**9. References**

392 Chronic Obstructive Pulmonary Disease – Current Concepts and Practice

transmitted directly via wireless broadband Internet to the radiologists in the hospital who were able to read a radiograph in real time. A firewall hardware has been used in order to protect the confidentiality of patient data. Only one radiography was performed at home in all patients, mainly a chest X-ray. All patients were very old (mean age 78 years in the entire sample), mostly multimorbid, functionally and cognitively impaired, at high risk of developing delirium in 62%. After radiological examinations an acute confusional status, according to the CAM criteria, requiring pharmacological treatment (antipsychotic drugs) appeared in 17% of patients in the Control group, whereas no one in the Intervention group developed delirium. Customer satisfaction for domiciliary X-rays was very good/excellent for 94%. This study demonstrates that a mobile, digital radiography service could be a good option for frail, vulnerable elderly and immobile patients at a compatible examination and image quality, and, due to our analysis, at a substantially reduced cost for the health care

Acute exacerbations of COPD are the most common cause of admission to hospital for respiratory illnesses. This causes an increased demand on hospital beds especially during the winter months. Increased provision of services in the community is one proposed

Intermediate care is a treatment model which bridges the interface between hospital and community care. It often involves cooperation between hospital doctors, general pratictioners, nurses, physioterapists and other healthcare professionals. A specific subtype of intermediate care is Hospital-at-home, were active treatment is provided by healthcare professionals in the patient's home for a condition that otherwise would require hospital care, always for a limited period. Providing acute hospital-level care in a patient's home can be a safe end efficacious alternative to hospital care, especially for frail elderly patients.

The physician-led substitutive "clinical unit" hospital-at home model of Torino provides care that substitutes entirely for an inpatient acute hospital admission; an intensity of care, including medical and nursing care, similar to that provided in the hospital, commensurate with the severity of illness treated; and care that usual community-based home care services cannot provide. Some prior studies of hospital at home for COPD have been of early discharge hospital at home models that treat patients at home with nursing care after they have been admitted to and stabilized in the acute hospital. Davies and collegues in their study of substitutive hospital at home care for COPD employed a nurse-based model that provided only twice daily nursing visits for a period of 3 days and although responsibility for patients rested with hospital physicians, patient's clinical condition did not necessarily require hospital physician's visits at home (Davies et al., 2000). Our intervention targeted very elderly patients with multiple comorbid illnesses, functional impairments and a fairly elevated degree of clinical severity, as shown by the APACHE mean score. These patients need frequent home visits by doctors, nurses and physiotherapists who work together as a team. In our experience HHS care was associated with a reduction in hospital readmission for COPD patients. In addition, HHS care was associated with improvements in quality of life and depression symptoms and a reduction in costs of care. HHS is appropriate for this target population that is especially susceptible to iatrogenic consequences of hospital care

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**8. Conclusion** 


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**20** 

*Thailand* 

**Chest Mobilization Techniques** 

*Faculty of Associated Medical Sciences, Chiang Mai University* 

**Gas Exchange in Chronic Lung Disease** 

The clinical treatment and rehabilitation of chronic lung disease such as Chronic Obstructive Pulmonary Disease (COPD) is very challenging, as the chronic and irreversible condition of the lung, and poor quality of life, causes great difficulty to the protocol for intervention or rehabilitation. Most of the problems are, for example, air trapping and destroyed parenchymal lung, which cause chest wall abnormalities and respiratory muscle dysfunction that relate to dyspnea and decreased exercise tolerance (ATS/ERS 2006). Many intergrated problems such as increased airflow resistance, impaired central drive, hypoxemia, or hyperinflation result in respiratory muscle dysfunction, for instance, lack of strength, low endurance level, and early fatigue. Lung hyperinflation in COPD increases the volume of air remaining in the lung and reduces elastic recoil, thus giving rise to air trapping, which results in alveolar hypoventilation (Ferguson 2006). Thus, poor biomechanic chest movement and weak respiratory muscles affect respiratory ventilation (Jones & Moffatt, 2002). Furthermore, in COPD, the combination of V/Q mismatch, diffusion limitation, shunt and hypoventilation or hyperventilation is presented commonly, which leads to gas exchange impairment (West 2003). To solve inefficient ventilation from thoracic pump dysfunction, thoracic mobility exercise or mobilization techniques can be performed (Rodrigues & Watchie, 2010). Chest mobilization is one of many techniques and very important in conventional chest physical therapy for increasing chest wall mobility and improving ventilation (Jennifer & Prasad, 2008). Either passive or active chest mobilizations help to increase chest wall mobility, flexibility, and thoracic compliance. The mechanism of this technique increases the length of the intercostal muscles and therefore helps in performing effective muscle contraction. The techniques of chest mobilization are composed of rib torsion, lateral stretching, back extension, lateral bending, trunk rotation, etc. This improves the biomechanics of chest movement by enhancing direction of anterior-upward of upper costal and later outward of lower costal movement, including downward of diaphragm directions. Maximal relaxed recoiling of the chest wall helps in achieving effective contraction of each intercostal muscle. Thus, chest mobilization using breathing, respiratory muscle exercise or function training allows clinical benefit in chronic lung disease, especially COPD with lung hyperinflation or barrel-shaped chest (Jones & Moffat,

**1. Introduction** 

**for Improving Ventilation and** 

Donrawee Leelarungrayub *Department of Physical Therapy,* 


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