COPD ASTHMA CHRONIC BRONCHITIS EMPHYSEMA

is a disease of respiratory tract that Chronic means that cough and

produce an obstruction to airflow
DEFINITION and ultimately can affect both
mechanical function and gas
exchange capability of the lung.
Clinical syndrome characterized
by an increase in the reactivity of
tracheobronchial tree to various
stimuli.
expectoration have persisted for
is abnormal enlargement of the alveoli
at least 3 months and repeated
accompanied by destructive changes
for at least two consecutive
of the alveolar walls.
years.

• Genetic (e.g. Alpha 1 -antitrypsin 1-It is a disease of uncertain ▪ Pulmonary congestion in cases -most common cause is cigarette
deficiency) etiology. of left sided heart failure. smoking.
PREDISPOSING • Environmental. 2-It increases in children not ▪ Chronic sinusitis.
FACTORS • Cigarette smoking Air pollution adults. -alpha 1-antitrypsin deficiency (A1AD)
▪ Chest deformities e.g.
• Modern medicine increased in 3-Allergens, respiratory irritants, kyphoscoliosis.
geriatric population. cold air, emotional stresses & ▪ Genetic predisposition.
chemical substances may
▪ Extreme age is more common.
aggravate the symptoms.
PHYSICAL Vesicular breath sound with ▪ Prolonged expiratory wheezing. • The chest increases in AP view,
EXAMINATION: prolonged forced expiratory time dorsal kyphosis, elevated ribs and
with manifestation of widening of costo-chondral angle
1) CHEST EXAM
hyperinflation. leads to barrel chest.
1-Barrel chest increased anterior-posterior 1-Cyanosis in blue bloater type. ▪ Cough starts dry then  Cyanosis and digital clubbing.
diameter 2-Jugular venous distention & productive.  Hypertrophy of accessory muscles.
2) INSPECTION 2-horizontal ribs hepatomegaly .6-Dyspnea.
3-wide inter-costal spaces ▪ Dyspnea.  Peripheral edema.
3-RT ventricular insufficiency.
4-wide sub-costal angle.  Cyanosis, typically in lips and
4-pitting edema of ankles.
5-bilateral limitation of chest expansion. 5-inability speak with tachypnea fingers.
 Peripheral edema

Trachea is central and TVF is
3) PALPATION deceased bilaterally
hyper-resonance with
encroachment on cardiac and
4) PERCUSSION
hepatic dullness.
1-diminished breath sound with
prolonged expiration
5) AUSCULTATION 2-generalized rhonchi
3-early inspiratory crepitations
4-distant heart s
ounds
Pulmonary rehabilitation improves
dyspnea, exercise capacity and
TREATMENT quality of life in patients with
COPD.
1-Retractions – intercostal , supra tactile fremitus normal
& sub – sternal.
2-Diaphoresis with evidence of
paradoxical pulse.
1- Hyperinflation , hyper
resonance.
1-prolonged exhalation &
wheezing.
Oxygen therapy: -(> 15 hours per
day).
-Diaphragm breathing ex :
rehabilitation during pre & during
program.
-Butekyo breathing ex : during
attacks.
hyper-resonance with
encroachment on cardiac and
hepatic dullness.
▪ Crackles.
▪ Prolonged expiratory wheezing.
 Diffusely decreased breath
sound
Medical treatment: Antibiotics,
Expectorants, Anti allergic.
difficult to palpate apex beat (all due
to hyperinflation)
1-Hyperresonance that continues
below these boundaries can be
suggestive of hyperinflation
2-Cardiac dullness
 Prolonged expiration; wheezing.
 crackles with inspiration
 ecreased breath sounds, audible
expiratory wheeze.
Medical treatment:
▪ Antibiotics
▪ Bronchodilator.
▪ Expectorants.
 1-Strength training : -It is
performed by using gravity and
elastic bands.
EXERCISE -Exercises were done for arms and
TRAINING legs.
2-Aerobic training : The initial
training intensity corresponded to
50% of the initial maximal work
rate achieved during maximal
exercise test for up to 45 min.
1- Chronic Bronchitis
TYPES 2- Emphysema and
3- Asthma
4- Reversible " spasm or sputum"
5- Irreversible " degeneration or
fibrosis "
6- Localized " tumor or foreign
body "
1- Diaphragmatic breathing,
emphasizing control but not
forceful expiration.
2- Pursed - lip breathing .
3- Butokyo breathing .
4- Effective coughing .
5- Postural drainage.
6- Postural training.
7- Relaxation of upper chest &
accessory Ms by positioning.
1-Extrinsic asthma (due to
external factors).
2-Intrinsic asthma (due to
internal factors)
3-Occupational asthma (related
to the occupation).
4-Stable asthma (related to
certain causes)
5-Unstable asthma (unrelated to
certain causes).
6-Status Asthmatics-asthma (not
respond to traditional
management).
• Rest in acute phase.
• Teach the patient the right way
of breathing.
• Pursed – lip breathing.
• Postural drainage.
• segmental breathing exercise.
• exercise connected with
breathing.
• sustained breathing exercise.
• acute: just 10 day only
• chronic : from 3 months to 2 y.
• Pursed-lip breathing.
▪ Teach the patient the right way of
breathing to prolong the time of
expiration.
▪ Positioning to increase ventilation.
▪ Posture exercise to correct the
abnormal positions.
▪ Central emphysema ▪ Pan
emphysema ▪ Distal emphysema
 Pink buffer: 1- decrease of
ventilatory drive
2-intense dyspnea with pursed lip
3-patient thin & pink sputum volume
No HF .
4-pan lobular emphysema.
5-Mild or moderate hypoxemia
without hypercapnia.
6-severe expiratory air flow
obstruction.
 Blue buffer: 1- poor ventilatory drive
2-Cyanotic.
3-large sputum volume, recurrent
chest infection , edematous. RT HF.
4-centrilobular emphysema.
5-hypercapnia + hypoxemia.
6-severe air flow obstruction.
 ▪ Respiratory failure.
▪ Left-sided heart failure.
complication ▪ Pulmonary infections.
▪ Bronchial obstruction and
collapse.
▪ Pneumothorax.
▪ Salt and fluid retention.
▪ Protein-uria and nephritic
syndrome.
▪ Erythrocytosis.
▪ Complications of chronic cough.
1-chronic cough with
expectoration.
Symptoms: 2-chest pain.
3-gradual progressive dyspnea with
wheezing.
1-tachycardiac & hypoxemia
2-increase respiratory rate as
Signs: tachypnea with working accessory
Ms.
3-Head: puffiness of eye lids.
4-Neck: congested veins.
5-Upper Limb: clubbing finger
1-Bronchospasm.
2-Inflammation.
3-Severe asthma: leads to
emphysema.
1-Bronchoconstriction. ▪ Expectoration → mucoid then  Shortness of breath on
2-Dyspnea + wheezing. mucopurulent. exertion
3-breathing shallow – rapid. ▪ Reduced FEV1-1RV  Hyperventilation
4-poor posture: rounded ▪ Temperature-high in acute  Expanded chest
shoulders & forward head. attack with headache.  Swelling.
1-hypercapnea due to respiratory ▪ Hypercapnia and hypoxemia. Dyspnea is present during physical
dysfunction. dyspnea, fatigue, possible exertion or at rest.
2-hypoxemia. clubbing of fingers. cough and expectoration present.
3-silent chest.
4-central cyanosis.
5-difficulty in taking with
tachycardia.
6-disturbed conscious.
 Restrictive lung Dry pleurisy Pleural effusion Pneumothorax Empyema
dysfunction (RLD)
DEFINITION In dry pleurisy, there is -The presence of excess fluid - Is the accumulation of air It is the presence of bus in
RLD are characterized little or no fluids between 2 layers of pleura. within pleural cavity the pleural space
by reduced total lung accumulates in the pleural -The capillary network of the - If the air enters the pleural secondary to many chest
capacity (TLC), Vital cavity → leads to visceral pleural surface space, the pressure within disease
capacity or resting lung inflammation of pleura of produce fluid lining of pleura, space changes from sub
volume. one or both sides with no any - atmospheric to atmospheric
detectable free exudates. 1- excess amount of fluid is or supra-atmospheric
removed by lymphatic system. pressure.
2-Disturbance in production of
this fluid & in its removal can
lead to the development of
pleural effusion.
PHYSICAL
EXAMINATION:

1- CHEST EXAM
2-INSPECTION - Shallow rapid breathing bulging, unilateral bulge in tension - Sudden fever
-Signs of acute illness asymmetrical breathing, pneumothorax with - Sweating
(fever) limitation of chest motion & diminished respiratory - Malaise
- Asymmetric breathing negative littin sign movement - Chest pain
- Clubbing fingers
3- PALPATION - Tenderness 1) Tracheal & mediastinum Mediastinal shift to the - Tenderness
shift opposite side in tension - increase palpable
2) Loss of TVF pneumothorax & diminished fremitus
TVF
4- PERCUSSION chest is dull sounding
5- AUSCULTATION “grating,” “creaky
-Pleuritic friction rub
TREATMENT - Medical treatment:
(antibiotics, anti-
inflammatory, antipyretics
& analgesic).
EXERCISE TRAINING: - Rest in bed in proper
alignment
- Application of moist heat.
-Bandage of painful side.
- Positioning to prevent
deformity.
TYPES: divided into 2 groups 1) The pleural space is the
1-Intrinsic lung disease area between the
(disease of lung mesothelium of the parietal
parenchyma): & visceral pleura
cause inflammation or 2) Pleural fluid contains a
scarring of lung tissue or small no.of cells “mostly
results in filling of air mononuclear cells,
spaces with exudates 3) Pleuritic chest pain
(pneumonitis) originates from the
2-Extrinsic disease: parietal pleura not the
dullness
loss of breathing sound
1) Treatment of underlying
cause .
2) Build up the body
resistance by diet .
3) Intrapleural injection by
fibrinolytic .
4) Under water seal drainage.
5) Physical Therapy.
1) Hydro thorax.
2)Empyema (pyothorax).
3)Hemo-thorax.
4) Chylo-thorax.
5) Fibrothorax.
hyper resonance with dullness
displacement of upper border
of liver
diminished or absent sound of - Pleural rub
breath - crackles
1-Conservative treatment:
bed rest & analgesics
2-Underwater seal: in tension,
secondary & large
pneumothorax
3-Treatment of the cause 4-
Surgical treatment
5-Physical therapy
 Disease of chest wall, visceral pleura which has
pleura & respiratory no pain receptors.
muscles 4) Pleuritic pain worsens
sharply during inspiration
Complication 1) Pulmonary fibrosis. - Primary "tuberculosis” 1) Infection which cause - Pneumonia
2) Pulmonary edema. - Lung abscess. empyema - Lung abscess
or Causes: 3) Pleural effusion. - Secondary "Pneumonia” - 2) Fibrosis which leads to - Tuberculosis
4) Thoracic Carcinoma . fibro-thorax - Infected pleural effusion
musculoskeletal - Sub diaphragmatic 3) Lung collapse - Bronchial carcinoma
pain. abscess.
5) Rib fracture.
6) Morbid obesity.
7) Increased abdominal
pressure.
- Dry cough -During the acute onset: - Sudden fever
Symptoms: - Dyspnea High fever - Dry cough - - Sweating
- Pleuritic pain “stitching & Pleuritic pain - Toxemia – - Malaise
localized pain" Dyspnea. - Chest pain
- During gradual onset: - Clubbing fingers
Dull aching pain –Fatigue.
 Cystic Fibrosis
DEFINITION -persistent pulmonaryinfection,
pancreatic insufficiency.
-Lungs which are affected by
cystic fibrosis produce mucus
which contains lesswater than it
should and is sticker.
PREDISPOSING
FACTORS
PHYSICAL EXAMINATION: - Increased anteroposterior chest
diameter (Barrel chest).
1- CHEST EXAM
- Cyanosis.
- Digital clubbing.
2- INSPECTION - peripheral edema and
distention.
- cough, sputum production, and
hemoptysis.
tenderness
3- PALPATION
hyper resonant lungs
4- PERCUSSION
Bronchiectasis
abnormal and irreversible
dilatation of the bronchi, results
from chronic airway infection
and/or inflammation.
- pleuritic chest pain.
-Clubbing of the digits.
-severe effort of cough.
- Swelling of the lower eye lids
may be result from chronic
cough.
-Ascites.
-chest tightness.
dullness
Lung abscess
Lung abscess is a necrotic,
Suppurative, cavitative lesion
mainly due to infection by
pyogenic organisms.
almost always caused by
aspiration of oral secretions by
patients who have impaired
consciousness.
Finger clubbing
-chest tightness.
Dullness
Pneumonia
Pneumonia occurs when the
normal defense mechanisms of
the respiratory system fail to
adequately protect the lungs
from infection.
1-COPD, such as chronic
bronchitis and emphysema.
2-Suppurative long diseases as in
Cystic fibrosiss.
chest pain.
productive cough
 Increased tactile fremitus.
large amounts of purulent
sputum.
Dullness
 , wheeze or crackles and
productive cough.
5- AUSCULTATION
*Medical treatment:
- Antibiotic therapy.
TREATMENT - Correct for abnormal genes.
- bronchodilators either inhaled.
EXERCISE TRAINING - Percussion and postural
drainage.
- Chest expansion exercises
- Forced expiratory techniques or
huffing.
- Autogenic drainage to mobilize
secretions.
TYPES
Liver  -Hepatic steatosis -
Portal hypertension.
Complication or Causes: Heart -Right ventricular
hypertrophy -Pulmonary artery
dilation.
Bone  -Hypertrophic
osteoarthropathy –Clubbing.
- wheezing & crackles.
- High protein diet.
- Correction of anemia.
- Improvement of hygienic
condition.
1- Postural drainage.
Treatment is aimed at controlling
infections and bronchial
secretions, relieving airway
obstruction, and preventing
complications.
-severe lung infections.
(pneumonia, tuberculosis, fungal
infections).
-abnormal lung defenses
-obstruction of the airways by a
foreign body or tumor.
Bronchial breath sounds
Inspiratory crackles
Physical therapy, postural
drainage, penicillin & other
antibiotics.
- Reduce work of breathing.
-Bacteroides.
-Fusobacterium.
-Peptostreptococcus.
-Prevotella.
-Streptococcus milleri.
-bacterial infections.
 Decreased breath sounds
 Bronchial breath sounds
 Rhonchi
 Crackles, Rales
 Increased vocal fremitus
1-Antiviral medication for flu
virus.
2-Antifungal medication for
fungal cause.
3-Rest and fluids.
4- OTC anti-fever and pain
medications.
*Gentle diaphragmatic
breathing.
*Localized basal expansion and
holding of breathing in full
inspiration.
*Postural drainage.
1-Lobar Pneumonia.
2-Bronchopneumonia.
1-Bacterial, viral or mycoplasmal
infection.
2-Inhalation of toxic chemicals,
smoke. dusts, or gases
3-Aspiration of food, fluid or
vomitus.
 Lungs  -Bronchiectasis -
Bronchitis -Bronchiolitis -
Pneumonia -Atelectasis -
Hemoptysis –Pneumothorax.
- Increased respiratory rate - pleuritic chest pain. - Malaise. 1-Difficulty of breathing
- Increased cardiac output and -blood streaking of the sputum. - Fever are accompanied by 2-Chest pain
Symptoms: blood pressure. -Hemoptysis. cough and pleuritic pain. 3-Coughing
- Cyanosis. -Clubbing of the digits. 4- Fatigue
- patient is thin due to -long standing cases complains of 5-Fever and chills
malabsorption. recurrent fever, fatigue, weight 6-Confusion
loss and loss of appetite. 7 -Headache
8-Muscle pain
-Tachycardia.
-Tachypnea.
Signs: -Hypotension.
 Hypertension POSTURAL DRAINAGE Diabetes Mellitus

DEFINITION -Hypertension is a major health problem, is the process of positioning patients to DM is not a single disease ,but a group of
especially because it has no symptoms. best utilize gravitational effects to enhance metabolic disorders ch; by increased fasting &
-Blood pressure is defined as the force of removal of secretion. postprandial blood glucose conc due to
the blood pushing against the walls of the decreased insulin secretion, decreased insulin
arteries. action, or both.
TYPES -Primary or essential: 1)Percussion. A.Type I (Immune mediated D.M)
It is account about 90% of cases of 2) Vibration. B. Type II (Insulin resistant D.M)
hypertension. 3) Shaking. C. Gestational diabetes mellitus.
- Secondary hypertension: D. Anti- insulin diabetes
It accounts 10% of cases of hypertension.
Risk Factors: - more common in men than women & in 1-Genetic predisposition.
people over age of 65 than in younger 2-Male gender.
persons. 3-Weight.
- stress, obesity, & poor diet or insufficient 4-Alcohol.
intake of nutrients. 5-Hypertension.
- Smoking and type II DM.
- age, gender, and race.
complications - Ischemic heart disease. 1-Hypoxemia. - Causes problems with circulation.
- Renal failure in 10% of cases. 2-Increased Intracranial Pressures. - Kidney damage (Nephropathy).
- Cerebral thrombosis. 3-Pulmonary Hemorrhage. - Too much glucose clogged up small blood
- Myocardial infarction (heart attack) 4-Pain or Injury to Muscles, ribs, Or Spine. vessels that carry blood in the body.
- heart failure. 5-Vomiting & Aspiration.
6-Bronchospasm.
7-Dysrthmias.
Symptoms -Headache. - Nausea
- Blurred vision - Vomiting
- Vertigo (Dizziness). - Weight loss
 - Flushed face. - Abdominal pain

Management ■ Diet control as weight and sodium 1- Goals of PD: Prevent accumulation of ■Age
reduction restriction. secretions in patients at risk for pulmonary ■ Lifestyle.
■ Blood pressure Muscle tension complications. ■ Physical abilities.
■Heart rate. 2- Remove secretions already accumulated ■Type of diabetes.
■ Maximize patient's quality of life, and in the lungs. ■ How long having diabetes.
general health. ■ Presence of complications.
■ Occupation and family support.
Treatment -Medications. -Abnormal chest x-ray consistent with ■To improve insulin sensitivity and glycemic
- Eating. atelectasis, mucus plugging, or infiltrates. control.
■ Avoid coffee and other stimulants, ■ For weight control.
alcohol, and tobacco. ■Daily clean and properly fitting socks.
Exercise -Aerobic exercise and relaxation training. -Maintain muscle tone & physical fitness.
- dynamic endurance exercise: such as -Lower blood glucose levels.
running or cycling. -Lower blood lipid levels .
-Increase sensitivity to medications .
-Aid meal planning in controlling weight.
Physical Examination -Abdominal exam.
- Cardiac exam.
- Blood pressure.
- Skin condition and edema, especially legs.
- Neurological exam.
Using 1- Use drainage position most appropriate
to the lung segments involved.
Contraindication 1)Severe hemoptysis.
2)Sever pulmonary edema. 3)Large pleural
effusion. 4)Pulmonary embolism. 5)Tension
pneumothorax.
6)Cardiac arrhythmia.

Contraindications to Percussion
or Vibration:
7)Sever hypertension.
8)Sever hypotension.
9)Recent myocardial infarction. 10)Aortic
aneurysms
11)Recent neurosurgery
12)Following esophagectomy
13)Surgical emphysema
14)Hiatus hernias.
15)Filling cycle of peritoneal dialysis.
16)Facial edema from burns. 17)Eye
operations.
-ln cases of CHF with orthopnea. -ln post
neurosurgeries avoid head down positions.
-ln post thoracic surgeries.
 CARDIAC REHABILITATION Phase I- in-patient period
an increasing evidence base the initial stage of the
as an intervention for patient's cardiac
DEFINITION: secondary prevention of rehabilitation pathway and
cardiac diseases. is considered as the
inpatient stage, or after a
step change' in the
patient's cardiac condition.
1-Frequency and Timing:
most patients begin with,
exercise program: short intermittent bouts 2
to 5 min of continuous
monitored ambulation
activity interspersed with
rest period, 2-3 times per
day and often 15 to 30 min
from 1-2 times per day.
2-Intensity:
according to individual
tolerance.
Phase II - early post-
discharge
-This is the immediate post-
discharge stage, this home-
based period conducted on
an outpatient basis
immediately after
hospitalization.
- is initiated within 2 weeks
of hospital discharge.
1-Frequency and Timing:
-The standard frequency
for exercises to improve
cardiovascular fitness is 3
times weekly.
-Patients usually need to
allow 30-60 minutes for
each session, which
includes warm-up and cool
down period ranges from 5-
10 minutes for each.
2-Intensity:
-The intensity prescribed is
in relation to patient's
target heart rate.
Phase III - supervised out- Phase IV - long-term
patient program maintenance of exercise
and lifestyle changes
This is traditionally the
outpatient education and
structured exercise
program component of
cardiac rehabilitation.
1-Frequency and Timing:
-1-2 times per week at a
supervised rehabilitation
class with additional,
independent home-based
exercise twice per week.
-Walking and other leisure
activities should be
incorporated on remaining
days.
-The time of conditioning
exercises initially started
from 5-10 min then
gradually increased to 20-
30 min excluding warm- up

1- Significant improvement
Patients should functional capacity
demonstrate the following 2- Psychological adaptation
in this phase: to chronic disease.
1- first exposure to risk
factor modification and
INFORMATION: education and acts as a
gateway to the next phases
of CR.
2- This independent
ambulation improves
selfconfidence and helps to
prepare the patient
psychologically for
subsequent pre-discharge
exercise testing.
- The Borg scale (RPE) may
be used.
3- The foundation of
behavioral and lifestyle
changes required for
continued risk factor
modification.
4- Exercise safely and
effectively, according to an
individual exercise
prescription.
1- This is the stage where
modification of risk factors
will start to be applied and
goals set in phase I CR
should start to be realized.
2- A follow-up treadmill
test may be used at 4-8
weeks after the patient
starts the program, and the
results should be used to
fine tune the exercise
training.
(5- 10 min) and cool-down
(5-10 min).
2-Intensity:
Establishing a training
intensity includes
development of a target
heart rate range.
5- Monitor his or her own 7- Identify specific goals for
heart rate or use scale of long-term maintenance of
perceived exertion lifestyle change and risk
effectively. factor reduction, relating to
6- Recognize warning signs own personal history.
and symptoms and take 8- Take responsibility to
appropriate action (e.g. monitor risk factors (i.e.
stop/reduce exercise level, smoking, blood pressure,
take glycerol trinitrate). cholesterol and diabetes).
1- Aerobic and muscular
strength and endurance
training that involves large
muscle groups in dynamic
movement.
2- walk, cycle, circuit
training are commonly used
in this phase.
 The review of -important for those
exercisebased patients and their families
AIMS: rehabilitation for coronary to have direct contact with
heart disease, post- appropriate healthcare
myocardial infarction and professionals.
re-vascularized patients
concluded that exercises
program is effective in
reducing cardiac deaths, in
reducing cardiac risk factors
and in enhancing
psychosocial factors.