THEORIES OF CHEST
DISEASES
FOR PHYSICAL THERAPY
THIRD YEAR STUDENTS
BY
DR: Mustafa Maged Abushady
Lecturer of chest diseaases &
tuberclusis ,faculty of medicine
CYSTIC
FIBROSIS
CF is a multisystem disorder that affects the chloride transport system in
exocrine.
Tissues, primarily secondary to a defect in the CF transmembrane regulator
(CFTR)protein.
CF is an autosomal recessive disease affecting approximately 1 in 2,500
whites and 1 in 17,000 blacks in the United States. The major pulmonary
finding in CF is bronchiectasis, which is an almost universal feature of this
disease. It may be the sole feature of CF in adults or those with genetic
variations of the disease.
The pathogenesis of airways disease in CF has been partially elucidated. In
bronchial epithelial cells, CFTR mutations decrease Chloride permeability
and Increase net sodium absorption. As a result, the volume of airway
surface liquid is decreased, mucociliary clearance is impaired, and cough
clearance is probably decreased.
Bronchiectasis associated with CF is believed to occur secondary to mucous
plugging of proximal airways and chronic pulmonary infection.
CLINICAL FEATURES OF BRONCHIECTASIS
Cough Chronic productive cough is prominent, Sputum is typically
produced daily) Sputum is typically mucoid and relatively odorless. During
infectious exacerbations, however,
sputum becomes purulent and may develop an o ensive odor, total
daily sputum amount has been used to characterize the severity of
bronchiectasis,
Intermittent hemoptysis, it is generally mild and manifested by blood
flecks in the patient'susual purulent sputum. Bleeding usually originates
from dilated bronchial arteries, which contain blood at systemic
pressures. Therefore, massive hemoptysis may occur but is rarely a
cause of death.
Breathlessness and Dyspnea obstruction following Pleuritic chest pain is an Fatigue is commonly reported,
typically occurs in patients destruction of the bronchial intermittent finding, it is most weight loss often occurs in
with extensive bronchiectasis tree. commonly secondary to patients with severe
observed on chest chronic coughing but also bronchiectasis.
radiographs. Wheezing is occurs in the setting of acute
commonly reported and may exacerbation.
be due to airflow
Signs
Wheezing may be due to airflow obstruction from secretions,
destruction of the bronchial tree leading to airway collapsibility
Crackles and rhonchi are often observed in association with
active infections and acute exacerbations
Clubbing Digital clubbing is an inconsistent finding in patients·
Signs of cor pulmonale Right-sided heart failure may be
observed, including peripheral edema, hepatomegaly, and
hypoxia
INVESTIGATIONS
CXR Posterior-anterior and lateral chest radiographs should be obtained in allpatients. Chest radiograph
sensitivity is only 50% findings are occasionally sufficient for confirming the diagnosis of bronchiectasis.
HRCT of the chest CT scanning, particularly high-resolution CT (HRCT) scanning of the chest, CT sensitivity and
specificity reportedly are 84-97% and 82-99%,respectively.
Complete blood count
Sputum microbiology
Pulmonary function tests
Immunoglobulins A, M, E, G levels.
CFTR gene level
MANAGEMENT
The main aims of management are:
►Identify and treat underlying cause to prevent disease progression.
►Maintain or improve pulmonary function.
►Reduce exacerbations.
►Improve quality of life by reducing daily symptoms and exacerbations.
►In children, achieve normal growth and development.
►Patients with primary or secondary immune deficiency should be under joint care with
a clinical immunologist.
►Patients with CF should be referred to a CF specialist center.
Antimicrobial chemotherapy:
Antibiotics are given during the acute exacerbation only, Patients need
higher antibiotic dose, and for longer time period (usually 2 weeks
minimum) than people without bronchiectasis
Aerosolization of an antibiotic Tobramycin at a dose of 300 mg BID
every other month for six months in patients with CF had a 100-fold
reduction in sputum
microbial density, improved FEV1, and decreased hospitalizations
compared to patients receiving placebo aerosol Preventive antibiotic
therapy
Treatment response is usually assessed by a fall in sputum volume and
change to mucoid from purulent or mucopurulent sputum, with an
improvement in systemic symptoms and spirometry
Treatment of associated airflow obstruction/wheeze
with inhaled bronchodilators
Mucolytic while maintaining adequate general
hydration, which may improve the viscidity of
secretions,
Annual influenza and pneumococcal vaccinations
FURTHER
Reflux treatment if aspiration
MANAGEMENT
Immunoglobulin replacement therapy Patients found to
have immunoglobulin deficiency
Surgery may be indicated for life-threatening
hemoptysis
Transplant is most commonly performed for CF
bronchiectasis,
PHYSIOTHERAPY IN CF
Physiotherapy: airway clearance techniques and exercise Good
bronchial hygiene is paramount in the treatment of bronchiectasis,
because of the tenacious sputum and defects in clearance of mucus
in these patients.
Postural drainage with percussion and vibration is used to loosen and
mobilize secretions.
Devices available to assist with mucus clearance include flutter
devices, intra pulmonic percussive ventilation devices, and incentive
spirometry.