segunda-feira, 28 de março de 2011

Chronic Obstructive Pulmonary Disease (COPD) - Part II

Physical Examination

Physical examination focuses on exercise performance, muscle strength, dyspnea and mucus retention/clearance. Physical examination of patients with dyspnea, reduced physical activity and impaired exercise capacity involves clinical inspection (movement speed, effort, dyspnea, use of rollator, leaning forward position, cyanosis, muscle atrophy, peripheral edema), chest wall configuration (hyperinflation, deformities), respiratory movement (respiratory rate, paradoxical thoracic-abdominal movement at rest and during exercise, accessory respiratory muscle activity, activity of abdominal muscles). [2]
In patients with impaired mucus clearance, physical examination focuses on the evaluation of coughing and huffing techniques and the quality and quantity of mucus. To evaluate the quality of the patients coughing, the parameters include appropriate inspiratory volume, expiratory (abdominal) muscle contraction, and the occurrence of airway collapse or thoracic pain during coughing. The presence of mucus retention is assessed by listening to breathing sounds (auscultation), and palpating the chest. In addition, the quantity, color and quality of expectorated mucus are examined. [2]


Apart from pharmaceutical interventions, various multidisciplinary pulmonary rehabilitation programs with physical therapy have been designed to control symptoms, maintain the patients’ physical tolerance and teach them to acquire coping skills, breathing skills and relaxation techniques. Physical therapy seeks to enhance or maintain the cardiopulmonary functions of the patients, teach them to acquire pursed lip breathing, coordinated breathing skills, and energy conservation techniques, keeping in mind that the main goal of the physical therapy is to facilitate the patient to carry out with their normal life. The patients can also be taught relaxation methods, to help them manage situations of high anxiety and stress. [1]
The general goal of treatment is to reduce or eliminate the patients body function impairments and to improve his activities and participation, thus improving his quality of life. Reducing dyspnea, improving exercise capacity and physical activity, improving mucus clearance, improving knowledge, self management and self efficacy, are the most common goals for physical therapy. [2]
To achieve improvement of exercise capacity and physical activity, we need to improve the cardiorespiratory fitness, the muscular strength and endurance, and the flexibility. The cardiorespiratory fitness can be improved in any activity that uses large muscle groups that can be maintained continuously and is rhythmical and aerobic in nature (walking, cycling, stair climbing, swimming). This training should be done 3-5 days per week, 20-60 minutes continuous or intermittent (sessions of 10 or more minutes), 40-60% of heart rate reserve/VO2 peak, or 5-6 on the modified Borg scale. The muscular strength and endurance can be improved with resistance training of the major muscle groups of upper and lower limbs. This training should be done 2-3 days per week in 8-15 repetition through 2-5 sets, using a load of 60-80% of 1RM (Repetition Maximum). The flexibility training includes stretches for the major muscle groups that should include appropriate static and/or dynamic techniques. Should be done 2-3 days per week with 4 repetitions for 15-30 seconds. To reduce dyspnea, there are breathing exercises that can be taught to the patients by the physical therapists, such as active expiration, slow and deep breathing, and pursed lips breathing (reduction of hyperinflation and improvement of gas exchange), and diaphragmatic breathing (improvement of thoraco-abdominal movements, and improvement of respiratory muscle function). Besides these breathing exercises, the physical therapist can also do some relaxation exercises to reduce anxiety and dyspnea, do some inspiratory muscle training, improve the respiratory muscle function, and teach the patient that forward leaning is an effective method to alleviate dyspnea. [2]
To improve the mucus clearance, physical therapy employs a variety of methods. Patients are taught mucus clearance techniques that enable them to effectively clear secretions from the airways themselves. Physical activity enhances the mucus transport trough the airways, thus enhancing mucus clearance. Forced expiration, like huffing and coughing, is effective and can be used independently by patients. If coughing or huffing does not result, in the expectoration of mucus, the physical therapist should promote the mucus transport by using forced expiratory techniques, in combination with postural drainage or manual chest compression and vibration. Manual compression during coughing or huffing may be needed in patients with expiratory muscle weakness. Appropriate self-management seems important to achieve potential long-term benefits (fewer exacerbations, slower deterioration of pulmonary function). There are other techniques, like postural drainage, for local retention of large amounts of mucus), positive expiratory pressure (PEP), insufflators/exsuflattor, chest percussion, and mechanical vibration. [2]    
Because COPD is a chronic condition, the physical therapist should educate the patient to enhance compliance and improve self-management skills. The aim of this self-management is the patient achieves the levels of physical activity needed to improve and maintain health. To promote and maintain health, it is recommended that older adults practice moderate intensity aerobic physical activity for a minimum of thirty minutes, five days a week. They can also practice vigorous intensity aerobic physical activity for a minimum of twenty minutes, three times a week. [2]

[1] Chan, S. C. C. (2004). Chronic obstructive pulmonary disease and engagement in occupation. American Journal of Occupational Therapy, 58, 408–415
[2] Gosselink, R. et al. (2008). Clinical Practice Guideline for Physical Therapy in patients with COPD – Practice Guideline. KNGF Clinical Practice Guideline, 118 (4)

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