14.2 Asthma, Restrictive Disease, CF and TB
Key Takeaways
- Asthma safety for physiotherapy includes recognising poorly controlled disease, exercise-induced symptoms, and ensuring prescribed rescue inhaler access—without diagnosing or independently changing medication regimens.
- Restrictive patterns (e.g. interstitial lung disease/fibrosis) limit lung expansion and often show rapid shallow breathing and desaturation on exertion; exercise is carefully titrated with monitoring.
- Cystic fibrosis airway clearance is a lifelong, individualised cornerstone; techniques evolve with age, disease stage, and patient preference, always alongside medical CF care.
- TB physiotherapy prioritises infection control, appropriate PPE/isolation awareness, and avoiding unnecessary aerosol-generating procedures outside controlled protocols.
- Across asthma, ILD, CF, and TB, scope boundaries matter: escalate medical deterioration, do not invent drug or oxygen changes, and collaborate with specialist teams.
Quick Answer: Asthma → stop provocative load, upright calm breathing, prescribed rescue inhaler per action plan, escalate if severe. Restrictive/ILD → interval exercise with SpO2 monitoring and oxygen as prescribed; dry cough ≠ default percussion. CF → lifelong individualised daily ACT + exercise inside a specialist team. TB → airborne isolation/PPE first; no casual shared-gym ACT while infectious.
Beyond COPD, APC cardiorespiratory cases frequently sample asthma, restrictive lung disease (including pulmonary fibrosis/interstitial lung disease), cystic fibrosis (CF), and tuberculosis (TB) infection-control reasoning. Entry-level physiotherapists must keep people moving safely, clear airways when indicated, and respect medical and public-health boundaries in Australian acute, community, private, and paediatric-transition settings.
Asthma: Safety First for Physiotherapy
Asthma is a chronic airway disease with variable airflow obstruction, airway inflammation, and hyper-responsiveness. Symptoms include wheeze, chest tightness, cough, and dyspnoea—often intermittent and trigger-related (exercise, cold air, allergens, infection, occupational exposures).
What APC expects from you
- Screen for current control: recent nocturnal symptoms, reliever use frequency, activity limitation, recent ED/hospitalisation, and known triggers.
- For exercise-induced bronchoconstriction / exercise-induced asthma, warm-up strategies, appropriate intensity progression, environmental modification (cold/dry air), and ensuring the person has their prescribed reliever (rescue) inhaler available are physiotherapy-relevant. You support adherence to the medical asthma action plan; you do not invent new pharmacotherapy.
- Stop and escalate if the person develops severe respiratory distress, inability to speak in full sentences, cyanosis, extreme agitation or drowsiness, SpO2 concern, or failure to respond to their prescribed reliever plan as directed by their medical team.
- Breathing pattern retraining and anxiety–breathlessness education may help selected patients, but they never replace anti-inflammatory controller therapy prescribed by medical practitioners.
- Poor control before a planned high-intensity session is a reason to modify or defer, not to “break the wheeze with sprints.”
Scope boundaries (high-yield traps)
| Within physio scope | Outside physio scope |
|---|---|
| Activity modification; warm-up; monitoring symptoms/SpO2 when used | Diagnosing asthma subtype from spirometry alone as a medical label in isolation of the team |
| Checking the person has access to their prescribed rescue inhaler and knows when their plan says to use it | Changing preventer doses, starting oral steroids, or stopping controllers |
| Recognising red-flag acute asthma and calling for medical help | Treating life-threatening asthma with physio techniques only |
| Supporting exercise as part of overall health when medically controlled | Forcing high-intensity exercise during an acute exacerbation |
Australian vignette pattern: adolescent or adult in gym/physio clinic becomes wheezy mid-session. Correct sequence: stop provocative load → sit upright, calm breathing → use their prescribed reliever as per their action plan/medical advice → reassess → urgent medical care if not improving or if severe features appear. Do not continue circuit training “to push through.”
Community sports and school settings add practical detail: know where the inhaler is, involve carers/teachers within privacy rules, and do not rely on a shared “clinic ventolin” as a substitute for the person’s prescribed plan unless local emergency protocol explicitly covers that situation.
Restrictive Disease and Pulmonary Fibrosis
Restrictive patterns reduce lung expansion and total lung capacity. Causes relevant to physio cases include interstitial lung diseases (ILD) such as idiopathic pulmonary fibrosis (IPF), connective-tissue-disease-associated ILD, neuromuscular weakness (overlap with neurology), obesity hypoventilation contributions, pleural restriction, and chest wall deformity.
Clinical pattern for reasoning
- Dyspnoea on exertion, often progressive
- Rapid shallow breathing pattern
- Dry cough in many fibrotic ILDs (contrast with productive COPD/bronchiectasis)
- Desaturation on exertion is common in ILD—monitor SpO2 when available and work within prescribed oxygen targets
- Digital clubbing, fine crackles, and advanced disease features may appear in medical history stems
- Exercise intolerance from gas exchange limitation and deconditioning
Physiotherapy emphasis in fibrotic/restrictive disease
- Exercise training adapted to dyspnoea and desaturation (often interval walking, cycle ergometry, and strength training) as part of PR-style care when referred and stable.
- Oxygen awareness: many patients use ambulatory oxygen on medical prescription during exertion. Do not alter flow without orders.
- Energy conservation and pacing for severe disease; maintain functional independence and social participation goals.
- Airway clearance is not the default unless secretions are a problem (e.g. combined disease). Blind percussion for dry fibrotic cough is low value.
- Red flags: rapid decline, new chest pain, fever, haemoptysis, right-heart failure signs, or profound desaturation—medical review, not more exercise.
| Feature | COPD (obstructive emphasis) | Fibrotic ILD (restrictive emphasis) |
|---|---|---|
| Sputum | Often productive phenotypes | Often dry cough |
| Breathing pattern | Hyperinflation, prolonged expiration themes | Rapid shallow breathing |
| Exertional SpO2 | Variable; targets individual | Desaturation common—monitor closely |
| ACT role | High if secretions | Usually low unless secretions present |
| Exercise structure | Continuous or interval | Often interval-friendly for desaturation |
ILD patients may be candidates for transplant pathways or palliative-adjacent goals in advanced disease. Maintain realistic, person-centred goals and sensitive communication. Anxiety about “every desaturation means dying” needs education and graded confidence-building—not false reassurance that SpO2 does not matter.
Cystic Fibrosis: Airway Clearance Across the Lifespan
Cystic fibrosis is a genetic multisystem disease (CFTR dysfunction) with thick secretions, chronic airway infection/inflammation, progressive lung damage, pancreatic and nutritional issues, and other organ involvement. Modern CF care is highly specialised (including CFTR modulator therapies for many eligible people); physiotherapists remain central for airway clearance, exercise, and musculoskeletal/postural care within the multidisciplinary CF team.
Lifespan ACT principles
- Infants/young children: caregiver-delivered techniques and play-based activity; education of families; techniques change as the child grows.
- School age/adolescence: transition toward independence, adherence support, sport participation with secretion management planned around school/sport.
- Adults: personalised ACT repertoire (ACBT, autogenic drainage, PEP/oscillating PEP, exercise as ACT adjunct, adjunctive devices as prescribed/available), often twice daily or more when unwell.
- Exacerbations: intensity and frequency of ACT usually increase under team guidance; medical treatment (antibiotics, hospitalisation) runs in parallel.
- End-stage considerations: balance benefit vs fatigue; goals may shift toward comfort and essential function.
Key APC ideas: ACT is routine and long-term, not a one-off hospital trick; exercise is medicine for CF when medically appropriate; infection control between patients matters in clinics (cohorting/time separation policies vary by service—follow local protocols); nutritional and medical issues are team-managed—do not give unsupervised dietary mega-advice that conflicts with dietitians.
Musculoskeletal complications (thoracic stiffness, incontinence with coughing, postural changes, arthropathy) may appear in adult CF stems—address with standard MSK reasoning while prioritising respiratory stability. Urinary incontinence with coughing is a real adherence barrier; treat it as part of CF physio care, not an embarrassing side note.
| Life stage | ACT emphasis | Common APC trap |
|---|---|---|
| Infant/child | Caregiver technique + play activity | Assuming hospital ACT only |
| Adolescent | Independence + adherence + sport planning | Ignoring school schedule and body image |
| Adult | Individualised daily repertoire + exercise | Stopping ACT “because on antibiotics” |
| Exacerbation | Increase frequency/intensity with team | Maximal gym work while febrile and hypoxic |
Tuberculosis: Infection Control for Physiotherapists
Tuberculosis is a mycobacterial infection; pulmonary TB is the form most relevant to respiratory physio. Transmission risk is highest with infectious pulmonary TB via aerosolised droplet nuclei. Physiotherapy interventions that provoke cough can be aerosol-generating in effect.
Infection-control priorities (exam-level)
- Know the isolation status. Do not casually mobilise an infectious TB patient through shared gyms or waiting rooms against isolation policy.
- PPE and room controls. Follow organisational airborne precautions (e.g. N95/P2 respirator fit-checked use as required, negative-pressure rooms where indicated). Standard masks may be insufficient for airborne pathogens—follow local policy, not improvisation.
- Minimise unnecessary aerosol-generating procedures. Only perform ACT, suction, or exercise that provokes heavy coughing when clinically essential and within protocol.
- Hand hygiene, equipment cleaning, and waste as per infection control standards.
- Team communication. Clarify with medical/infection-control teams before group PR or shared equipment use.
- Beyond infection control, once non-infectious or appropriately managed, physiotherapy supports mobility, secretion management if needed, and rehabilitation of deconditioning—similar safety principles to other respiratory illnesses.
Public health angle: delayed recognition of possible TB (chronic cough, night sweats, weight loss, haemoptysis, epidemiological risk) should prompt medical investigation—not endless symptomatic physio for “chest infection” without medical review when red-flag systemic features exist. In Australian practice, notify and pathway rules sit with medical/public health systems; your job is to flag concern and follow isolation, not to run a parallel diagnostic service.
Integrating the Four Conditions in APC Cases
| Condition | Dominant physio problems | Signature safety theme |
|---|---|---|
| Asthma | Variable obstruction, exercise triggers | Rescue inhaler access; stop acute severe attacks |
| Restrictive/fibrosis | Expansion/gas exchange limit, exertional desaturation | SpO2-guided, oxygen orders respected |
| CF | Lifelong thick secretions + infection | Daily ACT + specialised team care |
| TB | Infection risk + possible deconditioning | Airborne precautions / isolation discipline |
Mixed cases exist (e.g. asthma–COPD overlap, CF with MSK pain, ILD with anxiety, post-TB bronchiectasis). Always prioritise airway and gas-exchange safety, then infection control, then function.
Setting Notes
Private MSK clinic: new exercise-induced wheeze is not “just deconditioning”—screen asthma history and inhaler access. Paediatric/community CF: family education and adherence beat perfect technique taught once and forgotten. Ward TB query: isolation status before corridor walking practice. ILD outpatient: interval walking with oximetry often beats continuous maximal corridor goals.
Closing Exam Anchor
For this cluster: asthma = control and rescue-plan safety during exercise; fibrosis/restrictive = paced, monitored exercise with oxygen awareness; CF = lifespan ACT individuality inside a specialist model; TB = infection control before clever techniques. Stay inside scope on medicines and oxygen, and escalate deterioration early.
A 16-year-old with known asthma becomes wheezy and tight-chested during a supervised exercise session. They have their prescribed reliever inhaler with them. What is the most appropriate immediate physiotherapy action?
Which physiotherapy emphasis is most appropriate for a stable outpatient with idiopathic pulmonary fibrosis who desaturates on continuous walking but can complete shorter bouts with recovery?
For an adult with cystic fibrosis who produces large volumes of thick sputum daily, which statement best reflects entry-level physiotherapy reasoning?
You are asked to treat a ward patient with suspected infectious pulmonary TB who is still under airborne isolation. Which action best reflects safe practice?
A private-practice client reports chronic productive cough for months, night sweats, unexplained weight loss, and recent haemoptysis after returning from a high-prevalence region. They want “chest physio for a lingering infection.” What is the best next step?