Pulmonary Rehabilitation & COPD ASTHMA Netraya Nimpitakpong MD., C.Ped. Physical Medicine & Rehabilitation Department, Faculty of Medicine, Thammasat University

COPD & Asthma Breathing Why need rehabilitation?...

What is Pulmonary Rehabilitation? Chest physical therapy Home base exercise Recreation activity even Playing…

What is Pulmonary Rehabilitation? Chest physical therapy Home base exercise Recreation activity even Playing… But need to be aim to “GOAL”

GOALS of Pulmonary Rehabilitation for COPD & Asthma patient Prevent airway obstruction Improve airway clearance + ventilation Reduce energy costs during respiration

overall functional capacity Teach the patient how to deal with short-of-breath attacks Improve endurance Prevent accumulation of secretion & Increase the effectiveness of the cough mechanism Improve a patient’s overall functional capacity

COPD & Asthma Breathing What is the difference?...

COPD & Asthma attack Normal Breathing Deep & slow rate Quiet breathing & relax Use normal respiratory muscles Short shallow & rapid rate Wheezing & restless! Use respiratory muscles + Accessory muscles

How they feel when being breathlessness!! Increase respiratory rate lower alveoli ventilation & increase work load

How they feel when being breathlessness!! Breath in-breath out through mouse (instead of nose) Cold air cold airway increase bronchospasm Breath out …faster than normal  collapse small airway & increase air trapping

COPD & Asthma attack Normal Breathing Normal airway diameter Optimal secretion Effective cough Collapse airway diameter Excessive and sticky secretion Not enough breathing in Poor cough

Airway collapse why?

Airway collapse Collapse small airway then air was trapped in alveoli

Same principle as given medication COPD & Asthma Pulmonary Rehabilitation How ????? Same principle as given medication

Medication/ Pulmo Rehab Acute exacerbation Long term maintenance Medication/ Pulmo Rehab Positioning Pursed lip Diaphragmatic breathing Improve secretion drainage: cough, postural drainage, percussion Chest mobilization Aerobic exercise

Deal with “Acute Exacerbation” !!! How do I stop my breathlessness? Learn to teach the patient how to deal with short-of-breath attacks

ACUTE EXACERBATION!!! ตั้งสติ… Proper Position

ACUTE EXACERBATION!!! When short of breath start….patient can feel scary. It helps the patient know what to do their can stay calm even they're short of breath. Pursed-lip breathing and diaphragmatic breathing will both help. These breathing methods prevent or reduce the trapped air in lungs, and allow patient to breathe in more fresh air. Thus teach them as the following;

ACUTE EXACERBATION!!! Stop and rest in comfortable position, lower his/her head and shoulders Breathe in through the nose, and blow out through the mouth, breathe in and blow out just as fast as is necessary Begin to blow out more slowly and for a longer time. Don't force it. Use pursed lip breathing, then slow rate of breathing down Begin breathing through the nose Begin doing diaphragmatic breathing and stay in this position for 5 minutes longer

Comfortable positions when patient has short of breath Sitting: Sit with back against the back of the chair. Head and shoulders should be rolled forward and relaxed downwards. Rest the hands and forearms on thighs, palms turned upwards. Don’t teach them to lean on their hands (นั่งเท้าคาง) in this position. Their feet should be on the floor, knees rolled slightly outwards.

Sitting: Lean back into the chair in a slouched position, Head rolled forward, shoulders relaxed downward. Rest the hands gently on stomach. Keep the feet on floor, knees rolled outward Place a pillow on a table and sit down, arms folded and resting on the pillow. Keep the feet on the floor or a stool, and rest head on your arms.

Standing: The same manner as the sitting can be used while standing, arms resting on kitchen counter or back of chair, not leaning, knees bent slightly, one foot in front of the other. Lean with back to the wall, a pole, etc. Place feet slightly apart and at a comfortable distance from the wall, head and shoulders relaxed. Sitting: Lean back into the chair in a slouched position, Head rolled forward, shoulders relaxed downward. Rest the hands gently on stomach. Keep the feet on floor, knees rolled outward Place a pillow on a table and sit down, arms folded and resting on the pillow. Keep the feet on the floor or a stool, and rest head on your arms.

Let the air escape naturally- don't force the air out of lungs Pursed lips breathing Let the air escape naturally- don't force the air out of lungs “Keep doing pursed lip breathing until no longer short of breath”

ACUTE EXACERBATION!!! Pursed lips breathing Breathe in slowly through the nose for 1 count Purse lips as if you were going to whistle (แบบผิวปาก, เป่าเทียนเบาๆ) Breathe out gently through pursed lips for 2 slow counts, breathe out twice as slowly as the breathed in (ให้ง่ายหายใจเข้านับ หนึ่ง...สอง... หายใจออก นับ หนึ่ง..สอง...สาม...สี่)

tr Diaphragmatic Breathing Accessory muscle Diaphragm

Diaphragmatic breathing Let the patient sit and relax shoulders in a comfortable chair slightly lean backward for easy to breathing training. 1st step: Put one of patient’s hand on his/her upper chest, and the other on belly just above waist for monitor the movement of chest and belly while breathing. Diaphragmatic breathing

Diaphragmatic breathing 2nd step: Let them breathe in slowly through nose – instruct the patient that they should be able to feel the hand on their belly moving out but the hand on chest shouldn't move.

Diaphragmatic breathing 3rd step: Breathe out slowly through pursed lips – instruct the patient that they should be able to feel the hand on the belly moving in as they breathe out.

Long term maintenance Want to be stronger! Learn to improve pulmonary fitness and also effective coughing

Adequate Cough

Maintenance: Cough Training Sit down, head slightly lean forward, place both feet firmly on the ground. Demonstrate a sharp, deep, double cough to the patient place the patient’s hands on his/her abdomen, let them try to making ”k” sound this manner make the vocal cord tightening, closure glottis, abdominal contraction then patient can detect the feeling when vocal cord closing.

Maintenance: Cough Training Breathe in deeply using diaphragmatic breathing & try to hold the breath for three seconds. While keeping mouth slightly open, cough out twice. The first cough should bring up the phlegm, and the second cough should move it towards the throat. Take a break and repeat these steps once or twice if necessary

Chest mobilization Limb & body movement synchronized with breath in and breath out Improve chest expansion better ventilation & gas exchange

Chest mobilization ท่าที่ 1 กางแขนขึ้นเป็นรูปตัววี (V) ยืดอก หายใจเข้าลึก จากนั้นลดแขนลงมาอยู่ระหว่างขาสองข้าง ก้มตัวพร้อมๆกับหายใจออก

Chest mobilization ท่าที่ 2 ยกมือสองข้างขึ้นแตะบริเวณท้ายทอย แอ่นยืดแขนและอก หายใจเข้าลึก จากนั้นหุบแขนเข้า โน้มศีรษะและก้มตัวลงพร้อมๆกับหายใจออก

Chest mobilization ท่าที่ 3 มือสองข้างประสานกัน เหยียดแขนขึ้นไปด้านข้างและเอี้ยวบิดตัว หายใจเข้าลึก จากนั้นลดแขนลงมาที่ขาด้านตรงข้าม ก้มตัวพร้อมกับหายใจออก ทำจนครบ 6-10 ครั้ง แล้วบิดไปอีกด้านด้วย

Chest mobilization ท่าที่ 4 ยกมือขึ้นข้างหนึ่งขึ้นเหนือศีรษะ แล้วเอนตัวไปด้านตรงข้าม หายใจเข้าลึก จากนั้นลดแขนลงวางข้างตัว พร้อมกับหายใจออก จนครบ 6-10 ครั้ง แล้วสลับเอนตัวไปอีกข้าง

: 30 minute/day, 3 days/week Aerobic Exercise : 30 minute/day, 3 days/week

Retraining of breathing How do I stop my breathlessness? Retraining of breathing Learn to relax by use the proper position & pursed lip breathing when breathlessness Learn to use Diaphragmatic breathing & segmental breathing technique Learn to do the effective coughing

สงสัยอะไร ถามได้นะคร้าบ :D ขอบคุณครับ สงสัยอะไร ถามได้นะคร้าบ :D