DEFINATION-”Emphysema is a condition of the lung characterised by Permanent dilation of the air spaces distal to thr terminal bronchioles with destruction of the walls of these airways”.It is always associated with chronic bronchitis and is difficult to distinguish the two Conditions during life.
CAUSES AND TYPES OF EMPHYSEMA
causes and predisposing factors-
1-CONGENITAL OR PRIMARY EMPHYSEMA –May be caused by the alfa1-antitrypsin deficiency.This is a rare in-herited condition, which affect one person in 4000 and results in the complete absence of one of the key antiprotease systems in the lung.This consequence is the early development of COPD, especially if the patient is already smoker.Although alpha1-antitrypsin deficiency is responsible for less than 1 per cent of cases of COPD, Its hereditary nature means that is worth diagnosing.It should, therefore, be consideres in any young COPD patient.
EMPHYSEMA may be SECONDARY to other factors, such as:
1.Obsructive airways disease -e.g. asthma , cystic fibrosis and chronic bronchitis.
2.Occupational lung disease-e. g. pneumoconiosis.
3.Compensatory to contraction of one secton of the lung-e.g. fibrous collapse or removal , when the remaining lung expands to fill the space.
TYPES OF EMPHYSEMA
Emphysema is usually of the panacinar (panlobular) types.
In centrilobular emphysema the upper zones of the lung are usually affected.This causes gross disturbance of the ventilation /perfussion relationship since there is a relatively well-preserved blood supply to the alveoli, but the amount of oxygen reaching the capillary is decreased owing to the damage to airways proximal to the alveoli.
2.PANACINAR EMPHYSEMA-Predominantly affects the lower lobes and lower lobe involvement is more common in individuals with alfa1-antitrypsin deficiency. This has a less drastic effect on the ventilation/perfussion relationship, since the blood supply in the damaged areas is decreased in proportion to the decreased ventilation in those areas.
The alveoli and the small distal airways are primarily affected by the disease, followed by effects in the larger airways . Elastic recoil is usually responsible for splinting the bronchioles open. However, with emphysema, the bronchioles lose their stabilizing function and therefore causing a collapse in the airways resulting in gas to be trapped distally.
There is an erosion in the alveolar septa causing there to be an enlargement of the available air space in the alveoli.
There is sometimes a formation of bullae with their thin walls of diminished lung tissue.
Smoking contributes to the development of the condition initially by activating the inflammatory process . The inhaled irritants cause inflammatory cells to be released from polymorphonuclear leukocytes and alveolar macrophages to move into the lungs. Inflammatory cells are known as proteolytic enzymes, which the lungs are usually protected against due to the action of antiproteases such as the alpha1-antitrypsin . However, the irritants from smoking will have an effect on the alpha1-antitrypsin, reducing its activity. Therefore emphysema develops in this situation when the production and activity of antiprotease are not sufficient to counter the harmful effects of excess protease production . A result of this is the destruction of the alveolar walls and the breakdown of elastic tissue and collagen. The loss of alveolar tissue leads to a reduction in the surface area for gas exchange, which increases the rate of blood flow through the pulmonary capillary system .
CLINICAL FEATURE OF EMPHYSEMA-
1. PROGRESSIVE DYSPNEA-Shortness of breath occurs initially on exertion , but as the disease progresses it will gradually occure after less and less activity and finally at rest .
2. RESPIRATORY PATTERN –The patient has a ‘fishlike’ inspiratory gasp, which is followed by prolonged, forced expiration usually against ‘pursed lips’.A ‘flick’ or bounce of the abdominal muscles may be seen on expiration as the outward flow of air is suddenly checked by obstruction of the airways.
3.COUGH WITH SPUTUM-This will be present if the disease is associated with chronic bronchitis or if there is infection.
4.CHEST SHAPE-The chest becomes barrel-shaped and fixed in inspiration, with widening of the intercostal spaces.There may also be indrawing of the lower intercostal spaces and supraclavicular fossa on inspiration .This is also associated with the difficulty of ventilating stiff lungs through narrowed airways.The ribs are elevated by the accesory muscles of respiration and there is loss of thoracic mobility.
5. POOR POSTURES-There may be a thoracic kyphosis plus elevated and protracted shoulder girdle.
6. POLYCYTHEMIA-This may develop in response to prolonge decrease in pao2 owing to the ventilation/perfusion imbalance.
7. CORE PULMONALE-This occurs in advanced stages of thje disease.
8.LUNG FUNCTION-The FEV1/FVC ratio is usually below 70per cent. RV is increased and lung volume may exceed the predicted total lung capacity(TLC).
EXAMINATION-The percussion note will be normal or hyper-resonant due to air trapping. Auscultation will reveal decreased breath sounds and prolonged expiration.
The chest X-RAY shows low flat diaphrams and hyperinflation.
PROGNOSIS OF EMPHYSEMA-The patients become progressively more disabled, with death ultimately occuring from respiratory failure.Complications of the emphysema is pneumothorax due to the rupture of the emphysematous bulla, and congestive cardiac failure.
MEDICAL MANAGEMENT OF COPD-
PRINCIPLES OF TREATMENT-
1-Decrease the bronchial irritation to a minimum stop smoking , avoid dusty, smoky , damp or foggy atmosphere.
2- Control infections-The should have a supply of antibiotics at home and receive a vaccination against influenza each winter.
4-Control/decrease the amount of sputum
6-Long-term oxygen therapy (LTOT)
1- Beta2 agonists-(salbutamol and turbutalin) ,and long acting beta agonist (salmeterol and formoterol) the 2-Anticholinergics-(Ipratropium bromoide and Oxitropium bromide)
3-Xanthen derivatives -(Theophyllin and Aminophyllin)
1- Corticosteroids-(Beclometason, Budesonide)
PHYSIOTHERAPY MANAGEMENT IN COPD-
Goals of treatment for COPD include:
- Relieving symptoms
- Slowing progress of the disease
- Improving exercise tolerance (ability to stay active)
- Preventing and treating complications
- Improving overall health
- COPD is not a reversible condition and has no cure yet, but conservative treatment for COPD can slow its progression (smoking cessation being the most important).
PHYSIOTHERAPY TRATMENT FOR COPD-
Aims of COPD Therapy
- To remove excess bronchial secretion and reduce the airflow obstruction.
- To establish the coordinated pattern of breathing
- To promote relaxation and improve posture
- To improve the mobility of thorax, shoulder girdle and neck
- To increase the exercise tolerance
- To encourage a full and active life style.
Means of COPD Treatment
1.POSTURAL DRAINAGE (P.D) is necessary for all patients. In chronic bronchitis regular postural drainage should be given. In case of acute emphysema, postural drainage is not necessary but in an infection episode, where sputum may be present PD may be needed. The optimum position must be established with individual and advice for postural drainage at home.
Clapping and Shaking are effective over the affected lung segments and help to loosen and move the secretions to central airways during expiration. Then ask the patient to take 2-3 coughs to remove the secretions out. If the patient is unable to clear the secretions which are accumulated in lungs, then increased ventilation and humidification by IPPB conjoint with P.D are provided. This is very effective for patient. But in presence of emphysematous bullae, it is contraindicated because of risk of causing pneumothorax.
2. ACTIVE CYCLE OF BREATHING TEQNIC
The Active Cycle of Breathing Techniques (ACBT) is an active breathing technique performed by the patient to help clear their sputum the lungs. The ACBT is a group of techniques which use breathing exercises to improve the effectiveness of a cough, loosen and clear secretions and improve ventilation.
ACBT consists of three main phases:
2.Deep Breathing Exercises or thoracic expansion exercises
3.Huffing OR Forced Expiratory Technique (F.E.T)
Additionally, a manual technique (MT) or positive pressure can be added if and when indicated, to create a more complex cycle to help improve removal of secretions on the lungs.
Breathing control is used to relax the airways and relieve the symptoms of wheezing and tightness which normally occur after coughing or breathlesness. Breathing should be performed gently through the nose using as little effort as possible. If this is not possible then breathing should be done by mouth. If it is necessary to breathe out through the mouth this should be done with ‘pursed lips breathing’. While performing this technique it is important to encourage the patient use it as an opportunity to reduce any tension they may have, Encouraging the patient to close their eyes while performing Breath Control can also be beneficial in helping to promote relaxation. It is very important to use Breathing Control in between the more active exercises of ACBT as it allows for relaxation of the airways. Breathing Control can also help you when you are short of breath or feeling fearful, anxious or in a panic. The length of time spent performing Breathing Control will vary depending on how breathless patient feels.
When using this technique with a patient as part of the ACBT the patient should be instructed to usually 6 breaths. Instructions to patient: Rest one hand on your stomach and keep your shoulders relaxed to drop down. Feel your stomach rise as you breathe in and fall when you breathe out.
2.Deep Breathing Exercises
Deep breathing is used to get air behind the sputum stuck in small airways:
Relax your upper chest.
Breathe in slowly and deeply.
Breathe out gently until your lungs are empty – don’t force the air out.
Repeat 3 – 4 times, if the patient feels light headed then it is important that they revert back to the Breathing Control portion of the cycle.
At the end of the breath in, hold the air in your lungs for 3 seconds (this is known as an inspiratory hold).
Deep breathing/thoracic expansion exercises recruit the collateral ventilatory system assisting, the movement of air distal to mucus plugs in the peripheral airways.
Deep breaths to utilise collateral channels and get air behind sputum to mobilise it towards larger airways and towards the mouth. Instructions to patient:
- Relax your shoulders.
- Place both hands on either side of ribs.
- Breathe in deeply feeling as your ribs expand.
- Breathe out gently as far as you can until your lungs feel empty.
- Deep breathing/thoracic expansion is usually repeated 4 times.
3.Huffing or FET (FORCE EXPIRATORY TECNIC)
The FET is an integral part of the ACBT described by Pryor and Webber .
- A huff is exhaling through an open mouth and throat instead of coughing.Huffing moves sputum from the small airways to the larger airways, from where they are removed by coughing. Coughing alone does not remove sputum from small airways.
1.Take a small-medium sized breath in
- Squeeze the breath out by contracting your tummy muscles and keep your mouth and throat open to perform a huff. This small-medium sized huff helps with the removal of sputum in the lower reaches of the lungs.
- To remove sputum in the higher portions of the lungs take a large breath in.
- Squeeze the air out as before to perform a huff.
- Cough and expectorate any sputum. If no sputum is produced with 1 or 2 coughs, try to stop coughing by encouraging the patient to use Breathing Control, the main technique used in between the more active stages of the as ACBT.
- Allow your breathing to settle with breathing control and then repeat the cycle until your chest feels clear.
Small long huffs move sputum from low down into chest whereas big short huffs moves sputum from higher up into chest, so use this huff when it feels ready to come out, but not before; huffs work via dynamic compression.
Instructions to patient:
2.Take a medium sized breath in.
Squeeze the breath out fairly hard and fast keeping mouth and throat open. Imagine trying to steam up a mirror or blow a tissue held out in front of you.
Attempt to clear sputum 2-3 times then return to breathing control (Phase one) to relax airways.
Repeat as above except for a larger breath in to remove secretions/sputum in other areas of the lungs.
In case of acute exacerbation of chronic bronchitis the physiotherapy must be given vigorously. IPPB has great value in this case. It is given with mask to improve ventilation. It is important to observe the chest wall movement and level of consciousness. The patient should be observed for any signs of drowsiness after taking the treatment. Assisted ventilation with vigorous chest shacking and postural drainage are more effective. A ventilatory mask providing controlled oxygen therapy is usually required.
3.BREATHING EXERCISE- should be given in a correct way in treatment for COPD. The main emphasis is given on diaphragmatic breathing with relaxed expiration. The diaphragmatic breathing with decreased upper chest movements and relaxed shoulder girdle is preferred. Expansion of basal lung segments are taught to ventilate these areas.
Pursed lip breathing with prolonged expiration is given as treatment for COPD especially in presence of emphysematous bullae.
3. POSTURE CORERECTION Patient should be taught to attain maximal relaxation of the upper chest as well as movements of lower chest. The main emphasis is on relaxed and controlled diaphragmatic breathing. For maintaining posture the patient should not be kept with forward head and rounded shoulder.
4. THORACIC MOBILITY EXERCISE are given along with shoulder girdle movements. Free active exercises for whole spine to prevent kyphosis and fixed inspiration.
Important COPD exercise in sitting is trunk turning with loose arm swinging in rotation for relaxation. It is also essential to emphesise postural awareness so that the patient practices shoulder girdle retraction and lateral rotation of arm.
5. These patients should be as mobile and active as possible. Their exercise tolerance may be increased by gradually increasing the distances walked both on the flat and upstairs or slopes while practising breathing control. A graduated exercise programme can also be given to these patients during the later part of their stay in hospital and should be continued at home.
6. In daily life style patient should avoid smoking and encouraged to keep fit and eat sensibly. For gaining relaxation, swimming helps very much. Jerky and quick movements should be strictly avoided.