Respiratory & chest xrays

Hillegass and Sadowsky (2001, p266-9) define asthma as a chronic inflammatory disease of the airways which affects the tracheobronchial tree sensitivity to allergens and pollutants which cause constriction of the bronchial smooth muscles, reduced cillary activity and increased mucus secretion. Auscultations may reveal crackles on inspiration as alveoli snap open when filling with air and a wheeze as the air turbulently navigates its way through constricted and obstructed airways. Such a presentation would indicate to the physiotherapist that the patient is suffering from reduced lung volumes with retained secretions and an increased work of breathing. If not all of the airways are narrowed then the patient may well have the ability to expectorate some retained secretions and thus active cycle of breathing is indicated. Active cycle of breathing technique (ACBT) using forced expiratory techniques (huffs and coughs), thoracic expansion exercises (deep breathing with 3 second inspiratory hold to incorporate collateral ventilation) with relaxed breathing have been shown to be effective in clearing bronchial secretions and increasing lung volumes (Pryor and Prasad, 2002).

If the secretions were not mobilising using ACBT, then humidified air via Hudson mask or saline nebulisers are indicated to moisten the airways so the sputum has a less adhesive surface to stick to. The moisture also provides the cillia with a preferred working environment (fluid blanket) so the bodies own secretion removal system will benefit (cillary action).

A CXR common to asthma suffers has a flattened diaphragm and hyperinflated chest or barrel chest indicating to the physiotherapist that air is not able to leave the lung, thus increasing the pressure within the chest. Here the use of Continuous positive airways pressure (CPAP) is indicated. CPAP splints open collapsing alveoli and bronchioles by raising the positive expiratory end pressure, resulting in better V/Q matching and less air being trapped in the distal airways.

According to Hillegass and Sadowsky (2001) when looking at a severe acute asthma suffer one may see evidence of fatigue, shortness of breath (dyspnoea) and distress. The physiotherapists may chose to position the patient comfortably (supported sitting or side lying) and attempt to calm them before further assessment. Should the patient experience increased work of breathing as airways are becoming constricted and obstructed it signifies to the physiotherapist that relaxation techniques to bring the patients respiratory rate under control would be an effective start to treatment.

According to Pryor and Prasad (2002) postural drainage or gravity assisted positioning is a useful method to improve V/Q matching and help mobilise retained secretions formed by increased mucus production. Chest percussion or vibrations can be used with breathing exercises and postural drainage to dislodge and encourage the movement of secretions in a particular region of the lung, however evidence suggests this could also cause further bronchospasm in patients with chronic lung disease (Pryor and Prasad 2002, p431, Campbell, O’Connell and Wilson 1975, Wollmer, Ursing, Midgren and Eriksson 1985) hence is contraindicated for the sensitive asthma suffer.

The management of asthma by using bronchodilators via inhalers or nebulisers, relaxed breathing techniques and positioning (sitting or standing), is common for chronic suffers with increased work of breathing. During severe acute episodes where problems are retained sputum, reduced lung volumes or hyperinflation and increased work of breathing due to bronchospasm more intensive management is necessary. Salbutamol nebulisers are effective bronchodilators and the physiotherapist may decide to check the patient’s charts in order to time their treatment to occur just after a dose as the airways will be at maximal dilation, thus allowing air entry and secretion expectoration.