6 a s th m a a n d w h o h a v e f a ile d to assess th e s e v e rity o f a s th m a a d e q u a te ly . O n ly a sm a ll p e rc e n ta g e o f p a tie n ts p re s e n tin g w ith a c u te se v e re a s th m a w ill f a il to re s p o n d to a ll th e m e a s u re s o u tlin e d a b o v e a n d th e s e p a tie n ts m a y n e e d i n tu b a tio n a n d v e n tila tio n as a life -sa v in g p ro c e d u re . A lth o u g h p a tie n ts w ith se v e re a tta c k s o f a s th m a m a y b e s y m p to m a tic a lly b e tte r w ith in m in u te s a n d h o u r s o f in s titu tin g a p p r o p r ia te tre a tm e n t, it o fte n ta k e s m a n y d a y s o f tre a tm e n t to a c h ie v e c o m p le te r e v e rs ib ility o f a irw a y s o b s tru c tio n . T w ic e d a ily m o n ito r in g o f p e a k flow r a te o r F E V 1 /F V C , a n d p u ls e r a te d u rin g th e re c o v e ry p e r io d w ill b e th e m o s t a c c u ra te m e a n s o f a sse ssin g p ro g ress. In terval T herapy T h e o b je c t o f in te rv a l th e ra p y o f a sth m a is to k e ep th e p a tie n t a s y m p to m a tic a n d to k e e p p u lm o n a ry fu n c tio n as close to n o r m a l as p o ssib le . T h is s h o u ld b e a c h ie v e d w ith th e lea st a m o u n t o f d ru g s p o ssib le . I n so m e p a tie n ts re g u la r u se o f a d ry a e ro s o l w ill b e a ll th a t is re q u ir e d , w h e re a s o th e r s m a y n e e d m o re in te n s iv e “ ro u n d -th e -c lo c k ” d ru g th e r a p y in c lu d in g in h a le d a n d o r a l c o rtic o s te ro id s . A s a s th m a is a flu c tu a tin g c o n d itio n , th e ra p y n e e d s c o n tin u a l a d ju s t­ m e n t to c o p e w ith e x a c e rb a tio n s a n d re m iss io n s . T h e u se o f a d ia r y c a rd k e p t b y a n in te llig e n t p a tie n t, c o m b in e d w ith s e ria l m e a su re s o f p e a k flow r a te o r F E V 1 /F V C , e n a b le u s to fo llo w th e p a tt e r n o f a sth m a in a n y in d iv id u a l p a tie n t a n d to re g u la te h is th e ra p y a c c o rd in g ly . P r e c ip ita tin g fa c to rs m u s t b e a v o id e d w h e re v e r p o ss ib le . I t m u s t b e e m p h a s iz e d th a t such o p tim u m in te rv a l th e r a p y re q u ire s fu ll p a tie n t co­ o p e r a tio n a n d th is can o n ly b e a c h ie v e d if th e p a tie n t is e d u c a te d a b o u t h is dise ase, a n d is w illin g to c o o p e ra te . D e s e n s itiz a tio n to a lle rg e n s p la y s a little r o le in th e o v e ra ll m a n a g e m e n t o f m o s t a s th m a tic s b u t m a y be im p o r ta n t in a fe w c a re fu lly se le c te d p a tie n ts w ith specific a lle rg ie s. P H Y S IO T H E R A P Y W h a t is th e r o le o f th e p h y s io th e r a p is t in a s th m a ? S h e is, in m y v iew , a v ita l p e rs o n in th e tre a tm e n t o f th e a s th m a tic p a tie n t. N o t o n ly s h o u ld sh e d e liv e r w et a e ro s o liz e d b r o n c h o d ila to r s , a n d h e lp th e p a tie n t c o u g h a n d c le a r se c re tio n s , b u t she s h o u ld h a v e a ni to in h e lp in g to e d u c a te p a tie n ts a b o u t t h e i r disease th e u se o f th e ir v a r io u s d ru g s, p a r tic u la r ly b r o n r ^ d ila to rs . H e r ro le in c o m fo rtin g a n d re a ss u rin g h p a tie n t w ith se v e re a s th m a in th e h o s p ita l se ttin g m n o t b e u n d e re s tim a te d a n d sh e c a n m a k e a re a l c o m ' 1 b u t io n in th is a re a . I t is n o w w e llk n o w n th a t v igorori' chest p h y s io th e r a p y is d a n g e ro u s d u rin g severe a sth rrf a n d is se ld o m re q u ir e d b e tw e e n a tta c k s. G e n tle ne c u ssio n a n d tip p in g m a y b e o f so m e v a lu e in p a tie n t' w ith e x cessive se c re tio n s a sso c ia te d w ith com plicatin b ro n c h ie c ta s is . B re a th in g e x erc ises in th em se lv es a re of lim ite d v a lu e b u t p r o v id e a b a sis f o r inter-reaction b e tw e e n p a tie n t a n d t h e r a p is t w h ic h le a d s to increased p a tie n t confidence. T h e p h y s io th e r a p is t sh o u ld bp f a m il ia r w ith th e W r ig h t ’s P e a k F lo w M e te r a n d the V ita lo g r a p h a n d sh e s h o u ld u s e th e s e ro u tin e ly to assess th e re s u lts o f th e b r o n c h o d il a to r th e ra p y she is a d m in is te r in g to h e r p a tie n t. D E A T H F R O M A S T H M A A lth o u g h d e a th f r o m a s th m a w as th o u g h t to be u n ­ c o m m o n a t th e t u r n o f th e c e n tu ry it is n o w widelv a c c e p te d th a t n o t o n ly d o e s d e a th o c c u r f r o m asthm a b u t t h a t in m a n y cases th is m a y b e p re v e n ta b le . One o f th e s tr ik in g fe a tu r e s w h ic h h a s b e e n em phasized r e c e n tly is h o w i n a d e q u a te th e a sse ss m e n t a n d tre a t­ m e n t o f a s th m a h a s b e e n in m a n y p a tie n ts d ying of a sth m a . Im p ro v e m e n t i n a sse ss m e n t a n d tre a tm e n t of p a tie n ts w ith a c u te a s th m a a n d im p ro v e m e n t in in te r­ v a l m a n a g e m e n t o f th e m a n y a s th m a tic s in o u r pop u ­ la tio n w ill r e q u ir e e d u c a tio n o f d o c to rs , p h y sio ­ th e ra p is ts a n d p a tie n ts a b o u t th e d ise a s e , a n d the p ro v is io n o f a d e q u a te sta ff a n d fa c ilitie s . C O N C L U S IO N S A s th m a is a c o m m o n d is o rd e r. I t p ro d u c e s a g reat d e a l o f su ffe rin g a n d a n o t in c o n s id e ra b le m o rta lity . O u r u n d e rs ta n d in g o f th e c o n d itio n h a s advanced g re a tly in th e la s t d e ca d e, a n d th e b e n e fit o f our. im ­ p ro v e d k n o w le d g e n o w n e e d s to b e tra n s la te d into p a tie n t c a re , n o t o n ly in sp e c ia lis e d u n its , b u t th ro u g h ­ o u t a ll h e a lth c a re services. JUNE 1978P H Y S I O T H E R A P Y PHYSIOTHERAPY IN OBSTRUCTIVE AIRWAYS DISEASE M IS S D . G A S K E L L , M .C .S .P . T h e p h y s io th e r a p y te c h n iq u e s u se d in th e tre a tm e n t o f a s th m a , c h ro n ic b r o n c h itis a n d e m p h y s e m a a r e v e ry s im ila r, b u t th e i r a p p lic a tio n in th e tre a tm e n t o f th ese d ise ases is to ta lly d iffe re n t. F o r th is r e a s o n t h e d ise ases w ill b e d e a lt w ith se p a ra te ly . A sthm a P h y s io th e r a p y m a y b e o rd e re d f o r a s th m a p a tie n ts w h o se c o n d itio n w ill v a r y f r o m th e p e rs o n in s ta tu s a s th m a tic u s to so m e o n e c o m p le te ly fr e e o f a s th m a a t th e tim e o f tre a tm e n t. T h e ty p e o f p a tie n t se e n b y p h y s io th e ra p is ts in o u t ­ p a tie n t d e p a rtm e n ts w ill v a ry f r o m a y o u n g c h ild to th e o ld e r in d iv id u a l w ith m o re c h ro n ic d isease. I t sh o u ld n o t b e n e c e s s a ry f o r o u tp a tie n ts to a tte n d f o r lo n g p e rio d s o f tre a tm e n t, sin c e th e r o le o f th e p h y s io th e r a ­ p is t is to e d u c a te th e p a tie n t a n d h is re la tiv e s in how to c o p e w ith h is c o n d itio n a t h o m e . I t m a y b e necessary to tr e a t th e p a ti e n t s u b s e q u e n tly f o r lim ite d p e rio d s o f tim e d u r in g a c u te e x a c e rb a tio n s , b u t if th e p a tie n t has b e e n c o rre c tly tr a in e d b y th e p h y s io th e r a p is t, h e should b e a b le to c o p e o n h is o w n f o r m o s t o f th e tim e. T h e a im s o f tre a tm e n t a re to a c h ie v e b ro n c h o d ila ta - tio n , to re m o v e a n y s e c re tio n s p re s e n t a n d t o te a c h the p a tie n t h o w to c o n tro l h is b r e a th in g in v a rio u s re ­ la x e d p o sitio n s . C h ild re n m a y r e q u ir e p o s tu re exercises. I t is h e lp f u l to assess p a tie n ts b e fo re a n d a fte r p h y s io th e ra p y b y m e a n s o f a p e a k flow m e te r o r a V ita lo g ra p h y . M a n y o u tp a tie n ts w ill get a m e a s u r a b le re s p o n s e to a b r o n c h o d ila to r g iv e n b y m e a n s o f a p re s s u ris e d a e ro so l, p ro v id in g th e y a re u s in g th e device c o rre c tly . P a tie n ts w h o d o n o t get a g o o d , re sp o n se are fre q u e n tly u sin g th e d e v ic e in c o rre c tly a n d it is im por- R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) * fo r th e p h y s io th e r a p is t to c h ec k o n th is a n d , if tan ssary, to use a p la c e b o a e ro s o l to e d u c a te th e netient in th e c o r re c t te c h n iq u e . T h e r e a r e a fe w * tie n ts w h o seem to get a b e tte r re sp o n se f r o m w et P a , u l i s a t i o n a n d in th e s e cases th e p re s c rib e d b ro n c h o - !rlator can b e d e liv e re d by m e a n s o f a s im p le n e b u lis e r n off oxygen o r a n a ir c o m p re ss o r. (T h e H u d s o n o r u jn in e b n e b u lis e rs a re s u ita b le f o r th is .) I t is n o t ,..-essary to d e liv e r b r o n c h o d ila to r s b y m e a n s o f IP P B f o r this g ro u p o f p a tie n ts (W e b b e r et al. 1974). \ l a x i m u m b r o n c h o d ila tio n w ill h a v e b e e n a c h ie v e d bout te n m in u te s a f te r th e in h a la tio n o f th e d ru g a n d n a t i e n t s w ith se c re tio n s s h o u ld b e e n c o u ra g e d to c o u g h t this stage. M a n y c h ro n ic a s th m a tic s h a v e se c re tio n s and benefit f r o m p o s tu r a l d ra in a g e o r a m o d ifie d f o r m 0f this c o m b in e d w ith b a s a l e x p a n s io n a n d c hest shaking- I t s h o u ld b e re m e m b e re d t h a t ex ce ssiv e c o u g h ­ ing can in c re a s e a irw a y s o b s tr u c tio n a n d t h a t a sth m a patients sh o u ld n o t b e fo rc e d to c o u g h u n n e c e ssa rily . It is im p o r ta n t to te a c h p a tie n ts h o w to b re a th e w h e n in re sp ira to ry d istre s s; th e y s h o u ld b e in s tr u c te d to get •pto a re la x e d p o s itio n (h ig h sid e ly in g , fo r w a r d le a n Jtting o r k n e e lin g , re la x e d s ittin g o r s ta n d in g ), a n d to do gentle d ia p h r a g m a tic b r e a th in g a t t h e ir o w n ra te . Once th e y h a v e a c h ie v e d a m o re c o n tro lle d a n d c o ­ o r d in a te d p a tt e r n o f b re a th in g , th e y m a y th e n b e a b le to slow d o w n t h e ir r e s p ir a to r y ra te . B r e a th in g ex erc ises alone w ill n o t a lte r th e r e s u lts o f p u lm o n a r y f u n c tio n tests in a s th m a tic p a tie n ts ; th e a im is to te a c h th e patient to b r e a th e w ith th e m in im u m o f effo rt. P a tie n ts w ith se v e re a s th m a w h ic h is n o t re s p o n d in g to tre a tm e n t m a y h a v e to b e a d m itte d to h o s p ita l. Assessment is e x tre m e ly im p o r ta n t a n d , if p o ss ib le , a peak flow c h a r t s h o u ld b e k e p t in o r d e r to m o n ito r the p a tie n t’s p ro g re ss. T h e p re s c rib e d b r o n c h o d ila t o r should be d e liv e re d b y m e a n s o f a s im p le n e b u lis e r. O ccasionally IP P B c a n b e u se d , a lth o u g h it s h o u ld only be c o n sid e re d if th e p a ti e n t is v e ry e x h a u s te d o r is k n ow n to h a v e p a r ti c u la r ly la rg e a n d te n a c io u s p lu g s of sp u tu m as in a sp e rg illo sis. T h e in h a la tio n is g iv e n in a sittin g o r h ig h sid e ly in g p o sitio n . C e rta in p a tie n ts s t a r t to c o u g h s p o n ta n e o u s ly d u rin g the in h a la tio n a n d o n c e it is c o m p le te d a ssista n c e can be g iven b y g e n tle s h a k in g to a lt e rn a te sid e s o f th e chest in a s ittin g o r h ig h sid e ly in g p o s itio n . I f th e cough is n o t p ro d u c tiv e , th e p h y s io th e r a p is t s h o u ld n o t persist in a tte m p ts to m o b ilis e se c re tio n s , as th is w ill only a g g ra v a te b ro n c h o s p a s m . I n th is s itu a tio n , the patient s h o u ld b e m a d e c o m fo rta b le a n d e n c o u ra g e d p b re a th e w ith th e m in im u m o f e ffo rt a n d th e tr e a t ­ m ent r e p e a te d f o u r h o u r s la te r. U n til b ro n c h o d ila ta tio n has b e e n a c h ie v e d , it is im p o s s ib le to m o b ilis e th e secretions a n d s e v e ra l tr e a tm e n ts a re s o m e tim e s n e c e s­ sary b e f o re th e p a ti e n t is a b le to e x p e c to ra te . O nce th e p a t i e n t ’s c o n d itio n s ta rts to im p ro v e , th o se wth excessive se c re tio n s w ill b e n e fit f r o m p o s tu r a l d ra in a g e a f te r u s e o f th e b r o n c h o d ila to r . I f th e p a tie n t is d y sp n o e ic h e m a y n o t t o le r a te t h is a n d it is b e tte r to tre a t h im in a lte r n a te s id e ly in g o r h ig h s id e lying. W h e n th e re s u lts o f p u lm o n a ry fu n c tio n te s ts h a v e im p ro v e d a n d s ta b ilis e d , th e n e b u lis e r s h o u ld b e d is ­ con tin u e d a n d th e b r o n c h o d il a to r g iv e n b y m e a n s o f a p re ssu rise d a e ro s o l. B e fo re d is c h a rg e f r o m h o s p ita l, the p h y s io th e r a p is t s h o u ld e n s u re th a t th e p a tie n t a n d his re la tiv e s k n o w h o w to m a n a g e a t h o m e. I t is v e ry r a r e to h a v e to in tu b a te a n d v e n tila te a n asthm a p a tie n t, b u t i f th e P C 0 2 is ra is e d a n d p u ls u s p a ra d o x u s is p re s e n t, i t m a y b e n e c e ssa ry to v e n tila te such a p a tie n t as a life -sa v in g m e a su re . P h y s io th e r a p y has no r o le to p la y in th e tr e a tm e n t o f a p a tie n t im m e ­ d iate ly a f te r in tu b a t io n as m a n u a l h y p e rin fla tio n (“b a g -sq u e e z in g ”) a n d s h a k in g o f th e c h est w ill o n ly a g g rav a te th e b ro n c h o s p a s m ( G o rm e z a n o a n d jUNlE 1978 3 B r a n th w a ite 1972). O n c e b r o n c h o d ila ta tio n h a s b e e n a c h ie v e d , g e n tle p h y s io th e ra p y c a n b e c o m m e n c e d in o r d e r to m o b ilis e se c re tio n s . A b r o n c h o d ila to r s h o u ld b e g iv e n b e fo re p h y s io th e ra p y a n d it is h e lp fu l to in s til n o r m a l s a lin e in to th e e n d o tra c h e a l tu b e d u rin g tre a tm e n t. I n itia ll y th e p a tie n t s h o u ld b e tu rn e d o n to a lte rn a te sides a n d g e n tle chest s h a k in g p e r fo r m e d o n e x p ir a tio n in tim e w ith th e v e n tila to r. If th is d o e s n o t h a v e a d e tr im e n ta l effect, w h ic h w ill b e sh o w n by in c re a s e d in s p ir a to r y p re s s u re o n th e v e n tila to r , m a n u a l h y p e rin fla tio n c a n b e a tte m p te d . I f a n y signs o f i n ­ crea se d b ro n c h o s p a s m b e c o m e a p p a r e n t, th e tre a tm e n t m u st b e m od ifie d . O n c e th e p a tie n t has b e e n e x tu b a te d , tre a tm e n t w ill b e c o n tin u e d as b e fo re . C h ron ic B ron ch itis T h e m a i n p r o b le m in c h ro n ic b r o n c h itis is h y p e r ­ s e c re tio n o f m u c u s a n d th e p r im a r y a im o f p h y s io ­ th e ra p y is to assist th e p a tie n t in c le a ra n c e o f h is se c re tio n s . A s t h e d ise a s e p ro g re s se s, th e p a tie n t m a y d e v e lo p s e c o n d a ry e m p h y s e m a a n d w ill r e q u ir e h e lp w ith c o n tr o l o f b re a th in g . P h y s io th e r a p y s h o u ld b e a d ju s te d to c o p e w ith th e d o m in a n t fa c to r. I n th e e a rly sta g es o f th e d ise a s e , th e s e p a tie n ts w ill b e seen in o u tp a tie n t d e p a rtm e n ts a n d th e m a in a im o f p h y s io th e r a p y is to te a c h th e p a tie n t h o w to c le a r h is se c re tio n s a n d to tr y to in c re a s e h is e x e rc is e to le ra n c e . I f th e p a tie n t is d y sp n o e ic , p o s itio n s o f r e la x a tio n w ith b r e a th in g c o n tro l c a n b e h e lp f u l a n d th e p a tie n t s h o u ld b e t a u g h t h o w to c o n tr o l h is b r e a th in g w h e n w a lk in g u p h ill o r o n sta irs . A s in a sth m a , th e s e p a tie n ts s h o u ld a tte n d f o r t r e a tm e n t in o r d e r to le a rn h o w to c o p e o n th e ir o w n a t h o m e a n d s h o u ld o n ly a tte n d s u b s e q u e n tly d u rin g a c u te e x a c e rb a tio n s o f t h e i r d isease. I f th e p h y s io th e r a p is t is a b le to d e v o te tim e to e d u c a t­ ing th e s e p a tie n ts a n d th e ir re la tiv e s in h o w to m aiiag e a t h o m e , r a th e r t h a n tre a tin g n u m e ro u s c h ro n ic o u t ­ p a tie n ts f o r u n lim ite d p e rio d s o f tim e , m u c h w ill h a v e b e e n a ch iev e d . I t m a y b e h e lp f u l to g e t a n o u tp a ti e n t to use a b r o n c h o d ila t o r b e fo re g iv in g p o s tu r a l d ra in a g e . I t is im p o r ta n t to te a c h th e p a tie n t h o w to c le a r h is s e c re ­ tio n s e a c h d a y a t h o m e a n d to sh o w h im h o w to tip h im s e lf tw ic e d a ily . I f th e b e d c a n n o t b e tilte d , a sim p le m e th o d is to tie a p ile o f n e w s p a p e rs to g e th e r a n d p la c e p illo w s o v e r th is ; th e p a tie n t can lie o v e r th is in o r d e r to tilt th e th o ra x . I f re la tiv e s a re w illin g to h e lp , th e y sh o u ld b e sh o w n h o w to p e rc u ss a n d sh a k e th e chest w all. I t is i m p o r t a n t f o r p a tie n ts w ith c h ro n ic b ro n c h itis to ta k e e x erc ise, a n d a s im p le m e a n s o f d o in g th is is to g iv e th e p a tie n t a c e rta in d is ta n c e to w a lk o r a n u m b e r o f s ta ir s to c lim b e a c h d a y a n d to g ra d u a lly in c re a s e th e tim e a n d d is ta n c e : e.g. to w a lk u p a n d d o w n five ste p s f o r tw o m in u te s a n d g ra d u a lly in c re a s e th e tim e a n d th e n th e d is ta n c e (M c G a v in e t al, 1977). P a tie n ts w h o a re d y s p n o e ic s h o u ld b e t a u g h t b r e a th ­ ing c o n tr o l as f o r a s th m a a n d it is im p o r ta n t to tea ch c o n tro lle d rh y th m ic a l b r e a th in g o n s ta irs a n d h ills (e.g. o u t f o r tw o ste p s a n d in f o r oiie step). T h e m a in a im o f o u tp a tie n t p h y s io th e r a p y is to e d u c a te th e p a tie n t a n d h is re la tiv e s in h o m e m a n a g e ­ m e n t. L o n g -te rm tre a tm e n t is n o t n e c e ssa ry , a lth o u g h th e p a ti e n t s h o u ld b e a b le to r e tu r n f o r f u r t h e r t r e a t ­ m e n t if a fre s h in fe c tio n o c cu rs. P a tie n ts a d m itte d to h o s p ita l w ith a c u te e x a c e rb a ­ tio n s o f c h ro n ic b r o n c h itis w ill r e q u ir e v ig o ro u s p h y s io ­ th e r a p y to assist in r e m o v a l u f se c re tio n s . A lth o u g h m a n y o f th e m m a y b e su ffe rin g f r o m c o r p u lm o n a le , o n c e a s u ita b le m e d ic a l re g im e h a s b e e n e sta b lish e d , th is s h o u ld n o t b e a d e te r r e n t to g iv in g p o s tu ra l d r a in ­ age a n d m o s t p a tie n ts w ill to le r a te th is. I t is o fte n 7F I S I O T E R A P I E R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 8 P H Y S I O T H E R A P Y JUNE 1978 h e lp fu l to g iv e a b r o n c h o d ila to r p r i o r to p h y s io th e ra p y a n d c e r ta in p a tie n ts w ill b e n efit f r o m a d d itio n a l h u m id ity . I f th e p a tie n t h a s diffic u lty in m o b ilis in g h is se c re tio n s a n d b e c o m e s e x h a u s te d d u rin g p h y s io th e ra p y , it m a y b e h e lp fu l to use I.P .P .B . d u rin g p o s tu ra l d r a in ­ a g e f o r a lim ite d p e rio d . M o s t p a tie n ts w ill b e a b le to m a n a g e w ith a m o u th p ie c e b u t if th e y a re c o n fu se d o r u n c o -o p e ra tiv e , th e u se o f a m a s k m a y b e n e ce ssa ry . I f a m a s k is u s e d a n d th e p a tie n t is se m i-c o m a to se , it is im p o r ta n t to e n s u re t h a t th e c h e s t w a ll is m o v in g a d e q u a te ly , o th e rw is e C 0 2 c a n b u ild u p in th e m ask. I t is i m p o r ta n t to a d ju s t th e p re s s u re a n d flow r a te o f th e m a c h in e c o rre c tly in o r d e r to a c h ie v e c h e s t w a ll m o v e m e n t. T h e p a tie n t c a n be g iv e n p o s tu ra l d ra in a g e w h ile I.P .P .B . is b e in g u s e d a n d th e c h est w a ll sh a k e n o n th e e x p ir a to r y p h a se . T h is is o f te n v e ry effe c tiv e in th e m o b ilis a tio n o f se c re tio n s . T re a tm e n ts s h o u ld last a b o u t tw e n ty m in u te s a n d be r e p e a te d tw o -h o u rly in i­ tia lly . I f th e p a tie n t d oes n o t c o u g h s p o n ta n e o u s ly , it m a y b e n e c e s s a ry to c a rry o u t n a s o p h a ry n g e a l su c tio n d u rin g tre a tm e n t. V ig o r o u s a n d e ffective p h y s io th e ra p y c a n o f te n p r e v e n t th e n e e d f o r i n tu b a t io n o f th e s e p a tie n ts . O n th e r a r e o c c a sio n s t h a t su c h p a tie n ts a r e in tu b a te d a n d v e n tila te d , p h y s io th e ra p y , c o n sistin g o f m a n u a l h y p e rin fla tio n c o m b in e d w ith c h e s t s h a k in g a n d p o s tu ra l d ra in a g e , s h o u ld b e c o m m e n c e d as so o n as th e p a tie n t h a s s ta b ilis e d o n th e v e n tila to r. T h e a im is to c le a r th e se c re tio n s a s q u ic k ly as p o s s ib le in o r d e r to a v o id tr a c h e o s to m y a n d lo n g -te rm v e n tila tio n . E m ph ysem a T h e m a in a im o f p h y s io th e r a p y f o r e m p h y s e m a is to te a c h th e p a tie n t a m o re c o -o rd in a te d a n d c o n tro lle d p a tt e r n o f b re a th in g , to te a c h p o s itio n s o f r e la x a tio n th a t h e c a n u se w h e n d y sp n o e ic , to try to in c re a s e e x e rc is e to le ra n c e , a lth o u g h th is w ill p r o b a b ly be lim ite d , a n d to d e al w ith in fe c tio n s w h e n th e y o c cu r. C o n tro lle d d ia p h r a g m a tic b r e a th in g w ith re la x e d e x ­ p i r a t i o n s h o u ld b e t a u g h t in h ig h sid e ly in g a n d fo rw a rd le a n s ittin g ; th is c a n p ro g re s s to th e u s e o f th e u p r ig h t p o s itio n , a n d e v e n tu a lly th e p a tie n t s h o u ld b e a b le to b r e a th e in th is m a n n e r w h e n sta n d in g o r w a lk in g a b o u t, a lth o u g h th is m a y ta k e tim e . S o m e e m p h y s e m a ­ to u s p a tie n ts g e t a c e r ta in a m o u n t o f re s p o n s e f r o m a b r o n c h o d il a to r a n d , if so, th is s h o u ld be g iv e n bef0 p h y s io th e ra p y . re A p ro g ra m m e o f g ra d u a te d w a lk in g s h o u ld be Worked o u t f o r e a c h in d iv id u a l as f o r c h ro n ic b ro n c h itis , a n e m p h y s e m a to u s p a tie n t w ill b e lim ite d in ’ th a m o u n t h e c a n do. V e ry se v e re ly d is a b le d p a tie n ts a / so m e tim e s h e lp e d by a h ig h w a lk in g f r a m e a n d an o x y g e n c y lin d e r c a n b e a tta c h e d to it if necessary. M a n y e m p h y s e m a to u s p a tie n ts h a v e p ro b le m s with b a th in g a n d d re ssin g , a n d a d v ic e f r o m a n occu p a tio n a l t h e r a p is t o n th e s e a sp e c ts c a n b e in v a lu a b le . T h e m a jo r ity o f e m p h y s e m a to u s p a tie n ts do n o t have a la rg e a m o u n t o f s e c re tio n s a n d th e s e c a n u su a lly be c le a re d by s h a k in g th e c h est w a ll in h ig h sid e lying o r ly in g flat o n a lte rn a te sid es if th e p a tie n t will to le ra te it. B e ca u se o f t h e ir fla tte n e d d ia p h ra g m s , the m a jo r ity o f e m p h y s e m a to u s p a tie n ts a r e u n a b le to to le r a te tip p in g . T h e r e is a te n d e n c y f o r th e m to get a irw a y s h u td o w n w h ilst c o u g h in g w h ic h c a n som etim es re s u lt in c o u g h sy n c o p e ; th e p a tie n t s h o u ld be in­ s tru c te d to ta k e a n o th e r b r e a th in a f te r e v e ry tw o or th r e e c o u g h s. i I f a p a tie n t h a s d ifficulty in m o b ilis in g h is secretions* I.P .P .B . c o m b in e d w ith c h est s h a k in g m a y be h e lp fu l’ b u t th e in s p ir a to r y p re ssu re s s h o u ld b e k e p t lo w e r than n o r m a l a n d it is c o n tra -in d ic a te d if a n y la rg e bullae a r e p re se n t. I n c o n c lu sio n , th e r o le o f p h y s io th e r a p y in th e tre a t­ m e n t o f o b s tru c tiv e a irw a y s d ise ase is to e d u c a te the p a tie n t a n d h is fa m ily in h o w to m a n a g e a t h o m e and to tr e a t a n y su b s e q u e n t a c u te e x a c e rb a tio n s th a t occur e ith e r in h o s p ita l o r a s a s h o rt-te rm o u tp a tie n t. R eferen ces 1. G o rm e z a n o , J. a n d B ra n th w a ite , M . A . (1972): Effects o f p h y s io th e r a p y d u rin g in te r m itte n t p o s itiv e pres­ s u re v e n tila tio n . A n a e s th e s ia 27, 258 - 264. 2. M c G a v in , C. R ., G u p ta , S. P ., L lo y d , E . L. and M c H a rd y , G . J. R . (1977): T h o r a x , 32, 307. 3. W e b b e r, B. A ., Shenfield, G . M . a n d P a te rs o n , J. W. (1974): A c o m p a ris o n o f th r e e d iffe re n t tec h n iq u es f o r g iv in g n e b u lis e d a lb u te ro l to a s th m a tic patients. A m e ric a n R e v ie w o f R e s p ir a to r y D ise a se . 109, 293- 295. K R IT IE S E S O R G V E R F M G I N G V A N S U ID E L IK E A I'R IK A H ie r d ie m u ltid is s ip lin e re v e re n ig in g is o p 24 F e b r u a r i e 1978 g e stig e n a lle m ed ie se, v e rp le g in g s e n p a ra - m e d ie se p e rs o n e e l w a t a k tie f by in te n sie w e s o rg be- tro k k e is, is w e lk o m a s lede. A lle a n d e r p e rs o n e w a t b e la n g ste l in in te n sie w e sorg is w e lk o m as g e affilie erd e led e (so n d e r stem reg). L id m a a ts k a p s lu it in b y w o n in g v a n sim p o s ia (“ w o r k ­ s h o p s ”)/k o n g re s s e tee n d ie v a sg e ste ld e f o o i, ’n k w a rta a lik s e n u u s b r ie f e n ty d s k rifo p s o m m in g s d ie n s . L e d e g e ld e is as v olg: L e d e R 5 ,0 0 p e r ja a r G e a ffilie e rd e led e R 2 ,0 0 p e r ja a r P e rs o n e w a t b e la n g stel k a n in v e rb in d in g tr e e m e t: D r. N . B u c h a n a n , M e ta b o lie s e E e n h e id , B a ra g w a n a th H o s p ita a l, P o s k a n to o r B e rts h a m . 2013. C R IT IC A L C A R E M E D IC IN E SO C IE T Y F O R S O U T H E R N A F R I C A T h is m u ltid is c ip lin a r y so c ie ty w as in a u g u r a te d on 2 4 th F e b r u a r y 1978 a n d m e m b e rs h ip is o p e n to all m e d ic a l, n u rs in g a n d m e d ic a l a u x ilia r y p e rs o n n e l actively in v o lv e d in C ritic a l C a re M e d ic in e . A ffilia te m e m b e rs h ip (w ith o u t v o tin g rig h ts ) is open to a ll o th e r p e rso n s in te re s te d in c ritic a l care. M e m b e rs h ip a llo w s th e a tte n d a n c e a t w o rk s h o p s/ co n g resses a t th e sp ecified fee, r e c e ip t o f a q u a rte rly n e w s le tte r a n d j o u r n a l a b s tr a c tio n se rv ice . S u b s c rip tio n fe e s a re as fo llo w s :— M e m b e rs R 5 ,0 0 p e r a n n u m A ffilia te m e m b e rs R 2 ,5 0 p e r a n n u m I n te r e s te d p e rs o n s s h o u ld c o n ta c t:— D r . N . B u c h a n a n , M e ta b o lic U n it, B a ra g w a n a th H o s p ita l, P . 0 . 0 B e rts h a m , T v l. 2013. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )