Dr.

Afaq Ahmad; PT
Cardiopulmonary Physical therapy
 COPD
• Chronic Obstructive Pulmonary
Disease

• A progressive disease that affects the

lungs, making it difficult to breathe
 COPD: An Umbrella Term

• Umbrella term used to describe

progressive lung diseases which include:

• Emphysema
• Chronic bronchitis
• Refractory (irreversible) asthma
• Severe bronchiectasis
 Other Names for COPD
• Chronic Obstructive Lung Disease (COLD)

• Chronic Lower Respiratory Disease

(CLRD)
 COPD
• Chronic obstructive pulmonary disease (COPD)
is a lung ailment that is characterized by a
persistent blockage of airflow from the lungs.

• It is an under-diagnosed, life-threatening lung

disease that interferes with normal breathing
and is not fully reversible.
 Symptoms
• Breathlessness
• Abnormal sputum (a mix of saliva and mucus
in the airway)
• A chronic cough
• Daily activities can become very difficult as
the condition gradually worsens
 Understanding COPD
• Critical to first understand normal lung function

Image courtesy of The National Institute of health

Lungs with COPD

Image courtesy of The National Institute of health

 Emphysema
Clinical Manifestations

– Dyspnea
• Progresses in severity
• Patient will first complain of
dyspnea on exertion and progress to
interfering with ADLs and rest
 Chronic Bronchitis
Clinical Manifestation
– Bronchospasm at end of paroxysms of coughing
– Cough
– Dyspnea on exertion
– History of smoking
– Normal weight or heavyset
– Ruddy (bluish-red) appearance d/t
• polycythemia (increased Hgb d/t chronic hypoxemia))
• cyanosis
 Chronic Bronchitis
Clinical Manifestation
– Hypoxemia and hypercapnia
• Results from hypoventilation and 
airway resistance + problems with
alveolar gas exchange
 Causes
• Most cases of COPD occur as a result of long-term
exposure to lung irritants that damage the lungs and
the airways

•  The most common irritant that causes COPD is

cigarette smoke

• In rare cases, a genetic condition called alpha-1

antitrypsin deficiency may play a role in causing COPD
 Causes
Cigarette smoking
• Nicotine stimulates sympathetic nervous
system resulting in:
 HR
 Peripheral vasoconstriction
 BP and cardiac workload
 Causes

• Compounds problems in a person with CAD

• Ciliary activity
• Possible loss of ciliated cells
• Abnormal dilation of the distal air space
• Alveolar wall destruction
• Impairs psychomotor performance and judgment
• Cellular hyperplasia
• Reduction in airway diameter
• Increased difficulty in clearing secretions
 Who is at risk?
• People who smoke or are exposed to smoke

• People who have a family history of COPD are more likely to

develop the disease if they smoke

• Long-term exposure to other lung irritants also is a risk factor

for COPD

• Almost 90% of COPD deaths occur in low- and middle-income

countries, where effective strategies for prevention and control
are not always implemented or accessible.
 Assessment of severity of COPD

Historical features:
Examination:
• Exercise tolerance
• Breathlessness with everyday activities • Features of malnutrition
• Presence of chronic cough
• High volume of sputum, suggestive of • Features of obesity
bronchiectasis (sedentary lifestyle)
• Hemoptysis, suggestive of malignancy
• Home O2 requirement • Central cyanosis
• Home CPAP requirement • Breathlessness at rest
• Pattern of bronchodilator use
• Pattern of steroid use • Hyper-expanded chest
• Frequency of hospitalizations • Degree of air entry
• Previous mechanical ventilation
• Anorexia and weight loss • Signs of right heart failure
 Investigations
• A simple diagnostic test called “Spirometry“
measures how much air a person can inhale
and exhale, and how fast air can move into
and out of the lungs

• Spirometry can detect

COPD long before its
Symptoms appear. 
 COPD
Diagnostic Studies
• Chest x-rays early in the disease may not show
abnormalities
• High-resolution CT to assess the severity of
emphysematous changes
• Pulmonary function studies
– Reduced FEV1/FVC and  residual volume and
total lung capacity
– Degree of hypoxia and hypercapnia
 COPD
Diagnostic Studies

• ABGs
–  PaO2
–  PaCO2 (especially in chronic bronchitis)
–  pH (especially in chronic bronchitis)
–  Bicarbonate level found in late stages COPD
• Others:
- Bicarbonate levels
-Hb (polycythemia)
-TTE (pulmonary pressures)
Methods of investigation of patients with COPD
according “GOLD”
• Investigation of external breathing (spyrometry);
• Bronchodilatation test;
• Cytology of sputum;
• Blood analysis;
• X-ray;
• ECG;
• Blood gases;
GOLD staging uses four categories of severity for
COPD, based on the value of FEV1
Stages Categories of Severity FEV1/FVC Range

Stage I Mild COPD FEV1/FVC<0.70 FEV1≥ 80% normal

Stage II Moderate COPD FEV1/FVC<0.70 FEV1 50-79%

normal

Stage III Severe COPD FEV1/FVC<0.70 FEV1 30-49%

normal

Stage IV Very Severe COPD FEV1/FVC<0.70 FEV1 <30% normal,

or <50% normal
with chronic
respiratory failure
present*
Investigation of external breathing

• FVC – max air volume which is expired during forced

expiration after max inspiration;
• FEV1 (<80 %)
• FEV1/FVC (<70 %)
• Peak flow (of expiration)
 X-ray signs of COPD
• Lungs are enlarged
• Diaphragm is located lower than normally
• Narrow heart shadow
• Sometimes – emphysematous bullas
COPD
Bronchodilatation test
• Is necessary to find bronchial reversibility
• Spyrometry has to be provided before and 15
min after inhalation of 400 mkg of Salbutamol
(or 30-45 min – 80 mkg of Ipratropium)
• Increasing of FEV1 more than 15 % tells us
about reversibility
 Treatment
• COPD has no cure

• Quitting smoking is the most important step

an individual can take to treat COPD

• Other treatments for COPD may include

medicines, vaccines, pulmonary rehabilitation
(rehab), oxygen therapy, and surgery.
 Managing COPD
• COPD symptoms usually slowly worsen over time

• A cold, the flu, or a lung infection may cause

symptoms to intensify

• Prescription antibiotics may treat infections and

other medicines, such as bronchodilators and
inhaled steroids, can help facilitate breathing
 Managing COPD
• Avoid lung irritants
• Get ongoing care
• Manage the disease and its symptoms
• Prepare for emergencies
 COPD
Collaborative Care: Oxygen Therapy
• O2 therapy aiming at a SpO2 around 90%
• Raises PO2 in inspired air
• Treats hypoxemia
• Titrate to lowest effective dose
 COPD
Collaborative Care: Respiratory Therapy
• Breathing retraining
• Pursed-lip breathing
• Prolonged exhalation prevents bronchiolar
collapse and air trapping
• Diaphragmatic breathing
• Focuses on using diaphragm instead of
accessory muscles to achieve maximum
inhalation and slow respiratory rate.
 COPD
Collaborative Care: Respiratory Therapy
• Huff coughing
Chest physiotherapy – to bring secretions into
larger, more central airways
– Postural drainage
– Percussion
– Vibration
 Positions for Postural Drainage
Positions for Postural Drainage
 COPD
Collaborative Care: Surgical Therapy
– Lung volume reduction surgery
– Lung transplant
 COPD
COPD
Collaborative
Collaborative Care:
Care: Drug
Drug Therapy
Therapy

• Bronchodilators – as maintenance therapy

– -adrenergic agonists (e.g. Ventolin)
• MDI or nebulizer preferred
– Anticholinergics (e.g. Atrovent plus salbutamol at
first 2-hourly then gradually decreases)
 COPD
Collaborative Care: Nutritional therapy
• Full stomachs press on diaphragm causing
dyspnea and discomfort
• Difficulty eating and breathing at the same
time leads to inadequate amounts being eaten
 COPD
Collaborative Care

– Nutritional therapy
• Rest at least 30 minutes prior to eating
• Use bronchodilator before meals
• 5-6 small meals to avoid bloating
• Avoid foods that require a great deal of chewing
• Avoid exercises and treatments 1 hour before and after
eating
 COPD
Collaborative Care

– Nutritional therapy
• Avoid gas-forming foods
• High-calorie, high-protein diet is recommended
• Supplements
• Avoid high carbohydrate diet to prevent
increase in CO2 load
 IMPLICATIONS
• Adequate metabolic control should be established before an
exercise programme is initiated.
• HR and BP evaluations should be incorporated in all physical
therapy evaluations as DM patients exhibit abnormal
hemodynamic responses to activities.
• Self monitoring of blood glucose levels is essential. Avoid
vigorous and prolonged exercise if blood glucose levels are
250- 300 mg/dl and should not exercise at all if blood
glucose exceeds 300 mg/dl or if there is any ketosis. Likewise
exercises are contraindicated when blood glucose levels are
80-100 mg/dl because of greater risk of hypoglycemia.
• Restrictive lung diseases are characterized by
reduced lung volumes, either because of an
alteration in lung parenchyma or because of a
disease of the pleura, chest wall, or
neuromuscular apparatus
• The first is intrinsic lung diseases or diseases
of the lung parenchyma. The diseases cause
inflammation or scarring of the lung tissue
(interstitial lung disease) or result in filling of
the air spaces with exudate and debris
(pneumonitis).
• The second is extrinsic disorders or extra-
pulmonary diseases. The chest wall, pleura,
and respiratory muscles are the components
of the respiratory pump, and they need to
function normally for effective ventilation.