Ms Lucy is 19 years old went to emergency unit due to SOB or dyspnea after a hard ride horse. These symptoms become worse after exposure with dust inhalation. During the physical examination the result reveals that she is awake, inability to rest, mild difficulty to breath, slight sweating and sitting in front of the bed leaning forward with his arm rest on his knees. She often coughs with productive in small amounts of greenish sputum. SCM tenderness and reduce chest expansion and expiration
longer than inspiration. On auscultation musical whistling sound heard entire chest area. She experienced slight pyrexia a week ago, restlessness, coughing with greenish yellow phlegm, and she claimed on and off slight whistling in her chest over a past few years ago. According to her there is no any medical illness related to the lungs and no significant of lung disease for her family members.
According to my knowledge Ms Lucy condition is allergic asthma which is one of the obstructive pulmonary diseases type. These bronchi airways become narrow, inflamed and reducing flexibility of smooth muscle contraction in bronchi and lead to muscle spasm causing difficulty in breathing especially during expiration. Asthma can be divided to allergy and non-allergy asthma. According Ms Lucy situation, her symptoms triggered by dust inhalation during the horse hard ride which is known as allergy asthma.
It caused by bronchial inflammation secondary to inhalation of ambient dusts, gases, fumes and animal dander. OA may also be defined as variable airflow limitation caused by a specific agent in the workplace (Bardana EJ, Montanaro A, 2001).
Several Pathophysiology factors contribute to dyspnoea include an increased intrinsic mechanical loading of the inspiratory muscles, Increased mechanical restriction of the chest wall, Functional inspiratory muscle weakness, increased ventilator demand related to capacity, gas exchange, abnormalities, and dynamic airway compression or, cardiovascular effects, Cardiovascular effect (R Gosselink, 2004).
PRIORITIZING THE PROBLEMS
Dyspnea is the unpleasant awareness of difficulty breathing or shortness of breath (SOB) in a proper setting such as at rest or with limited exertion. It is described the feelings of breathlessness or sensation of air needed at rest or during exercise. Dyspnea is most of distressing symptoms of respiratory diseases, often causing the patient to reduce physical activity and seek a medical attention. SOB frequently impairs the ability to work or exercise and even interferes with the simplest activities of daily living like eating, bathing, speaking, and sleeping.
STERNOCLEIDOMASTOID (SCM) MUSCLE SPASM
Increase of SCM muscle in tensed due to increase work of breathing in accessory muscle which is patient unable to expand fully the entire lung because of the reducing ability of respiratory during to breath out all the stale air in alveoli.
REDUCE CHEST EXPANSION/CHEST CIRCUMFERENCES/CHEST DIAMETER
Subjects were instructed to fully inhale and exhale in the standing or sitting position. The differences between full inhalation and exhalation were known as chest expansion. The chest circumference measured using a tape measurement at 3 levels: at the axilla (4th rib) for upper chest movement, xiphoid process for middle chest movement and 10th costal cartilage levels for lower chest movement. The chest diameter was measured using a caliper in the anteroposterior (AP) and mediolateral (ML) directions at the xiphisternal junction, (Anong Tantisuwat, PhD1)*, Premtip ThaveeraItham, PhD12014).
Wheezing sound is generated by the vibrations of the wall of a narrowed or compressed airway as air passes through at high velocity. The diameter of an airway may be reduced by bronchospasm, mucosal edema, or foreign objects. Low pitch continuous sounds are often associated with the presence of excessive sputum in the airway. A sputum flap vibrating in the airstream may produce low-pitched wheezes that clear after the patient cough. Wheezing can be heard during exhaled by using of stethoscope or audible.
According to Robert L. Wilkins, Susan Jones Krider, Richard L. Shedon (1995) Vital Sign shown blood pressure is 130/85mm Hg (increase slightly), respiratory rate is 38bpm which is tachypnea and Heart rate is 100bpm tachycardia. Arterial blood gas shown that PaO2 is 49mmHg which is partial pressure of oxygen in arterial blood reduce which is lung cannot transfer oxygen from the environment to the circulatory blood due to bronchi inflammation and secretion.
SPIROMETRY is FEV1 1.5 L
Spirometry measure the maximal volume of air exhaled during the first second of expiration. It is a forced maneuver, highly significant and the best indicator of obstructive diseases. It reflects the flow characteristics in the larger airways. Acute reduction in FEV1 as occurs in asthma cause ventilation perfusion mismatching and hypoxemia. The degree of hypoxemia generally depends on the severity of the airway obstruction as assessed by the reduction in FEV1 the more significant the hypoxemia. Acute decrease in FEV1 initially results in respiratory alkalosis.
FORCE VITAL CAPACITY (FVC) is 2.1 L
Obstructive lung disease causes a reduction in the FVC by causing a slow rise in the residual volume (RV). Since the lung is contained in the thoracic cage, which is relatively rigid structure, space must be made for this expanding RV. The only space readily available is that used by volume capacity (VC). Therefore, as the RV increase, VC reduces.
PEAK FLOW IS 140L/MIN
Peak flow can be identifying the severity of the airways obstruction. If the peak flow less than 100L/min, severe obstruction is present 100-200L/m indicates moderate obstruction and over 200L/m suggests mild diseases. Peak flow can be used by the asthmatic patient to self-monitor home care.
According to R Gosselink (2004) there are a few treatment options as follows;
Efficacy of breathing techniques aiming at improvement of inspiratory muscle function; Breathing techniques and body positions aim to improve the length-tension relationship and increase strength and endurance of the inspiratory muscles, such as:
Active expiration will increase elastic recoil pressure of the diaphragm, and the rib cage. The release of this pressure after relaxation of the expiratory muscles will help the next inspiration. In healthy subjects, active expiration is brought into play only with increased ventilation.
Relief of dyspnea is often experienced by patients in the forward leaning position. The effect of this position seems unrelated to the severity of airway obstruction, changes in minute ventilation or improved oxygenation.
RESPIRATORY MUSCLE TRAINING
Respiratory muscle training divided into three types; inspiratory muscle training, inspiratory resistive training, threshold loading and normocapnic hyperpnoea (NCH). During inspiratory resistive breathing the patient inspires through a mouthpiece and adapter with and adjustable diameter. This resistance is flow dependent. Adequate training intensity is only achieved by feedback of the target pressure since flow and pressure are tightly coupled. More recently a flow independent resistance was developed, so-called threshold loading with a valve that opens at a critical pressure.
Efficacy of breathing techniques aiming at improvement of thoracoabdominal movements; Alterations of chest wall motion are common in patients with asthma and COPD. Several studies have described an increase in rib cage contribution to chest wall motion such as;
During diaphragmatic breathing the patient is told to move the abdominal wall predominantly during inspiration and to reduce upper rib cage motion. This aims to improve chest wall motion and the distribution of ventilation, to decrease the energy cost of breathing, the contribution of rib cage muscles and dyspnea and to improve exercise performance.
TIMING OF BREATHING
Since, for given minute ventilation, alveolar ventilation improves when breathing at a slower rate and higher tidal volume (TV), this type of breathing is encouraged for patients with impaired alveolar ventilation.
Efficacy of breathing techniques aiming at reduction of hyperinflation and improvement of gas exchange; Hyperinflation is due to altered static lung mechanics (loss of elastic recoil pressure, static hyperinflation) and dynamic factors (air trapping and increased activity of inspiratory muscles during expiration, dynamic hyperinflation). The idea of decreasing dyspnea by reducing dynamic hyperinflation of the rib cage is based on the assumption that this intervention will result in the inspiratory muscles working over a more advantageous part of their length-tension relationship such as;
The rationale for relaxation exercises arises from the observation that hyperinflation in (partial) reversible airway obstruction is, at least in part caused by an increased activity of the inspiratory muscles during expiration.
PURSED LIPS BREATHING
Pursed lips breathing (PLB) aims to improve expiration both by its active and prolonged expiration and by preventing airway collapse. The subject performs a moderately active expiration through the half-opened lips inducing expiratory mouth pressures of about 5 cm H20. PLB appears to be effective in improving gas exchange and reducing dyspnea (R Garrod, 2002).
RIB CAGE MOBILIZATION TECHNIQUES
Mobilization of rib cage joints appears a specific aim for physiotherapy as rib cage mobility seems to be reduced in obstructive lung disease. Subjective will instructed to inhaled along with shoulder girdle movement, hold for two to three second and exhaled along with bending trunk forward and compress the abdominal wall inside.
Feeling of the difficulty breathing makes feels depressed and distressing. A some other health related measures completed: the Medical Research Council (MRC) Dyspnea scale, used to classify participants according to the magnitude of task that stimulates dyspnea (range 1 to 5, with higher scores corresponding to worse status); the St George’s Respiratory Questionnaire (SGRQ), a standardized questionnaire for the assessment of health related quality of life in obstructive lung disease (higher scores
connote greater impairment) and the Hospital Anxiety and Depression scale (HAD) a widely used tool for assessing psychological distress (7 items tap anxiety with a score range of 0 to 21, and 7 items tap depression with a score range of 0 -21; higher scores indicate greater emotional distress).
Pulmonary function tests and the six-minute walk distance test (6MWD) were conducted at study entry according to American Thoracic Society (ATS) guidelines, and values for forced expired volume in one second (FEV1) and forced vital capacity (FVC) were expressed as a percentage of age, gender, and height predicted normal (i.e., FEV1% and FVC%, respectively). Values for the distance walked during the 6MWD are reported in meters.
Participants were allocated to BTS stepwise management for adults with asthma according to prescribed medications (Step 1: Mild intermittent asthma – inhaled short-acting ß2 agonist as required, Step 2: Regular preventer therapy – inhaled steroid 200-800mg, Step 3: initial add-on therapy – inhaled long-acting ß2 agonist, Step 4: persistent poor control – increased inhaled steroid, addition of fourth drug example leukotriene receptor antagonist, Step 5: continuous or frequent use of oral steroids).
6 MINUTES WALKING TEST
The walking test were conducted in an enclosed corridor on a course 33-meter long. The patient was instructed to walk from end to end, covering as much ground as they could during the time. To encourage patient the supervisor sat in a chair at one end of the course, avoiding eye contact with the patient and remaining silent. Encourage patient with “you are doing well” or “keep up the good work.” Inform patient about the time and keep on asking patient the level of SOB (Can med Assoc J 1985).
The subjects instructed to quantify their feelings of breathlessness. This was defined as the feeling of an uncomfortable need to breathe and not any other sensation associated with exercise such as fatigue or their awareness that ventilation had increased. At the end of each minute of exercise subjects asked to estimate their level of breathlessness if any using a modified Borg scale; 0-10 (0 is nothing at all and 10 is maximal breathlessness (R. C. Wilson and P. W. Jones 1990).
MAXIMAL INSPIRATORY PRESSURE (PI MAX) & MAXIMAL EXPIRATORY PRESSURE (PE MAX):
Goal: To measure the strength of the respiratory muscles”,
Technique: the amount of pressure the subject can generate in:
Deep inspiration (inspiratory muscles): (Pi-max)
Deep expiration (expiratory muscles): Pe-max
Normal value: Pi-max (-60) & Pe-max (+120) cm H2O
Indications: neuromuscular diseases, unexplained decreases in VC & MVV Weaning (Pi-max > -30) Maher K. Tabba MD, MS (2019).
Measures the lung volume change during forced breathing maneuvers; forced vital capacity (FVC), forced expiratory volume in the first second (FEV1) Maher K. Tabba MD, MS (2019).
Allergic asthma is very common; there are other types of asthma with different kinds of triggers. For some people, asthma can be triggered by exercise, infections, cold air, gastro esophageal reflux disease or stress. Many people have more than one kind of asthma trigger. However asthma can be trigger by a strong emotion like cry, laughing, nervous and fatigue, etc.
Total no of words: 2071