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STRATEGIES FOR

REDUCED OF BREATHLESS

Sevgi Ozalevli, PhD, PT, Assoc.Prof.

School of Physical Therapy and Rehabilitation,

Dokuz Eylul University, Izmir.

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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 PositionsForward LeaningPursed 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

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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

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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 management-a consensus statement. Am J Respir Crit Care Med 1999

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Reduced elastic lung recoil Increased airway resistance

Expiratory flow limitation

Acute dynamic lung hyperinflation

Dyspnea

O’Donnell, 2007

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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

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Jones PW, 1998

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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

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Treatment of Dyspnea

Pharmacologic treatment Treatment with non-pharmacologic methods

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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 PositionsForward Leaning Pursed-lip Breathing Regulation in Breathing Pattern And Active Expiratory Tecnique Dyaphragmatic Breathing Exercise

4. Exercise Training5. Respiratory Muscle Training 6. Oxygen Therapy 7. Noninvasive Positive Pressure Ventilation8. Conductive Addition Therapies

YogaWalking Aids Walking And Exercise With MusicHypnosis Acupuncture-acupressırBiofeedback Neuromusculer Electric Stimulation (NMES) Use Cool Air To Face Organisation Of Environment Air And ConditionsPsychological SupportNutritional Support

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Patient/Family Education

in education program for reducing breathlessness It should be included

control of breathingorganization of home and environmentTo limit number of people in roomregulation of temperature and humiditystrategies for coping with stress, anxiety and depressiondeveloping self care coping strategies

AMA:EPEC 1999AMA:EPEC 1999

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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.

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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 strategiesQuality of sleepFunctional activities Quality of life

Work of breathing Heart rate Perception of dyspnea

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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, 1990Mahler, 1990

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Christenbery, 2005

Strategies for reducing breathlessness in patients with COPD

%

Moved slower 72Kept still 68Used extra oxygen 53

Practiced breathing exercises 47

Planned a decrease in activity 43

Exposed self to cool air 40Change of daily living activities 37

Took extra inhaler 32Change dressing 27

Changed eating habits 24

Used assistive devices 9

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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.

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Tecniques For Regulating Breathing And increasing Capacity

Of Pulmonary

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Relaxation Exercise and Positions

EfficacyEnsure breathing controlRegularize breathing rateIncrease tidal volumeReduce severity of anxietyReduce working of breathingReduce heart rateImprove quality of sleepReduce accessory muscles activitiesReduce perception of dyspnea

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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

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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.

Patients with chronic heart failure, n=158 Study group, 14 wks, progressive muscle relaxation by home program and workshopControl group, relaxation education, 45min

According to the control group, in study group; psyhologial stress, severity of dyspnea and fatigue were reduce..

Breathing rateAnxietyDyspnea

Yu, J Psychosom Res, 2007

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Progressive muscle relaxation

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Forward leaning

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Forward Leaning

Barach, 1974 Sharp, 1980Druz, 1982Delgato, 1982O’Neil, 1983

•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

20-45°

Dyspnea Diaphragm function

Hyperinflation ?

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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 byİmproved pulmonary gas change and reduced dyspnea by increased tidal

volume,İmproved deep and slow breathing and increased exercise capacity.

PLBE, a simple-easy technic, no need device, useable during the walking andother activities Puente-Maestu, 2006

Gigliotti, 2003Collins, 2001 Spahija, 2005

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12 wks, 1st wk-10 min, 4th wk- 25 min

in PLBE group, according to the expiratory muscle training andcontrol group,

Severity of dyspnea reducedInspiratory muscle strength and physical functional capacityincreased

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Reduced breathing frequence, increased tidal volume

and PaO2 improve alveolar ventilation, functional status and

reduce perception of dyspnea.

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

Regulation in Breathing Pattern And Active Expiratory Tecnique

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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

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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

Gigliotti, 2003, Ambrosino, 2004Reardon, 2005, Porta, 2005O’Donnell, 2005, Lacasse, 2006Georgiadou, 2007

Ventilatory limitation

Loss of physical

performance

Deconditioning

Dyspnea

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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, 2006Ries, 2007Geddes, 2008Shahin, 2008

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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, 2006Ries, 2007Geddes, 2008Shahin, 2008

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Oxygen TherapyOxygen;

Obtaines bronchodilatation

Reduces ventilatory demand

Reduces lung hyperinflation

ALLEVIATES DYSPNEA

This effect is independent from oxygen desaturation at rest.

Fujimoto, Chest, 2002

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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

Oxygen Therapy in COPD

IC ↑, EELV ↓ Dyspnea and leg fatigue ↓ and exercise time ↑ Relief not always correlated to degree of hypoxemia

O’Donnell, 2001

Alvis, 2003Wouters, 2006

Peters, Thorax 2006

Low-density oxygen = heliox 72 % + O2, 28 % or Heliox 79 % + O2, 21%

in COPD patients;Dynamic hyperinflation ↓Severity of dyspnea ↓ exercise capacity ↑

Chiappa, 2009Barclay, 2006

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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).

Ambulatory oxygen is useful.Eaton, 2002

Ozalevli, 2007

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not chronically hypoxic COPD patients, exertional desaturation 88% (n=41), 4L.min O2

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Rest of Respiratory Muscles and Mechanic Ventilation

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

Noninvasive Positive Pressure Ventilation

CPAP

With nasal mask, 30-60 min, 7.5-8 cmH2O CPAP

reduces dyspnea, improves QOL

Chest 2000; 118:1582-90

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1

2

3

4

5

M0 M12 M24

LTOT

NPPV

* *

MRC dyspneaMRC dyspnea

Stable hypercapnic COPD patients

6 months LTOT (n=47)

NPPV + LTOT (n=43)

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.

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suppl. O2 (2.3 L/min) suppl. O2 (2.3 L/min) + NPPV (29±4 mbar, 20/min)

Six minute walking test

20, COPD, FEV1 %27

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Dreher, 2007

Dyspnea 6↓4 (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

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Conductive addition therapies

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

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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

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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

Walking Aids (Rollators)

Solway, 2002Probst, 2004Gupta, 2006Crisafuli, 2007

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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 improvingfunctional exercise capacity by reducing dyspnea and rest duration.

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Walking And Exercise With MusicIn COPD patients, walking with music;

Not changes severity of dyspnea.Brooks, 2003

Pfiste, 1998

Decreases anxiety, fear of activity and dyspnea

Bauldoff, 2002Sidani, 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

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Hipnoz

17 asthma and allergy patients (mean age 13.4)

Hypnosis for relaxation and symptom control1 month followDyspnea reduced in child specially which teaching self-hypnosis

There is not enough research about this issue

Pediatrics 2001;107(2).

Hypnosis

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Acupuncture&Acupressure

Acupuncturein COPD patients, No change in dyspnea

Lewith, 2004Vicker, 2005

reduces dyspnea severity Jobst, 1986Maa, 1997

Acupressure is a non-invasive method which can used at home.need to research of it’s effects

44 COPD patients, 7 sessions/week, 6 wks, acupressure

Severity of Dyspnea ↓ (p<0.05)Wu, J Adv Nurs, 2004

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BiofeedbackUsed with aim of

improving breathing controldeveloping functional staturegulating breathing patternincreasing tidal volumedeveloping relaxationdecreasing stress

It was found that biofeedback with breathing voice was reduced bronchospasm according to the control group in mild-modarate asthma patients in study

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Biofeedback Incentive spirometry Pulse Oksimetry PEF meter

EMG Biyofeedback

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Patients with COPD, n=20,Biofeedback with pulse oxymeter (with follow heart rate and peripheral saturation)

+ Walking program

10 wks,Increase walking distanceReduce dyspneaImprove quality of life

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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

Neuromuscular Electrical Stimulation

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Conclusion: Electrical stimulation + usual rehabilitation was

reduce dyspnea during the daily life activities

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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)

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Strategies which are no have evidence and need research

Organisation of enviroment air and conditions Humidity, very hot and dirty air = Bronchospasm + Dyspnea

Nutritional Support

High carbohydrate = Severe Dyspnea

High fat + Low carbohydrate = Mild Dyspnea

Psychological and Psychosocial Support

Anxiety and depression ↓ = Dyspnea ?

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Conclusion Breathlessness is a multifactorial problem

The best strategy for reducing it

Multifactorial assessment

Breathlessness

55THANKS