Cardiorespiratory fitness

Physiotherapy management for B ronchial 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.

Cardiorespiratory fitness

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Physiotherapy management for Bronchial Asthma