Case study in respiratory physiotherapy

Case study – Bronchiectasis out-patient

Not about the disease:

Bronchitis is an inflammation or swelling of the bronchi. Bronchi are the passageways that
move air into the lungs. When these passageways are swollen and inflamed, it makes getting
air into the lungs difficult and can cause difficulty breathing. Bronchitis is always associated
with a cough that produces mucus. There are two types of bronchitis: acute and chronic.

Acute bronchitis happens after being sick with a virus or cold. The illness will start in the
nose and travel to the throat and eventually land in the lungs in the form of bronchitis. People
can feel very sick with bronchitis, but it usually is not serious and they eventually return to
their normal health.

Chronic bronchitis is a long-term illness. It is diagnosed in individuals who have a

productive cough (a cough with mucus) for more than three months. This form of bronchitis is
often found in people who have smoked and have COPD (chronic obstructive pulmonary
disease). It is the more serious bronchitis that can lead

Subjective assessment

PC 53-year old female

Attending routine multidiciplinary bronchiectasis clinic apoiment

HPC Diagnosed 2 weeks ago with chronic bronchitis. Since diagnosis the
patient reports daily production of mucopurulent secretions with
excessive coughing and feelings of fatigue.

PMH Gastric oesophageal reflux

SH Married with two children, employed full time as a teacher,

normally leads an active lifestyle with two to three visits a
week to the gym, although this has decreased over the past
3/12 .Consumes alcohol occasionally, smokes up to 15
cigarettes/day, does not make excess food, consumes 2
cups of coffee/day.
Consultant
Handover Patient is currently stable but is concerned about the
impact of her cough and increased sputum on everyday
life, especially in relation to her work, where she frequently
does formal presentations

Objective assessment

Respiratory Ventilation

SV room air SpO2 99% RR 12

CXR
Bronchiectatic changes present in right lower lob
ABG
Not appropriate to be taken as stable

CVS Temp 37○C HR 85 BP 150/70

CNS Nil of note

Renal Nil of note

MSK Nil of note

Microbiology Staphylococcus aureus in sputum sample 2 weeks ago.

Patient position Sitting in chair

Observation Looks well, good colour, breathing pattern normal

Patient actively trying to suppress cough and noise of secretions

Ascultation Presence of bronchial rallies, inflamed and especially sibilant (wheezing)

Palpation Shows a diminished pectoral jerk

Percussion Hypersensitivity throughout the lung area

Patient testing:

1. Assessing the degree of dyspnea in the effort will be done through the anamnesis. This test
will be done as follows: ask the patient to climb 15-20 steps- the first grade dyspnea is
observed

2. Conversation and reading test: During conversation with the patient, it is carefully
observed how it breathes,I notice dyspnea and mild cyanosis in the skin and mucous
membranes. We ask the patient to read a hard-spoken text, asking her for a variety of
reading rhythms. After having been done several times, it has been found that the patient
breaks off, there is a slight fatigue, a heavy breathing.

3. The TV test: while the patient will watch a TV program , having the completely deviated
attention from his own respiration, he finds resting breathing which is altered, in a rhythm,
a tahipnee is observed.

4. Candle test: having some distance from the mouth, the sick hold a burning candle in which
it blows. The longer the distance decreases, the more obstructive the syndrome is. The
patient manages to turn off the candle at a distance of 45 cm.

5. The thoracic perimeter : with a centimeter band, the chest circumference is measured in
the inspiratory and maximal exhaled at the base of the thorax, in the middle and subaxilar.
The evolution of these measurements is an indirect appreciation of improvement in vital
capacity or improvement of untreated disease.

6. Apnea test: asks the patient for maximum inspiration to make an apnea as long as possible.
The more respiratory dysfunction is, the shorter the duration of apnea, and apnea at the
end of expiration will be almost impossible. Timed duration is 20 seconds.

Radiological Examination:

Lungs radiography:

- symmetrical thorax, left costodiafragmatic sinuses, relatively homogeneous indoor opacity .

Subcostal ¾ cm.

- drawing emphasized bilaterally

- high pulmonary hills bilateral

- heart button prominent

- heart leveled

Spirometry

Breathing on the spirometer - which is not only a tool for measuring the vital capacity and
progress achieved through respiratory gymnastics, but also a means of completing all the
other exercises performed by inspired and expired amplitude directed.

FVC . 2,02 4,21 48,0%

FEV1. 1,91 3,49 54,9%

- mixed ventilation dysfunction, medium shape.

It was followed by broad spectrum antibiotics, expectorants, bronchodilators,

antihistamines.

Evolution:

Favorable, with recommendations:

- to avoid cold and humidity,

- continue treatment according to the prescription.

In addition to medical treatment, the patient also benefits from physiotherapy. The patient
was presented in the physiotherapy cainet two weeks after diagnosis with the doctor's
recommendation. At the office, the patient is made by a physiotherapist who sets up a
recovery program to help improve health.

Functional diagnosis:

- respiratory dysfunction;
- decrease in oxygen capacity in breathing air;
- difficulty breathing, causing the degree I to occur when climbing stairs;
- altered heart muscle ( BP: 150/80mmHg);
- limiting movements to physical effort.

Treatment goals:

- improving respiratory circulation,

- bronchial disobstruction,
- reeducation of diaphragm and abdominal wall,
- decreasing BP within normal physiological limits for patient age,
 - improving ventilation by better coordination of the toraco-abdominal „motor pump”
through a good breathing muscle training,
- reducing the respiratory rate, while increasing the amplitude of respiratory
movements,
- enhancement of thoracic and diaphragm movements,
- adapting the body to physical effort.

Means and methods used:

From the beginning of the recovery program the patient is taught:

- to breathe through the nose and expire on the mouth,

- inspiration to be slow and deep
- the expiration time is twice bigger than the inspiration,
- we advise the patient to relax during the recovery program, thus reducing the
emotional state that contributes to diminishing or even eliminating bronchospasm,
dyspnoea and cough.
- throughout the program I communicate with the patient and explain each exercise in
part, I assure him that he understood, thus succeeding in terminating the patient 's
confidence. Recovery will be much faster and more efficient, the patient doing each
exercise with confidence that the disease will improve.

Exercises:

The initial gymnastics position is dorsally decubed. It recommends inspiration on the nose,
which prolonged breaths with pronouncing vocals and consonants.

To re- educate the diaphragm movements , breath exercises with abdominal weights, jerky
breathing, and diaphragm with closed glottis are used.

Mobilization of the chest is done by means of trunk exercises accompanied by swinging of

the arms in a standing and slanted position with twists and bends. Also, the flexion of the
spine in the lumbar region favors the mobilization of the chest.

These exercises can include light (alternate walking) outdoors, various sportswear elements
and sporting games, activities that improve overall work capacity and body calming.

Dynamic breathing: is that breathing intensified by increasing metabolic oxygen demand

and hence increased circulatory and respiratory function. This is done through exercises that
put into practice important muscle masses and increased rhythm of execution.

Static breathing: better known as respiratory gymnastics, is based on exercises that

influence, in particular, respiratory mechanics (chest and diaphragm). It consists of volitional,
extensive breaths, associated with trunk and limb movements. The purpose of tonifying
thoracic respiratory muscles, diaphragm and abdomen, as well as creating a correct
respiratory steriotype.

Educating the correct respiratory steriotype is achieved through breathing controlled largely
breathing is done with the bulging of the chest and abdomen by lowering the diaphragm and
pressing the viscera of the abdomen and the expiration by lowering the ribs and climbing the
diaphragm which results in a cheerful thorax and abdomen sucking.

Static breathing exercises ( posture ):

From the dorsal decubitus:

- with the head resting on a small pillow, the shoulders not on the pillow, or a roll in the
cervical area; with the trunk raised to 45 degrees, with the raised part of the bed;
- with upper limbs pressed a pillow to the abdomen;
- there is a pillow that can easily stretch the hips and knees under the thighs and knees,
the legs with your fingers up on a support , knees bent at 900 with the plants on the
bed, or g gouged bows at 600 in support of the pillow, the plants on the bed or with the
lower limbs in the "turkish" position.

From the lateral decubitus:

- he head: sits on a small pillow or a cervical scroll
- trunk: slightly horizontal (raised) or raised to 45 °, supported by pillows or lifting of
the distal part of the bed,
- upper limbs: abduction arms of 300 – 400, crossed forearms in the abdomen, bent,
press a pillow in the abdomen; or relaxed by the body; relaxed, or in abduction of 600
– 800.
- lower limbs: stretched one over the other; knees bent at 900, or knees bent at 600, her
hips and knees bent, or with the lower limbs one stretched and the other bent.

Sitting exercises:
a) Seated in bed:
- the head slightly flexed ; the trunk slightly flexed:
 upper limbs: with abduction arms of 30o - 40o, crossed forearms at the
level of the abdomen or flexed, press a pillow at the level abdomen, or
abducted and bent keep the knee.
 lower limbs: stretched, under the knee a pillow that lightly flexes the knees,
the legs with your fingers up, leans on a support, bent thighs, knees bent at
90o with plants on the bed; bent thighs, knees bent at 60o in support of a
 pillow, plants on the bed, or with lower limbs in the "turkey" position, or
with one hunched and the other bent.
b) Sitting at the edge of the bed:

- the head slightly flexed; the trunk is slightly kyphosis; upper limbs:

 arms abducted from 300 to 400, crossed forearms at the level of the
abdomen ;
 flexed , presses a pillow at the level of the abdomen;
 relaxed next to the body;
 arms abducted from 300 to 400 slightly flexed, hands on the thighs;
 abduction of the arms of 500 – 600, forearms on the thighs.

- lower limbs: flexed with soles on the ground.

c) Seated on a chair:

- the head in light flexion; the trunk supported by pillows, positioned between
the spine slightly curved and seat back; upper limbs :

 arms in abduction of 300 – 400 the hands are supported on the thighs;
 flexed , presses a pillow at the level of the abdomen;
 relaxed next to the body.

- lower limbs: flexed with soles on the ground.

d) Sitting on a chair with support on a table:

- the head slightly flexed; the trunk is slightly kyphosis; upper limbs:

 arms in abduction of 600 – 800, 900 flexed, crossed forearms on a pillow

on the support surface;
 arms in abduction of 600 – 800, flexed, a forearm on a pillow on the
support surface, the other supports the head;
 arms in abduction of 600-800, flexed , forearms on a pillow on the
supporting surface, support the head.

- lower limbs: flexed with soles on the ground.

Some of the variants I also mentioned:

 sitting on the bed or on the floor, the knees are flexed, the plants on the ground,
the arms hanging next to the body, the trunk slightly flexed;
 the Mohammedan position;
 sitting on the calves and soles, hands on the thighs, slightly flexed the trunk.
 e) From orthostatism:

- the head: straight or slightly flexed;

- the trunk:

 in ax, the spine right as extensive as possible, abdomen withdrawn to

the trunk and pelvis plane;
 bend.

- upper limbs:

 symmetrical hanging next to the body;

 hanging relaxed;
 abducted at 600-800 the hands support the thighs.

- lower limbs:

 Stretched out (knees stretched out). The center of gravity falls in the
middle of the leg's polygon. Everything as decontracted.
 Slightly flexed.

Dynamic exercises:

1. The patient's initial position is placed in dorsal decubitus. It is recommended to inspire

on the nose and then expire prolonged, with pronounced vocals and consonants.
(repeats 8-10 times)
2. In the same position, with the hands on the abdomen, breathing will be done at the
chest level, when the inspiration is performed, the hands will depart, and at the
moment of expiration the hands will approach, (repeat 8-10 times)
3. From the dorsal decubitus, the legs stretched out, hands next to the body: carrying
arms laterally above the head and distance the legs with inspiration, return with
expiration. (repeat 8-10 times)
4. From the dorsal decubitus, the knees bent, a weight on the abdomen (2-5 kg).
Inspiratory lifting the abdominal wall, expiring with decompression. To accentuate the
expiration, a lift of the knees at the chest is performed. (repeat 8-10 times)
5. From dorsal decubitus with the knees flexed , the trunk with inspiration rises, upper
limbs stretched forward go over knees, return with expiration. Exercise may be
aggravated if lifting of the chest is done with hands on the back of the neck. (repeat 8-
10 times)
6. From the same position it lift lower limbs with extended knees. ( repeat 8-10 times)
7. With his knees bent, the soles supported on the bed, the left arm on his right hip,
concomitant with the head and shoulders raised, with inspiration; then pushing the left
 arm obliquely upwards with the head twisting to the left with expiration (repeat 6-8
times).
8. From the same position: knees bent, soles on the ground, hands under the head ,
approaching the elbows of one another- expiration , bringing lateral elbows with the
feet slipping on the support plane - slow breathing. (repeat 8-10 times)
9. From dorsal decubitus: arms stretched up to raise the trunk to 90 degrees, bringing the
arms to the side, and exiting the legs with inspiration, returning with expiration.
(repeat 8-10 times).
10. From the same position: forced exhalation by physiotherapist pressing on the bent
knees, prolonged inspiration with upper arms and leg stretching, physical therapist
opposing resistance. (repeat 8-10 times)
11. From dorsal decubitus with a pillow to the level of the head, upper limbs next to trunk,
upper limb abduction with inspiration, return with expiration. In the same position
with trunk inclination. ( repeat 8-10 times)
12. From side to side, with a pillow under the base of the hemithorax, the inferior
homolateral limb semiflexed. Breathing in the abdomen. (repeat 8-10 times)
13. From the lateral decubitus, the lower limbs slightly flexed, the patient being relaxed: a
very rapid expiration is performed, pronouncing the letter "f". It is repeated several
times, the diaphragm rises rapidly while the chest is concentrically closed by
contracting the oblique muscles . There is a deep inspiration followed by two quick
exits: the first, short, and the longer. Repeat several times.
14. Inspired inspiration for toning the diaphragm is done by pronouncing a "sucked", "s",
with the tongue on the upper teeths, placing a finger between the lips open or
breathing on a nostril, the other being brushed with a finger. Repeat several times.
15. From lateral decubitus: with a pillow under the lower back or the head left below to
open the hemithorax. Inspired, the extended arm is rooted with the trunk to the back,
eyes and head watching the movement of the hand. At the expiration, the arm returns
to the trunk, then continues its race beyond the edge of the bed, while the trunk rotates
to the edge of the bed. Repeat several times.
16. From the ventral decubitus, the abdomen on a pillow; a weight (2-9 kg) is placed on
the chest. Breathing abdominal type. ( Repeat 8-10 times)
17. From sitting: his hands rest on his thighs. In inspiration the arm twists to the back, the
torso twists in the same direction, the head and the head follow the hand. In the
expiration the movement is reverse. (Repeat 8-10 times)
18. From the same position: one hand on the top of the head, the other resting on the thigh.
Inspiratory, the trunk, arm and head are rotated toward the hemodiaction of the
trained. In the expiration, the movement is reversed and the movement continues in a
reverse rotation, associated with the bending of the trunk. (Repeat 8-10 times)
19. From the standing position with the support of the hands, with the legs approaching in
the inspiration, removal the legs in the expiration. (Repeat 10 times)
20. With the knees flexed, the soles supported on the bed, the left arm to the right hip,
concomitant with the raising of the head and shoulders, with inspiration; then dragging
the left arm obliquely upward, with the head twisting to the left, with the expiration.
(Repeat 6-8 times)
 21. From the position seated with the trunk slightly inclined forward and the knees
removed, abdominal breathing. Repeat several times.
22. From the semi-sitting position: sitting on the chair with a 1 kg lifter in each hand:
inspiration with duction side arms , expiration with lowering of arms and bending of
the trunk forward . (Repeat 8-10times)
23. Four-legged: The abdomen is strongly retractable (expiring), maintaining 3-5 seconds
contraction. Repeat several times.
24. From orthostatism, with legs distant, inspire with trunk flexion, expire in return.
(Repeat 8-10 times)
25. From orthostatism, with the help of a cane, standing with the legs distant and the cane
held horizontally, with arms up to the shoulders; inspires concomitantly with lifting of
the arms in the extension of the body; expire, concomitantly with flexed knees forward
and arms lowered to the ground. (Repeat 6-8 times)
26. From the same position: the legs distant with my hands on the hips, inspire with the
torsion of the trunk, expire with return; then: inspire with the extension of the trunk,
expire with return to the original position. (Repeats 8-10 times)
27. At the stall bars: standing with his back on the stall bars, the hands grab a bar of the
stall bars; inspirating concomitantly with the torsion of the trunk, expiring
concomitantly with returning to the initial position . (Repeat 8-10 times)
28. From the orthostatism: sitting with a 2 kg lifter in each hand, bending the trunk to the
right, the right arm sliding on the right thigh, the left hand under the left axle with
inspiration, and on the return with expiration. (Repeat 8-10 times)
29. From the same position: standing with his hands resting on the back of a chair, feet far
apart, lateral glances, alternately with the left and right legs, with inspiration and
expiration, slow rhythm. (Repeat 8-10 times)
30. I ask the patient to switch to a device from the gym , ergometric bicycle where she
will pedal with a small force of 2-3 kg, (increasing progressively from day to day) for
10 minutes.
31. The program ends with a walk in the gym, at a slow pace with breathing pleasure; with
the shaking of the limbs.

Physical therapist also performs bronchial drainage associated with pressure exerted on the
chest during expiration, external chest vibrations that help detach secretions from the walls.

Recommendations and Observations:

 I recommended that the patient avoid cold, wet and prolonged orthostatism that may
make it difficult for the peripheral circulation;
 I advised the patient not to give up the exercises of respiratory gymnastics after
discharge;
 I have indicated to the patient that, after discharge, practice cycling and swimming,
being beneficial for maintaining health and preventing the progression of the diseases
they suffer;
 I advised the patient to quit smoking being harmful and seriously damaging health;
 I advised the patient to continue applying the new skills acquired during the admission
period and after going home.
 Bibliography

1. Cardiovascular and Pulmonary Physical Therapy , Second Edition

Author: Joanne Watchie

Publisher: Saunders, 2010

2. Respiratory Physiotherapy , 2nd Edition

Authors: Jane Cross Mary Ann Broad Beverley Harden Matthew Quint Paul
Ritson Sandy Thomas

Publisher: Churchill Livingstone Elesevier, 2008

3. Rehabilitation of the Patient with Respiratory Disease

Author: Cherniak, Neil S

Publisher: McGraw-Hill,1998