Nefes Darliği İle Baş Edebi̇lme Yöntemleri̇

Nefes Darliği İle Baş Edebi̇lme Yöntemleri̇

STRATEGIES FOR REDUCED OF BREATHLESS Sevgi Ozalevli, PhD, PT, Assoc.Prof. School of Physical Therapy and Rehabilitation, Dokuz Eylul University, Izmir. 1 Content of the presentation

Breathlessness = Dyspnea, Definition, Causes Of Dyspnea Treatment Of Dyspnea, Non-pharmacologic Methods Patients And Familiy Education Strategies For Reducing Work Of Breathing And Consumption Of Oxygen Tecniques For Regulating Breathing And increasing Capacity Of Pulmonary Relaxation Exercise And Positions Forward Leaning Pursed Lips Breathing Regulation in Breathing Pattern And Active Expiratory Tecnique Diaphragmatic Breathing Exercises

Exercise Training Respiratory Muscle Training Oxygen Therapy Rest Of Respiratory Muscles And Mechanic Ventilation Conductive Addition Therapies 2 Breathless Dyspnea, Definition

The sensation of difficulty in breathing Breathing discomfort Inability to breathe deeply enough Increased respiratory effort that is unpleasant and regarded as inappropriate by the patient Awareness of respiratory distress Feeling breathless, suffocated Experiencing air hunger Richards, 1935 Mahler, 1984 3 Dyspnea Definition The experience derives from interactions among multiple physiological, psychological, social, and environmental

factors, and may induce secondary physiological and behavioral responses. American Thoracic Society. Dyspnea: mechanisms, assessment and managementa consensus statement. Am J Respir Crit Care Med 1999 4 Reduced elastic lung recoil Increased airway resistance Expiratory flow limitation Acute dynamic lung hyperinflation Dyspnea ODonnell, 2007

5 Causes of Chronic Dyspnea Airway disease

Parenchymal lung disease Pneumonia Pleural disease Pulmonary vascular disease Chest wall disease Respiratory muscle dysfunction Cardiovascular Anemia Decondition Psychological factors 6 Jones PW, 1998 7 Possible mechanism contributing to dyspnea in COPD

1. Increased ventilatory demand a. Increased physiological dead space b. hypoxemia c. Early onset of lactic acidosis d. Limp muscle weakness due to deconditioning, systemic effects of COPD, and/or poor nutrition. 2. Dinamic airway compression 3. Dynamic hyperinflation a. Increase in elastic loading b. Shortening of the vertical muscle fibers of the diaphragm (functional weakness) 4. Respiratory muscle weakness 8 Treatment of Dyspnea Pharmacologic treatment Treatment with non-pharmacologic methods

9 Non-pharmacologic Strategies 1. Patient/Family Education 2. Strategies for reducing work of breathing and consumption of oxygen 3.Tecniques For Regulation Breathing And increasing Capacity Of Pulmonary Relaxation Exercise And Positions Forward Leaning Pursed-lip Breathing Regulation in Breathing Pattern And Active Expiratory Tecnique Dyaphragmatic Breathing Exercise 4. Exercise Training 5. Respiratory Muscle Training 6. Oxygen Therapy 7. Noninvasive Positive Pressure Ventilation

8. Conductive Addition Therapies Yoga Walking Aids Walking And Exercise With Music Hypnosis Acupuncture-acupressr Biofeedback Neuromusculer Electric Stimulation (NMES) Use Cool Air To Face Organisation Of Environment Air And Conditions Psychological Support Nutritional Support 10 Patient/Family Education in education program for reducing breathlessness It should be included

control of breathing organization of home and environment To limit number of people in room regulation of temperature and humidity strategies for coping with stress, anxiety and depression developing self care coping strategies AMA:EPEC 1999 11 Patient/Family Education The coaching of nebulized bronchodilator therapy should be included on patients and familly education. During the therapy, unsupported seated and prolonged use of upper limbs, and rapid and shallow breathing pattern

should be keep down. 12 Strategies for reducing work of breathing and consumption of oxygen It is important to teach breathing with normal tidal volume and lower chest wall by relaxation to upper chest wall and shoulder and neck muscles Effects of this strategies Quality of sleep Functional activities Quality of life Work of breathing

Heart rate Perception of dyspnea 13 Strategies for reducing work of breathing and consumption of oxygen Aims

Reduce unsupportive body positions Reduce works which is doing against gravity Reduce change positions Reduce speed and deep of ventilation Reduce activity of accessory respiratory muscles Use advantage body positions (forward leaning) Use breathing control during the daily living activities Use relaxation in daily life Improve strategies for cope with stress Mahler, 1990 14 Strategies for reducing breathlessness in patients with COPD %

Moved slower 72 Kept still 68 Used extra oxygen 53 Practiced breathing exercises 47 Planned a decrease in activity

43 Exposed self to cool air Change of daily living activities 40 Took extra inhaler 32 Change dressing 27 Changed eating habits

24 Used assistive devices 9 37 Christenbery, 2005 15 The effects of education on the dyspnea perception? It has been determined that the patient education reduces dyspnea, increases quality of life,

improves life style adaptations, which include the use of inhaler, relaxation tecniques, energy conservation techniques, and strategies for coping with stress. Hunter & Hall, 1989. Howland, 1986. 16 Tecniques For Regulating Breathing And increasing Capacity Of Pulmonary 17 Relaxation Exercise and Positions Efficacy Ensure breathing control

Regularize breathing rate Increase tidal volume Reduce severity of anxiety Reduce working of breathing Reduce heart rate Improve quality of sleep Reduce accessory muscles activities Reduce perception of dyspnea 18 Relaxation Positions

High side lie Supin position with high head lie Forward leaning with supported upper extremities Forward leaning with supported by table Supported forward and rearward standing 19 Progressive muscle relaxation This is important strategy of breathing which is teaching to patient, inspiration

with contraction of all muscles groups during 5-10 sec and expiration with relaxation. Breathing rate Anxiety Dyspnea Patients with chronic heart failure, n=158 Study group, 14 wks, progressive muscle relaxation by home program and workshop Control group, relaxation education, 45min According to the control group, in study group; psyhologial stress, severity of dyspnea and fatigue were reduce. . Yu, J Psychosom Res, 2007 20 Progressive muscle relaxation

21 Forward leaning 22 Forward Leaning 20-45 Dyspnea Reduces scalen and sternomastoid muscles activities Increases transdiaphragmatic pressure Regulatesthoracoabdominal motions

Pectoral muscles by aid of supported upper extremities elevate upper ribcage Regulates and increased diaphragm function Increases Pimax Diaphragm function Hyperinflation ? Barach, 1974 Sharp, 1980 Druz, 1982 Delgato, 1982 ONeil, 1983 23

Pursed-lips Breathing Reduces FRC by increase bronchial diameter Delayes air way collaps by increased end expiratory lung volume Reduces dinamic hyperinflation Conclusion; It was determined that the PLBE was increased SaO2 and PaO2, alveolar ventilation, reduced PaCO2, breathing rate, minute ventilation by mproved pulmonary gas change and reduced dyspnea by increased tidal volume, mproved deep and slow breathing and increased exercise capacity. PLBE, a simple-easy technic, no need device, useable during the walking and

Puente-Maestu, 2006 other activities Gigliotti, 2003 Collins, 2001 Spahija, 2005 24 12 wks, 1st wk-10 min, 4th wk- 25 min in PLBE group, according to the expiratory muscle training and control group, Severity of dyspnea reduced Inspiratory muscle strength and physical functional capacity increased 25 Regulation in Breathing Pattern And Active Expiratory Tecnique

There is a positive correlation between the accessory respiratory muscles activity and severity of dyspnea Breslin, Chest, 1990 Slow and Deep Breathing (lower frequency, higher tidal volume breathing) Use for; improves of abnormal chest wall motions, reduces working of breathing, reduces activities of accessory respiratory muscles and dyspnea Reduced breathing frequence, increased tidal volume and PaO2 improve alveolar ventilation, functional status and reduce perception of dyspnea. 26 Diaphragmatic Breathing Increases abdominal motions and reduces upper rib cage motions No changes ventilation distribution Reduces working of breathing

Reduces severity of dyspnea Sackner, 1984 Grimby, 1975 Diaphragmatic breathing increases work of breathing in patients with severe COPD Gosselink, 1995 27 Exercise Training Exercise training for reduce dyspnea; Interval training

Upper extremities exercise Exercises must done with breathing control Aerobic + strength exercises Respiratory muscle training

Minimum 4 wks Patients education Ventilatory limitation Decondition ing Dyspnea Loss of physical performance

Gigliotti, 2003, Ambrosino, 2004 Reardon, 2005, Porta, 2005 ODonnell, 2005, Lacasse, 2006 Georgiadou, 2007 28 29 Respiratory Muscle Training In COPD patients, hastenes respiratory muscles adaptation respiratory muscle strength and endurance nocturnal desaturation exercise capacity tidal volume without changed minute ventilation breathing frequence (by increases expiration time and tidal volume)

Reduces dyspnea Gosselink, 2006 Ries, 2007 Geddes, 2008 Shahin, 2008 30 Respiratory Muscle Training In generally, respiratory muscle training was programmed with; Pimax 25-35 % 15 -30 min, 3-5 day/wk, 6-8 wks Gosselink, 2006 Ries, 2007

Geddes, 2008 Shahin, 2008 31 Oxygen Therapy Oxygen; Obtaines bronchodilatation Reduces ventilatory demand Reduces lung hyperinflation ALLEVIATES DYSPNEA This effect is independent from oxygen desaturation at rest. Fujimoto, Chest, 2002 32

Oxygen Therapy in COPD IC , EELV Dyspnea and leg fatigue and exercise time Relief not always correlated to degree of hypoxemia ODonnell, 2001 Alvis, 2003 Wouters, 2006

Peters, Thorax 2006 There was a low-grade scientific evidence that oxygen improves dyspnea in some patients with advanced pulmonary disease at rest. Gallagher, J Pain Palliat Care Pharmacother, 2004 Low-density oxygen = heliox 72 % + O2, 28 % or Heliox 79 % + O2, 21% in COPD patients; Dynamic hyperinflation Severity of dyspnea exercise capacity Chiappa, 2009 Barclay, 2006 33 Ambulatory oxygen is useful.

Eaton, 2002 Ozalevli, 2007 6-minute walking tests performed in room-air conditions (A6MWT) and with supplemental oxygen (O6MWT) in patients with chronic obstructive pulmonary disease (COPD) and exercise-induced oxygen desaturation. Walking distance was longer with the O6MWT than with the A6MWT (p=0.001). The O6MWT resulted in a smaller increase in dyspnea, leg fatigue, and heart rate and a smaller drop in pulsed saturation than the A6MWT (p<0.05). 34 not chronically hypoxic COPD patients, exertional desaturation 88% (n=41), 4L.min O2 35 Rest of Respiratory Muscles and Mechanic Ventilation

Noninvasive Positive Pressure Ventilation CPAP With nasal mask, 30-60 min, 7.5-8 cmH2O CPAP reduces dyspnea, improves QOL CPAP; Reduces inspiratory muscles effort Reduces inspiratory breathing work Improves diaphragmatic activity Improves quality of sleep Severe COPD, acute exacerbations COPD, severe congestive heart diseases, severe interstitial lung disease, sleep-apnea and neuromuscular disease Chest 2000; 118:158290 36

5 Stable hypercapnic COPD patients LTOT NPPV 4 6 months LTOT (n=47) 3 NPPV + LTOT (n=43) *

2 * 1 M0 M12 MRC dyspnea M24 Compared with long-term oxygen therapy alone, the addition of noninvasive positive pressure ventilation to long-term oxygen therapy in stable

chronic obstructive pulmonary disease patients with chronic ventilatory failure improved dyspnoea. 37 Six minute walking test suppl. O2 (2.3 L/min) + NPPV (294 mbar, 20/min) suppl. O2 (2.3 L/min) 20, COPD, FEV1 %27 38 Dyspnea 64 (M.Borg Scl)

Walking distance 209 252m In chronic hypercapnic chronic obstructive pulmonary disease, high-intensity noninvasive positive-pressure ventilation can administered during walking programs Dreher, 2007 39 Conductive addition therapies

Yoga Walking aids Walking and exercise with music Hypnosis Acupuncture-Acupressr Biofeedback Neuromusculer Electric Stimulation (NMES) Organisation of Environment air and conditions Use cool air to face Nutritional support Psychological support

40 Yoga Yoga = Deep breathing + Relaxation improves control of breathing by teaching deep and effective breathing and breathing awareness COPD patients, 12 wks, 2 sessions/wk, yoga Severity of Dyspnea *** Health-related quality of life Functional capacity Donesky-Cuenco, 2009 41 Walking Aids (Rollators) Improve forward leaning

support upper extremities position stabilization to upper rib cage Increase maximal volounter ventilation Decrease perception of dyspnea and leg fatigue Increase functional capacity and status in daily living activities Improve courage and morale Solway, 2002 Probst, 2004 Gupta, 2006 Crisafuli, 2007 42 Walking Aids

Forty, stable, severe COPD patients, One 6MWT was performed unaided, and the other was performed with a rollator Use of the rollator & reduction in dyspnea (p < 0.001) Conclusion: Use of a rollator was effective in improving functional exercise capacity by reducing dyspnea and rest duration. 43 Walking And Exercise With Music In COPD patients, walking with music; Not changes severity of dyspnea. Brooks, 2003 Pfiste, 1998

Decreases anxiety, fear of activity and dyspnea Bauldoff, 2002 Sidani, 2004 Exercise with music is a important strategy which make possible doing exercises with longer time and higher severity De Peuter, 2004 Need more research 44 Hipnoz Hypnosis

Pediatrics 2001;107(2). 17 asthma and allergy patients (mean age 13.4) Hypnosis for relaxation and symptom control 1 month follow Dyspnea reduced in child specially which teaching self-hypnosis There is not enough research about this issue 45 Acupuncture&Acupressure Acupuncture in COPD patients, No change in dyspnea Lewith, 2004 Vicker, 2005

reduces dyspnea severity Jobst, 1986 Maa, 1997 44 COPD patients, 7 sessions/week, 6 wks, acupressure Severity of Dyspnea (p<0.05) Wu, J Adv Nurs, 2004 Acupressure is a non-invasive method which can used at home. need to research of its effects 46 Biofeedback Used with aim of improving breathing control developing functional statu regulating breathing pattern

increasing tidal volume developing relaxation decreasing stress It was found that biofeedback with breathing voice was reduced bronchospasm according to the control group in mild-modarate asthma patients in study 47 Biofeedback Incentive spirometry Pulse Oksimetry

PEF meter EMG Biyofeedback 48 Patients with COPD, n=20, Biofeedback with pulse oxymeter (with follow heart rate and peripheral saturation) + Walking program 10 wks, Increase walking distance Reduce dyspnea Improve quality of life 49

Neuromuscular Electrical Stimulation Severe COPD patients (n=15) Home based NMES 6 wks Peripheral muscle strength, maximal exercise capacity were increase. Severity of Dyspnea (CRDQ) was reduce (p<0.05) Performance of daily life activities was improve.

Neder, Thorax, 2002 50 Conclusion: Electrical stimulation + usual rehabilitation was reduce dyspnea during the daily life activities 51 Strategies which are no evidence and need research Use cool air to face the use air to face, nasal mucousa and pharinx with hand fan is reducing dyspnea by innerve

fasial reseptors on trigeminal nerve Cheap, simple method!!! In health individual, effective (Schwartzstein, 1987) In COPD patients, effective (Galbraith, 2007) In severe COPD patients, not effective, In patients with cardiac disease, effective (Baltzan, 2000) 52 Strategies which are no have evidence and need research Organisation of enviroment air and conditions Humidity, very hot and dirty air = Bronchospasm + Dyspnea Psychological and Psychosocial Support Anxiety and depression = Dyspnea ? Nutritional Support

High carbohydrate = Severe Dyspnea High fat + Low carbohydrate = Mild Dyspnea 53 Conclusion Breathlessness is a multifactorial problem The best strategy for reducing it Multifactorial assessment Breathlessness 54 THANKS55

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