| Evidence based case study in management of acute | | | | specific area of pathology was described. Relaxation |
| Exacerbations of COPD. | | | | exercises were done for upper chest and neck to |
| Introduction: | | | | increase the ventilation, abdominal areas. Patient was |
| Chronic pulmonary diseases have become increasingly | | | | also taught home postural drainage to help in early |
| one of the most common chronic lung diseases and a | | | | recovery. |
| major cause of morbidity and mortality in modern | | | | Walking and cycling was encouraged, as it is most |
| world. It is characterized by airflow limitation that is not | | | | widely used modalities of exercise training in chronic |
| fully reversible. | | | | obstructive pulmonary disease rehabilitation (Vallet et al, |
| Chronic Obstructive Disease is a leading cause of | | | | 1997). Patient was given endurance (aerobic) training |
| the death in the worldwide (Calverley et al, 2003). The | | | | program for 4-12 weeks (Casaburi et al, 1997; Wijkstra |
| condition can result in loss of work quality and quality | | | | et al, 1996), and she attended supervised training |
| of the life can be significantly effected (Barnes, 1999). | | | | sessions 2-5 times a week. Each session duration |
| In UK 27,478 men and woman die because of the | | | | was 20-30 minute. |
| chronic obstructive lung diseases and most of the | | | | Applying techniques: |
| death ( more than 90%) was in the age of above 60 | | | | Techniques for vibration and postural drainage |
| years old(British Thoracic Society. 2006). | | | | (Gumery et al 2001) were applied with consideration to |
| Rehabilitation for patients with chronic lung diseases is | | | | the contraindications and patients condition and |
| well established and widely accepted as means of | | | | motivation. As the patient was on long term of cortico- |
| enhancing standard therapy in order to improve | | | | steroid treatment, possibility of osteoporosis was |
| symptoms and maximise the patients function | | | | considered which may led to fracture while doing |
| (Siafakas et al, 1995; Ries, 1990; Casaburi, 1993; | | | | tapping in postural drainage. |
| Fishman, 1996). In 1974, the American College of Chest | | | | Re-evaluation: |
| Physicians (ACCP) focused in there definition of | | | | The patient was re-evaluated after the secretions |
| Pulmonary rehabilitation on three important features | | | | were mobilised and on observation, patients breathing |
| and they suggested that Successful pulmonary | | | | was found to be more effective. The progress was |
| rehabilitation depends on three importance features, | | | | slow as the patient was reconditioned. Patient was |
| Individuality of each case, Multidisciplinary team | | | | encouraged to remain active to help in early recovery. |
| approach and attention to physiopathology and | | | | Patient and family was given education about |
| psychopathology of each case. | | | | restoration and maintenance of exercise tolerance and |
| One of the main problems with COPD patient is the | | | | basic self-management. Home visits were made to |
| increase in the pulmonary secretions leading to | | | | check for adequate heating, and health or safety |
| increase in shortness of breath. These two factors | | | | hazards. In addition, this visit was also supportive for |
| affect the patient’s function and quality of life. For | | | | the family. |
| exacerbation, Physiotherapy is often required to help | | | | The exercise was prescript for the patient to keep the |
| clear secretions and reduce WOB, including | | | | patient fit and increase the vital capacity. The mode of |
| non-invasive ventilation to prevent intubation | | | | the exercise was related to the patient’s life style |
| (Alexandera, 2001). | | | | and the patient was encouraged to use stationary |
| There are various techniques, which can be used in | | | | bike. The bike was suggested as it supports 85% of |
| physiotherapy to improve patient’s condition. The | | | | the body weight, and large muscle groups can be |
| research suggests that the postural drainage is | | | | exercised with less strain than walking (Bach and |
| beneficial in clearing the chest from secretions | | | | Haas, 1996, p.309). Furthermore, exercise programs for |
| (Clarke,1989;Faling,1986), respiratory muscle relaxation | | | | the muscles of ambulation were prescribed as they |
| manoeuvre is effective for improving the pulmonary | | | | are a part of virtually every program of pulmonary |
| function of pulmonary emphysema patients (Fujimoto | | | | rehabilitation (Ries, 1990; Casaburi, 1993; Carter et al, |
| et al, 1996), relaxation can help reduce dyspnoea and | | | | 1992; Olopado et al, 1992). Over the period of |
| anxiety in chronic obstructive pulmonary disease | | | | rehabilitation, the patient also said that her functional |
| (COPD) patients (Louie, 2004). | | | | capabilities improved and this helped her to great |
| Case description :( case history, physical examination, | | | | extent in her ambulation. Exercises were also given for |
| and intervention) | | | | muscles of the shoulder girdle as these muscles can |
| Patient is a 67-years-old woman with acute | | | | help provide support to pull on the ribcage (Criner et al, |
| exacerbation in Chronic Obstructive Pulmonary | | | | 1988). Patient was encouraged to resume her sports |
| Disease (COPD). She complained of increased | | | | hobbies – bowling to combine exercise and |
| shortness of breath with loose, non-productive cough. | | | | recreation. |
| A febrile on auscultation, bilateral rales, rhonchus, and | | | | Patient was scheduled for a follow up appointment |
| expiratory wheezing. Patient said she is on | | | | after 6 weeks of rehab and treatment to monitor the |
| bronchodilators and low-dose steroid. Patient said she | | | | patient’s progress. (Broussard 1979; Fujimoto et al. |
| has been suffering from this problem since 10yrs and | | | | 1996; Gift, Moore, and Soeken, 1992; Louie, 2004). |
| has been on medication since. She does not do any | | | | Patient was also provided with breathlessness rating |
| exercises and her general practitioner who she usually | | | | scale to check her breathlessness after each session |
| sees has never mentioned about seeing any | | | | of exercise. |
| physiotherapist. Recently during this episode of acute | | | | On the follow up appointment subjective and objective |
| exacerbation, she was advised by the hospital doctor | | | | re assessment was done. Patient as observed to |
| to see a physiotherapist. | | | | check the breathing pattern and frequencies, |
| The strategy in this case study used was the | | | | auscultation was done to check the chest for any |
| problem-solving model, which included following six | | | | signs of secretion and obstructions. The patient was |
| steps; | | | | sent to take x-ray to check the clarity of the chest. |
| Step 1: Patient assessment, | | | | Stair climb test was done and there was a good |
| Step 2: defining the problem,step3: determining the | | | | progress in the patient’s condition as the result was |
| goals,step4: identifying appropriate techniques, | | | | increased significantly from 10 steps in 2 minute before |
| Step 5: applying the techniques,step6: re-evaluation of | | | | 6 week to 25 step. |
| the patients situation(Donna,1987). | | | | Improvement was also seen on the self reported and |
| Evaluation and assessment: | | | | measured breathlessness rating scale where the |
| Accurate assessment is the key player of | | | | patient scored 2 whereas she scored 4 during initial |
| physiotherapy and forms the bases of rational | | | | assessment and also the recovery rate post |
| practice. A Problem based assessment leads to | | | | exercises reduced from 5-10mins to 2-5mins and the |
| reasoning in the pulmonary rehabilitation. As result, a | | | | patient also reported that she was doing fine the day |
| thoughtful evaluation will guide to both effectiveness | | | | and was comfortable. |
| and efficiency because time will be saved by | | | | Summary: |
| avoiding unnecessary treatment (Physiotherapy in | | | | From the above case study, it can be derived that |
| Respiratory Care An evidence-based approach to | | | | patients suffering with similar conditions can benefit |
| respiratory and cardiac management). | | | | from appropriate exercise and active lifestyle. It is very |
| Ward reports and medical notes of the patient were | | | | important to keep encouraging the patients and |
| evaluated to know about; | | | | educating them regarding the condition and help those |
| · The past and present relevant | | | | to self manage. |
| history. | | | | Although suggestions for appropriate management |
| · social history , accommodation | | | | can be made based on available evidence, the |
| · Conditions required precautions in | | | | supporting literature is spotty. |
| relation to certain treatments e.g. light-headedness | | | | References |
| ,bleeding disorders or swallowing disorders | | | | 1. Alexandra Hough 2001, Physiotherapy in |
| · Recent cardiopulmonary | | | | Respiratory Care An evidence-based approach to |
| resuscitation to examine the X-ray in case of gastric | | | | respiratory and cardiac management, third edn, Nelson |
| aspiration or fracture | | | | Thomas Ltd, United Kingdom. |
| · Checking for possibly of bony | | | | 2. Back, J. R. & Haas, F. pulmonary |
| metastases, long-standing steroid therapy that this | | | | rehabilitation. Phys.Med.Clin.North Am [7], 205-406. 1996. |
| leads to risk of osteoporosis and checking for the | | | | 3. Barnes PJ 1999, Managing chronic obstructive |
| history of radiotherapy over the chest. These all | | | | pulmonary disease Science Press, London. |
| findings contraindicate percussion or vibration over the | | | | 4. Bradley, J., Howard, J., & Wallace, E. 1999, |
| ribs. | | | | "Validity of a modified shuttle test in adult cystic |
| · The patient’s experience | | | | fibrosis", Thorax, vol. 54, pp. 437-439. |
| increased shortness of breath and the assessment | | | | 5. British Thoracic Society 2006, The Burden of |
| indicate airway secretion. | | | | Lung Disease, Second edn. |
| A part of the patient evaluation was subjective | | | | 6. Broussard, R. 1979, "Using relaxation for |
| assessment and that was by listening to patient’s | | | | COPD", Am.J.Nurs, vol. 79, no. 11, pp. 1962-1963. |
| problem in her own words. Following symptoms were | | | | 7. Calverley PM & Walker P 2003, "Chronic |
| checked: | | | | obstructive pulmonary disease", Lancet, vol. 362, pp. |
| Respiratory symptoms by looking for the how long the | | | | 1053-1061. |
| symptoms been troublesome. | | | | 8. Carter R, Coast JR, & Idell S 1992, |
| · Frequency, duration, and the severity. | | | | "Exercise training in patients with chronic obstructive |
| · Any pain, chest pain, musculoskeletal | | | | pulmonary disease", Med Sci Sports Exerc, vol. 24, pp. |
| pain or cardiac pain. | | | | 281-291. |
| · Checking functional limitations including | | | | 9. Casaburi R & Petty TL 1993, Principles |
| the daily living. | | | | and practice of pulmonary rehabilitation WB Saunders, |
| · Observation to check the breathing | | | | Philadelphia. |
| rate and pattern before the patient a ware of the | | | | 10. Clarke, S. W. Rationale of airway clearance. |
| physiotherapist’s presence to avoid any role-play. | | | | Eur.Respir.J.Suppl 7, 599-603. 1989. |
| · General appearance , colour, hand | | | | 11. Criner GJ & Celli BR. Effect of unsupported |
| checked which is a good and rich source of | | | | arm exercise on ventilatory muscle recruitment in |
| information like cold hand indicate a poor cardiac | | | | patients with severe chronic airflow obstruction. Am |
| output, oedema, jugular venous pressure, chest shape. | | | | Rev Respir Dis 138, 856-861. 1988. |
| Objective measurement: | | | | 12. Donna L & Frownfelter 1987, Chest Physical |
| Exercise testing was used to monitor the progress of | | | | Therapy and Pulmonary Rehabilitation an |
| the patient due following few reasons: | | | | Interdisciplinary Approach. 2 edn, Year Book Medical, |
| · Lung function tests are not a good | | | | INC, Chicago. |
| predictor of exercise capacity (Bradley et al, 1999). | | | | 13. Faling, L. J. 1986, "Pulmonary rehabilitation--physical |
| · The laboratory tests are for | | | | modalities", Clin.Chest Med, vol. 7, no. 4, pp. 599-618. |
| physiological measurement rather than monitoring of | | | | 14. Fujimoto, K. e. a. 1996, "Effects of muscle |
| patients progress. | | | | relaxation therapy using specially designed plates in |
| · The patients own estimate of | | | | patients with pulmonary emphysema", Intern.Med, vol. |
| exercise tolerance is not objective (Hough, 2001). | | | | 35, no. 10, pp. 756-763. |
| Exercise testing: | | | | 15. Gift, A., Moore, T., & Soeken, K. 1992, |
| As long as the patient was not suffering from acute | | | | "Relaxation to reduce dyspnea and anxiety in COPD |
| breath illness, exercise testing was used as an | | | | patients", Nurs.Res, vol. 41, no. 4, pp. 242-246. |
| objective measure to monitor the progress. Oximetry | | | | 16. Gumery, L., Proyer, J., Prasad, S. A., & Dodd, |
| on exercise testing was used which is advisable to | | | | M. clinical guidelines for Physiotherapy Management of |
| measure the level of oxygen during the exercise | | | | Cystic Fibrosis. 2001. CSP. |
| (Martine et al, 1992). Because the patient was in acute | | | | 17. Louie, S. W. 2004, "The effects of guided |
| exacerbation condition, only simple stair climbing testing | | | | imagery relaxation in people with COPD", |
| was used and count the number of steps can be | | | | Occup.Ther.Int, vol. 11, no. 3, pp. 145-159. |
| climbed up and down in 2 minute and rest allowed but | | | | 18. Martin D, Powers S, Cicale M, Collop N, Huang D, |
| included within the 2 minutes. Each minute was | | | | & Criswell D 1992, "Validity of pulse oximetry |
| passed the patient was informed about the time. The | | | | during exercise in elite endurance athletes", J Appl |
| result of the test was only 10 steps per 2 minutes. | | | | Physiol, vol. 72, no. 2, pp. 455-458. |
| Exercise testing revealed increased shortness of | | | | 19. Olopade CO, Beck KC, & Viggiano RW |
| breath and from assessment of patient, it was clear | | | | 1992, "Exercise limitation and pulmonary rehabilitation in |
| that she had airway secretions. | | | | chronic obstructive pulmonary disease", Mayo Clin |
| Defining the problem: | | | | Proc, vol. 67, pp. 144-157. |
| Shortness of breath was probably due to increased | | | | 20. Ries AL 1990, "Position paper of the American |
| secretions with the patient and so physiotherapy was | | | | Association of Cardiovascular and Pulmonary |
| planned after the use of bronchodilators. Percussion | | | | Rehabilitation: scientific basis of pulmonary rehabilitation", |
| can trigger bronchospasm in patients with asthma and | | | | J Cardiopulmonary Rehabilitation, vol. 10, pp. 418-414. |
| in this case would benefit to have maximum | | | | 21. Siafakas NM, Vermeire P, & Pride NB 1995, |
| bronchodilator prior to treatment. (Donna 1987) | | | | "Optimal assessment and management of chronic |
| Determining the Goals: | | | | obstructive pulmonary disease (COPD): the |
| Promote airway clearance; encourage relaxation and | | | | European Respiratory Society Task Force", Eur Respir |
| breathing exercise; encourage exercise to promote | | | | J, vol. 8, pp. 1398-1420. |
| airway clearance. | | | | 22. Vallet G, Ahmaidi S, & Serres I 1997, |
| Identifying Appropriate Techniques: | | | | "Comparison of two training programmes in chronic |
| Due to short shortness of breath, modified | | | | airway limitation patients: standardized versus |
| positioning was used for postural drainage as per the | | | | individualized protocols", Eur Respir J, vol. 10, pp. 114-122. |
| patients comfort, turning the patient side to side to | | | | 23. Wijkstra PJ, van der Mark TW, & Kraan J |
| prevent any shortness of breathiness (Hough 1991). | | | | 1996, "Effects of home rehabilitation on physical |
| Trendelenberg position was also used with percussion | | | | performance in patients with chronic obstructive |
| and vibration was gently applied due to consideration | | | | pulmonary disease (COPD)", Eur Respir J, vol. 9, pp. |
| that the patient was on long-term steroid therapy. | | | | 104-110. |
| Emphasis was placed on both lower lobes as no | | | | |