improve secretion mobilization and airway clearance. The technique can be done in any position. Quiet, tidal volume breathing is performed by the patient prior to a mid-to-large inhalation initiated from the lower rib cage. Then the glottis remains open and the air is then “huffed” out. The sound should be very breathy and the mouth should be in a shape of an “O.” There should not be a high-pitched wheezing sound, as this would indicate too forceful of a maneuver, which would promote airway narrowing. The technique is easy to learn, can be performed independently, and can be taught to youngsters by using games that employ bubbles, cotton balls, handheld mirrors, and ping pong balls. The individual is taught to use huffs to loosen and then clear audible secretions until the huff sounds dry.
The active cycle of breathing technique (ACBT) combines the forced expiratory technique, bronchial drainage, and manual techniques. This technique is easy to learn, easy to teach, and can also be performed by the patient independently. The individual assumes a bronchial drainage position and focuses on a quiet breathing pattern using the lower rib cage area without upper chest movement. This is followed by a large inspiration again initiated in the region of the lower rib cage, a breath-hold for 3 to 4 seconds, and finally a sigh out through an open mouth. The theory of the inspiratory hold allows for air to equalize from an “open alveoli” to a “clogged one” to assist with secretion clearance from the blocked alveoli, thereby increasing the efficiency and effectiveness of the technique. This cycle can be repeated as dictated by the patient and then followed by one to two huffs to clear the secretions. The full cycle can then be repeated (see Fig. 17-6B). A caregiver or the patient may assist with manual techniques during expiration (such as vibration or shaking), but this is not necessary; rather, it is indicated if the patient feels it is beneficial.
Autogenic drainage (AD) (A) versus active cycle of breathing (ACB) (B), both from spirograms of normal individuals. AD: phase 1 = peripheral loosening of mucus; phase 2 = collection of mucus in large airways; phase 3 = transport of mucus to the mouth. ACB: BC = breathing control, FET = forced expiration technique. (Republished with permission of Lippincott Williams & Wilkins, from Savci S, Ince DI, Arikan H. A comparison of autogenic drainage and the active cycle of breathing in patients with chronic obstructive pulmonary disorders. J Cardiopulm Rehabil. 2000;20(1); permission conveyed through Copyright Clearance Center, Inc.)
Breathing Strategies: Assisted Cough/Huff Techniques5,10,14,43,57,59
The huff or forced expiratory technique was explained previously. The assisted cough can be employed independently or with the help of an assistant. The technique can be as simple as placing a pillow over an incision to help splint the area or as vigorous as using a manual technique at the time of the cough. Massery describes four types of manual assistance: costophrenic (hand placement), abdominal thrust, anterior chest compression, and a counter-rotation assist.14 Refer to Chapter 20 and the CD-ROM for explanations and demonstrations of these maneuvers. Pain, fullness of gastric contents, mental status, innervation, and expertise of the instructor or caregiver are a few factors to consider when determining whether an assisted cough is appropriate. After a surgical procedure, the simple act of coughing may be limited because of pain, which will inhibit a large inhalation and a forceful exhalation. Assisting a patient with splinting of the incision, along with assuring that adequate pain medication is provided, may improve the pain tolerance.
In Julia's case, she has pain with coughing from GI and musculoskeletal symptoms. During forced expiratory techniques, huffing, or controlled coughing, she may use hand placement to brace her lower rib cage, a towel wrapped around her lower rib cage, or a pillow to brace against the abdominal area and lower rib cage to lessen the complaint of pain and assist with a more effective cough. If the pain subsides with the bracing, Julia could be instructed to press inward on the lower rib cage and upward on the abdominal area to improve her cough.
The cough is best performed using a flexed posture. Another way of performing an assisted cough is to instruct the patient to assume certain postures to encourage flexion, such as sitting forward while in bed. Julia could be instructed that sidelying with hips and knees flexed may be an advantageous position to enhance her cough. Also while in bed, her head could be elevated on pillows (or by raising the head of the hospital bed) to increase flexion; Julia may already have her trunk and hips flexed. The disadvantage of elevating the head of the bed to place the patient in the flexed position is that the volume of air inhaled during the initial phase of the cough may be limited. If in a standing position, the patient could be taught to bend forcefully at the waist during the cough to assist with the movement of air. One disadvantage of this position is safety; if the patient is unstable or has near syncopal episodes with coughs, there is an opportunity for injury by bumping or falling against objects.14
Breathing Strategies: Autogenic Drainage10,43,57,59–61
AD is an airway clearance technique that can be used independent of assistance. This is a challenging technique to learn, requires a great amount of concentration, should only be instructed by experienced clinicians, and initially may be time consuming to use. However, these disadvantages are offset by the great freedom the technique offers to patients with pulmonary disease.
The technique can be done in sitting position and, once learned, can be performed nearly anywhere. Coughing is suppressed initially, and only lower chest wall movement is encouraged. Because the technique utilizes some of the same theories of active cycle of breathing (equalization of air across alveoli for mobilization of secretions), the bronchioles and alveoli should be fully developed to get the full benefit. This physiological consideration, plus the great level of concentration and patience required, makes this technique less suitable for patients younger than 12 years.
The patient is instructed to breathe out through an “o”-shaped mouth (or the nose) while learning the technique. The patient should be taught to listen during inhalation and exhalation for noises indicative of secretions such as high-pitched wheezes, gurgling, or popping sounds. The timing and pitch of these sounds give cues to where the secretions may be located. If the sounds are heard initially on inhalation and are lower in pitch, most likely the secretions are in the larger, upper airways. These airways must be cleared with huffs or coughs prior to continuation of the technique. If these larger airways are not cleared, the patient will experience frustration from trying to continuously suppress the urge to cough. The patient should practice quiet breaths, using only the lower rib cage. A mirror is a good teaching tool to make sure the upper chest remains still during the technique.
Once the patient is comfortable with using only the lower rib cage, he or she is instructed to exhale down into expiratory reserve volume. This should be “sighing” out rather than a forceful exhalation. Once expiratory reserve volume is reached, the individual should inhale a “tidal volume” breath at this level. If the patient feels light-headed or dizzy at any time, he or she can resume a regular breathing pattern until the feeling subsides. The sounds described here should occur following multiple cycles at this low lung volume (a tidal volume breath just into expiratory reserve volume). Once the sounds are heard close to mid-exhalation, the patient then inhales to a slightly larger volume to move closer to a volume of breath where normal tidal volume would be performed. Again, if the patient feels light-headed or dizzy, he or she should resume normal tidal volume breaths or a couple of larger breaths until these symptoms pass. The patient is instructed to resume a “midlevel” of breathing and not to move to a higher level until the popping, wheezing, and gurgle sounds are heard midway through the exhalation phase. Once the sounds occur at this point in the breathing cycle, the patient can take a much deeper breath to reach the highest part of the pattern. Again, once the highest level of breathing is reached, only the amount of air in a tidal volume is used. If symptoms are experienced anytime during this phase of the cycle, instruct the patient to take a regular or larger breath until the symptoms pass and then resume the cycle where he or she left off. Once mobilized, the secretions are cleared through huffing or coughing.
The keys to this technique are airflow and volume control, suppression of cough until secretions are mobilized, inspiratory hold at the end of inhalation to equalize air across alveoli, and most importantly, patience. Because of the immense amount of concentration and the requirement of using audible and tactile cues, this technique is not appropriate for all patients with excessive production of sputum. See Figure 17-6 for a schematic of AD compared to active cycle of breathing.
Breathing Strategies: Techniques to Maximize Ventilation, Pursed-Lip Breathing, Paced Breathing4,15,62,63
Although this category of breathing strategies is placed under the heading of Airway Clearance in the Guide, these techniques are also useful in other situations when secretion removal is not the primary goal. Many of these techniques may be incorporated into daily activities or exercise routines. This section also includes techniques useful for promotion of energy conservation or relaxation.
Techniques to maximize ventilation: The terms diaphragmatic breathing or lower rib cage breathing are both used to describe strategies to expand the lower chest in place of upper chest expansion. In order to teach lower rib cage breathing, the client should be in a comfortable position. The preferred position is one that enhances the movement of the diaphragm against gravity (side-lying or semifowlers). A tactile cue of a hand or a tissue box over the lower rib cage will help visualize how the lower rib cage should move on inhalation and exhalation. On inhalation, the hand on the lower rib cage or tissue box should rise, indicating air filling the lungs. When done correctly, the upper chest will have little movement because there should not be large volumes of air moved during a relaxation technique.
Stacking breaths is a useful technique to maximize ventilation when the volume of air a patient/client can inhale is limited. This may be due to a neuromuscular insult, postsurgical pain, trapped air, weak muscles, or large inspiratory airflow leading to bronchospasm. Breath stacking is accomplished by taking a small-to-moderate size breath and adding it to two or three additional breaths to increase inspiratory volume, thereby decreasing atelectasis, moving air behind the secretions, and increasing inspiratory volume to enhance a huff or cough. The patient is instructed to take in siplike volumes of air on top of one another without exhaling. After three to four breaths, an inspiratory hold should be done for 1 to 2 seconds followed by a huff or a controlled cough. It may be helpful for the patient/client to see a demonstration and use a mirror for visual cues. Any symptoms of dizziness or light-headedness are indications to stop the technique. The inhalation and inspiratory hold phases of breath stacking can be incorporated with many other airway clearance techniques such as the forced expiratory technique, AD, active cycle of breathing, PEP, oscillating positive pressure, and during bronchial drainage and manual techniques.
Segmental breathing combines manual cues and breathing control to improve ventilation to specific areas of the chest wall. If during evaluation of chest wall movement asymmetry is identified, this could coincide with the underlying pathology of pneumonia, an area with pleuritic chest wall pain or an area with poor air movement from retained secretions. Placing a hand on that area and coordinating chest wall movement with downward hand movement will enhance expansion in this area. Facilitation or inhibition of a segment can be controlled with proper timing, hand placement, and verbal cues for breathing coordination. Utilization of the principles of proprioceptive neuromuscular techniques will allow the therapist to increase chest wall movement, stimulate a productive cough in some cases, and improve overall ventilation and chest wall symmetry.
Combining pursed-lip breathing during exhalation with diaphragmatic breathing should enhance relaxation and promote a better overall breathing pattern with less accessory muscle use. Pursed-lip breathing is accomplished by breathing in through the nose to a count of “1, 2” and out via pursed lips to a count of “1, 2, 3, 4.” This will prolong the expiratory phase, slow the RR, and delay small airway closure. It will also decrease dyspnea, improve airflow, and calm anxiety. Instruct the patient to sit in front of a mirror or use a handheld mirror for feedback. Repeat the previous sequence of taking a breath in through the nose and exhaling via the lips in a whistle-ready position. If the patient or client is very anxious, it is not as important how the breath is taken in, as how the air is exhaled through the pursed lips. If the patient or client has end-stage lung disease and the diaphragms are flattened from air trapping, diaphragmatic breathing may not be as beneficial as pursed-lip breathing.
Pursed-lip breathing and diaphragmatic breathing should be incorporated into functional activities like walking. This strategy is referred to as paced breathing. The patient is instructed to take a breath in through the nose and walk two steps to a count of “1, 2.” The patient then exhales to a count of “1, 2, 3, 4” as they walk the next 4 steps. The inspiration-to-expiration ratio is 1:2, thus prolonging the expiratory phase and delaying small airway closure. Once the patient is able to use these strategies on level surfaces, they can advance to stair climbing. Instruct the patient to use a “step-to” strategy (ie, one foot meets the other on the same step), and avoid “step-over-step” (ie, one foot moves past the other to the next step above). Also make sure that his or her foot is placed fully on the step and not on the edge before going up to the next step. A handrail may allow the patient to use accessory muscles as needed. A handrail may also lessen the fear of falling, thereby reducing the anxiety that accompanies fear. Fear of falling promotes anxiety, which leads to shortness of breath and poor airflow.
Expiratory exercises that prolong the expiratory phase can be used as measurable outcomes as well as interventions. Instructing the patient/client to read a phrase, sentence, or paragraph aloud promotes expiratory control. The number of words stated during exhalation can be measured by the patient/client for feedback and demonstration of progress. This same technique can incorporate singing for expiratory airflow control. The patient can place a hand on the abdominal area to palpate abdominal muscle activation during the technique. This exercise will promote endurance training of the expiratory muscles and can be used during ADL in combination with conservation techniques.
Manual/Mechanical Techniques: Assistive Devices5,8,10,31,42,44,57,60,61,64–74
PEP, oscillatory PEP (Flutter or Acapella), HFCWO, intrapulmonary percussive ventilation (IPPV), and the Frequencer are all mechanical devices used for airway clearance.
PEP can be produced using pursed lips, a mouthpiece, a mask, or various devices. For the purpose of airway clearance, only the devices used for PEP will be discussed in this section. The technique(s) are easy to learn, can be performed in the sitting position, done independently, taught to children, are very portable, and have been shown to be an effective method of airway clearance. There are many devices available in the market at a wide variety of prices. The devices used should include an exhalation port, a release-type valve, and be used for only a single individual. Ideally, they should also have a port for either oxygen or nebulized medication to be delivered during the technique. Pressures between 10 and 20 cm H2O are optimal to build up back pressure and promote equalization of pressure across alveoli for mobilization of secretions. The back pressure is also theorized to promote airway stabilization to increase time for secretion mobilization.
The individual is instructed to sit upright with his or her elbows on a table, to exhale just greater than a normal tidal breath, and inhale into the mask or mouthpiece of the device. A manometer is placed in-line to measure pressure levels and give visual cues. A resistor is placed in the exhalation port to promote positive pressure in the range of 10 to 20 cm H2O. When initially teaching an individual how to use the device, a larger resistor is used with progressively smaller ones put in place until the desired pressure range is reached. The manometer acts as biofeedback until the individual has learned the sequence. If a mouthpiece is used instead of a mask, a nose clip should be used to prevent air leakage. As with other devices used for airway clearance, secretions are expectorated by huffing or coughing.
Oscillating positive pressure is an alternative to a stable level of pressure in PEP devices. These pocket-sized devices (Flutter or Acapella) provide the benefits of a positive-pressure device plus the “interruptions” from the oscillations that promote changes in the viscosity of the secretions and enhance expiratory airflow. This category of PEP devices has been shown to be an effective mode of airway clearance. Pneumothoraces, claustrophobia, recent facial or nasal surgery, or injury are precautions that should be considered when weighing the benefits against the risks of using positive-pressure devices for airway clearance.
HFCWO (the Vest Airway Clearance System or the SmartVest System) is an individually sized chest wall jacket powered by a generator, which promotes secretion clearance of the entire lung fields while performed in the seated position (Fig. 17-7). HFCWO offers the advantage of independence and has been shown to be an effective airway clearance method. The device has been used in the home, acute and long-term care settings, and intensive care settings. The principal theory of the vest is that at various pressures and oscillations, airflow is enhanced and viscosity of secretions is altered, which promotes ease of secretion mobilization and clearance. The device requires an electrical source, comes with a prefitted vest, a compressor unit, a hand or foot pedal, and tubes to connect the vest to the compressor. Three frequency ranges are used to enhance secretion movement: 5 to 10 cycles/s, 10 to 15 cycles/s, and 15 to 20 cycles/s.
The Vest airway clearance system. (Courtesy of Advanced Respiratory, Inc, St Paul, MN.)
The individual is instructed to start at the lower settings to allow loosening of secretions from the periphery and then progress to the higher settings to move the secretions toward the upper airways for expectoration. More than 10 minutes should be spent at each level to promote the most efficient and effective airway clearance. A nebulizer can be used along with the vest. A properly fitted vest is imperative for comfort and to limit side effects such as nausea, abdominal discomfort, chest wall discomfort, and complaints of urinary urgency. If an indwelling venous catheter is in place, padding can be placed around the site to limit discomfort. These devices are expensive but are covered by most insurance companies.
The IPPV device works in a similar way to HFCWO. The device is based on theories of airflow and oscillation but is delivered internally via a mouthpiece compared to HFCWO, which is external. Cost and comfort are two key areas of patient concern, as a feeling of claustrophobia and chest fullness may be experienced during the application of the device. The changes in frequency and pressure delivered internally assist with airway stabilization, thereby decreasing secretion viscosity and enhancing secretion mobilization.
The Frequencer is a newly developed device for airway clearance. The electroacoustical device, which has recently received FDA approval in the United States, applies vibrations at a rate of 20 to 120 Hz to the chest wall to assist with the mobilization of mucus. A preliminary study demonstrated that the Frequencer was equal to conventional postural drainage and percussion in 22 patients with CF when used between 25 and 40 Hz. Although safety and efficacy of the Frequencer have been demonstrated, its use is not yet widespread enough to determine acceptance by the CF population.
Manual/Mechanical Techniques: Chest Percussion, Vibration, and Shaking8–10,12,42,43,57,60,72,75
Manual techniques have traditionally been used to enhance bronchial drainage. These techniques include percussion, vibration, and shaking, which are often collectively referred to as traditional chest PT. Treatments with these techniques can be performed with an assistant, independently via self-percussion/vibration, or with mechanical devices. The mechanical devices may be difficult to hold in the correct position to get the similar effect of manually delivered percussion or vibration. The mechanical devices can be expensive if not covered by insurance and could be unreliable at producing the correct rate and pressure required for optimal airway clearance. On the other hand, performing the technique manually can be fatiguing for the person performing the technique as well as for the person receiving the percussion, vibration, or shaking. Correct hand posture and position are needed to prevent injury to the performer and receiver of the percussion. The caregiver may be at risk for a repetitive-type injury at the wrist, elbow, or shoulder, and the individual receiving the technique may be at risk for bruising, soreness, and fractures of the ribs if too much pressure is applied and the patient does not communicate to the caregiver their tolerance to treatment.
The cupped-hand position is used for percussion to transmit energy through the chest wall to loosen thick secretions. The technique may be done concurrently with a drainage position to enhance secretion mobilization. Once the secretions are loosened with percussion, the techniques of vibration and shaking help to mobilize the secretions from the periphery and move them toward the trachea for expectoration and evaluation of the secretions. Vibration and shaking are done in a rhythmic pattern. The caregiver's shoulders should be positioned directly over the hands. As the patient exhales, a downward motion is made by the caregiver in a vibrating motion while maintaining full contact of the hands on the chest wall. Shaking results in an exaggeration of vibration and appears more like a plunging motion.
For each of the manual techniques, hand placement should avoid bony prominences such as the scapula, spinous processes, and clavicles. Ribs and breast tissue may be very sensitive and special care should be given in those areas. The patient receiving the manual techniques should be allowed to rest after three to four cycles. The caregiver should watch for fatigue and signs of decompensation: increased RR, reports of shortness of breath, a change in coloration or mental status, and a change from baseline breathing pattern. An individual may use self-percussion and vibration independent of a caregiver for certain drainage positions, but these exclude any of the posterior regions. Box 17-4 lists precautions for percussion and vibration.
Box 17-4 Precautions for Postural Drainage and Manual Techniques ||Download (.pdf)
Box 17-4 Precautions for Postural Drainage and Manual Techniques
Precautions for Bronchial Drainage and Manual Techniques5,42,44
Bruising/rib fractures/flail chest
Large pleural effusion
Recent burn graphs
Level of alertness
Risk for injury to caregiver and/or recipient
Nausea and vomiting
Increased intracranial pressure
Appropriate light, loose clothing
Indwelling venous catheter
Feeding tubes (jejunal, gastric)
Timing of tube feeds prior to treatment
Mechanical percussor/vibrators need electrical source, rate may be inconsistent
Positioning for Airway Clearance5,8,10,42,43,57,60–62,75
Bronchial drainage or postural drainage has been utilized for treating pulmonary congestion for decades. The primary principle of the technique is to utilize the shape and direction of the lung segments and to place the individual in gravity-enhancing postures or positions that drain the uppermost segment of the lung once in that position. Ten positions are used to drain all the segments of the lung (see Fig. 17-8). It may not be necessary to use all 10 positions. The treatment should be based on the PT examination to focus on the areas most in need in addition to being tolerated by the patient. Elevated BP, anxiety, esophageal reflux, and decompensation of the cardiopulmonary system are precautions, which should always be observed if this technique is utilized. Bronchial drainage can be done independently and modified to reduce the aforementioned precautions; however, performing all 10 positions can be very time consuming. Precautions for postural drainage should be observed (Box 17-4).
Postural drainage positions. Position 1 = patient leans back 30 degrees; position 2 = patient leans forward 30 degrees; position 3 = patient flatlying; positions 4 and 5 = patient with head down 15 degrees, rotated one-quarter turn backward; position 6 = patient with head down 30 degrees, sidelying; position 7 = patient with head down 30 degrees, prone; position 8 and 9 = patient with head down 30 degrees, rotated one-quarter turn forward; position 10 = patient prone with bed flat. (Reprinted with permission from the Cystic Fibrosis Foundation. An Introduction to Chest Physical Therapy. Bethesda, MD; 1997.)
Exercise for Airway Clearance15,17,43,60,75
Although not listed in the Guide under Airway Clearance Techniques, exercise may be used to enhance clearance of secretions. Exercise promotes improvement in ventilation, airflow, air volume, chest wall movement, secretion movement, and functional capacity. Exercise has not been advocated as an independent method of airway clearance for patients with chronic pulmonary conditions and should be performed in conjunction with other techniques. Exercise to enhance airway clearance should involve large muscle groups, thereby promoting an increase in tidal volume and airflow and be done regularly for a training effect. Exercise should be age appropriate and enjoyable for the patient. Oxygen desaturation and hemodynamic decompensation should be a key concern when initiating any type of an exercise program with a patient with pulmonary disease and excessive secretion production. Monitoring pulse oximetry is a must for patient safety. Precaution for musculoskeletal injury should also be included in the plan. Substituting one of the multiday airway clearance treatments with exercise will encourage independence and enjoyment and promote another component of health.