**8. Clinical implementation**

#### **Case 1: Chest mobilization treatment in the sub-acute stage**

**Illness history and medical treatment**: A sixty years old man, diagnosed with aspirated pneumonia and underlying cysticercosis from obstructive hydrocephalus, was admitted to hospital with respiratory failure. A physician treated him with tracheostomy and on a ventilator (tidal volume = 450 mL, I:E = 2.1, and respiratory rate = 16 bpm). A hematology

Chest Mobilization Techniques for Improving

**Case 2: Chest mobilization treatment in the acute stage** 

trunk rotation.

left)

reached.

Ventilation and Gas Exchange in Chronic Lung Disease 415

Fig. 16. Chest radiograph after 7 days of treatment (left) and Chest mobilization in sitting position with sternum compression, trunk extension and rotation (middle and right).

**Progressive treatment:** Passive chest mobilization in a sitting position by stimulating chest expansion in an anterio-posterior direction with sternum compression, back extension and

**Final outcomes:** In this case, chest mobilization in anterio-posterior direction or stimulated sternum movement increased chest expansion by evaluating the expiratory tidal volume (TVE), tidal volume, and SpO2. Patients who have stopped using a ventilator and are only on an O2 with T-piece can be discharged from hospital after 2 weeks treatment with chest mobilization. However, there is more intensive treatment such as sitting, standing and walking training, and weight training to increase the upper and lower limbs' strength.

**History of illness and medical treatment**: A sixty-three years old man was diagnosed with chronic lung disease, pneumonia and sepsis. A physician treated him with an orotracheal tube on a ventilator (Pressure support= 12 cmH2O, O2 = 35%, VTE = 150 mL). Blood gas results showed respiratory acidosis and moderate hypoxia with metabolic compensation. Medical problems after treatment were prolonged use of a ventilator (for one month), with recurrent infection and pneumothorax at the right lung, which was resolved by intercostal drainage (ICD). Then, the medical program for weaning off the ventilator was unsuccessful. **Chest X-ray:** Left lung atectasis and pneumothorax at the right lung with ICD (Figure 17

**Physical examination**: A thin man was using a ventilator and presenting general weakness, muscle atrophy and malnutrition. He produced very little chest expansion on either side.

**Treatment:** Initially, an upright position was combined with a chest mobilization technique on the left chest wall, and percussion to remove secretion was performed 3 times daily.

**Progession:** After 3 days of treatment, chest radiography was evaluated repeatedly (Figure 17), showing improvement of aerotion in the left lung, but atelectasis at the lower lung. The physician could not reduce pressure support while the patient was on the ventilator, but the expiratory tidal volume improved from 155 to 366 mL and an ICD was removed successfully. Unfortunately, remaining problems presented because of respiratory muscle weakness, and malnutrition, and the final goal of stopping the ventilator still had to be

Dullness presented at the left lung and hyperresonance at the right one.

test showed low haemoglobin (8.9 g/dL) and haematocrite (27.7%), and the chemistry lab test showed hyponatermia and hypoglycemia.

**Chest X-ray:** Interstitial infiltration of the left and right upper lobe (Figure 14).

**Physical examination**: A thin man, with general muscle atrophy, moderate dyspnea, use of accessory muscles during inspiration, decreased chest expansion on the left more than right side, dullness at the left lung, decrease of air entry with bronchovesicular breath sound and coarse crepitation in both lungs (Figure 14 right)

Fig. 14. Chest radiograph before treatment showing infiltration in the left lung and upper area of the right upper lobe (right), and general configurature of the chest wall showing very tight or stiff movement (left).

**Treatment:** Passive rib torsion at the left lung was added to the general chest physical therapy program; postural drainage, percussion, and breathing exercise (Figure 15) twice daily for 7 days.

Fig. 15. Passive rib torsion at the left chest wall 10 times per session during ventilation.

**Progession:** After treatment, repeated chest radiography showed improvement of aerotion and less infiltration in the left lung (Figure 16). Medical treatment could stop using a ventilator to supplement oxygen at 10 Lpm, with a T-piece for 1 hr alternately in a 4 hr period, because hypoglycemia, hyponatermia and malnutrition, dyspnea and use of some accessory muscles were present.

**Remaining problems:** General weakness, ineffective breathing, shortness of breath, minimized chest expansion and stiffness, and air entry reduction without crepitation.

test showed low haemoglobin (8.9 g/dL) and haematocrite (27.7%), and the chemistry lab

**Physical examination**: A thin man, with general muscle atrophy, moderate dyspnea, use of accessory muscles during inspiration, decreased chest expansion on the left more than right side, dullness at the left lung, decrease of air entry with bronchovesicular breath sound and

Fig. 14. Chest radiograph before treatment showing infiltration in the left lung and upper area of the right upper lobe (right), and general configurature of the chest wall showing very

**Treatment:** Passive rib torsion at the left lung was added to the general chest physical therapy program; postural drainage, percussion, and breathing exercise (Figure 15) twice

Fig. 15. Passive rib torsion at the left chest wall 10 times per session during ventilation.

**Progession:** After treatment, repeated chest radiography showed improvement of aerotion and less infiltration in the left lung (Figure 16). Medical treatment could stop using a ventilator to supplement oxygen at 10 Lpm, with a T-piece for 1 hr alternately in a 4 hr period, because hypoglycemia, hyponatermia and malnutrition, dyspnea and use of some

**Remaining problems:** General weakness, ineffective breathing, shortness of breath, minimized chest expansion and stiffness, and air entry reduction without crepitation.

**Chest X-ray:** Interstitial infiltration of the left and right upper lobe (Figure 14).

test showed hyponatermia and hypoglycemia.

coarse crepitation in both lungs (Figure 14 right)

tight or stiff movement (left).

accessory muscles were present.

daily for 7 days.

Fig. 16. Chest radiograph after 7 days of treatment (left) and Chest mobilization in sitting position with sternum compression, trunk extension and rotation (middle and right).

**Progressive treatment:** Passive chest mobilization in a sitting position by stimulating chest expansion in an anterio-posterior direction with sternum compression, back extension and trunk rotation.

**Final outcomes:** In this case, chest mobilization in anterio-posterior direction or stimulated sternum movement increased chest expansion by evaluating the expiratory tidal volume (TVE), tidal volume, and SpO2. Patients who have stopped using a ventilator and are only on an O2 with T-piece can be discharged from hospital after 2 weeks treatment with chest mobilization. However, there is more intensive treatment such as sitting, standing and walking training, and weight training to increase the upper and lower limbs' strength.

#### **Case 2: Chest mobilization treatment in the acute stage**

**History of illness and medical treatment**: A sixty-three years old man was diagnosed with chronic lung disease, pneumonia and sepsis. A physician treated him with an orotracheal tube on a ventilator (Pressure support= 12 cmH2O, O2 = 35%, VTE = 150 mL). Blood gas results showed respiratory acidosis and moderate hypoxia with metabolic compensation. Medical problems after treatment were prolonged use of a ventilator (for one month), with recurrent infection and pneumothorax at the right lung, which was resolved by intercostal drainage (ICD). Then, the medical program for weaning off the ventilator was unsuccessful.

**Chest X-ray:** Left lung atectasis and pneumothorax at the right lung with ICD (Figure 17 left)

**Physical examination**: A thin man was using a ventilator and presenting general weakness, muscle atrophy and malnutrition. He produced very little chest expansion on either side. Dullness presented at the left lung and hyperresonance at the right one.

**Treatment:** Initially, an upright position was combined with a chest mobilization technique on the left chest wall, and percussion to remove secretion was performed 3 times daily.

**Progession:** After 3 days of treatment, chest radiography was evaluated repeatedly (Figure 17), showing improvement of aerotion in the left lung, but atelectasis at the lower lung. The physician could not reduce pressure support while the patient was on the ventilator, but the expiratory tidal volume improved from 155 to 366 mL and an ICD was removed successfully. Unfortunately, remaining problems presented because of respiratory muscle weakness, and malnutrition, and the final goal of stopping the ventilator still had to be reached.

Chest Mobilization Techniques for Improving

left lung before treatment (Figure 19 left).

times daily (Figure 19 middle and right).

left) (Leelarungrayub et al., 2009).

periods.

Ventilation and Gas Exchange in Chronic Lung Disease 417

**Chest X-ray:** CXR shows specific atelectasis at the right lower lobe and hyperaerotion in the

**Physical examination**: A thin man using a ventilator presented with muscle weakness, atrophy and malnutrition. BMI was 13.5 kg/m2. Chest expansion was very small on both

**Treatment:** For general chest physical therapy with postural drainage, percussion and breathing exercises were carried out in the ward, such as upright position combined with a chest mobilization technique and compression on sternum, and trunk rotation was used to improve chest wall flexibility. An additional program of passive rib torsion, trunk extension and lateral stretching on a pillow was carried out as well. All programs were performed 3

Fig. 19. Chest radiograph showing atectasis of the right lower lobe and hyperaerotion in the left lung before treatment (right), Chest mobilization being performed with compression on sternum, trunk rotation of both sides, sterum and trunk rotation of both sides (middle and

**Clinical evaluation:** Efficiency of treatment was monitored using various parameters such as expiratory tidal volume, chest expansion at the mid axillary line with a tape and dyspnea, and followed up by CXR after treatment. This effective treatment used the single-case research design with the A (Pre-CPT), B (CPT treatment), and A (Post-CPT) model for 7 day

**Results** (Figure 20)**:** A 7 day control period (Pre-CPT) showed low expiratory tidal volume (ETV) (mean = 195± 30 mL) and chest expansion (mean = 2.1± 0.54 cm), and during the 7 days of treatment (CPT) benefits were shown by increased mean of ETV (260±49 mL) and chest expansion (3.6±0.22 cm). The dyspnea score was reduced from 6.4±1.14 to 4.4± 0.54. Statistical comparison using the Bloom Table showed significant changes in ETV, with 5 points, 4 points, and all points above the trend line from a Pre-CPT period. However, the Post-CPT and ETV showed deterious effects when treatment was stopped and all points went below the trend line, except for the dyspnea score and chest expansion, which maintained the same level. In both the Pre-CPT and CPT period, all data showed nonsignificant results of autocorrelation, which meant that the changes in each period did not

**Clinical implementation:** The chest mobilization technique is very important for improving ventilation and gas exchange in cases that are measured by lung volume and chest expansion, including dyspnea. In figure 20 shows the significant changes of this technique by increasing in a mean of all paprameter when compared to the before treatment of

come from disease progression, especially during treatment (CPT).

sides. Dullness presented in the left lung and hyperresonance at the right lung.

Fig. 17. Chest radiograph showing atelectasis of the left lung, and pneumothorax at the right lung with ICD before treatment (right) and after 3 days of treatment showing improvement of aerotion in the left lung with atelectasis of the left lower lobe (left).

**Progressive treatment:** An extensive program was carried out from previous treatment with passive chest mobilization in supine position because of weakness. Passive pectoralis muscle and breathing exercise were performed combined with diaphragmatic and intercostal muscle contraction by relearning.

Fig. 18. Passive chest mobilization being combined with breathing exercise of the intercostal and diaphragmatic muscles.

**Final outcomes:** For this case in the ICU stage, benefits of chest mobilization presented improvement of ventilation at the left lung, and more advantageous treatment was shown when combining other techniques such as breathing exercise with intercostal muscle and diaphragm relearning. However, treatment was unsuccessful in other factors such as pneumothorax, malnutrition and the patient's overall condition.

#### **Case 3: Chest mobilization treatment in the chronic stage**

**Illness history and medical treatment**: A sixty years old man was diagnosed with stable COPD and acute exacerbation because of prolonged use of a ventilator, no rehabilitation for 3 months, and unsuccessful weaning from the ventilator with recurrent infection and much secretion. Ventilator mode was maintained with pressure control (pressure support = 25 cmH2O, rate = 15 bpm, I:E = 1:2, FiO2 = 0.45, and PEEP =10 cmH2O. Blood gas showed moderate hypoxemia (PaO2 = 85 mmHg) with hypercapnea (PaCO2 = 55 mmHg) and completed compensation. Berodual forth for preventing bronchospasm and Fluimucil A600 for diluting the secretion were administered routinely.

Fig. 17. Chest radiograph showing atelectasis of the left lung, and pneumothorax at the right lung with ICD before treatment (right) and after 3 days of treatment showing improvement

**Progressive treatment:** An extensive program was carried out from previous treatment with passive chest mobilization in supine position because of weakness. Passive pectoralis muscle and breathing exercise were performed combined with diaphragmatic and intercostal

Fig. 18. Passive chest mobilization being combined with breathing exercise of the intercostal

**Final outcomes:** For this case in the ICU stage, benefits of chest mobilization presented improvement of ventilation at the left lung, and more advantageous treatment was shown when combining other techniques such as breathing exercise with intercostal muscle and diaphragm relearning. However, treatment was unsuccessful in other factors such as

**Illness history and medical treatment**: A sixty years old man was diagnosed with stable COPD and acute exacerbation because of prolonged use of a ventilator, no rehabilitation for 3 months, and unsuccessful weaning from the ventilator with recurrent infection and much secretion. Ventilator mode was maintained with pressure control (pressure support = 25 cmH2O, rate = 15 bpm, I:E = 1:2, FiO2 = 0.45, and PEEP =10 cmH2O. Blood gas showed moderate hypoxemia (PaO2 = 85 mmHg) with hypercapnea (PaCO2 = 55 mmHg) and completed compensation. Berodual forth for preventing bronchospasm and Fluimucil A600

of aerotion in the left lung with atelectasis of the left lower lobe (left).

pneumothorax, malnutrition and the patient's overall condition.

**Case 3: Chest mobilization treatment in the chronic stage** 

for diluting the secretion were administered routinely.

muscle contraction by relearning.

and diaphragmatic muscles.

**Chest X-ray:** CXR shows specific atelectasis at the right lower lobe and hyperaerotion in the left lung before treatment (Figure 19 left).

**Physical examination**: A thin man using a ventilator presented with muscle weakness, atrophy and malnutrition. BMI was 13.5 kg/m2. Chest expansion was very small on both sides. Dullness presented in the left lung and hyperresonance at the right lung.

**Treatment:** For general chest physical therapy with postural drainage, percussion and breathing exercises were carried out in the ward, such as upright position combined with a chest mobilization technique and compression on sternum, and trunk rotation was used to improve chest wall flexibility. An additional program of passive rib torsion, trunk extension and lateral stretching on a pillow was carried out as well. All programs were performed 3 times daily (Figure 19 middle and right).

Fig. 19. Chest radiograph showing atectasis of the right lower lobe and hyperaerotion in the left lung before treatment (right), Chest mobilization being performed with compression on sternum, trunk rotation of both sides, sterum and trunk rotation of both sides (middle and left) (Leelarungrayub et al., 2009).

**Clinical evaluation:** Efficiency of treatment was monitored using various parameters such as expiratory tidal volume, chest expansion at the mid axillary line with a tape and dyspnea, and followed up by CXR after treatment. This effective treatment used the single-case research design with the A (Pre-CPT), B (CPT treatment), and A (Post-CPT) model for 7 day periods.

**Results** (Figure 20)**:** A 7 day control period (Pre-CPT) showed low expiratory tidal volume (ETV) (mean = 195± 30 mL) and chest expansion (mean = 2.1± 0.54 cm), and during the 7 days of treatment (CPT) benefits were shown by increased mean of ETV (260±49 mL) and chest expansion (3.6±0.22 cm). The dyspnea score was reduced from 6.4±1.14 to 4.4± 0.54. Statistical comparison using the Bloom Table showed significant changes in ETV, with 5 points, 4 points, and all points above the trend line from a Pre-CPT period. However, the Post-CPT and ETV showed deterious effects when treatment was stopped and all points went below the trend line, except for the dyspnea score and chest expansion, which maintained the same level. In both the Pre-CPT and CPT period, all data showed nonsignificant results of autocorrelation, which meant that the changes in each period did not come from disease progression, especially during treatment (CPT).

**Clinical implementation:** The chest mobilization technique is very important for improving ventilation and gas exchange in cases that are measured by lung volume and chest expansion, including dyspnea. In figure 20 shows the significant changes of this technique by increasing in a mean of all paprameter when compared to the before treatment of

Chest Mobilization Techniques for Improving

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Fig. 20. Visual analog graphs of expired tidal volume (ETV) (right above), chest expansion (left above), dyspnea score (right below) with their autocorrelation with trend lines, and CXR showed an improvement of aerotion in the right lower lobe on the 7th day of treatment (left below). (Leelaraungrayub et al., 2009)

baseline. Expirated tidal volume and chest expansion were significant difference, and dyspnea score reduced. Moreover, chest radiography of post-treatment showed increasing in the lung volume and less infiltration.
