Physiotherapy management for Bronchial Asthma

Physiotherapy management for Bronchial Asthma 

Are you suffering from following things-

Tightness of Chest, discomfort of breathing duringmidnight or Early morning, stop the breathing (suddenly), Breathing stress (duringemotional conditions), lack of breath, Anxiety,Recurrent respiratory infections in environment changes, Cough, Cold extremity,people not able to speak full sentence,take precautions it may be a sign of asthma attack.

Bronchial asthma is a disease of the upper respiratory tract, our upper respiratory tract produce symptoms lsuch as shortness of breath in midnight wheez and cough periodically with change the environment.

It is termed as a reversible condition of upper respiratory tract of bronchus  associated with inflammation of airway, reversible changes in smooth muscle of bronchioles with hyper-responsiveness.

Due to inflammation of the mucosa, spasm of bronchial smooth muscle and over production of mucus reduce the diameter of upper respiratory tract with occlusion and narrowing.

It is mainly three types

•          Intrinsic
•       Extrinsic
•      Mixed

Common features of two major types of asthma
Features	Intrinsic	Extrinsic
Age	In adult	In child hood
Personal/Family history	Absent	Commonly present
Preceding allergic illness	Absent	Present
Allergens	None	present
Drug hypersensitivity	Present (usually aspirin)	None
Serum IgG levels	Normal	Elevated
Associated chronic bronchitis, nasal Polyps	Present	Absent
Emphysema	Common	Unusual

It is included in chronic obstructive disease because it produce COPD like symptoms.

What is the prevalence of asthma?

According to National Center for Health Statics and Center for Disease Control and Prevention it is in United States has increased from 7.3% to 8.4% in 2010. About 1 in 11 children and 1 in 12 adults suffered from asthmatic conditions. It is approximate 27.7 million people in United States suffered from this condition. According to WHO about 235 million people worldwide suffering from asthma.

What is the frequency of asthma attack symptoms?

Frequency	sever controlled	Sever uncontrolled
More then once a day	18%	55%
once a day	8%	15%
More than 2 times per week, but not daily	27%	22%
2 or less times per week, but not daily	36%	8%
Rarely	11%	0%

What are the risk Factors for Asthma?

Environmental Factor

•      Allergies from – fumes, cold air, dust and other product.

•      Upper respiratory tract infection with Bacteria, virus and fungal infection).

•      Smoking and tobacco chewing.

•      Occupational pollutants-eg. Sugar cane factory workers, formers.

•      Drugs (NASAID, Aspirin and B-Blockers).

•      Asthma attack during exercise (exercise induce asthma).

•      Asthma attack during Anxiety or in Emotional condition.

•      Idiopathic or related with autoimmune condition.

     Host Factor

•      Genetically inherited asthma attack

•      Asthma attack produce during obesity

•      Sex or Gender

It is 2 times more common in boys before 14 years and in adults it is more common in women.

      What are the pathological changes in asthma?

       Following changes occurs in upper respiratory tract in asthma

• Respiratory tract is hyper responsive may produces inflammation and increase production of mucus in excess amount within the airway. It may be normal or degenerated.
• Inflammation and hyper responsive of airway and increase amount of mucus production produced by some infections or allergens within the respiratory tract.
• Increase thickening of bronchial basement membrane because changes of epithelium and form twist strips due to collection of eosinophils in sputum.
• After collection of lymphocytes, eosinophils and plasma cells it may produce hypertrophy of submucosal glands and submucosal edema.

         

        Whatare the sing and symptoms of asthma?

         It is an obstructive pathology may produce following sing and symptoms

• Shortness of breath in midnight
• Feeling of anxiety
• Cyanosis may be present because of hypoxia due to lack of oxygen
• Cold extremity
• Usually wheez Crepitus/Crackles type of abnormal sounds are present
• Cough is more common sign in asthma patients
• Patient not able to speak full sentence
• Pulsus paradox changes in breathing pattern in severe cases
• Barrel shape chest deformity because increase anterior posterior diameter
• Present tripod sign in sever cases
• Hyper resonant percussion note are present
• Decrease tactile vocal fremitus with diminish breath sound
•  I: E ratio it will be changed >1:3

            What are the diagnostic test for asthmaattack?

           Global initiative for asthma (GINA) provides general guideline to help in the                 clinical diagnosis of asthma, which are based on patient’s symptoms and                       medical  history. 

           These are includes wheezing and history of following-

•         Recurrent tightness of chest in patients
•         Recurrent difficult of breathing in patients  
•         Recurrent cough in patients
•         Recurrent wheez type of abnormal sound

            Following tests are used to diagnose the asthma attack

            Pulmonary Function Test

            This test measure the variability of airflow limitation, severity, reversibility

         Criteriato diagnose asthma

           Following findings suggest it may be asthma

•   FEV1 =increase FEV1 of 12% (<200ml) after bronchodilator use  suggest    asthma attack
•    FEV1/FVC ratio = < 0.75 to 0.85
•    PEFR =60 L/m > =10-20%

         Pulmonary Function Test Findings

           Moderate To Severe Asthmatic Episode

            (Obstructive Lung Pathology)

           Forced Expiratory Volume and Flow Rate Findings

           FVC               FEV1            FEV1/FV Ratio                     FEF25%-75%

            ↓                       ↓                         ↓                                           ↓

          FEF50%         FEF200-1200           PEFR                            MVV

             ↓                       ↓                             ↓                                      ↓

            Lung Volume and lung Capacity Findings

            IRV                      ERV                        VT                              RV

          ↓or Normal       ↓ or Normal             ↑or Normal                       ↑

            VC                   IC                  FRC                  TLC                 RV/TLC Ratio

              ↓               ↓or Normal           ↑                 ↑ or Normal             ↑or Normal

       Note-FVC-forced vital capacity, FEV1-force expiratory volume in one second,           FEV1/FVC ratio-Ratio of FVC and FEV1, FEF-force expiratory flow 25%-75%,           PEFR-peak expiratory flow rate, MVV-maximum voluntary ventilation, VT-Tidal         volume, IRV-inspiratory reserve volume, ERV- expiratory reserve volume,                     Residual volume,VC-vital capacity, IC-inspiratory capacity, 

     FRC-functional residual capacity, TLC-total lung capacity.

      Arterial Blood Gases Analysis

      Mild to Moderate Asthmatic Episode

      Acute Alveolar Hyperventilation with Hypoxemia

(Acute Respiratory Alkalosis)

           pH           PaCO2         HCO3 −              PaO2           SaO2 or SpO2                               

            ↑                  ↓                ↓                  Normal  ↓                        ↓

                                   

                  

                    Severe Asthmatic Episode (Status Asthmatics)

                     Acute Ventilatory Failure with Hypoxemia

                       (Acute Respiratory Acidosis)

        

              pH           PaCO2               HCO3 −            PaO2     SaO2 or SpO2                                

               ↓                   ↑                         ↑                  ↓                   ↓

             Other diagnostic test

               Measure PEFR with peak flow meter

               Radiological findings-

                   (during asthmatic episode)

•  Shape chest-increase anterior/posterior diameter
•  Translucent lung field (dark)
•  Depressed or flattened diaphragm.

              Differential/Diagnosis

•   COPD
•  Tropical eosinophilia          
•   Obstruction of upper respiratory tract
•   Allergic lung disease other than asthma

             Management

•  Medical
•  Surgical
•   Physiotherapy

             Medical management-

             National asthma education and prevention plan (NAEPP) and 

            (GINA)  Global initiative for asthma provide evidence based  guideline for                 asthma management.

           The primary goals of asthma management are-

•   Attain and maintain control of clinical manifestations associated with     asthma.
•   Maintain normal activity level, including exercise'
•    Normalize or maintain respiratory functions as possible    
•   Prevent asthma exarvation
•    Avoid adverse effects from asthma medication
•    Prevent asthma mortality

   GINA provides followingfive components-

    Component 1: Develop patients/doctor partnership

    Component 2: Reduce and identify exposure to risk  factors

    Component 3: Assess, treat and monitor asthma

    Component 4: Manage asthma exacerbation

    Component 5: Special considerations eg. Pregnancy, obesity, surgery and others.

    Medical intervention to manage asthma-

• Mechanical ventilation noninvasive or invasive (if  required)
• Oxygen therapy protocol (if needed)
• Nebulization therapy protocal
• Following Drugs are used to maintain patients
• LABAs (long acting Beta2 agents)
• Inhaled corticosteroids
• Combination of Beta2 agents and corticosteroids
• Leukotriene inhibitors
• Xanthine derivatives
• SABAs (short acting Beta2 agents
• Ultra-short acting bronchodilators

      Surgical intervention to manage asthma-

        Bronchial thermosplasty

     Physiotherapy intervention for asthma management

      Goals for physiotherapy management-

            Shortterm Goals

•      Prevent intubation
•      Prevent mechanical ventilation invasive or noninvasive both
•      Reduce dyspnea
•      Facilitation mucociliary transport
•      Optimize secretion transport
•      Optimize alveolar ventilation
•      Decrease work of breathing
•      Normalize respiratory rate
•      Decrease work of heart

       

          long term goals

• Increase endurance, strength and power of respiratory muscles 
• Maximize aerobic capacity and oxygen transport
• Increase lung volume and lung capacity
• Optimize general muscle strength, endurance and power and oxygen level
• Design comprehensive lifelong rehabilitation protocol with patients

            Physiotherapy management in patient phase 

          A. IN EARLY STAGES –

          1. Patient education program

               -Education about disease prevention and control,

               -Explain about effect of smoking and weight reduction,

               -Explain about dyspnea reliving position during sudden asthma attack

               -Upper chest inhibition techniques.

          2. Pursed lip Breathing Exercises-

              Due to effect of positive pressure on respiratory    tract reduce narrowing of                  airway may produce relief to the patient.

          3. Upright positioning-

              During this position downward sifting of abdominal viscera increase                              efficiency or activation of diaphragm muscle and changes the diameter of                      airway may increase Tidal volume, and normalize respiratory rate improve                    ventilation perfusion.

          4. Expiratory exercises-

              Provide more repetition of expiratory exercise (10 R) compare to inspiratory                  exercise (5 R) may reduce air trapping in the lungs.

          

          5. Deep Breathing Exercises-

              Improve function of diaphragm and ventilation perfusion.

        B. Increase inspiratory and expiratory muscle training-

              Increase inspiratory and expiratory muscle endurance, strength and power                      with IMT (inspiratory muscle training) device.

          C. CHRONIC STAGES-

           1. Facilitation secretion –Huffing/Coughing, assisted coughing active or                             passive  techniques.

           2. Airway clearance techniques –Active cycle of breathing technique                               (ACBT), Autogenic drainage (AD), Postural drainage (PD) with percussion,                 vibration, shaking techniques.

           3. Facilitation ventilation patterns –Breath hold techniques, Incentive                             spirometer, diaphragmatic facilitation techniques can be use for better results.

               

            

         Physiotherapy management in out patints phase

         Exercise testing for bronchial asthma patients

• Screening of physiological functions should be necessary before and after exercise eg. SpO2, PFT, BP Cardiopulmonary Capacity with noninvasive method.
• The mode of exercise testing it should be treadmill or Cycle ergometer with standard progressive maximal testing protocol with appropriate age group child, adult, older adult. 
• To prevent exercise induced bronchoconstriction bronchodilator should be used to assess optimal cardiopulmonary capacity and vigorous intensity exercise (HR max or 40%-60%) lasting 4-6 min on treadmill or cycle ergometer.
• When Saturation of the SpO2 is decrease ≤ 80% it should be use as a termination criteria.
• To measure exertional dyspnea Borg CR 10 scale should be use and instructed to the patient for dyspnea and discomfort during the exercise testing session. 6 min walk test may be used in patients with moderate to sever persistent asthma.

        Main components are used for exercise training session:

       Warm-up: Cardiorespiratory and muscular endurance activities (light-to-moderate             intensity) at least 5–10 min.

       Conditioning: Aerobic, resistance, neuromotor, and/ or sports activities at least 20–           60 min/day with bouts according to individuals.

       Cool-down: cardiorespiratory and muscular endurance activities at least 5–10 min              with light-to-moderate intensity.

      Stretching: After the warm-up or cool down phase at least 10 min of stretching                  exercises needed.

      Frequency: 2-3 d/wk.

      Intensity: approximately at the ventilatory anaerobic threshold or at least 60% VO2          peak decide to progressive exercise testing with expired gases measurement or 80%            of walking speed decided from 6 min walk test with RPE (rating of perceived                      exertion) 11-13 on a 6-20 scale.

     Time: It shoud be at leatst 20-30 min/day.

     Type: It includes aerobic activity using large muscle groups in a rhythmic and                     continuous fashion eg. Walking, running, treadmill, cycle ergometer, swimming.

     Progression: After the first month if exercise prescription is well tolerated by the               individual  progression should be needed approximately 70% VO2 peak  and the                 frequency to 5 d/wk with each exercise session to 40 min /d.

     

     Resistance Exercise Training

    (Resistance exercise training, flexibility training and neuromotor training should follow      the same principle of exercise testing and prescription for healthy individuals)

    

     FITT-VP

     

     Frequency-Each major muscle group should be trained on 2–3 d/wk.

      

     Intensity-

•   60%–70% 1-RM (moderate-to-vigorous intensity) to improve strength.
•   >=80% 1-RM (vigorous-to-very vigorous intensity) for experienced strength trainers to improve strength.
• 40%–50% RM (very light-to-light intensity) for older individuals to improve strength in beginning of resistance exercise.
• 40%–50% 1-RM (very light-to-light intensity) may be beneficial for sedentary individuals to improve strength.
• <50% 1-RM (light-to-moderate intensity) to improve muscular endurance.
•  20%–50% 1-RM in older adults to improve power.

     Time: No specific duration known for effectiveness.

    

     Type: It should be involve each major muscle group with multi joint or single joint             exercises affecting more than one muscle group and targeting agonist and antagonist           muscle groups are recommended for all adults.

     

     Repetitions:

·                   8–12 repetitions is required to improve strength and power in most adults.

·                  10–15 repetitions is required to improve strength in middle-aged and older individuals.

·                  15–20 repetitions are recommended to improve muscular endurance.

     

     Sets:

·                  2–4 sets are required to improve strength and power for most adults.

·                 A single set is effective especially among older people.

·                  2 sets are effective to increase muscular endurance.

    

     Pattern:

·                   2–3 min rest intervals between each set of repetitions more effective.

·                  A rest of >=48 h between sessions for any single muscle group is suggested.

      

     Progression: A gradual progression of greater resistance, repetitions per set, or                   increasing frequency is suggested.

     

      

     Flexibility Training

     FITT-VP

     Frequency: It should be >=2–3d/wk.

      

     Intensity: Stretch the large group of muscle up to feeling of discomfort or tightness.

     

     Time: Holding a static stretch for 10–30s is recommended for most adults and 30–60s       for older individuals but it must be changed with stretching techniques.

     

     Type: It may be Static flexibility (i.e., active or passive), dynamic flexibility, ballistic         flexibility, and PNF.

     

    Volume: It should be 60 s of total stretching time for each flexibility exercise.

    

      Pattern:

·                To produce more effect of stretching it may require warm up with actively or passively       through light-to-moderate aerobic activity or application of externally moist heat packs       respectively.

·                  2–4 times repetition is recommended.

     

     Progression:

     Unknown

   Resourse:

   1.Kasper, Fouci et al;Harrisons principal of internal medicine              19th edition.
    2.Nicki R. Colledge,Brian R.walker, Stuart H.Raistone et al;               Devidsons principles and practice of medicine. 21th                         edition.
    3.Terry des Jardins, George G.Burtonet et al;Clinical                           menifestation and assessment of respiratory diseases;
       7th edition.
    4.Linda s., Ross Arena,Deborah Riebe et al;ACSM Guidline for          Exercise testing and priscripyion 9th edition 2014.
    5.Donna frowenfelter,elizabeth Dean et al;Cardiovascular and             pulmonary physical therapy;5th edition 2016.
    6.Robert M kacmarek, Jamesh k. stoller, Albert J Heuer;Egans           fundamental of respiratory care; 11th edition.