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332 PHYSIOTHERAPY

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PHYSIOTHERAPY

A M Yohannes, Manchester Metropolitan University, morbidity. Acute upper respiratory tract infections,
Manchester, UK including chronic lung diseases, are common causes
& 2006 Elsevier Ltd. All rights reserved. of visits to general practitioners; they are a common
cause of hospital admissions during the winter
months, particularly in the elderly.
Abstract Physiotherapy is the art and science of utilizing a
Physiotherapy has long been utilized in the treatment of patients variety of modalities to treat by using hands in order
with respiratory problems. In the late 1950s, breathing exercises to maximize physical function. Chest physiotherapy
were recommended as a treatment for patients with chronic chest
assists the clearance of secretions and reduces breath-
diseases but this suggestion was short-lived, as the efficacy of
these exercises was inconclusive. Until the late 1970s, chest lessness to improve lung function and reduce mor-
physiotherapy was a passive treatment on the part of the patient bidity and mortality. Excessive bronchial secretion
and the physiotherapist carried out manual chest physiotherapy retention may contribute to the development of
techniques including percussion, vibrations, and shaking with symptoms such as airflow obstruction, wheeze, short-
gravity-assisted positions. The development of the active cycle of
breathing technique (breathing control, lower thoracic expansion
ness of breath, fatigue, and cough.
exercises, and forced expiratory technique), autogenic drainage, Chest physiotherapy is defined as a combination of
and adjunct physiotherapy aids in the removal of secretions. several mucus-clearance techniques to treat patients
Procedures such as intermittent positive breathing techniques, with acute or chronic respiratory problems by as-
have enhanced the treatment of chest clearance for patients with sisting mucus transport in order to improve lung
acute or chronic respiratory problems. Chest physiotherapy is
function. These techniques can be used in a hospital
routinely employed as a prophylactic measure prior to major
surgery and postoperatively to prevent respiratory complications ward setting, either in isolation or with mechanical
such as atelactasis and pneumonia. However, most of the sys- devices, to treat patients with acute exacerbations,
tematic reviews that examined these techniques were inconclusive including those on life support machines in critical
in their findings. To ascertain the benefits of these techniques in situations in the intensive care unit.
terms of reducing respiratory morbidity and healthcare usage and
Impaired clearance of the airways may lead to the
to improve the quality of life for patients with chronic respiratory
problems, well-controlled clinical trials are needed. development of respiratory infection, leading to
acute infective bronchitis or, in more severe cases,
the development of atelactasis and consolidation
Introduction
(pneumonia). These factors may contribute to poor
Respiratory disease has a substantial impact on the gaseous exchange, decrease in ventilation perfusion,
health of the population at all ages and every level of and breathlessness due to airflow limitation. If they
PHYSIOTHERAPY 333

are not adequately treated and managed, persistent exercises after abdominal surgery showed that
infection may lead to chronic lung disease, for ex- breathing exercises have some benefits in reducing
ample, bronchiectasis. respiratory complications. However, other system-
The aims of chest physiotherapy are atic reviews have reported conflicting findings. In-
deed, no significant difference was reported in those
* to reduce breathlessness, studies that compared deep breathing exercises and
* to remove excess bronchial mucus secretions, incentive spirometry or continuous positive airway
* to increase exercise tolerance, pressure or intermittent positive pressure breathing.
* to prevent respiratory complications postsurgery, Thus the usefulness of chest physiotherapy in the
* to improve general fitness, prevention of pulmonary complications after cardio-
* to enhance gaseous exchange and reduce the work thoracic surgery remains inconclusive.
of breathing, and
* to encourage self-management for those with
chronic respiratory problems.
Postoperative Physiotherapy
The effects of anesthesia may compromise the mu-
Preoperative Physiotherapy
cociliary clearance system, which is a physical def-
It has been reported that pulmonary complications ense mechanism protecting the lungs from damage.
are common after cardiothoracic surgery and may In addition, the patient’s fear of pain and rupture of
increase the length of hospital stay, resulting in in- the incision, especially a high incision on the upper
creased healthcare expenditure. The most common abdomen, may compromise the function of the dia-
complications may include atelactasis (collapse of an phragm. For those patients with routine abdominal
area of lung) and pneumonia. surgery, the treatment should focus on breathing ex-
Chest physiotherapy is, generally, prescribed as a ercises to remove excess sputum secretions, encour-
prophylactic measure for patients admitted for major age effective coughing with or without support, and
surgery, to ensure that the lung fields are clear prior lower thoracic-expansion exercises to increase ven-
to surgery. It also enables the therapist to assess the tilation and perfusion in the bases of the lung in
patient’s respiratory effort, to teach the patient chest order to prevent atelectasis and pneumonia. Early
clearance and effective coughing techniques, and also ambulation with the support and encouragement of
determine exercise tolerance. Indeed, performing an the physiotherapist may assist in the prevention of
appropriate chest assessment will help the therapist deep vein thrombosis.
to design and implement appropriate treatment strat- The various chest physiotherapy techniques are dis-
egies postoperatively (see Table 1). cussed in terms of their efficacy, indications, contra-
Systematic reviews that investigated the benefits of indications, and evidence from systematic reviews. An
preoperative conventional chest physiotherapy tech- essential requirement for any of the techniques
niques versus other adjunct chest physiotherapy aids described below, if the patient is in pain, is admini-
have reported conflicting findings. Studies that com- stration of adequate analgesia prior to chest physio-
pared incentive spirometry versus deep breathing therapy treatment.

Table 1 Pre- and postoperative physiotherapy treatment

Respiratory system Circulatory system

Preoperative physiotherapy
Assess the lung fields which are clear and free from excess sputum Check the patient for circulatory problems including
retention and crackles deep vein thrombosis
Teach the patient breathing exercises and effective coughing techniques Teach ankle exercises – dorsal flexion, plantar flexion
Prepare the patient physically and psychologically for the operation
Assess both upper and lower limb strength and mobility
Postoperative physiotherapy
Assess the chest for sputum retention Advice on posture and positioning
Check for drains and tubes Instruct and monitor ankle exercises
Monitor the arterial blood gases and oxygen saturation Bed mobility
Teach breathing exercises routinely two to three times per day to keep Encourage walking at the bedside and within the ward
the airways clear
For those with sputum retention, encourage effective coughing
techniques supporting the wound
334 PHYSIOTHERAPY

Active Cycle Breathing Techniques chest. The technique can be performed two to three
times and interspersed with breathing control and
Active cycle breathing techniques (ACBT) is a cycle
rest.
of techniques of breathing control, lower thoracic-
This technique can be combined with a 3-second
expansion exercises, and the forced expiration tech-
‘inspiratory hold’ after full inspiration before the
nique, modifiable to each individual patient.
passive relaxed expiration. The benefit of a 3-second
Indications. ACBT is appropriate for mobilizing
hold at full inspiration has been claimed to decrease
and removing excess bronchial secretions in order to collapse of lung tissue. Care has to be taken for a
improve lung function without inducing hypoxemia.
patient with severe dyspnea. Further additional lung
Breathing Control volume can be achieved by using a ‘sniff’ maneuver
at the end of a deep inspiration with the purpose
Breathing control (BC) is normal tidal breathing of recruiting collateral ventilation. Customarily, the
using the lower part of the chest with relaxation of therapists have employed these techniques two or
the upper chest and shoulders. The aims of this tech- three times per session; however, evidence of their
nique are to encourage relaxation, ease breathless- efficacy is lacking.
ness, and enhance the normal breathing pattern. The Precautions are required for a patient with severe
patient should be comfortable and well supported in shortness of breath. No more than three or four deep
an upright sitting or half-lying position. However, breaths should be performed at a time, otherwise it
this can be modified according to the patient’s needs. may lead to dizziness. However, the technique can be
The technique requires minimal effort from the pa- interspersed with rest and in conjunction with
tient. The therapist may place one hand lightly on breathing control.
the upper abdomen and encourage breathing through Additional techniques such as chest percussion and
the nose, so that the air is warmed and filtered. As vibration can be incorporated during chest-expan-
the patient breathes in, the hand should be felt to sion exercises to mobilize secretions.
rise up and out; as the patient breathes out, the hand
sinks down and in. The technique should be per-
formed at the patient’s own pace. BC technique can Forced Expiratory Technique
be used as many times as possible on its own or as Forced expiratory technique (FET) is indicated for
part of ACBT to encourage normal breathing. This patients with excessive sputum retention. The tech-
technique is indicated for a patient with shortness of nique comprises one or two forced expirations
breath, hyperinflation, and those experiencing panic (huffs) and breathing control. There are two types
attacks/anxiety or for a patient who has had abdom- of huffs. (1) A huff using a mid-to-low lung volume
inal surgery and is unable to use the lower part of the (‘small breath in’) helps to move peripherally situated
chest due to pain. No contraindications for usage of secretions to proximal larger airways. It is performed
this technique have been reported so far. from mid-lung with a medium-sized breath and with
the mouth and glottis open. (2) A huff employing
Lower Thoracic-Expansion Exercises
higher lung volumes (‘a deep breath in’) can be used
Lower thoracic-expansion exercises (LTEE) are indi- to clear secretions from the larger airways. However,
cated for patients with poor expansion of the lungs FET is a difficult technique for some patients to grasp
due to collapse of a particular segment of the lung so patients should be taught in a simplified manner,
(atelectasis), possibly due to fear of pain and copious for example, blowing in a tube or cottonwool ball in
sputum retention. LTEE helps to increase collateral order to learn the correct FET technique.
ventilation so that the air behind the secretions may A reasonable amount of time needs to be spent with
help to mobilize secretions from the periphery of the the adult patient to execute the technique effectively.
lung to the central airways. Teaching children the FET technique using a peak
Thoracic-expansion exercises are deep breathing flow mouthpiece or blowing games is useful. Nor-
exercises emphasizing inspiration. Patients should be mally, two or three FETs are adequate within a session
comfortably supported with pillows in order to relax interspersed with breathing control. The advantage of
the upper chest. The technique can be applied single- this technique is that it can be used at different levels
handed at the affected lobe where the movement of of lung volumes and may assist the patients who pro-
the chest is to be encouraged or by placing both duce large amounts of sputum. Excessive use of FET
hands bilaterally at the lower bases of the lung, ap- may, however, lead to bronchospasm.
proximately at the level of the eighth ribs. Instruc- The FET technique uses the principle of the equal
tions include breathing in slowly and deeply and pressure point, which is the point where the pressure
filling up the lungs with air and expanding the lower within the airways is equal to the pleural pressure.
PHYSIOTHERAPY 335

The downstream of the equal pressure point towards


BC
the mouth, and the dynamic squeezing of airways
allows secretions to be mobilized to the upper air- FET BC
ways and is cleared by a huff from high lung vol- TEE
umes. This technique can be repeated a couple of Huff
times.
The cough is a natural protection mechanism for BC
airway clearance. It comprises of deep inspiration (a)
followed by short and sharp expiration that leads to
closure of the glottis. When the expiratory muscles BC
contract, causing a high increase in intrapulmonary
and abdominal pressure, there is a sudden expulsion BC TEE
of air as the glottis open rapidly. This helps to ex-
pectorate the sputum from the airways. Excessive Huff
continuous coughing may induce bronchospasm so FET
Huff BC
care is needed. (b)
ACBT is a successful, comfortable, and safe method
of bronchial chest clearance technique for the expec- BC
toration of secretions and is widely used by physio-
therapists to treat patients with respiratory problems. BC TEE
FET
The whole ACBT cycle should be performed two or
three times depending on the amount and the location Huff
BC
of secretions. There are no contraindications for this
technique.
The ACBT cycle sequence may be employed in BC
different combinations. For example, for a patient TEE
Huff
who is anxious and with overinflation, emphasis will FET
BC
be on breathing control, whereas for a patient with (c)
sputum retention, treatment may focus on lower Figure 1 Examples to demonstrate the flexibility of the active
thoracic-expansion exercises and forced expiratory cycle of breathing techniques. BC, breathing control; FET, forced
technique, interspersed with breathing control (see expiratory technique; TEE, thoracic-expansion exercises.
Figure 1).
the patient to participate in the treatment. The long-
term benefits and its usage in clinical practice require
Autogenic Drainage Technique
further investigation.
Autogenic drainage (AD) aims to maximize airflow
within the airways to enhance the clearance of mucus
Postural Drainage
and improve ventilation. The AD technique is not
used as widely as the active breathing cycle technique Postural drainage is indicated when the volume of
and is mostly employed in Germany, Netherlands, secretions is greater than 30 ml day 1, when the pa-
and Belgium. It has been claimed that AD improves tient is facing difficulty actively removing secretions,
mucus clearance from peripheral to central airways and conditions with excess sputum production prior
due to changes in airway caliber and breathing at to utilizing chest-clearance techniques.
different lung volumes during expiration. Chevaillier Technique. Secretions can be drained, as part of
originally described the three phases of AD as ‘un- self-management, from the affected part of the lobe
stick’, ‘collect’, and ‘evacuate’. Breathing at low lung or segment using gravity-assisted drainage positions.
volume may aid in the mobilization of secretions The gravity-assisted drainage positions are based on
(‘unstick’) from the periphery to the central airways, the anatomy of the bronchial tree (see Table 2).
breathing at mid-lung volume tends to collect the However, in a patient with severe chronic obstructive
mucus in the middle range, and breathing at high pulmonary disease, these positions may not be tol-
lung volume may assist in the expectoration of spu- erable and should be tailored and modified to the
tum (‘evacuate’) from the larger airways. Several individual lobe in a way the patient can tolerate. The
studies have commented that it is difficult for a duration of treatment may range from 10 to 20 min.
patient to learn autogenic drainage and it requires a The affected area of the lung should be positioned in
considerable amount of effort and cooperation from an uppermost position with or without a head-down
336 PHYSIOTHERAPY

Table 2 Gravity-assisted drainage positions

Lobe Position

Upper lobe 1 Apical bronchus 2 Sitting upright


2 Posterior bronchus
(a) Right 3 Lying on the left side horizontally turned 451 on to the
face, resting against a pillow, with another
supporting the head
(b) Left 4 Lying on the right side turned 451 on the face, with
three pillows arranged to lift the shoulders 30 cm
from the horizontal
3 Anterior bronchus 5 Lying supine with the knees flexed
Lingula 4 Superior bronchus 7 Lying supine with the body a quarter turned to the right
5 Inferior bronchus 7 maintained by a pillow under the left side from
shoulder to hip. The chest is tilted downwards to an
angle of 151
Middle lobe 4 Lateral bronchus 9 Lying supine with the body a quarter turned to the left
5 Medial bronchus 9 maintained by a pillow under the right side from
shoulder to hip. The chest is tilted downwards to an
angle of 151
Lower lobe 6 Apical bronchus 6 Lying prone with a pillow under the abdomen
7 Medial basal 8 Lying on the right side with the chest titled downwards
(cardiac) bronchus to an angle of 201
8 Anterior basal 10 Lying supine with the knees flexed and the chest tilted
bronchus downwards to an angle of 201
9 Lateral basal 11 Lying on the opposite side with the chest tilted
bronchus downwards to an angle of 201
10 Posterior basal 12 Lying prone with a pillow under the hips and the chest
bronchus tilted downwards to an angle of 201

tip for drainage of secretions. During this time, other including heart rate, respiratory rate, blood pressure,
techniques such as percussion, vibration, and shaking and oxygen saturation measured with oximetry.
can be incorporated as part of the treatment to Postural drainage immediately after meals should
loosen sticky secretions. For different gravity-assisted be avoided. The patient’s condition pre- and post-
positions (see Figures 2–14). treatment should be monitored with a stethoscope to
Contraindications to the head-down position may ensure that the affected area is clear.
include:

* Hypertension
* Severe dyspnea Relaxed Positions
* Recent surgery Patients with severe dyspnea expend more energy
* Severe hemoptysis and effort in daily activities. They may derive some
* Nose bleeds benefit by adopting relaxed positions so that the ab-
* Advanced pregnancy dominal content is not pressing on the dia-
* Esophagus hiatus hernia phragm resulting in apical breathing with excessive
* Cardiac failure usage of the accessory breathing muscles, especially
* Cerebral edema at rest or after mild exercise. These positions may
* Aortic aneurysm optimize the length and tension status of the dia-
* Head or neck trauma/surgery phragm to improve its function, and also assist re-
* Mechanical ventilation laxation of the accessory muscles to reduce
* Epileptic seizure breathlessness.
* Desaturation observed (whatever the reason) These relaxed positions may be helpful as self-
when the procedure is performed. management for the patient (by performing breathing
control to ease relaxation of the accessory muscles
During head-down position, it is important to and allow movement of the lower chest). They
monitor cardiovascular and respiratory parameters may assist to overcome the impact of breathlessness
PHYSIOTHERAPY 337

Figure 4 Posterior segment left upper lobe.

Figure 2 Apical segments upper lobes. Figure 5 Anterior segments upper lobes.

Figure 3 Posterior segment right upper lobe.


Figure 6 Apical segments lower lobes.

in daily activities (see Figures 15–19):


the effects of these positions to improve functional
activities or quality of life have not been conclusively
1. Upright sitting or relaxed sitting with forward
proved in controlled clinical trials.
leaning (Figures 15(a) and 15(b))
2. Forward lean standing (Figure 16)
3. Relaxed standing (Figures 17(a) and 17(b))
Manual Hyperinflation in Airway
4. Forward lean sitting (Figure 18)
Clearance
5. Forward kneeling (Figure 19)
Manual hyperinflation is one of the chest physio-
The therapists have prescribed these positions as a therapy techniques that is used in intensive care in
part of chest physiotherapy treatment for patients intubated patients. It involves using an ambu bag in
with chronic chest diseases. However, to date, order to produce a slow deep inspiration, inspiratory
338 PHYSIOTHERAPY

Figure 10 Anterior basal segments.


Figure 7 Lingula.

Figure 11 Lateral basal segment right lower lobe.


Figure 8 Right medial basal and left lateral basal segments
lower lobes.

Figure 12 Posterial basal segments lower lobes.

Figure 9 Right middle lobe.


and a high level of positive end expiratory pressure
410 cmH2O.
pause, and unobstructed expiration. The goals of A recent review of the usage of manual hyperin-
physiotherapy treatment are to remove secretions, flation in airway clearance remains inconclusive.
resolve atelectasis, and improve ventilation. These techniques, however, have been used widely in
Contraindications may include cardiovascular in- intensive care units for many years. Future studies
stability, barotraumas, severe bronchospasm, un- are needed to evaluate the correct dosage, patient
drained pneumothorax, raised intracranial pressure, position, and level of pressures and volumes.
PHYSIOTHERAPY 339

Manual Chest Physiotherapy


Percussion
Percussion or clapping is a synonymous term to de-
scribe the rhythmic clapping on the chest wall with
relaxed wrist and cupped hand, creating an energy
wave that is transmitted to the airways.
Indications. Tenacious secretions, when the patient
is unable to expectorate on their own.
Technique. It is performed using a cupped hand
with a rhythmical flexion and extension action of the
wrist. It requires usage of both hands. Depending on
the area of the chest, it may be more appropriate to
Figure 13 Assisted treatment in high side lying. use one hand to treat a specific lobe. For the infant,

Figure 14 Positioning: (a) sitting upright; (b) slumped sitting.

Figure 15 Relaxed sitting.


340 PHYSIOTHERAPY

chest clapping is performed using two or three fingers reduce any adverse consequence, the technique
of one hand. should be performed for 30 s, and interspersed with
Chest clapping should be performed over a layer of 3–4 lower thoracic-expansion exercises.
clothing to avoid sensory stimulation of the skin. To It is essential to be cautious of vigorous and rapid
chest clapping as this could lead to breath-holding
and may induce bronchospasm in a patient with
hyperreactive airways.
Contraindications. Severe osteoporosis and hem-
optysis.

Shaking

Shaking is the use of coarse oscillations produced by


the therapist’s hands compressing and releasing the
chest wall and applied during expiration phase only.

Figure 16 Forward lean standing. Figure 18 Forward lean sitting.

Figure 17 Relaxed standing.


PHYSIOTHERAPY 341

secretions and using mechanical aids to stimulate


lung function.

Suction
Indication. Excessive sputum production (plugging),
inability to cough effectively.
Technique. Suction catheter should be sterile to
prevent cross-infection. In practice, disposable cath-
eters are used. It is good clinical practice to explain
the procedure to the patient, if conscious, before
carrying out the suction. Ensure the catheter is po-
Figure 19 Forward kneeling. sitioned so as not to damage the airway mucosa. The
duration of treatment should be limited to 10–15 s.
Suction should be applied constantly while removing
Indication. Sputum retention. the catheter. Saline can be used as an aid to suction-
Technique. It should be performed following ‘a ing to assist in the clearing of secretions. The ex-
deep breath in’, during the expiratory phase. The tracted sputum should be sent to the laboratory for
hands are placed on the affected lobe in the direc- microbiological assessment in order to prescribe ap-
tions of the ribs to mobilize secretions. Care must be propriate antibiotics.
taken for patients using long-term steroids and pa- Contraindication. Severe hemoptysis, severe bron-
tients with osteoporosis, bony metastasis, and se- chospasm, and undrained pneumothorax.
verebronchospasm. Shaking is contraindicated over a The physiotherapist may also be involved in the
recent rib fracture or surgical incision. Evidence for treatment of this patient group to maintain full
its clinical use is sparse. range of movements of both upper and lower
limb extremities by performing passive and active
Vibrations assisted exercises in order to maintain soft tissue
length and function and also to reduce risks of de-
Vibrations are fine oscillations applied to the chest veloping edema and deep vein thrombosis in the
wall by the therapist’s hands and carried out during lower limbs. However, the evidence of preventing or
expiration after a deep breath in. The therapist reducing deep vein thrombosis requires further in-
should keep firm contact and direct the force inwards vestigation.
towards the center of the patient’s chest.
Indication. Sputum retention.
Contraindications. A recent rib fracture or surgical
incision. Exercise Therapy
Anecdotal evidence suggests that vibration has
Exercise therapy is a fundamental part of chest physio-
some benefit in the short term but there is a lack of
therapy. Patients with chronic chest diseases should
evidence of the long-term benefits of this technique.
be encouraged routinely to be involved in an aero-
A recent Cochrane review that investigated the
bic exercise program in order to improve general
benefits to bronchial hygiene of the use of percussion,
fitness, and increase exercise tolerance and functional
vibration, and shaking concluded that there is not
activities.
enough evidence to refute or support the efficacy of
Physiotherapists are in a unique position to
these techniques in treating patients with COPD and
prescribe appropriate exercise programs as part of
bronchiectasis. As most of the studies were small in
medical treatment for patients admitted in hospital
sample size, had poor methodological designs, and a
with acute exacerbations of chronic lung diseases.
lack of sensitive outcome measures, it would be dif-
The exercise regime should be tailored to the indi-
ficult to generalize the findings. Future studies should
vidual patient’s hobbies (if possible) and to baseline
focus on larger sample sizes, with controlled ran-
functional abilities. The purpose of the physio-
domized clinical trials being the best way forward.
therapy treatment is to maximize the patient’s
independent function and increase walking endur-
ance. The exercise program will need to determine
Intensive Care Unit
the intensity, type of exercise, setting, and patient
The role of the physiotherapist in the intensive care compliance in order to monitor the efficacy of the
unit is to treat intubated patients by clearing chest program.
342 PHYSIOTHERAPY

Ground-Based Walking Exercise limb muscles, for example, reduced strength and en-
durance of the quadriceps muscle. Quadriceps-
Walking improves both cardiovascular fitness, increa-
strengthening exercise should then be incorporated
ses exercise tolerance, and stimulates psychological
with the treatment program. Step aerobics have
well-being. It is simple to perform, safe, and able to be
been shown to improve general fitness. For those
incorporated into the daily routine of the patient. The
with severe chest diseases, graduated stair-climbing
exercise can be done at home and does not require
special equipment. In simplistic terms, patients with several times a day may improve general fitness
and quadriceps function. The home exercise pro-
chronic chest problems can monitor their own progress
gram can be devised using the bottom of the step and
by, for example, monitoring how many meters or miles
climbing up and down by holding a banister or
they have covered or for how long they have walked
stair rail. The intensity and duration of the exercise
per session.
program should be determined by the patient’s
There is no clinical guideline as to how many times
exercise tolerance and fatigability. However, patients
per week ground-based walking exercises will be re-
should be assessed prior to the exercise program
quired in order to produce a significant improvement
in the patient’s functional activities and quality of for other medical problems such as dizziness. If
the patient is unable to perform the exercise men-
life. Current customary clinical practice in the pre-
tioned above, this can be substituted by unweighted
scription of ground-based exercise by physiothera-
straight-leg raising when lying and knee extension
pists is two to three times per week for a duration of
when sitting.
approximately 30 min. This self-management exer-
cise program requires future investigation to find out
if it has any benefits in terms of reducing exacerbat- Stationary Cycling
ions of chronic respiratory disease. Stationary cycle can be used at home or in a local
gymnasium. This may provide more controlled exer-
Upper Limb Aerobic Exercise Training cise than ground-based walking. This form of exer-
Dyspnea on exertion is a primary problem for pa- cise is helpful in determining the level of exercise
tients with chronic chest problems. Patients very of- intensity achievable. Hence it can be used as a self-
ten have difficulties in performing overhead activities, monitored objective measure to determine the pro-
for example, lifting light objects from a shelf or gress of exercise capacity.
dusting. This often leads to fear and avoidance of All these exercise training modalities should be
these activities and in turn to atrophy by disuse and considered both in the clinical setting and as a self-
weakness of muscles in the upper limbs. This exac- management program at home to improve cardio-
erbates and promotes inactivity which may lead to a respiratory function and exercise tolerance for this
‘vicious circle’. Studies have reported that aerobic patient group.
exercise training in patients with chronic chest prob-
lems improves exercise tolerance and reduces meta-
bolic and ventilatory requirement. The following Conclusion
exercises can be prescribed by the therapists after Several chest physiotherapy techniques and adjunct
discharge (for home ‘use’). modalities are available in current clinical practice to
Unweighted arm exercise with repetitive bilateral treat patients with acute and chronic chest diseases.
shoulder flexion and abduction from neutral position Chest physiotherapy may be effective in improving
synchronized with breathing. The level of intensity of mucus transport. Whether it has any benefits on
the exercise program can be determined by assessing pulmonary function in the long term is not clear. In
the patient to see how many times he/she can per- addition, evidence from systematic reviews suggests
form the exercise. The frequency and intensity of the no single technique is superior than the other. The
exercise program can be increased over time. findings from research studies are inconclusive.
For those who are capable of weight-lifting, the Treatment for individual patients has to be ‘tailor-
exercise can be prescribed using light weights that made’ in light of the patient’s clinical findings, for
can be increased suitably. example, arterial blood gases and oxygen saturation,
in order to be effective. Further studies are required
Lower Limb Aerobic Exercise Training
to determine the efficacy and benefits of these phys-
Patients with chronic chest problems, especially older iotherapy techniques and modalities in short, me-
patients, spend substantial amount of their time in- dium, and long term in reducing length of hospital
doors leading a sedentary lifestyle. This may lead to stay, healthcare utilization, and impact on quality of
physical deconditioning and weakness of the lower life and self-management programs.
PLATELET-DERIVED GROWTH FACTOR 343

See also: Atelectasis. Exercise Physiology. Symp- Lapin CD (2002) Airway physiology, autogenic drainage and ac-
toms of Respiratory Disease: Cough and Other Symp- tive cycle of breathing. Respiratory Care 47: 778–785.
toms. Ventilation: Control. Pasquina P, Tramer MR, and Walder B (2003) Prophylactic res-
piratory physiotherapy after cardiac surgery: systemic review.
British Medical Journal 327: 1379–1381.
Pryor JA (1999) Physiotherapy for airway clearance in adults.
Further Reading European Respiratory Journal 14: 1418–1424.
Pryor JA and Prasad SA (eds.) (2002) Physiotherapy for respiratory
Denehy L (1999) The use of manual hyperinflation in airway and cardiac problems. In: Adults and Paediatrics, 3rd edn. Lon-
clearance. European Respiratory Journal 14: 958–965. don: Churchill Livingstone.
Harden B (2004) Emergency Physiotherapy. London: Church Liv- van der Schans CP, Postma DS, Koeter GH, and Rubin BK (1999)
ingstone. Physiotherapy and mucus transport. European Respiratory
Hough A (2001) Physiotherapy in Respiratory Care. An Evidence- Journal 13: 1477–1486.
Based Approach to Respiratory and Cardiac Management, 3rd West JB (2001) Pulmonary Physiology and Pathophysiology. An
edn. Chelthenham: Nelson Thornes. Integrated Case-Based Approach. Philadelphia: Lippincott Will-
Jones AP and Rowe BH (2000) Bronchopulmonary hygiene phys- iams & Wilkins.
ical therapy for chronic obstructive pulmonary disease and Yohannes AM (2001) Pulmonary rehabilitation and outcome
bronchiectasis (Cochrane Review). Cochrane Database of sys- measures in elderly patients with chronic obstructive pulmonary
tematic Reviews (2): CD000-045. disease. Gerontology 47: 241–245.

Plasminogen Activator and Plasmin see Fibrinolysis: Plasminogen Activator and Plasmin.

PLATELET-DERIVED GROWTH FACTOR

J C Bonner, CIIT Centers for Health Research, serum factor that stimulated the growth of arterial
Research Triangle Park, NC, USA smooth muscle cells during the pathogenesis of athe-
& 2006 Elsevier Ltd. All rights reserved. rosclerosis. Several groups subsequently purified this
major PDGF on the basis of its ability to stimulate
the growth of smooth muscle cells and other me-
Abstract senchymal cells. In the late 1980s, the genes encoding
Platelet-derived growth factor (PDGF) isoforms are polypeptide the classical PDGFs (PDGF-A and PDGF-B) along
mediators that play a major role in stimulating the replication, with two receptor genes (PDGF a-receptor – PDGFRa
survival, and migration of mesenchymal cells during the patho-
and PDGFb-receptor – PDGFRb) were cloned. More
genesis of fibrotic diseases. PDGF is secreted by a variety of cell
types including epithelial cells, macrophages, and fibroblasts as recently, two novel PDGFs (PDGF-C and PDGF-D)
a response to injury, and many proinflammatory cytokines me- were discovered that are proteolytically activated in
diate their mitogenic effects via the autocrine release of PDGF. the extracellular microenvironment. PDGF and its
PDGF-A and PDGF-B chain dimeric isoforms (PDGF-AA, receptors have been shown to play critical roles in the
PDGF-AB, and PDGF-BB) play important roles in the patho-
normal processes of development and tissue repair as
genesis of fibrosis. These isoforms promote myofibroblast
proliferation and chemotaxis, but also serve other functions well as in the pathogenesis of diseases such as cancer,
including stimulation of collagen production and promotion of atherosclerosis, and fibrotic diseases.
cell adhesion. Less is known regarding the significance of the
more recently discovered PDGF-C and PDGF-D chain isoforms.
The biological activity of PDGF is determined by the relative
Structure
expression of PDGF a-receptors and b-receptors on the cell sur-
face. These receptors are induced during lung fibrogenesis, The genes encoding the four PDGF polypeptide
thereby amplifying biological responses to PDGF isoforms.
chains are located on four different chromosomes.
PDGF action is further modulated in the extracellular milleau
by binding proteins, matrix molecules, and proteases. The human PDGF-A and PDGF-B genes are located
on chromosomes 7 and 22, whereas the PDGF-C and
PDGF-D genes are located on chromosomes 4
and 11, respectively. All four PDGFs are synthesized
Introduction
and assembled as disulfide-linked dimeric polypep-
In the 1970s, Ross and colleagues discovered plate- tides in the endoplasmic reticulum (ER) as inactive
let-derived growth factor (PDGF) in the search for a precursors, which are then proteolytically processed