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  1. DYSPNEA AND PULMONARY REHABILITATION APPLICATIONS Rengin Güzel MD Cukurova University Medical Faculty Dep of Physical Medicine and Rehabilitation

  2. PLAN • Definition • Dyspnea and quality of life • Techniques • Leaning forwards • Inspiratory muscle training • Diaphragmatic breathing • Relaxation • Pursed lip breathing • Self management strategies • Activities of daily living

  3. Dispne • Subjective experience of breathing discomfort, American Thoracic Society. Am J Respir Crit Care Med. 1999;159:321–340.

  4. Dispne • Subjective experience of breathing discomfort that is comprised of qualitatively distinct sensations that vary in intensity. American Thoracic Society. Am J Respir Crit Care Med. 1999;159:321–340.

  5. Dispne • Subjective experience of breathing discomfort that is comprised of qualitatively distinct sensations that vary in intensity. • The experience derives from interactions among multiple physiological, psychological, social and environmental factors, American Thoracic Society. Am J Respir Crit Care Med. 1999;159:321–340.

  6. Dispne • Subjective experience of breathing discomfort that is comprised of qualitatively distinct sensations that vary in intensity. • The experience derives from interactions among multiple physiological, psychological, social and environmental factors, and may induce secondary physiological and behavioral responses American Thoracic Society. Am J Respir Crit Care Med. 1999;159:321–340.

  7. Dispne • Subjective experience of breathing discomfort that is comprised of qualitatively distinct sensations that vary in intensity. • The experience derives from interactions among multiple physiological, psychological, social and environmental factors, and may induce secondary physiological and behavioral responses American Thoracic Society. Am J Respir Crit Care Med. 1999;159:321–340.

  8. Dispne • There is no objective physiological measure • Rather than measure everything thatcan be measured physiologically aboutthe respiratory system and then correlate these data with the patient’sdyspnea, we must look at the sensationsthemselves and the subject’s reactionto the sensations Julius Comroe 1966

  9. FEV1 % matched population of 100 men and women with COPD Women expressed more dyspnea than men for the same degree of airway obstruction Perhaps non respiratory factors such as anxiety, depression or coping mechanisms may play an important role in the perception of dyspnea in women. Gender factor Torres JP et al. Gender and respiratory factors associated with dyspnea in chronic obstructive pulmonary disease. Respir Res 2007, 8:18

  10. Dyspnea effects the patients quality of life • Sometimes not notified by the patient and can be overlooked by the clinician • Objective pulmonary measures like FEV1, are not always correlated to the patients perception of symptoms and quality of life. • Dyspnea is one of the major factors of dysability in COPD. Ries AL. Am J Med 2006; 119 (10A), S12-20.

  11. Health status and dyspnea improves • Depression ve anxiety improves Paz-Diaz H, Am J Phys Med Rehabil 2007;86:30–36.

  12. Outcome of pulmonary rehabilitation for COPD Cochrane Library 2006, issue 3

  13. Pulmonary rehabilitation improves the symptom of dyspnea in patients with COPD • Grade of recommendation, 1A

  14. CLINICAL IMPORTANCE OF DYSPNEA • Dyspnea is a protective mechanism that leads to necessary modification of behavior. • There is no ‘dyspnea circuit’ that can be totally shut down.

  15. Motor and sensory cortex Brain stem Ventilatory derive Capacity of respiratory muscles Load on respiratory muscles Respiratory Muscles Dyspnea Ventilory insufficiency J. Moxham , ERS Course, 2005

  16. LVRS Respiratory muscle training Cotrext Broncodilatation Oxygen Rehabilitation NIV Ventilatory derive Capacity of respiratory muscles Respiratory muscles Load on respiratory muscles Hyperinflation with muscle shortening and abnormal geometry Increased ventilation Airways obstruction Intrinsic PEEP Dyspnea Ventilatory Insufficiency J. Moxham , ERS Course, 2005

  17. DYSPNEA – THE BALANCING ACT SLEEP CNS DRIVE RESP. MUSCLE PUMP CAPACITY LOAD VENTILATORY FAILURE R Sergysels, ERS School Course

  18. 60 50 40 30 20 10 0 0 5 10 15 20 25 30 COPD Dyspnea Elastic and resistive load Inspiratory effor (Pes%MIP) CONTROLS Tidal volume (%VC) G Scano, ERS Course, 2005

  19. Management of dyspnea • Medication • O2 therapy • Exercise training • Breathing techniques

  20. Dyspnea improves

  21. Goals of breathing techniques • Improvement of ventilatory muscle functions • Improvement of thoracoabdominal movement pattern • Improvement of gas exchance • Reduction of dynamic hyperinflation Gosselink R. Chron Respir Dis. 2004;1: 163-72

  22. Dyspnea Exercise tolerance QUALITY OF LIFE

  23. 1. Improvement of ventilatory muscle function • Leaning forward • Respiratory muscle training

  24. COPD and ventilatory muscles • In COPD the diaphragm is adapted against increased chronic load and more resistant to fatigue, can arise more power at equivalent lung volumes • But ventilatory muscles are in a disadvantage due to hyperinflation • Inspite of all these adaptations, both functional muscle power and endurance are negatively effected • The net effect is respiratory muscle insufficiency.

  25. Joint (Chest wall displacement) Airway resistance Spindles (muscle tension) Golgi G Scano, ERS Course, 2005

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

  27. Leaning forwards • Length-tension relationship in muscles • When you lean forwards • Diaphragm lengthens and piston motion increases • Scalaneus and SCM muscle tension diminishes • Movement of chest wall is more effective • Wheeled walkers R Sergysels, ERS School Course

  28. Ventilatory muscle training • Breathing against an inspiratory load increases the maximum inspiratory pressure and endurance capacity of ventilatory muscles. • In patients with inspiratory muscle dysfunction • Increases exercise capacity • Reduces dyspnea • Reduces nocturnal desaturation ATS. Am J Respir Crit Care, 2006, (173) 1390

  29. Goals of breathing techniques • Improvement of ventilatory muscle functions • Improvement of thoracoabdominal movement pattern • Improvement of gas exchance • Reduction of dynamic hyperinflation Gosselink R. Chron Respir Dis. 2004;1: 163-72

  30. Improvement of thoracoabdominal movement pattern • Diaphragmatic breathing • Pacing of activities

  31. Diaphragmatic breathing • Diaphragmatic breathing pulls the air to the lower lobes of the lungs • Tenses when you breathe in • Relaxes when you breathe out and the air is expelled out with the spring action of the ribs

  32. May give rise to asyncronised and paradoxical breathing pattern • Efficacy could not be proven in RCTs. F. Gigliotti, ERS Course, 2005

  33. Pacing of activities • perform leg exercise during the expiratory phase of respiration, • perform unsupported arm activities during the inspiratory phase of the cycle • individuals do report less breathlessness with the alternate pacing, suggesting that the chest wall muscles recruited by individuals during inspiration 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.

  34. Pacing activities • Coordinating your activities with your breathing pattern • Count when you breathe in and out (3:6) • Eg when climbing stairs • Stop, breathe in through your nose • Climb 4-5 steps while you breathe out with PLB • Inhale again • Climb the other steps while you breathe out with PLB ….

  35. Goals of breathing techniques • Improvement of ventilatory muscle functions • Improvement of thoracoabdominal movement pattern • Improvement of gas exchance • Reduction of dynamic hyperinflation Gosselink R. Chron Respir Dis. 2004;1: 163-72

  36. Improvement of gas exchance and reduction of dynamic hyperinflation • Relaxation training • Pursed lip breathing • Chest wall mobilisation techniques

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

  38. Relaxation trainig Dyspnea  anxiety  CNS input increases  dyspnea increases These exercises should be a part of daily routine in order to manage dyspnea and control panic.

  39. Relaxing shoulders & arms • Rotate your shoulders in a circle a few times, or shrug them up and down. • Practice relaxing your shoulders and arms throughout the day. • Try to be aware of times when you are tense so that you can relax before you become short of breath.

  40. Positive thinking and visualization techniques to relax • Find a comfortable position and take a few controlled breaths. • Begin to imagine a setting that relaxes and calms you – the setting can be anywhere or anything from watching the waves at the beach to relaxing in your bed at home. • Stay focused on the setting, breathe, and relax your body. • Feel the tension leave your body.

  41. Relaxation trainig • Slowing down the respiratory rate may prolong expiration • Heart rate, respiratory rate, anxiety and dyspnea scores decrease with relaxation. Renfroe KL. Effect of progressive relaxation on dyspnea and state of anxiety in patients with chronic obstructive pulmonary disease. Heart Lung 1988; 17: 408-13.

  42. PLB • Easy to learn • Some patients perform PLB instinctively • Can be used during any activity that induces dyspnea Faling J, Clin Chest Med 1986

  43. PLB “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’.

  44. PLB • Relax your neck and shoulders • Inhale through your nose slowly (Count up to 3) • Exhale slowly, DO NOT PUSH • Your lips are like whistling • Like blowing out a hot soup • Flame of a candle should flicker but should not fade away • Exhale, twice the time that you inhaled (count up to 6)

  45. PLB • 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

  46. Modified PLB • Gently press the center of your lips with your finger • Permit the air escape through both sides of your lips • Your cheeks should be relaxed • This method decreases the risk of increased mouth back pressure.

  47. Pursed lip breathing During 6MW, respiratory rate decreases with PLB. 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. PLB can increase tidal volume and decrease respiratory rate. Gosselink R. Breathing techniques in patients with chronic obstructive pulmonary disease (COPD). Chron Respir Dis 2004; 1: 163–172.