Month: November 2011

Evidence based case study in management of acute Exacerbations of COPD.

Introduction:

Chronic pulmonary diseases have become increasingly one of the most common chronic lung diseases and a major cause of morbidity and mortality in modern world. It is characterized by airflow limitation that is not fully reversible.

 Chronic Obstructive Disease is a leading cause of the death in the worldwide (Calverley et al, 2003). The condition can result in loss of work quality and quality of the life can be significantly effected (Barnes, 1999). In UK 27,478 men and woman die because of the chronic obstructive lung diseases and most of the death ( more than 90%) was in  the age of above 60 years old(British Thoracic Society. 2006).

Rehabilitation for patients with chronic lung diseases is well established and widely accepted as means of enhancing standard therapy in order to improve symptoms and maximise the patients function (Siafakas et al, 1995; Ries, 1990; Casaburi, 1993; Fishman, 1996). In 1974, the American College of Chest Physicians (ACCP) focused in there definition of Pulmonary rehabilitation on three important features and they suggested that Successful pulmonary rehabilitation depends on three importance features, Individuality of each case, Multidisciplinary team approach and attention to physiopathology and psychopathology of each case.

One of the main problems with COPD patient is the increase in the pulmonary secretions leading to increase in shortness of breath. These two factors affect the patient’s function and quality of life.  For exacerbation, Physiotherapy is often required to help clear secretions and reduce WOB, including non-invasive ventilation to prevent intubation (Alexandera, 2001).

There are various techniques, which can be used in physiotherapy to improve patient’s condition. The research suggests that the postural drainage is beneficial in clearing  the chest from secretions (Clarke,1989;Faling,1986), respiratory muscle relaxation manoeuvre is effective for improving the pulmonary function of pulmonary emphysema patients (Fujimoto et al, 1996), relaxation can help reduce dyspnoea and anxiety in chronic obstructive pulmonary disease (COPD) patients (Louie, 2004).

Case description 🙁 case history, physical examination, and intervention)

Patient is a 67-years-old woman with acute exacerbation in Chronic Obstructive Pulmonary Disease (COPD). She complained of increased shortness of breath with loose, non-productive cough. A febrile on auscultation, bilateral rales, rhonchus, and expiratory wheezing. Patient said she is on bronchodilators and low-dose steroid. Patient said she has been suffering from this problem since 10yrs and has been on medication since. She does not do any exercises and her general practitioner who she usually sees has never mentioned about seeing any physiotherapist. Recently during this episode of acute exacerbation, she was advised by the hospital doctor to see a physiotherapist.

The strategy in this case study used was the problem-solving model, which included following six steps;

Step 1: Patient assessment,

Step 2: defining the problem,

step3: determining the goals,

step4: identifying appropriate techniques,

Step 5: applying the techniques,

step6: re-evaluation of the patients situation(Donna,1987).     

Evaluation and assessment:

Accurate assessment is the key player of physiotherapy and forms the bases of rational practice. A Problem based assessment leads to reasoning in the pulmonary rehabilitation. As result, a thoughtful evaluation will guide to both effectiveness and efficiency  because time will be saved by avoiding unnecessary treatment (Physiotherapy in Respiratory Care An evidence-based approach to respiratory and cardiac management).

Ward reports and medical notes of the patient were evaluated to know about;

·         The past and present relevant history.

·          social history , accommodation

·         Conditions required precautions in relation to certain treatments e.g. light-headedness ,bleeding disorders or swallowing disorders

·         Recent cardiopulmonary  resuscitation to examine the X-ray in case of gastric aspiration or fracture

·         Checking for possibly of bony metastases, long-standing steroid therapy that this leads to risk of osteoporosis and checking for the history of radiotherapy over the chest. These all findings contraindicate percussion or vibration over the ribs.  

·         The patient’s experience increased shortness of breath and the assessment indicate airway secretion.

A part of the patient evaluation was subjective assessment and that was by listening to patient’s problem in her own words. Following symptoms were checked:

Respiratory symptoms by looking for the how long the symptoms been troublesome.

·         Frequency, duration, and the severity.

·         Any pain, chest pain, musculoskeletal pain or cardiac pain.

·         Checking functional limitations including the daily living.

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