S e p t e m b e r , 1966 P H Y S I O T H E R A P Y Page 5 Physiotheraphy in Chest Conditions By M A R J O R I E M C D O W E L L , M. C.S.P. Phy siot he rap ist, B r o m p t o n Hosp ita l for Che st Diseases, L o n d o n , England. Chronic Bronchitis C h ro n i c Br onchitis in a lesser o r g re at er degree is p r e ­ valent th r o u g h o u t the worl d a n d certainly in the United K in gd o m it is a crippling and di sabling disease a n d a great deal o f research is being d o n e as to its causes, pr evention an d trea tme nt. C h ro ni c bron ch itis a n d em ph ys em a acc ou nt for the loss of m or e m a n h o u r s o f w o r k t h a n a ny o t h e r disease in Britain .—a b ou t 25-30 million day s a year, a n d in hospital r e spi rat ory diseases acc ou nt for ne arly o n e q u a r te r o f all admiss ions . In a c o un tr y such as o urs w it h over e m pl oy m en t this is o b v i o u s ­ ly a very serious m atter. Clim ate na tur all y plays a gr eat p a r t in re spi rat ory diseases as was dra m a tic al ly sh o w n by the great fog in L o n d o n in 1952 which lasted for fou r day s an d resulted in a n es timated 5,000 deat hs. A cold moist a tm o s p h e r e by itself does not particularly pred ispo se to r e sp ir at or y affections but if air pollution is ad d ed to it bro nc hitis a n d p n e u m o n i a tend to ensue. A very i m p o r t a n t cause o f bro nc hitis is sm oking. T o b a c c o smoke causes br onc hia l ir rit a tio n with the result th at ex­ cessive m uc us is fo rm ed . In time this will be com e evident in the for m o f muco id sput um . Treatment Prop hyl ax is is pr o b a b ly the most effective m e th od o f treatment available at the present time. This m ea ns wh e ne ve r possible avo iding infections, in ­ clement w e at h e r a n d ex po su re, an d ab o ve all giving up smoking. Until a few years ago ne arly all o u r br onc hit ic patients were tr eated as ou t patients because th ere were no beds available. T h e y c a m e twice a week for p h y s io th er a p y in classes lasting for a b o u t 40 minutes. T h e y were o f cour se told the impor ta nce a n d necessity o f pr act ising at h o m e, but this is obviously not the sa m e as h av ing the e n co ur a ge m e nt and help o f the phy siotherapist. T h e y also insisted up o n ke eping this a p p o in t m e n t w h a t ­ ever the weat he r, in spite o f being asked not to a tte nd in wet, cold or foggy days. T h e m aj o ri ty o f the patie nts also had little or no heat in g in their b e dr oo m s , so went from a stuffy living r o o m to a cold b e d ro o m which imme dia tel y star ted a “ wheeze” . T o d a y the picture is very different d u e to the decrease in T.B. in this c ou ntr y. Beds which were kept for patie nts with T.B. can n ow be used for the pati en t with c h r o ni c bronchitis and this has b r o u g h t a b o u t a d r a m a ti c ch an ge bo t h in t r ea t ­ ment an d in the well being o f the patient. T h e patient is usually ad m i t te d for a three weeks intensive course o f tr eat m en t. Lu ng fun ction and sp u t u m tests are d o ne , an tibiotics and steroids are given where necessary their effects wat che d c ar e ­ fully a nd th eir diet studied. Instead o f ph y si o th er a py twice weekly it is given 3 or 4 times daily a n d it is very h ear ten in g to see ho w quickly the patients re spo nd an d improve. O u r aims o f cour se are the sa m e: 1. Re la x at i o n — general an d local. 2. T ea ch i n g o f go od d i a p h r a g m a t ic an d lower costal breathing. 3. Modified po stural dra in a ge to help exp ecto ra tion. 4. T ea ch in g co n tro l o f b re at hi n g whilst w a lk in g — on the level, o n hills a n d stairs. 5. Ge nt le m ob ili sa tio n exercises for tr u n k an d t hor ax. 6. T ea ch in g pos itions to help overcome breathlessness. A position to help overcom e breathlessness. Thes e pa tients need a great deal o f very patient tr ea tm e n t; they are appreh en siv e a n d ne rvous a n d unwilling to d o a n y ­ thing which m ay m ak e th em m o r e breathless a nd start th em wheezing. T h e t h o u gh t o f a ny for m o f post ur al d r a in a ge frightens t h em ; they hav e slept with five or six pillows or even in an a rm c h ai r for long pe riods an d are afraid to lie flat. F o r this re as o n we hav e a modified for m o f po stural dr a in a g e which we call p os tu ra l coughing. T h e patient lies on one side with two pillows u nd e r his chest— his shoul de rs are on the bed and he needs two pillows u nde r his he ad an d his knees are bent. In this position percussion and shakings are given a n d we find it most effective. We like to give ten min ut es on each side, bu t at the beginning if the patient is very breathless he will only be abl e to to lerate five min ut es on one side a n d will need to sit up a nd get into the high side lying po sit ion : then 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. ) Page 6 P H Y S I O T H E R A P Y September, 1966 O ne o f the p o sitio n s to help overcom e breathlessness. af ter a rest will be a bl e to d o five m in u t e s o n the o t h e r side. T h is c an be g ra d ua lly pro gre ss ed as he im pr ove s. O f cour se the patie nts shou ld no t be left whilst th ey are in the p os tu ra l co ug h in g posi tio n, a n d t hey will need to d o it t hr ee or fou r times daily. Every pati en t is given a sheet o f exercises with d i ag r a m s sh ow in g all the po sit io ns to help t h e m whe n they a re b r e a t h ­ less, an d h ow to pra ctise th eir b re at h in g exercises t o ge th e r with tw o o r t h r ee simple relaxing exercises. T h e y practise all th e different po sit io n s an d discuss which po si tio n woul d help t h e m the mo st in a n y given circu mst anc e. T H E B IR D R E S P IR A T O R T h e pa tie nt w h o is very br eathless with sticky viscid s p u t u m which is almo st im possible to c o u g h up is p u t on a co ur se o f t r e a tm e n t wi th the Bird R e sp ir at or . T h e Bird is a n In t e rm i tt e n t Positive P re ss ur e R e s p i r a t o r whi ch gives 40 pe r cent o f oxygen an d 60 pe r cent o f air. At t h e onset o f in spi rat io n it delivers the mixtu re t h r o u g h a m o u th p i e ce until a p r e d e t e r m i n e d in tr a t h o r ac ic p re ssu re is r e ac h ed , usually 30 m m Hg, w h e n the flow stops a n d passive e x pi ra tio n ensues. Iso p re n al i n e is used in the neb ulize r to act as a b r o n c h o d il a t o r , 4 d r o p s o f 1 p e r cent so lu tio n in 46 d r o p s o f wa ter a n d if the s p u t u m is very viscid 2 d r o p s o f Axcosal is also a d d e d as this th ins d o w n the s p ut u m . I f the pa ti e n t is suffering b ad ly fro m A n o x i a a n d is only pa rtially c on sci ou s a m as k instead o f a m ou th pi e ce is used. P r o v i d i n g the Bird is used correctly, it is in va lu ab le but other wi se it is useless. T h e patie nt m u st just be t au gh t how t o b re at h using the bases o f his lungs because it is here the s p u t u m collects— t hu s he mu st be sh o w n h o w to use the B ird R espirator in use with a m outhpiece. mac hi ne. S o m e p ati en ts find this difficult an d it may take several visits befo re th ey m as te r the techniques. T h e ph y sio th er a p ist sets the m ac hi ne at the appro pri ate setting for e ach patient a c c or di n g to the s h a pe o f his chest a n d the a m o u n t o f resistance. She will e nc o ur a ge him to bre at h e with the bases o f his lungs by placing her ha n d s there a n d telling him to feel the air c o m in g in at the lower part o f his chest where he c an feel her hands. O nc e the patient u n d e r s t a n d s he c an co nt in u e the treat­ m ent alo n e , it sh o ul d be given 3 times a d a y for twenty m inutes. A f t e r a b o u t five m in u te s the patient will start co u g h in g and the s p u t u m will be e x p ect or at ed quite easily. It is very essential to prevent cross infection that each pati en t shou ld not only keep his o wn m o u th pi e ce but the who le o f the t u bi n g as well. T h is can all be sterilized when the tr e a tm e n t is finished. F o r the pati en t w h o is only se mi-conscious two physio­ th er a p is ts will be n e e d e d ; o n e to hold the mas k in position a nd m a i n t a i n the pati en t in a c o m f o r t a b l e position, and the o t h e r to give v ig or ou s p e rcu ss io n a nd shak ing s while the r e s p i r a t o r is being used. We find a ten m inu te tr eat m en t given t wo ho ur ly seems the mo st a d v a n t a g e o u s for these patients. E ver y pati en t p u t on to a co u rse with the Bird Respirator is t a u g h t by the p h ys io th er a pi st a nd f or this reason the res­ pi r at or s wh en used with the m as k o r m ou th pi e ce are part o f the e q u ip m e n t o f the P h y s i o t h e r a p y D e p a r t m e n t . B ird R espirator being u sed with a mask. 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. ) September, 1966 P H Y S I O T H E R A P Y Page 7 It has also been fo u n d th a t if a r e s p ira to r is n o t availab le, very good results can be o b ta in e d b y u sin g a h u m id ifie r w ith the same p ro p o rtio n o f Iso p re n a lin e a n d w a te r w ith a n oxygen cylinder. A gain it is esse n tia l fo r th e p h y sio th e ra p ist to be present a n d to give b re a th in g in stru c tio n s a n d sh a k in g s to the chest while th e hum id ifier is b e in g u se d . I n th is w ay the Isoprenaline will re a c h th e b a se s o f th e lu n g s a n d th e patient will be a ble to c o u g h q u ite easily. The Bird R e sp ira to r is also in v a lu a b le w ith th e P a ra p le g ic patient who has sp u tu m a n d is u n a b le to c o u g h . I t is v ery easy to feel in w hich a re a th e s p u tu m h a s colle cted , a n d th e patient should be tip p e d in th e a p p ro p ria te p o sitio n . H e m ay use either the m ask o r m o u th p ie c e ; a g a in s h a k in g a n d p e r­ cussion should be given a n d in a v e ry few m in u te s h e will start coughing. I f firm p re ssu re is th e n g iven o n th e a b ­ dominal wall he will get u p th e s p u tu m w ith o u t difficulty. Cystic Fibrosis A new and im p o rta n t field fo r p h y sio th e ra p y h a s re ce n tly been opened w ith th e tre a tm e n t o f b a b ie s a n d c h ild re n w ith Cystic Fibrosis o f th e P a n c re a s o r F ib ro s itic L u n g D ise a se. This is a disease o f c h ild h o o d w h ic h h a s b e co m e in cre asin g - I ly recognised since it w as first d e sc rib e d in 1938. M o d e m methods o f investigation a n d tre a tm e n t h a v e b e en highly successful in prolonging th e lives o f th e s e c h ild ren w h o n ow ha\e a good prospect o f e n te rin g a d o le sc en c e o r a d u lth o o d . The control o f p u lm o n a ry in fec tio n is th e k e y t o survival. The successful m an a g em e n t o f th is fe a tu re o f th e disease depends upon th e co m b in e d effo rts o f th e p h y sic ia n s, b a c ­ teriologist, p h y siotherapists a n d p a re n ts a c tin g as a te a m . Cystic fibrosis is a n in b o rn d isease w h ic h affects chiefly the lungs and digestive system . U n til it w as m ed ic ally re co g ­ nised 25 years ago these c h ild ren u su a lly d ie d o f p n e u m o n ia in the first year o f life. Later it was called m u covisidosis a n d th e e x p e c ta tio n of life was no m ore th a n five years. Today cystic fibrosis is k n o w n to b e th e c o m m o n e st genetically determ ined d iso rd e r a ffecting c h ild re n in B rita in . Most of the dam age is c au sed b y th e excessive v iscidity o r stickiness o f the m ucus w hich is p ro d u c e d in th e b ro n c h ii and also in the d u cts o f th e p a n c re a tic g la n d w h ic h p ro v id es enzy mes to help digestion. The m ajor clinical p ro b le m is th e lu n g s. T h e re is g re a t difficulty in keeping th e a ir pa ssa g es c le ar, e specially w h en infection with b acteria o r v iruses g re a tly in cre ases th e a m o u n t of mucus. I f the infection is n o t c o n tro lle d a re a s o f th e lu n g s will be destroyed, a n d m u ltip le lu n g c avities will d e velop. Until quite recently d o c to rs re lie d o n a n ti-b io tic s a lo n e to prevent lung infection a n d d id n o t e m p h a sise th e necessity and importance o f b re a th in g a n d c o u g h in g exercises. N o w while antibiotics re m a in a n e sse n tia l p a r t o f th e tre a tm e n t it is realised th at p h y sio th e ra p y to o is a b so lu te ly essential. Symptoms Shortly after b irth th e sy m p to m s m a y b e s lig h t; th e child will have a cough w hich is n o t u su a l a t a n e a rly age. T h e stools will be foul sm elling d u e t o th e p re sen c e o f larg e quantities o f pa rtially dig este d p r o te in a n d th e y will a lso contain large a m o u n ts o f u n a b s o rb e d fa t a n d a p p e a r oily and greasy. Usually the first sy m p to m th e m o th e r n o tic e s is t h a t th e child tastes salty w hen kissed. Treatment 1. Attention to n u tritio n . 2. Prevention a n d c o n tro l o f lu n g in fec tio n . 3. Respiratory e d u c a tio n a n d o th e r te c h n iq u e s fo r k e e p ­ ing clear th e re sp ira to ry p assages. The treatm ent m u st be s ta rte d a s e a rly as p o ssib le a n d therefore early diagnosis is e ssential. The child m ay o n ly be a few m o n th s o ld w h e n a d m itte d to hospital a nd will be b a rrie r n u rs e d to p re v e n t in fec tio n . The parents m u st realise t h a t p o s tu ra l d ra in a g e a n d breathing exercises a re e ssential fo r th e c h ild ’s su rv iv a l a n d must be continued fo r its w hole life. A s th e ch ild g ro w s o ld e n o u g h to u n d e r s ta n d ,'th e p h y sio ­ th e ra p y m u s t b e p re se n te d in su c h a w ay t h a t it is a c c ep te d a s p a r t o f th e d a ily life a n d n o t s o m e th in g th a t m a k e s h im differe n t fro m o th e r c h ild ren . F r o m th e very e a rly sta g es th e m o th e r will assist w ith th e tre a tm e n t in h o s p ita l so t h a t sh e k n o w s a n d co m p le te ly u n d e rs ta n d s h o w to c o n tin u e w h e n th e c hild goes ho m e. W ith b a b ie s it is o n ly p o ss ib le to give p o s tu ra l d ra in a g e. T h e y c a n b e tip p e d a n d s u p p o rte d in th e a p p ro p ria te p o sitio n o v e r a c u sh io n o r th e p h y s io th e ra p is t’s k n e es, a n d ge n tle sh a k in g s a n d p e rc u ss io n given. T h e ch ild w ill c o u g h b u t m o s t o f th e s p u tu m will b e sw allow ed. I t m a y b e n eces­ sa ry t o u se a fine c a th e te r w ith a s u c k e r to su c k o u t as m u c h as p o ssib le , e ith e r p u ttin g th e c a th e te r u p th e n o strils o r o v e r th e b a c k o f th e to n g u e . W h e n t h e c h ild re n a re b e tw ee n 2 \ a n d 3 y e ars o ld th e y w ill b e a b le t o s ta r t w ith b re a th in g exercises, le a rn in g d ia p h ra g m a tic a n d lo w e r c o sta l b re a th in g , a n d n o w th e y will b e a b le t o d o th e ir p o s tu ra l d ra in a g e in th e ir c o ts. I t will p ro b a b ly b e n e ce ssa ry to d ra in a ll a re a s o f th e lu n g s so a schem e m u st b e w o rk e d o u t so th a t e a c h a re a is d ra in e d , b u t th e c h ild re n d o n o t b e co m e e x h a u s te d a n d b e gin to d re a d th e p o s tu ra l d ra in a g e sessions. A s th e y g e t a little o ld e r th e y will a c c e p t it a s p a r t o f th e ir d a ily to ile t. L a te r loca lised b re a th in g exercises fo r a ll a re a s o f th e lu n g s will b e given a n d p o s tu ra l e xercises a d d e d . S om e c h ild re n m a y n e e d a lo b e c to m y a n d it is esse n tia l th a t th e y sh o u ld b e fit fo r th is , w ith th e re st o f th e ir lu n g fields c lear a n d g o o d loca lised m o v em e n ts. T h e s e c h ild re n a re v ery re w a rd in g to tr e a t a n d it is a g re at jo y to see th e m well a n d h a p p y a n d le a d in g a n o rm a l life a t h o m e a n d sc h o o l, esp e cially w h e n o n e re alises h o w b a d th e ir p ro g n o sis w as o n ly a few y e ars a g o . Photographs by: C liffo rd P h o to g ra p h y , U p p e r H a rle y S tre e t, L o n d o n , N . W . l . A ll ta k e n a t B ro m p to n H o s p ita l, L o n d o n . A. C. MILLER & CO. ORTHOPAEDIC MECHANICIANS Manufacturers and Suppliers of: O R T H O P A E D I C A P P L IA N C E S , A R T I F I C I A L L IM B S , T R U S S E S , S U R G I C A L C O R S E T S , U R IN A L S , A R C H S U P P O R T S , C O L O S T O M Y B E L T S , E L A S T IC S T O C K IN G S , A N K L E G U A R D S , W R IS T G U A R D S , E L B O W G U A R D S , K N E E G U A R D S , L I G H T D U R A L C R U T C H E S F O R C H I L D R E N , W O O D E N C R U T C H E S , A N D M E T A L E L B O W C R U T C H E S . Phone 23-2496 P.O. Box 3412 312 Bree Street, Johannesburg 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. )