4.3 Pulmonary Conditions & Airway Clearance

Obstructive vs Restrictive Lung Disease

Pulmonary Function Tests (PFTs) sort lung disease into two buckets, and the PTA must recognize the pattern because the breathing strategy and exercise tolerance differ. The single most discriminating number is the FEV1/FVC ratio.

Think of it this way: obstructive patients cannot get air out (slow, prolonged exhalation), while restrictive patients cannot get air in (stiff, small lungs). A COPD patient hyperinflates and uses pursed-lip breathing to empty; a fibrosis patient is short, fast, and shallow.

Breathing Re-Education for COPD

COPD patients trap air, flatten the diaphragm, and over-recruit accessory muscles. PTAs teach two foundational techniques:

Pursed-Lip Breathing (PLB)

1. Inhale slowly through the nose for about 2 seconds.
2. Exhale through pursed lips (as if blowing out a candle) for 4-6 seconds.
3. Aim for a 1:2 inspiration-to-expiration ratio.

PLB creates a small back-pressure that splints small airways open during exhalation, reduces respiratory rate, and lowers the work of breathing. Cue it during stair climbing, dressing, and any dyspnea flare.

Diaphragmatic ('Belly') Breathing

1. One hand on abdomen, one on chest.
2. Inhale through the nose so the abdominal hand rises while the chest hand stays quiet.
3. Exhale slowly, ideally with pursed lips.

Energy Conservation

PTAs reinforce pacing, planning, and prioritizing during ADLs: sit to dress, slide rather than lift, use long-handled tools, and schedule rest. The 'blow as you go' rule - exhale through pursed lips during the hard phase of a task - prevents breath-holding and Valsalva.

Postural Drainage Basics

Postural drainage uses gravity to move secretions from peripheral airways toward the trachea. The governing rule: position the affected lung segment uppermost.

Trendelenburg is contraindicated with severe resting dyspnea, recent neurosurgery, uncontrolled hypertension, severe gastroesophageal reflux, or unstable cardiac status - a frequent NPTE-PTA distractor.

Manual Techniques

• Percussion: rhythmic clapping with cupped hands over the draining segment for 3-5 minutes. Avoid over fractures, recent surgery, tumor sites, low platelets, and bony prominences (kidneys, spine, breast tissue).
• Vibration: fine oscillation applied during expiration only to move loosened secretions centrally.
• Shaking: a coarser version of vibration, also expiration-only.

Active Cycle of Breathing Technique (ACBT)

A self-administered three-part cycle used heavily in CF and bronchiectasis:

1. Breathing Control - relaxed, low-rate diaphragmatic breathing.
2. Thoracic Expansion Exercises - three to four deep inhalations with a brief hold to mobilize secretions.
3. Forced Expiration Technique (FET) / huffing - one or two huffs at low-to-medium lung volumes to clear central airways (a huff keeps the glottis open, unlike a cough).

Positive Expiratory Pressure (PEP) Devices

PEP and oscillating-PEP devices (Flutter, Acapella, Aerobika) generate back-pressure during exhalation, splint airways open, and vibrate secretions loose, letting patients clear independently. They are favored in CF home programs.

Exercise Considerations by Lung Pattern

The two patterns demand different coaching. The obstructive (COPD) patient needs a slow, controlled exhalation and a longer warm-up; they desaturate on exertion, so the PTA paces activity, allows pursed-lip recovery, and watches SpO2. The restrictive patient has stiff, small lungs and a rapid shallow pattern; they fatigue the respiratory muscles quickly, so the PTA emphasizes thoracic mobility, posture, and shorter bouts with frequent rests. For either pattern, supplemental oxygen titration is a medical or respiratory-therapy decision, never a unilateral PTA change.

Sequencing an Airway-Clearance Session

Order matters on exam scenarios. A bronchodilator (if prescribed) and humidification come first to open the airways, then postural drainage with percussion and vibration to mobilize secretions, then huffing or coughing to expel them, and finally a rest with re-checked vitals. Sessions are best scheduled before meals or at least one hour after eating to limit reflux and vomiting, and never immediately after a large meal in any head-down position.

Cystic Fibrosis Considerations

CF patients usually combine modes (ACBT plus PEP plus exercise) and often need sodium replacement and high-calorie intake. Infection-control cohorting is strict - never treat two CF patients in the same gym at the same time, and follow facility isolation policy to prevent cross-infection with organisms such as Burkholderia cepacia. Because CF is a progressive disease that taxes both lungs and nutrition, the PTA monitors for desaturation during clearance and exercise, encourages hydration, and reports any new fever, hemoptysis, or worsening dyspnea to the supervising PT promptly.