Effectiveness of segmental breathing and active cycle of breathing technique in the management of dyspnoea among covid-19 patients

Background

Coronaviruses are enveloped, positive single-stranded large RNA viruses which were first described in 1966 by Tyrell and Bynoe, who cultivated the viruses from patients with common colds. COVID-19 affects different people in different ways. Most infected people will develop mild to moderate illness and recover without hospitalization. Most common symptoms are fever, cough, tiredness, loss of taste or smell and less common symptoms are sore throat, headache, aches and pains, diarrhoea, a rash on skin, or discolouration of fingers or toes, and red or irritated eyes. Serious symptoms are difficulty breathing or shortness of breath, loss of speech or mobility, confusion and chest pain.

Common Investigations done to confirm the Corona virus are real-time reverse transcription polymerase chain reaction (RT-PCR), CT, Chest X-ray. Various drugs were fielded for therapy but evidence support only Oxygen, anticoagulants and steroids. Antivirals and anti-inflammatory drugs have a role in selected patients.

Physiotherapy management in Covid

Studies have shown that pulmonary rehabilitation programmes are beneficial in patients who develop Covid lung disease.

Physiotherapists play an essential role in the team of health professionals that support patients recovering from Covid lung disease. Pulmonary rehabilitation programmes significantly improve the patient’s health by reducing breathlessness, and in improving lung function thereby improving the patients’ functional ability. Better health leads to improvements in lung function and thereby improving quality of life.

Physiotherapists should also be able to advice on exercise, which is important to maintain general fitness. Physical therapy examination and interventions should be provided only when there are clinical indications for need such as “mobilization, exercise, and rehabilitation, for e.g. in patients with comorbidities creating significant functional decline and/or (at risk) for ICU-acquired weakness”. It is essential to assess oxygen status, cardiac stability (look at ECG, enzymes, and echo), and hemodynamic stability with activity before enrolling the patient of COVID-19 for physiotherapy. Direct physical therapy interventions should be considered only when there are significant functional limitations.

Definitions

COVID-19

According to WHO, Coronavirus disease (COVID-19) is an infectious disease caused by the SARS-CoV-2 virus. The patient presents with severe acute respiratory infections [fever and at least one sign/symptom of respiratory disease (e.g., cough, shortness breath)] and requiring hospitalization with no other etiology that fully explains the clinical presentation.

Segmental breathing exercises

Segmental breathing, also referred to as localised respiration, is consciously directed to one segment of the chest while the other segments remain relaxed. This expansion breathing is used to improve ventilation and oxygenation. This exercise presumes that inspired air can be actively directed to a specific area of lung and increases movement of the thorax overlying that area of lung.

Active cycle of breathing

The active cycle of breathing techniques (ACBT) have been shown to be effective in the clearance of bronchial secretions and to improve lung function without increasing hypoxemia or airflow obstruction. It is a cycle of breathing control, thoracic expansion exercises and the forced expiration technique.

Peak expiratory flow rate:

Peak expiratory flow rate (PEFR) is the maximum flow rate generated during a forceful exhalation, starting from full lung inflation. PEFR primarily reflects large airway flow and depends on the voluntary effort and muscular strength of the patient. In normal subjects PEFR is determined by: The size of the lungs, lung elasticity, the dimensions and compliance of the central intra-thoracic airways, the strength and the speed of contraction of the respiratory muscles. The normal values relate to the height and gender. PEFR must be ascertained separately using a peak flow meter.

Modified Borg Dyspnoea Scale

Rating of perceived exertion (RPE) is a widely used and reliable indicator to monitor and guide exercise intensity. The scale allows individuals to subjectively rate their level of exertion during exercise or exercise testing. Developed by Gunnar Borg, it is often also referred to as the Modified Borg Scale.

General aspects of Covid-19.

Dyspnea is one of the most prominent symptoms of COVID-19. Since COVID-19 affects the respiratory system, pulmonary rehabilitation has an important place in the treatment of patients. Our clinical observations suggest that dyspnea is observed even in patients with mild COVID-19 pneumonia. Patients with COVID-19 pneumonia who undergo deep breathing exercise with triflo will have a lower dyspnea level, lower anxiety level and higher quality of life than the patient group in which this exercise is not applied.

Deep breathing exercises are effective in addressing dyspnoea, anxiety and quality of life in patients treated for COVID-19. Respiratory rehabilitation can be a crucial part of treatment for patients with COVID-19. Breathing exercise, even for a short period, is effective in improving certain respiratory parameters in patients with COVID-19. As a non-invasive and cost-effective respiratory rehabilitation intervention, breathing exercise can be a useful tool for a health care system overwhelmed by the COVID-19 pandemic.

According to the guidelines on respiratory rehabilitation for patients with COVID 19, techniques such as postural drainage, clapping on the back of patients to facilitate expectoration, and sputum disruption with machine vibration can be used to address sputum retention and in facilitating sputum expectoration among patients.

Prone-position ventilation is a very important rescue therapy for critically ill COVID-19 patients. The application rate of prone-position drainage is relatively high in COVID-19 patients, with good outcomes, suggesting that early application of prone-position drainage in COVID-19 patients may avoid the progression to critical illness and improve prognosis.

Airway clearance techniques are an essential part of routine respiratory physiotherapy, enabling bronchial secretion clearance-the mucus overproduction and retaining results in lung function deterioration and disrupts effective pulmonary rehabilitation. Several mucus clearance methods are included in the physiotherapy daily routine of patients.

Segmental breathing technique on Covid-19

Segmental breathing is performed on a segment of lung, or a section of chest wall that needs increased ventilation or movement. Hypoventilation occur in certain areas of the lungs because of chest wall fibrosis. Therefore, it will be important to emphasize expansion of such areas of the lungs and chest wall.

Expected Outcomes

• To increase lung volume
• To clear secretions
• To improve gas exchange
• To control breathlessness
• To increase exercise capacity
• To reduce blood pressure
• To reduce obesity
• To relaxation for stress reduction

Breathing exercise can be classified as inspiratory and expiratory. Some of the breathing exercises stress inspiration thereby increasing lung volume where as others stress on expiration which assists in clearance of secretions. Breathing exercises can be given if patient is conscious and cooperative.

Three types of segmental breathing that target the apical, lateral and posterior segments of the lower lobes are apical expansion exercises, lateral costal breathing and posterior basal expansion exercises.

The following technique further stresses inspiration. First squeeze chest during expiration then stretch at the very end of expiration, allow inspiration to occur. Near the end of inspiration apply a series of 3 or 4 gentle stretches rather similar to repeated contractions.

Active cycle of breathing technique on Covid-19.

Active cycle of breathing techniques utilizes combinations and cycles of airway clearance techniques to ventilate obstructed lung segments. The active cycle of breathing techniques (ACBT) have been shown to be effective in the clearance of bronchial secretions and to improve lung function without increasing hypoxemia or airflow obstruction. It is a cycle of breathing control, thoracic expansion exercises and the forced expiration technique.

Rehabilitation intervention should target SpO2 > 90% with titration of supplemental oxygen to maintain target saturation. Pause in activity should occur if SpO2 drops below target or Borg scale dyspnea score > 3 with consideration of breathing technique like pursed lip breathing with resumption of exercise intervention once SpO2 reaches target.

Peak expiratory flow meter on Covid-19.

The peak flow meter, a simple and portable device, has been available since 1959. Since that time, there have been many publications pointing out its usefulness. A valid measurement of peak expiratory flow (PEF) requires a brief maximum exhalation from total lung capacity (TLC) since it is effort- and volume-dependent. Its measurement represents the maximum expiratory flow occurring within 150 msec of commencing expiration and the first few hundred ml of volume expired forcibly from TLC. PEF is a useful index of airway obstruction correlating fairly well with FEV1.

The monitoring of peak expiratory flow (PEF) is widely recommended in international guidelines for Covid-19 management. In these patients, the predicted percentage of PEF correlates reasonably well with the predicted percentage for forced expiratory volume in the first second (FEV1) and provides an objective measure of airflow limitation when spirometry is not available. The value of this method is widely recognized as suitable for monitoring the disease’s progression and its treatment. The monitoring of PEF also helps to monitor the patient’s improvement after a particular mode of treatment. In general, PEF is reduced in all types of respiratory diseases.

Forced expiratory volume:

It is measured by peak flow meter. Forced expiratory volume is the maximal flow achieved during an expiration delivered with a maximal force starting from maximal lung function. It consists of three zones named as Green zone, Yellow zone, Red zone whereas green zone indicates that the dyspnea is under good control, yellow zone indicates caution which means respiratory airways are narrowing, red zone indicates emergency which means severe airway narrowing.

Breathing pattern assessed by Modified Borg’s dyspnoea scale:

Rating of perceived exertion is a widely used and reliable indicator to monitor and guide exercise intensity. The scale allows individuals to subjectively rate their level of exertion during exercise or exercise testing. The original Borg scale or category scale (6 to 20 scale), and the revised category-ratio scale (0 to 10 scale). The original scale was developed in healthy individuals to correlate with exercise heart rates and to enable subjects to better understand terminology. RPE scales are particularly valuable when HR measures of exercise intensity are inaccurate or dampened, such as in patients on beta blocker medication. This is due to the scales ability to capture the perceived exertion from central cardiovascular, respiratory and central nervous system functions.

Treatment procedure:

1. Segmental breathing technique

Patient position: Lying, sitting, half lying.

Therapist position: Walk standing position.

Procedure:

Segmental breathing, also referred to as localized expansion breathing, is the exercise used to improve ventilation and oxygenation. This exercise, which presumes that inspired air can be actively directed to a specific area of lung, emphasizes and increases movement of the thorax overlying that lung area. This exercise attempts to preferentially enhance localized lung expansion and use manual counter pressure against the thorax to encourage the expansion of that specific area of thorax in hope of improving ventilation to a specific part of the lung.

Segmental breathing technique consists of the following steps:

• The surface landmarks that demarcate the affected area was identified.
• The hands were placed on the chest wall overlying the bronchopulmonary segment or segments requiring treatment.
• Firm pressure was applied to that area at the end of the patient’s expiratory maneuver. (Pressure should be equal and bilateral)
• The patient was instructed to inspire deeply through his or her mouth, attempting to direct the inspired air towards the hand of the therapist.
• The hand pressure was reduced as the patient inspired. (At the end of inspiration, the therapist’s hand was applying no pressure on the chest.)
• The patient was instructed to hold his or her breath for 2 to 3 seconds at the completion of inspiration.
• The patient was instructed to exhale.
• This sequence was repeated until the patient could correctly execute the breathing maneuver.
• The exercises were progressed by instructing the patient to use his or her own hands or a belt to independently execute the program.

2. Active cycle of breathing technique:

Patient position: Sitting, lying or side lying.

Therapist position: Walk standing position.

Procedure:

Active cycle of breathing technique can be performed in sitting, lying or side-lying positions. Initially, should start in a sitting position until comfortable and confident to try different ones. Extensive evidence supports its effectiveness in sitting or gravity assisted positions. A minimum of ten minutes in each productive position is recommended.

The ACBT may be performed with or without an assistant providing vibration, percussion and shaking. Self percussion/compression may be included by the patient.

3. Breathing control technique:

The patient is asked to breathe in and out gently through nose if can. If not, breathe through mouth instead. Ask the patient to let go of any tension in body with each breath out and keep shoulders relaxed. Gradually make the breaths slower. The patient is asked to close the eyes to help to focus on breathing and to relax. Breathing control should continue until the person feels ready to progress to the other stages in the cycle.

4. Thoracic expansion exercises:

The patient is asked to keep the chest and shoulders relaxed. The patient now takes a long, slow, deep breath in, through nose if can. At the end of the breath in, hold the air in lungs for 2-3 seconds before breathing out (this is known as an inspiratory hold). Breathe out gently and relaxed, like a sigh. Repeat 3 – 5 times. If the patient feels light headed then it is important that they revert back to the breathing control phase of the cycle.

5. Forced Expiratory Technique:

The patient is asked to Huff and cough at different, controlled lengths to move mucus up to the larger airways. This huffing should be repeated until all mucus has been huffed out of the lungs.

Peak expiratory flow rate

Zone	Reading	Description
Green zone	80 to 100 percent of the usual or normal peak flow readings are clear.	A peak flow reading in the green indicates that the covid is under good control
Yellow zone	50 to 79 percent of usual or normal peak flow readings.	Indicates caution.  It means respiratory airway is narrowing and additional medication may be required
Red zone	Less than 50 percent of usual or normal peak flow readings.	Indicates a medical emergency. Severe airway narrowing may be occurring and immediate action needs to be taken. This would usually involve contacting a doctor or hospital.

Modified Borg Dyspnoea Scale

0 – Nothing at all 0.5 – Very, very slight (just noticeable) 1 – Very slight 2 – Slight 3 – Moderate 4 – Somewhat severe 5 – Severe 6 – Severe 7 – Very severe 8 – Very severe 9 – Very, very severe (almost maximal) 10 – Maximal

Conclusion

In conclusion, because of the disabling effects of COVID-19, physiotherapy would be an inseparable part of the treatment. Anyone can benefit from deep breathing techniques, but they play an especially important role in the COVID-19 recovery process. The exercises can be easily incorporated into your daily routine. Altogether, physiotherapy interventions, including mobilization, chest physiotherapy, and exercise training, could be considered as both prophylactic and therapeutic strategies for all patients after recovery.