dyspnea and pulmonary rehabilitation applications

DYSPNEA AND DYSPNEA AND PULMONARY PULMONARY

REHABILITATION REHABILITATION APPLICATIONSAPPLICATIONS

Rengin Güzel MDRengin Güzel MDCukurova University Medical Cukurova University Medical

FacultyFacultyDep of Physical Medicine and Dep of Physical Medicine and

RehabilitationRehabilitation

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PLANPLAN DefinitionDefinition Dyspnea and quality of lifeDyspnea and quality of life TechniquesTechniques

Leaning forwardsLeaning forwards Inspiratory muscle trainingInspiratory muscle training Diaphragmatic breathingDiaphragmatic breathing RelaxationRelaxation Pursed lip breathingPursed lip breathing

Self management strategiesSelf management strategies Activities of daily livingActivities of daily living

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DispneDispne Subjective experience of breathing Subjective experience of breathing

discomfort,discomfort,

American Thoracic Society. Am J Respir Crit Care Med. 1999;159:321–340.

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discomfort that is comprised of discomfort that is comprised of qualitatively distinct sensations that qualitatively distinct sensations that vary in intensity. vary in intensity.


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discomfort that is comprised of discomfort that is comprised of qualitatively distinct sensations that qualitatively distinct sensations that vary in intensity. vary in intensity.

The experience derives from The experience derives from interactions among multiple interactions among multiple physiological, psychological, social physiological, psychological, social and environmental factors, and environmental factors,


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discomfort that is comprised of discomfort that is comprised of qualitatively distinct sensations that vary qualitatively distinct sensations that vary in intensity. in intensity.

The experience derives from interactions The experience derives from interactions among multiple physiological, among multiple physiological, psychological, social and environmental psychological, social and environmental factors, and may induce secondary factors, and may induce secondary physiological and behavioral responsesphysiological and behavioral responses


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DispneDispne SubjectiveSubjective experience of breathing experience of breathing

discomfort that is comprised of discomfort that is comprised of qualitatively qualitatively distinct sensationsdistinct sensations that vary that vary in intensity. in intensity.

The experience derives from interactions The experience derives from interactions among multiple physiological, among multiple physiological, psychological, social and environmental psychological, social and environmental factors, and may factors, and may induce secondary induce secondary physiological and behavioral responsesphysiological and behavioral responses


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Dispne Dispne There is no objective physiological measureThere is no objective physiological measure

Rather than measure everything that can be measured physiologically about the respiratory system and then correlate these data with the patient’s dyspnea, we must look at the sensations themselves and the subject’s reaction to the sensations

Julius Comroe 1966

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Gender factorGender factor FEV1 % matched FEV1 % matched

population of 100 men population of 100 men and women with COPD and women with COPD

Women expressed more Women expressed more dyspnea than men for dyspnea than men for the same degree of the same degree of airway obstruction airway obstruction

Perhaps non respiratory Perhaps non respiratory factors such as anxiety, factors such as anxiety, depression or coping depression or coping mechanisms may play mechanisms may play an important role in the an important role in the perception of dyspnea perception of dyspnea in women. in women. Torres JP et al. Gender and respiratory factors associated with dyspnea in chronic obstructive pulmonary disease. Respir Res 2007, 8:18

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Dyspnea effects the patients quality of Dyspnea effects the patients quality of lifelife

Sometimes not notified by the patient Sometimes not notified by the patient and can be overlooked by the clinicianand can be overlooked by the clinician

Objective pulmonary measures like Objective pulmonary measures like FEV1, are not always correlated to the FEV1, are not always correlated to the patients perception of symptoms and patients perception of symptoms and quality of life.quality of life.

Dyspnea is one of the major factors of Dyspnea is one of the major factors of dysability in COPD. dysability in COPD.

Ries AL. Am J Med 2006; 119 (10A), S12-20.

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Health status and dyspnea Health status and dyspnea improves improves

Depression ve anxiety improvesDepression ve anxiety improves

Paz-Diaz H, Am J Phys Med Rehabil 2007;86:30–36.

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Outcome of pulmonary Outcome of pulmonary rehabilitation for COPDrehabilitation for COPD

Cochrane Library 2006, issue 3

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Pulmonary rehabilitation improves the symptom of dyspnea in patients with COPD

– Grade of recommendation, 1A

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CLINICAL IMPORTANCE OF CLINICAL IMPORTANCE OF DYSPNEA DYSPNEA

Dyspnea is a protective mechanism Dyspnea is a protective mechanism that leads to necessary modification that leads to necessary modification of behavior.of behavior.

There is no ‘dyspnea circuit’ that can There is no ‘dyspnea circuit’ that can be totally shut down. be totally shut down.

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RespiratoryMuscles

Load on respiratory muscles

Ventilatory derive

Motor and sensory cortex

DyspneaVentilory

insufficiency

Capacity of respiratory muscles

Brain stem

J. Moxham , ERS Course, 2005

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Respiratory muscles

Load on respiratory muscles

Increased ventilationAirways obstruction

Intrinsic PEEP

Ventilatory derive

Cotrext

DyspneaVentilatory

Insufficiency

Capacity of respiratory muscles

Hyperinflation with muscle shortening and abnormal geometry

LVRSRespiratory

muscle training

BroncodilatationOxygen

RehabilitationNIV

J. Moxham , ERS Course, 2005

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RESP.MUSCLEPUMP

CAPACITY LOAD

CNSDRIVESLEEP

VENTILATORYFAILURE

DYSPNEA – THE BALANCING ACT

R Sergysels, ERS School Course

2020

60504030

1020

0

0 5 3010 15 20 25

Inspiratory effor

(Pes%MIP)

Tidal volume (%VC)

COPDCOPD

CONTROLSCONTROLS

ElastiElastic andc andrreesistive loadsistive load Dy

spne

aDy

spne

a

G Scano, ERS Course, 2005

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Management of dyspneaManagement of dyspnea MedicationMedication O2 therapyO2 therapy Exercise training Exercise training Breathing techniquesBreathing techniques

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Dyspnea improvesDyspnea improves

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Goals of breathing Goals of breathing techniquestechniques

1.1. Improvement of ventilatory muscle Improvement of ventilatory muscle functionsfunctions

2.2. Improvement of thoracoabdominal Improvement of thoracoabdominal movement patternmovement pattern

3.3. Improvement of gas exchance Improvement of gas exchance 4.4. Reduction of dynamic hyperinflationReduction of dynamic hyperinflation

Gosselink R. Chron Respir Dis. 2004;1: 163-72

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Dyspnea

Exercise tolerance

QUALITY OF LIFE

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1. Improvement of ventilatory 1. Improvement of ventilatory muscle functionmuscle function

Leaning forwardLeaning forward Respiratory muscle trainingRespiratory muscle training

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In COPD the diaphragm is adapted against In COPD the diaphragm is adapted against increased chronic load and more resistant increased chronic load and more resistant to fatigue, can arise more power at to fatigue, can arise more power at equivalent lung volumes equivalent lung volumes

But ventilatory muscles are in a But ventilatory muscles are in a disadvantage due to hyperinflationdisadvantage due to hyperinflation

Inspite of all these adaptations, both Inspite of all these adaptations, both functional muscle power and endurance are functional muscle power and endurance are negatively effected negatively effected

The net effect is respiratory muscle The net effect is respiratory muscle insufficiency.insufficiency.

COPD and ventilatory COPD and ventilatory musclesmuscles

2727Golgi (muscle tension)

Airway resistance

Joint(Chest wall displacement)

Spindles

G Scano, ERS Course, 2005

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Leaning forwardsLeaning forwards

O'Neill S. Thorax 1983; 38: 595-600.

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Length-tension relationship in musclesLength-tension relationship in muscles When you lean forwards When you lean forwards

– Diaphragm lengthens and piston motion Diaphragm lengthens and piston motion increasesincreases

– Scalaneus and SCM muscle tension Scalaneus and SCM muscle tension diminishesdiminishes

– Movement of chest wall is more effectiveMovement of chest wall is more effective

Wheeled walkersWheeled walkers

R Sergysels, ERS School Course

Leaning forwards

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Ventilatory muscle trainingVentilatory muscle training Breathing against an inspiratory load Breathing against an inspiratory load

increases the maximum inspiratory increases the maximum inspiratory pressure and endurance capacity of pressure and endurance capacity of ventilatory muscles.ventilatory muscles.

In patients with inspiratory muscle In patients with inspiratory muscle dysfunctiondysfunction– Increases exercise capacityIncreases exercise capacity– Reduces dyspneaReduces dyspnea– Reduces nocturnal desaturationReduces nocturnal desaturation

ATS. Am J Respir Crit Care, 2006, (173) 1390

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Improvement of Improvement of thoracoabdominal movement thoracoabdominal movement

patternpattern

Diaphragmatic breathingDiaphragmatic breathing Pacing of activitiesPacing of activities

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Diaphragmatic Diaphragmatic breathingbreathing

Diaphragmatic breathing pulls the air Diaphragmatic breathing pulls the air to the lower lobes of the lungsto the lower lobes of the lungs

Tenses when you breathe inTenses when you breathe in Relaxes when you breathe out and Relaxes when you breathe out and

the air is expelled out with the spring the air is expelled out with the spring action of the ribsaction of the ribs

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May give rise to asyncronised and May give rise to asyncronised and paradoxical breathing patternparadoxical breathing pattern

Efficacy could not be proven in Efficacy could not be proven in RCTs.RCTs.

F. Gigliotti, ERS Course, 2005

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Pacing of activitiesPacing of activities perform leg exercise during the perform leg exercise during the

expiratory phase of respiration, expiratory phase of respiration, perform unsupported arm activities perform unsupported arm activities

during the inspiratory phase of the during the inspiratory phase of the cyclecycle

– individuals do report less breathlessness with the individuals do report less breathlessness with the alternate pacing, suggesting that the chest wall alternate pacing, suggesting that the chest wall muscles recruited by individuals during inspiration muscles recruited by individuals during inspiration are able to rest during the expiratory phase.are able to rest during the expiratory phase.

Breslin, E. H. Dyspnea-limited response in chronic obstructive pulmonary disease: Reduced unsupported arm activities.Rehabilitation Nursing, 1992; 17(1), 12-20.

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Pacing activitiesPacing activities Coordinating your activities with your Coordinating your activities with your

breathing pattern breathing pattern Count when you breathe in and out (3:6)Count when you breathe in and out (3:6)

Eg when climbing stairsEg when climbing stairs– Stop, breathe in through your noseStop, breathe in through your nose– Climb 4-5 steps while you breathe out with PLB Climb 4-5 steps while you breathe out with PLB – Inhale againInhale again– Climb the other steps while you breathe out Climb the other steps while you breathe out

with PLB …. with PLB ….

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Improvement of gas exchance Improvement of gas exchance and reduction of dynamic and reduction of dynamic hyperinflationhyperinflation

Relaxation trainingRelaxation training Pursed lip breathingPursed lip breathing Chest wall mobilisation techniquesChest wall mobilisation techniques

4040Thomas JR et al. Clinical management of dyspnoea. Lancet Oncol 2002;3:223-28

Sensory receptors:•medullary chemoreceptors•peripheral chemoreceptors (carotid and aortic bodies)•pulmonary vagal afferents (stretch receptors, irritant receptors and alveolar C fibers•peripheral mechanoreceptors in muscles, tendons and joints

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Dyspnea Dyspnea anxiety anxiety CNS input CNS input increases increases dyspnea increases dyspnea increases

These exercises should be a part of These exercises should be a part of daily routine in order to manage daily routine in order to manage dyspnea and control panic.dyspnea and control panic.

Relaxation trainigRelaxation trainig

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Relaxing shoulders & armsRelaxing shoulders & arms Rotate your shoulders in a circle a Rotate your shoulders in a circle a

few times, or shrug them up and few times, or shrug them up and down.down.

Practice relaxing your shoulders and Practice relaxing your shoulders and arms throughout the day.arms throughout the day.

Try to be aware of times when you Try to be aware of times when you are tense so that you can relax are tense so that you can relax before you become short of breath.before you become short of breath.

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Positive thinking and Positive thinking and vvisualization techniques to isualization techniques to

relaxrelax Find a comfortable position and take a few Find a comfortable position and take a few

controlled breaths.controlled breaths. Begin to imagine a setting that relaxes and Begin to imagine a setting that relaxes and

calms you – the setting can be anywhere or calms you – the setting can be anywhere or anything from watching the waves at the anything from watching the waves at the beach to relaxing in your bed at home.beach to relaxing in your bed at home.

Stay focused on the setting, breathe, and Stay focused on the setting, breathe, and relax your body.relax your body.

Feel the tension leave your body.Feel the tension leave your body.

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Relaxation trainigRelaxation trainig

Slowing down the Slowing down the respiratory rate may respiratory rate may prolong expirationprolong expiration

Heart rate, respiratory Heart rate, respiratory rate, anxiety and rate, anxiety and dyspnea scores dyspnea scores decrease with decrease with relaxation.relaxation.

Renfroe KL. Effect of progressive relaxation on dyspnea and stateof anxiety in patients with chronic obstructive pulmonary disease.Heart Lung 1988; 17: 408-13.

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PLBPLB•Easy to learn •Some patients perform PLB instinctively

•Can be used during any activity that induces dyspnea

Faling J, Clin Chest Med 1986

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PLBPLB

“Our aim is to exhale the dirty air that is trapped in the airways so that we can have space for the fresh air to enter our lungs’.

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Relax your neck and shouldersRelax your neck and shoulders Inhale through your nose slowly (Count up to Inhale through your nose slowly (Count up to

3)3) Exhale slowly, DO NOT PUSH Exhale slowly, DO NOT PUSH

– Your lips are like whistlingYour lips are like whistling– Like blowing out a hot soupLike blowing out a hot soup– Flame of a candle should flicker but should not Flame of a candle should flicker but should not

fade awayfade away– Exhale, twice the time that you inhaled (count up Exhale, twice the time that you inhaled (count up

to 6)to 6)

PLBPLB

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PLBPLB

•Slight obstruction to expiration flow at the mouth •Generates back pressure through the airways •Stenting effect to help prop open the airways•Assist expiration and lung emptying

•This mouth back pressure must be in the range of 5-10 cm water pressure

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Modified PLBModified PLB Gently press the center of your lips Gently press the center of your lips

with your fingerwith your finger Permit the air escape through both Permit the air escape through both

sides of your lipssides of your lips Your cheeks should be relaxedYour cheeks should be relaxed

This method decreases the risk of This method decreases the risk of increased mouth back pressure.increased mouth back pressure.

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Pursed lip breathingPursed lip breathing

Garrod R. An evaluation of the acute impact of pursed lips breathing on walking distance in nonspontaneous pursed lips breathing chronic obstructive pulmonary disease patients. Chron Respir Dis 2005; 2:67-72.

Gosselink R. Breathing techniques in patients with chronic obstructive pulmonary disease (COPD). Chron Respir Dis 2004; 1: 163–172.

During 6MW, respiratory rate decreases with PLB.

PLB can increase tidal volume and decrease respiratory rate.

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Expiration is prolonged, and tidal Expiration is prolonged, and tidal volume generally increases with volume generally increases with modest transient improvements in modest transient improvements in gas exchange gas exchange

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Possible dyspnea-relieving Possible dyspnea-relieving factorsfactors

– altered breathing pattern (slower and deeper)altered breathing pattern (slower and deeper)– improved ventilation-perfusion relationships,improved ventilation-perfusion relationships,– improved arterial oxygen desaturation and CO2 improved arterial oxygen desaturation and CO2

elimination, elimination, – altered pattern of ventilatory muscle altered pattern of ventilatory muscle

recruitment, which may optimize diaphragmatic recruitment, which may optimize diaphragmatic length and assist inspiration, length and assist inspiration,

– reduced lung hyperinflation as a result of reduced lung hyperinflation as a result of reduced breathing frequency and prolongationreduced breathing frequency and prolongation

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DYSPNEA DURING ACTIVITYDYSPNEA DURING ACTIVITY Do Not panicDo Not panic Stop the activityStop the activity Lean forward, place your arms, think Lean forward, place your arms, think

about relaxing your arms, shoulders about relaxing your arms, shoulders Exhale twice the time you inhale with Exhale twice the time you inhale with

PLBPLB Stay in this position until you control Stay in this position until you control

your breathing. your breathing.

5454Christenbery TL. Heart Lung 2005;34:406-14

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Supervised exercise training in a Supervised exercise training in a structured pulmonary rehabilitation structured pulmonary rehabilitation program is the gold standart. program is the gold standart.

For patients that cannot attend the For patients that cannot attend the standart program; education, daily standart program; education, daily home exercises, and telephone home exercises, and telephone contact two times a week can contact two times a week can improve dyspnea and quality of life.improve dyspnea and quality of life.

Kohlman-Carrieri V. J Cardiopulm Reh. 2005; 25: 275-284.

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Improvement in quadriceps strength and dyspnea in daily tasks after 1 month of electrical stimulation in severely deconditioned and malnourished COPD.

Vivodtzev I. Chest 2006; 129(6): 1540-8.

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NMES can be offered as an adjunctive therapy in patients with severe muscle deconditioning.

ATS. Am J Respir Crit Care, 2006, (173) 1390

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Activities of daily Activities of daily livingliving D

ispne

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Tarih:Tarih:1.Oturarak1.Oturarak2.Oturarak: elleri ters-ön 2.Oturarak: elleri ters-ön yararakyararak3.Oturarak: parmakları sayarak3.Oturarak: parmakları sayarak4.Otur/kalk4.Otur/kalk5.Oturarak: şap şap oyunu5.Oturarak: şap şap oyunu6.Oturarak: çapraz dize şaplat6.Oturarak: çapraz dize şaplat7.Oturarak: omuzlara çapraz 7.Oturarak: omuzlara çapraz şaplatşaplat8.Tek ayak üzerinde ayakta dur.8.Tek ayak üzerinde ayakta dur.9.Ayakta, bir yere tutunarak, 9.Ayakta, bir yere tutunarak, dizleri sağa sola götürdizleri sağa sola götür10.Oturarak yere top at10.Oturarak yere top at

Solunum frekansı

.

6060

Günlük Yaşam Aktiviteleri Çemberi Hastanın Adı Soyadı:Fizyoterapist:20 dakika içinde 6 aktiviteyi sıra ile yapabilecekleri kadar tekrar ederler, hedef 20 dakikanın en etkin şekilde kullanılmasıdır. Her aktivitenin tekrar sayısı not edilir

Tarih: Tarih: Ellerde birer kg’lık ağırlık taşı Ellerde birer kg’lık ağırlık taşı Bir kg’lık ağırlığı sedyenin bir Bir kg’lık ağırlığı sedyenin bir tarafından diğer tarafına taşıtarafından diğer tarafına taşıBir iki basamak merdiven in çıkBir iki basamak merdiven in çıkHulahup içine gir çıkHulahup içine gir çıkMutfak dolabına 5 bardak yerleştir/ Mutfak dolabına 5 bardak yerleştir/ kapağı kapat/ tezgaha koy/kapağı kapat/ tezgaha koy/Bir sandalyeden kalk 5m uzaktaki Bir sandalyeden kalk 5m uzaktaki sandalyeye otursandalyeye otur

Kalan dakika:Kalan dakika:

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Solunum frekansıSolunum frekansı

6262


6363


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Günlük Yaşam Aktiviteleri Çemberi Hastanın Adı Soyadı:Fizyoterapist:20 dakika içinde 6 aktiviteyi sıra ile yapabilecekleri kadar tekrar ederler, hedef 20 dakikanın en etkin şekilde kullanılmasıdır. Her aktivitenin tekrar sayısı not edilir

Tarih: Tarih: Yat / ayağa kalk Yat / ayağa kalk Sandalye taşıSandalye taşıSedyenin üzerinden diğer tarafa geçSedyenin üzerinden diğer tarafa geçİki ağırlığı mutfak rafına koyİki ağırlığı mutfak rafına koyiki yükü eline al, dizlerde iki yükü eline al, dizlerde emekleyerek taşıemekleyerek taşıİp atlaİp atla

Kalan dakika:Kalan dakika:

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Change in lifestyleChange in lifestyle

Continuation of exercisesContinuation of exercises– Level of educationLevel of education– Previous exercise behavioursPrevious exercise behaviours

girişimbilgi

yetenekleryeterlilik davranış

değişikliğiSağlık etkileri

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CONCLUSIONCONCLUSION Some adaptations develop Some adaptations develop

instinctly.instinctly. The effectivenes of PLB, leaning The effectivenes of PLB, leaning

forwards and inspiratory muscle forwards and inspiratory muscle training has been shown.training has been shown.

Self management will improve with Self management will improve with the usage of learned techniques in the usage of learned techniques in daily routine.daily routine.

THANK YOU THANK YOU FOR YOUR FOR YOUR ATTENTIONATTENTION

With RespectWith Respect

dyspnea and pulmonary rehabilitation applications

Documents

patients dyspnea

perception of dyspnea

symptom of dyspnea

dyspnea effects

j respir crit care

distinct sensations

environmental factors

respiratory factors