Physiotherapy Management of Breathlessness

1. Relaxation position for breathlessness patients

Patients should be placed in a relaxed position and encourage to do ‘diaphragmatic’ breathing at his own rate. The rate of breathing does not matter at this stage; it is the pattern of breathing that is important.

Positions

i. High side lying (fig A)

Five or six pillows are used to raise the patient’s shoulders while lying on this side. One pillow should be placed the waist and axilla, to keep the spine straight and prevent slipping down the bed. The top pillow must be above the shoulders, so that only the head and neck are supported. The underneath forearm can be placed under the head pillow, or resting on the bed underneath the pillow in the waist. It is more comfortable if the knees are bent and the top leg placed in front of the one beneath.  

This position is helpful for patient in acute respiratory distress or those who suffer from acute breathlessness during the night.

ii. Forward lean setting (fig B, C)

 The patient sits at the table leaning forward from the hips with the head and upper chest supported on several pillows. The back must be kept straight, so that diaphragmatic movement is not inhibited. Children can sit or kneel with the head and upper chest resting against pillow.

iii. Relaxed sitting (fig D)

This is an unobstrusive position that can be taken up easily. The back should be kept straight, with the forearms resting on the thighs and the wrists relaxed.

 iv. Forward lean standing (fig E)

 If there is nowhere to sit many breathless patients find this position beneficial. The patient should lean forward with the forearm resting on an object of suitable height, such as the windowsill or banisters.

v. Relaxed standing (fig F)

 The patient can lean back against a wall with the feet placed slightly apart and approximately 30cm away from it. The shoulders and arms should be relaxed.

   

2. Breathing retraining

i. Breathing control on walking: - When the patient is able to control his breathing in necessary relaxed positions, progression can be made to the control of breathing while walking on the level, up stairs and on the hills.

Breathing in rhythm with their steps can be helpful; for example, breathing out for two steps and in for one step, out for three steps and in for two steps, or out for one step and in for one step. The correct breathing pattern will vary with each individual.

ii. Functional activities: - Some patients tend to become distressed when bending forward (e.g. to tie shoes laces). Many of them breathe in before bending down and experience discomfort due to the upward pressure of the abdominal contents against a flattened diaphragm. This discomfort is less if breathing out is encouraged while bending down. The next breath-in take place during the return to an upright position.

Many patients will need advice and help with daily activities such as bathing and dressing; often simple aids can help in making everyday tasks easier.

3. Mechanical ventilation

It is a process by which room air or O2 enriched air is moved into and out of the lungs mechanically.

It is mean of supporting patient until they recover the ability to breath independently.

Objectives

·        To reverse hypoxemia

·        To reverse acute respiratory acidosis

·        To relieve respiratory distress

·        To prevent or reverse atelectasis

·        To reverse ventilatory muscle fatigue.

·        To increase lungs volume

·        To maintain or improve cardiac output

·        To stabilize chest

·        To reduce or manipulate WOB

4. O2  therapy

O2 can improve both breathlessness and exercise tolerance but before prescribing a simple 6min walk test should be done.

5. Energy demand

There should be a balance between the energy supply and energy demand.

      Increases energy supply

·        Nutrition

·        O2 therapy

·        Fluid and electrolyte balance

·        O2 to inspiratory muscles

  Decrease energy demands

·        Stress reduction by counseling of patients

·        Rest/sleep

·        Positioning

·        Relaxation

·        Breathing re-education

·        Mechanical support