Guidelines for the physiotherapy management of the adult, medical, spontaneously breathing patient
Authors: J Bott, S Blumenthal, M Buxton, S Ellum, C Falconer, R Garrod, A Harvey, T Hughes, M Lincoln, C Mikelsons, C Potter, J Pryor, L Rimington, F Sinfield, C Thompson, P Vaughn, J White
Journal: Thorax (2009)

RECOMMENDATIONS IntroductionPhysiotherapy should be offered to patients with a variety of medical respiratory conditions, with the aim of breathlessness management and symptom control, mobility and function improvement or maintenance, and airway clearance and cough enhancement or support.Strategies and techniques include: rehabilitation, exercise testing (including for ambulatory oxygen assessment), exercise prescription, airway clearance, and positioning and breathing techniques.Physiotherapy may be helpful for postural and/or musculoskeletal dysfunction and pain, and provide help in improving continence, especially during coughing and forced expiratory manoeuvres.Physiotherapists are usually central to the delivery of pulmonary rehabilitation and may be instrumental in the non-invasive ventilation service.Physiotherapists are frequently involved in the delivery of oxygen and some nebulised substances, as well as providing vital monitoring of, for example, ventilatory function and cough effectiveness.Some complementary therapies may be appropriate in some situations (Web Appendix 1).Recommendations are listed for each diagnostic group.A concise version of this guideline is available on the BTS website. Chronic obstructive pulmonary disease (COPD) Management of breathlessness PositioningRecommendations c Advise on passively fixing the shoulder girdle for optimising ventilatory muscle efficiency and relief of breathlessness.(Grade D) c Assess the effectiveness of forward lean sitting on relief of breathlessness in all patients with COPD, in both the chronic and acute settings.(Grade C) c Advise modification of the forward lean position for use in standing and lying, for patients for whom forward lean sitting is effective.(Grade D) Walking aids Recommendations c Assess the effectiveness of a rollator frame for patients with COPD disabled by breathlessness.(Grade B) c Assess the effectiveness of a gutter rollator frame in the acute setting, for patients with COPD severely disabled by breathlessness, especially the elderly.(Grade B) c Teach individualised energy conservation techniques to help reduce dyspnoea during activities of daily living.(Grade D) Breathing techniques Recommendations c Teach patients with COPD breathing control at rest to see if it helps relieve dyspnoea.(Grade D) c Diaphragmatic breathing should not be taught routinely to patients with severe COPD.(Grade C) c Teach pursed lips breathing during exertion as a potential strategy to reduce respiratory rate and aid recovery in patients with COPD.(Grade C) c Teach exhalation on effort (''blow as you go!'') as a potential strategy to reduce dyspnoea in patients with COPD.(Grade D) c Teach relaxed, slower, deeper breathing as a potential strategy to facilitate more effective ventilation during exertion in patients with COPD.(Grade D) c Teach paced breathing as a strategy to maintain control of breathing and reduce dyspnoea during exertion in patients with COPD.(Grade D) Ventilation feedback training Recommendation c Ventilation feedback training is not indicated in patients with COPD.(Grade C) Managing anxiety and panic Recommendation c Teach patients with COPD positioning, breathing and relaxation strategies to help manage anxiety and panic attacks.(Grade D) Pulmonary rehabilitation Recommendations c Pulmonary rehabilitation should include exercise training of the muscles of ambulation.(Grade A) c Pulmonary rehabilitation should incorporate strength training of both upper and lower limbs.(Grade A) c Information, advice and education should be integral to pulmonary rehabilitation.(Grade A) c Pulmonary rehabilitation should be made available to all appropriate patients with COPD.(Grade A) Field exercise tests Recommendation c The recommended number of practice walks must be included when assessing exercise tolerance with a field exercise test for the prescription of either exercise or ambulatory oxygen.(Grade C) Peri-and postexacerbation pulmonary rehabilitation Recommendations c Consider pulmonary rehabilitation soon after exacerbation for patients with COPD.(Grade B) c Consider some form of rehabilitation during exacerbation to maintain mobility and function in patients with COPD.(Grade D)