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Defnition of Terms
Atelectasis
Atelectasis is a state of lung tissue characterized
by the collapse of alveoli so they become airless.
It is associated with many pulmonary
abnormalities,
both
pathological
and
mechanical, and is caused by obstruction of a
bronchial airway (e.g., by mucus or tumor), lung
compression (e.g., by pleural effusion,
pneumothorax, or marked elevation of the
diaphragm),
and
insufficient
surfactant
production, as well as inadequate inspiratory
volume. Atelectasis is commonly seen in
postoperative patients, particularly when there is
an abdominal or thoracic incision, and in those
with neurologic and musculoskeletal disorders
that hinder proper lung expansion.
Atelectasis occurs only if there is blood flow to
the affected alveoli, allowing absorption of
gases.
It can occur as microatelectasis, which
involves a diffuse area of terminal lung units, or
as segmental or lobar atelectasis, which follows
anatomic distribution of a blocked airway.
Pneumonia
Pneumonia is an inflammatory process of the
lung parenchyma, which results from infection
in the lower respiratory tract, inhalation of
noxious chemicals, or aspiration of food or
fluids into the lungs. It typically leads to
consolidation of some or all of the alveoli as
they fill with exudate and cellular debris. Many
conditions are associated with an increased risk
of developing pneumonia, including impaired
airway defense mechanisms (e.g., due to
cigarette smoking, upper respiratory infection,
or dehydration), chronic obstructive lung
Pneumothorax
Epidemiology
Frequency
United States
For intrinsic lung diseases, studies cite an
overall prevalence of 3-6 cases per 100,000
persons. The prevalence of idiopathic pulmonary
fibrosis (IPF) is 27-29 cases per 100,000
persons.(I pulled some recent refs with varying
numbers.[2, 3] The prevalence for adults aged 3544 years is 2.7 cases per 100,000 persons.
Prevalence exceeded 175 cases per 100,000
persons among patients older than 75 years.
Exposure to dust, metals, organic solvents, and
agricultural employment is associated with
increased risk.
In North America, the prevalence of sarcoidosis
is 10-40 cases per 100,000 persons.
The incidence of chronic interstitial lung
diseases in persons with collagen-vascular
diseases is variable, but it is increasing for most
diseases.
Kyphoscoliosis is a common extrinsic disorder.
It is associated with an incidence of mild
deformities amounting to 1 case per 1000
persons, with severe deformity occurring in 1
case per 10,000 persons.
Other nonmuscular and neuromuscular disorders
are rare, but their incidence and prevalence are
not well known.
According to the CDC, 35.9% of Americans
older than 20 years are obese, and 69% of
Americans are at least overweight (BMI 25-30).
International
In Sweden, the prevalence rate for sarcoidosis is
64 cases per 100,000 persons. In Japan, the
prevalence rate of sarcoidosis is 10-40 cases per
100,000 persons. The prevalence of sarcoidosis
is difficult to determine, and tuberculosis is
common.
The worldwide prevalence of fibrotic lung
diseases is difficult to determine because studies
have not been performed.
Race
Although a familial variant of IPF exists, a
genetic predisposition is not documented. US
prevalence of sarcoidosis is estimated to be 1017 times higher among African Americans
compared to white Americans.
Sex
Lymphangioleiomyomatosis (LAM) and lung
involvement in tuberous sclerosis occur
primarily in premenopausal women, although a
handful of cases of LAM have been reported in
men. Men are more likely to have
pneumoconiosis because of occupational
exposure, IPF, and collagen-vascular diseases
(eg, rheumatoid lung). Worldwide, sarcoidosis is
slightly more common in women.
Age
IPF is rare in children. Some intrinsic lung
diseases present in patients aged 20-40 years.
These include sarcoidosis, collagen-vascular
associated diseases, and pulmonary Langerhans
cell histiocytosis (formerly referred to as
histiocytosis X). Most patients with IPF are
older than 50 years.
Mortality Rate
when
the
parasternal intercostals, as depicted in Figure 23. During deep or labored breathing, the
accessory muscles of inspiration are recruited.
At rest, expiration is a passive process,
occurring as the inspiratory muscles relax and
lung elastic recoil takes over. During forced
expiration and coughing, the abdominal and
internal intercostal muscles are activated.
Respiratory muscle weakness and limited
endurance can impair gas exchange and lead to
respiratory insufficiency or failure, especially
PHYSIOLOGY
It is RESPIRATORY
important for physical
therapists to
understand the factors that contribute to normal
functioning of the respiratory system in order to
appreciate
normal
versus
abnormal
physiological indicators, both at rest and during
exercise, as well as the implications for physical
therapy interventions.
BASIC
FUNCTIONS
RESPIRATORY SYSTEM
OF
THE
exchange;
hypoxic
vasoconstriction
is
stimulated to reduce blood flow to alveoli that
are not being ventilated (i.e., alveolar dead
space).
Ventilationperfusion (V /Q) matching: The
degree of physical correspondence between
ventilated and perfused areas of the lungs; the
optimal V/Q ratio is 0.8 (4 parts ventilation to 5
parts perfusion) to maintain normal gas
exchange.
Oxygenhemoglobin (O2Hb) binding: The
level of oxygen saturation of the arterial blood,
as shown in Figure 2-5; normal arterial oxygen
saturation (SaO2) is 95% or more.
Disorders of cardiovascular/pulmonary
origin, such as pulmonary edema or
pulmonary embolism
Inadequate
or
abnormal
pulmonary
development (bronchopulmonary dysplasia)
advanced age
Extrapulmonary causes
IV. ETIOLOGY
syndrome,
Cardiovascular
drugs:
amiodarone,
angiotensin-converting
enzyme
(ACE)
inhibitors,
anticoagulants,
b-blockers,
dipyridamole, flecainide, protamine, tocainide
Inhalants: aspirated oils (mineral or neutral oils,
animal fats) and oxygen
Miscellaneous
drugs:
bromocriptine,
dantrolene. hydrochlorothiazide, methysergide,
tocolytic agents, tricyclic antidepressants, Ltryptophan
V. Pathophysiology/Mechanism of Injury/Pathology
General pathophysiology of restrictive lung disorders; severe ventilatory limitation provokes progression
to events below the dashed line and their sequelae, which are illustrated in Figure 4-1, possibly leading to
respiratory failure and/or cor pulmonale. Clinical manifestations of various events are enclosed in circles.
DOE, Dyspnea on exertion; IC, inspiratory capacity; PA, pulmonary arterial; RV, residual volume;
TLC, total lung capacity; VC, vital capacity;
V/Q , ventilation-perfusion.
RLD results in limited lung expansion.
If a lung is less compliant, greater
transpulmonary pressure is required to
expand it to any given volume, which is
usually less than normal.
Sign or Symptom
Anorexia, weakness, fatigue, weight loss
Bradycardia
Breath sounds
Chest pain
Coma, convulsions
Confusion, concentration, restlessness,
irritability
Cough
Crackles, or rales
Cyanosis
Diaphoresis
Digital clubbing
Dullness to percussion
Fever
Hypercapnia (paco2)
Hypoxemia (pao2)
Mediastinal shift
Nasal secretions
Orthopnea (SOB when recumbent)
Resonance to percussion
Resonance to percussion
Rhonchi, wheezes
Sputum production
Stridor
Tachycardia
Tachypnea
Vocal fremitus
Vocal fremitus
Wheezes
Clinical Manifestations
Atelectasis
Clinical Manifestations
Few or no symptoms if atelectasis evolves
slowly; possible fever and cough
If acute collapse of a large section of lung:
Profound dyspnea
Severe hypoxemia
Tracheal and mediastinal shift toward the
affected side, with elevated diaphragm,
Reduced or absent breath sounds, crackles and
possible wheezes
Chest x-ray showing well-defined area of
increased density, volume loss, and tracheal and
mediastinal shift toward the affected side
Pneumonia
Clinical Manifestations
Rapid, shallow breathing, which becomes more
pronounced during exercise
Dyspnea on exertion (DOE), which may
progress to resting dyspnea
Possible repetitive, nonproductive cough
Fatigue, loss of appetite, weight loss
Clinical Manifestations
possible
hypotension,
and
Clinical Manifestations
Tachycardia
arrhythmia
Pallor or cyanosis
Tachycardia, possible arrhythmias
Decreased breath sounds with crackles,
possible wheezing and rhonchi
Refractory hypoxemia with associated
symptoms; usually hypocapnia initially, then
hypercapnia
Abnormal chest x-ray with bilateral patchy
peripheral infiltrates and often air bronchograms
Pulmonary Edema
The clinical features of cardiogenic and
noncardiogenic pulmonary edema are similar:
Dyspnea, respiratory distress
Orthopnea (dyspnea when lying flat),
paroxysmal nocturnal dyspnea (awakening at
night with acute shortness of breath) Pallor or
cyanosis
Diaphoresis
Tachycardia, possible arrhythmias
Anxiety, agitation
Bibasilar or diffuse crackles, possible wheezes
Abnormal chest x-ray with pulmonary
congestion or central infiltrates
Third heart sound (S3)
Pulmonary embolism (PE)
The signs and symptoms of both deep venous
thrombosis (DVT) and PE are often nonspecific,
so that many patients who are evaluated with
diagnostic tests for the following complaints
associated with PE do not end up with the
correct diagnosis:
with
rapid
feeble
pulse,
ELECTROCARDIOGRAPHY
as other chronic diseases, are the 6-min and 12min walk tests (6MWT and 12MWT,
respectively), during which clients are asked to
walk as far as they can during the time of the
test, with rests allowed as needed. Although
these tests are often considered submaximal,
they may be near maximal in patients with
severe obstructive lung disease.
PULMONARY IMAGING STUDIES
FLUOROSCOPY
Fluoroscopy produces radiographic images with
real-time display of a patients breathing that
may be highlighted with a radioopaque contrast
agent.
Fluoroscopy offers a quick and inexpensive
method of detecting lesions that are obscured by
ribs or that can be seen clearly only in an
unusual oblique projection (e.g., some pleural
plaques, retrocardiac nodules), as well as
pulsatile nodules and masses.
It is used most commonly to guide
interventional procedures, such as needle or
transbronchial biopsies or catheter angiography,
to detect minor variations in symmetry of
diaphragmatic motion seen in phrenic nerve
damage, and to diagnose air trapping in small
children with suspected foreign body aspiration.
COMPUTED TOMOGRAPHY
With computed tomography (CT), x-ray beams
pass through a body part in multiple projections
in order to produce clear crosssectional images
of various body tissues with good contrast
resolution. Chest CT is valuable in evaluating
mediastinal masses, hilar abnormalities, thoracic
aortic dissection, diffuse lung disease, pleural
abnormalities, presence of metastatic lesions,
and resectability of bronchial carcinoma, and in
quantifying the severity of emphysema and its
appropriateness for lung reduction surgery.
During conventional CT scanning, patient
movement on the table alternates with data
acquisition via the rotating x-ray source (i.e.,
data are acquired from one tissue plane, and then
NUCLEAR MEDICINE/SCINTIGRAPHIC
IMAGING STUDIES
Scintigraphic studies employ radioactive
imaging agents to light up various tissues
during imaging, using a gamma counter.
VENTILATIONPERFUSION SCANNING
Ventilationperfusion ( V/Q ) scans use
radionuclides to evaluate and compare the
distribution of ventilation and perfusion within
the lungs.
EMISSION
IMAGING
AND
PLEURAL
Pleurocentesis
is
also
performed
therapeutically to relieve respiratory impairment
caused by pleural effusions.
THORACOSCOPY/PLEUROSCOPY
Thoracoscopy, often with video, can be used to
visualize most intrathoracic structures, including
the pleurae. It is used most commonly as an
alternative to open pleural biopsy when
malignant disease is suspected and a diagnosis
has not been made despite repeated
thoracenteses and pleural biopsies. Furthermore,
therapeutic interventions are often performed
thorascopically, using video-assisted thoracic
surgery (VATS), including debridement in
tuberculosis and empyema; diathermy, laser
coagulation, or endostapling in recurrent
pneumothorax; pleurodesis in malignant
effusion and pneumothorax; as well as visual
placement of drains.
MEDIASTINOSCOPY
MEDIASTINOTOMY
AND
VIII.
MANAGEMENTS
Pharmacological Management
Antihistamines
Antihistamines are used to block histaminemediated reactions associated with seasonal
allergies. They reduce mucosal congestion,
irritation, and discharge caused by inhaled
allergens, and they also reduce coughing and
sneezing associated with the common cold. They
are often combined with decongestants.
The first-generation antihistamines readily
crossed the bloodbrain barrier to enter the
brain, causing the common side effects of
sedation, fatigue, dizziness, and blurred vision.
In addition, their anticholinergic effects may
cause drying of secretions and lead to further
airway obstruction in some patients.
Newer, second-generation antihistamines
include astemizole (Hismanal), loratadine
(Claritin),
terfenadine
(Seldane),
and
fexofenadine (Allegra). They do not easily cross
the blood brain barrier, so they are far less
likely to cause sedation or other CNS side
effects. However, some may produce
cardiotoxicity with serious arrhythmias.
Antitussives
Antitussives suppress the cough reflex and are
used to treat the irritating, dry, hacking cough
associated with minor throat irritations and the
common cold. They are not indicated for
productive coughs.
Two main classifications of drugs provide
antitussive effects: nonnarcotic, over-thecounter, cough suppressants (e.g.,
Physiotherapeutic management
BREATHING EXERCISES AND
Diaphragmatic Breathing
Diaphragmatic Breathing When the diaphragm
is functioning effectively in its role as the
primary muscle of inspiration, ventilation is
efficient and the oxygen consumption of the
muscles of ventilation is low during relaxed
(tidal) breathing.When a patient relies
substantially on the accessory muscles of
inspiration, the mechanical work of breathing
(oxygen consumption) increases and the
efficiency of ventilation decreases. Although the
diaphragm controls breathing at an involuntary
level, a patient with primary or secondary
pulmonary dysfunction can be taught how to
control breathing by optimal use of the
diaphragm and decreased use of accessory
muscles.
Procedure
Segmental Breathing
Two examples of segmental breathing that target
the lateral and posterior segments of the lower
lobes are described in this section. However,
segmental breathing techniques also may need to
be directed to the middle and upper lobes if there
is accumulation of secretions or insufficient lung
expansion in these areas.
Pursed-Lip Breathing
Many therapists believe that gentle pursed-lip
breathing and controlled expiration is a useful
procedure, particularly to relieve dyspnea if it is
performed appropriately. It is thought to keep
airways open by creating back-pressure in the
airways. Studies suggest that pursed-lip
breathing decreases the respiratory rate and the
work of breathing (oxygen consumption),
increases the tidal volume, and improves
exercise tolerance
Procedure
Have the patient assume a comfortable position
and relax as much as possible. Have the patient
breathe in slowly and deeply through the nose
and then breathe out gently through lightly
pursed lips as if blowing on and bending the
Specific Techniques
To Mobilize One Side of the Chest
Self-Assisted Technique
While in a sitting position, the patient crosses
the arms across the abdomen or places the
interlocked hands below the xiphoid process .
After a deep inspiration, the patient pushes
inward and upward on the abdomen with the
wrists or forearms and simultaneously leans
forward while attempting to cough.
Splinting
If chest wall pain from recent surgery or trauma
is restricting the cough, teach the patient to
splint over the painful area during coughing.
Have the patient press the hands or a pillow
firmly over the incision to support the painful
POSTURAL DRAINAGE
Postural drainage (bronchial drainage), another
intervention for airway clearance, is a means of
mobilizing secretions in one or more lung
segments to the central airways by placing the
patient in various positions so gravity assists in
the drainage process. When secretions are
moved from the smaller to the larger airways,
they are then cleared by coughing or
endotracheal suctioning. Postural drainage
Atelectasis
Specific Treatment
Prevention (e.g., airway clearance techniques,
breathing exercises, mobilization)
Removal of obstruction
Vigorous chest physical therapy techniques
to mobilize mucous obstructions
Flexible bronchoscopy with lavage for
removal of mucus plugs and retained
secretions
Bronchoscopic or surgical removal of
aspirated foreign object
Excision of tumor
Treatment of underlying disorder if not
obstructive atelectasis
regarding
overstressing
bones
and
musculoskeletal structures.
Patients with pain that limits activity will
tolerate exercise better with effective
analgesia; however, excessive sedation can
impair ventilation and gas exchange.
PT interventions that may benefit patients with
RLD and include the following:
Airway clearance techniques if poor
secretion management
Techniques
to
increase
pulmonary
compliance (e.g., breathing exercises,
thoracic mobility and posture exercises,
soft tissue mobilization)
Coughing techniques 4Respiratory muscle
training
Chest mobility, posture exercises
Endurance
exercise
training
with
appropriate modifications, such as lowlevel activity initially with gradual
progression, periodic rest periods to
increase patient tolerance for more
vigorous activities, coordination of
breathing with activity, and supplemental
oxygen for hypoxemic patients
Relaxation training
Energy
conservation
and
work
simplification techniques
Creative problem solving to deal with
functional limitations
DIFFUSE/INTERSTITIAL LUNG DISEASE
AND PULMONARY FIBROSIS
Specific Treatment
Withdrawal of causative agent, if known
Early corticosteroids
Pulmonary rehabilitation and other treatment
interventions for RLD
Pleural Effusion
Specific Treatment
Observe for natural reabsorption
Segmental expansion and diaphragmatic
breathing exercises to prevent underlying
atelectasis; increased mobilizaton
Thoracentesis
Chest Trauma
Specific Treatment
Maintain oxygenation (supplemental oxygen,
mechanical ventilatory assistance)
Analgesia
Breathing exercises, mobilization as able
Possible surgery for internal fixation of flail
segment
Possible extracorporeal membrane oxygenation
(ECMO) if all else fails
Thoracic Deformity
Specific Treatment
Close observation for progression; bracing
versus surgical correction
Supplemental oxygen, mechanical ventilatory
assistance when indicated
Thoracic mobility and breathing exercises
Pneumothorax
Specific Treatment
Observation (i.e., allow natural reabsorption) if
small and asymptomatic
Simple manual needle aspiration versus
intrapleural smallcaliber catheter or chest tube
insertion
Segmental expansion breathing exercises
Acute Respiratory Distress Syndrome
Specific Treatment
Treatment of underlying disease
Supplemental oxygen
Mechanical ventilation (usually with low tidal
volume and high positive end-expiratory
pressure [PEEP])
Nutritional and fluid balance support
Prevention and treatment of complications
(e.g., barotraumas and nosocomial infections)
Pulmonary Edema
Specific Treatment
Prompt diagnosis of the cause of pulmonary
edema is critical to appropriate treatment. The
treatment of increased perfusion pulmonary
edema is described on the preceding page; the
REFERENCES