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Guidelines for the physiotherapy
management of chronic obstructive
pulmonary disease
Subin Solomen
Website:
www.pjiap.org
Abstract:
DOI:
10.4103/PJIAP.PJIAP_46_18 The purpose of the article is to provide guidelines for the physiotherapy management of patients with
chronic obstructive pulmonary disease (COPD). The various publications on the same topic were
brought together with input from several textbooks in the field of cardiorespiratory physiotherapy
and translated into clinical practice. This article briefs with definition, risk factors, prevalence, clinical
features, investigations, differential diagnosis, and management of COPD patient. Then, information
on physiotherapy management during acute exacerbation phase and during stable phase is detailed.
The article provides specific details on the rationale of why and especially how to implement exercise
training in patients with COPD.
Keywords:
Chronic obstructive pulmonary disease, exercise training, guidelines, physiotherapy, pulmonary
rehabilitation

Introduction rehabilitation are improved exercise

capacity, reduced perceived sensitivity of

C hronic obstructive pulmonary

disease  (COPD) is a common,
preventable lung disorder characterized
breathlessness, improved health‑related
quality of life  (HRQOL), reduced number
of hospitalisation, and improved arm
by progressive, poorly reversible function.[5]
airflow limitation often with systemic
manifestations, in response to tobacco A diagnosis of COPD should be considered
smoke and/or other harmful inhalational in persons having chronic symptoms of
exposures. The established risk factors for cough, sputum production, shortness
COPD are tobacco smoking, exposure to of breath, and/or wheezing, especially
biomass fuel smoke, occupational exposure, among those with prolonged exposure to
and alpha‑1 antitrypsin deficiency.[1] The risk factors for the disease. COPD patients
Department of prevalence of COPD in India according to may demonstrate various physical signs
Physical Medicine that may either be due to the primary
and Rehabilitation,
previous studies was 4.46% in males and
Government Medical 2.86% in females.[2,3] Chronic obstructive disease or an associated complication.[1] The
College, Kottayam, pulmonary disease is a major cause of signs elicited in inspection are shortened
Kerala, India morbidity and mortality in India. Drug inspiratory to expiratory (I: E) ratio, pursed
treatment alone does not optimize therapy. lip breathing (PLB), use of accessory muscles,
Address for
correspondence: Pulmonary rehabilitation has been found jugular venous distension, labored breathing
Dr. Subin Solomen, to improve the physical efficiency of COPD signs, pulsus paradoxus, barrel‑shaped
Department of patients. [4] The benefits of pulmonary chest, peripheral edema, dyspnea relieving
PMR, Government posture and muscle wasting and during
Medical College,
Kottayam ‑ 686 008,
palpation subxiphoid shift of apex beat,
This is an open access journal, and articles are restricted chest expansion. The findings seen
Kerala, India.
distributed under the terms of the Creative Commons
E‑mail: subins2001@
Attribution‑NonCommercial‑ShareAlike 4.0 License, which
rediffmail.com
allows others to remix, tweak, and build upon the work
How to cite this article: Solomen S. Guidelines for
Submission: 19‑10‑2018 non‑commercially, as long as appropriate credit is given and the
the physiotherapy management of chronic obstructive
Revision: 09-01-2019 new creations are licensed under the identical terms.
pulmonary disease. Physiother ‑ J Indian Assoc
Accepted: 21-05-2019 Physiother 2019;13:66-72.
Published: 07-10-2019 For reprints contact: reprints@medknow.com

66 © 2019 Physiotherapy - The Journal of Indian Association of Physiotherapists | Published by Wolters Kluwer - Medknow
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Solomen: Physiotherapy management of COPD

in percussion are hyperresonant in lung field, obliteration were included in this review. The author concluded with
of cardiac dullness, lower level of liver dullness, and moderate level of evidence as pulmonary rehabilitation,
lower diaphragmatic levels. The auscultatory findings including at least 4 weeks of exercise training leads to
seen are diminished breath sound, early inspiratory clinically and statistically significant improvements
crackles, loud pulmonic component in the second heart in health‑HRQOL in patients with COPD. Pulmonary
sound and rhonchi or wheeze in expiration.[6‑8] Special rehabilitation also leads to a clinically and statistically
maneuvers such as forced expiratory time and snider significant improvement in functional exercise capacity.
match test was also done in COPD patients. A  forced Five randomized controlled trials on the effect of
expiratory technique  (FET) of more than 6 s suggests pulmonary rehabilitation on outcomes following an acute
airway obstruction.[9] In the snider match test, where the exacerbation of COPD, which met the inclusion criteria
patient attempts to blow out a lighted match held 15 cm and are included in this review. The author concluded
from the mouth and if the patient were unable to do so that pulmonary rehabilitation (within 1 month of hospital
indicates severe ventilatory dysfunction.[10] discharge) after acute exacerbation significantly reduces
hospital readmissions (relative risk, 0.50; 95% confidence
Pulmonary function test is a simple and accurate tool interval, 0.33–0.77; P = 0.001) and leads to a statistically
to assess airflow obstruction. In COPD patients, forced and clinically significant improvement in HRQOL.[5]
expiratory volume in 1 s  (FEV1)/forced vital capacity
ratio is reduced, and FEV1 is reduced. A  reversibility Physiotherapy Management of Acute
testing differentiates COPD from asthma as in COPD
Exacerbation of Chronic Obstructive
patients do not show reversibility in airflow obstruction
after administration of bronchodilators. As peak Pulmonary Disease
expiratory flow meter instrument is inexpensive,
portable, and easy to operate and maintain, it has An exacerbation of COPD is an acute event characterized
often been advocated as a surrogate measure for by sustained worsening of any of the patient’s respiratory
FEV1. The radiological abnormalities associated with symptoms (cough, sputum quantity and/or character,
COPD are flattened diaphragm, hyperinflated lung dyspnea) that is beyond normal day‑to‑day variation and
fields, widened intercostal spaces, and tubular or leads to a change in medication, and where other causes
boot‑shaped heart. The differential diagnoses of COPD of acute breathlessness have been clinically excluded. The
include asthma, congestive heart failure, bronchiectasis, precipitants of acute exacerbations of COPD (AECOPD)
tuberculosis, constrictive bronchiolitis, and diffuse include infections, nonadherence to medication, or
panbronchiolitis.[1,11] inhalation of irritants such as tobacco smoke or particles,
and air pollution. Clinical features of exacerbation of
Severity staging of COPD is important for disease COPD are characterized by symptoms such as reduction
prognostication as well as for treatment. GOLD in activities of daily living and altered sensorium, labored
guidelines classify COPD into mild  (FEV 1  ≥80% breathing signs such as intercostal indrawing, Hoover’s
predicted), moderate (50% ≤ FEV1 < 80%), severe (30% sign, supraclavicular indrawing and paradoxical
≤ FEV 1   <50%), and very severe  (FEV 1   <30%) chest wall movement, increase in heart rate  (HR) and
disease.[12] Body‑mass, airflow Obstruction, Dyspnea, respiratory rate (RR), marked central cyanosis, reduced
and Exercise  (BODE) index   is also used for severity systolic blood pressure  (BP), reduction in saturation
staging in COPD patients, but it is not known whether needs the patient to be hospitalized. While elevated
treatment can be tailored according to the BODE index.[13] blood urea nitrogen, altered mental status, pulse >109
Bhattacharjee et al.[14] conducted a study to find out the beats/min, age >65 years) score may help in deciding
susceptibility of chronic obstructive pulmonary disease patients who need management in an intensive care
among bike riders in Bangalore using BODE index unit. The differential diagnosis of AECOPD includes the
and concluded that more than 4  h of bike riding is 6Ps; pneumonia, pulmonary embolism, pneumothorax,
associated with the chances of developing COPD even in pleural effusion, pulmonary edema (heart failure), and
nonsmokers; therefore, there is significant susceptibility paroxysmal atrial tachycardia  (arrhythmias). Medical
of COPD among bike riders in Bangalore. management of exacerbation of COPD includes
short‑acting bronchodilators through inhaled route,
An evidence‑based review conducted in 2012 determined oral glucocorticoids, antibiotics, and noninvasive
the effectiveness and cost‑effectiveness of pulmonary ventilation  (NIV). NIV should be used early in the
rehabilitation in the management of chronic obstructive management of respiratory failure due to AECOPD,
pulmonary disease during acute exacerbation and in weaning from invasive mechanical ventilation, used
stable phase. Seventeen randomized controlled trials even in settings where arterial blood gas monitoring
on the effect of pulmonary rehabilitation on outcomes is not routinely available. Continuous positive airway
in stable COPD which met the inclusion criteria and pressure, Bi‑level positive airway pressure, and
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Solomen: Physiotherapy management of COPD

intermittent positive airway pressure are the common tissue hypoxia and preserve cellular oxygenation.
mode used for noninvasive ventilation.[1] Venturi mask is the oxygen delivery device of choice
in AECOPD. The nasal cannula delivers a variable FIO2
Aims of physiotherapy for acute exacerbation of COPD depending on the minute ventilation; the lower the
are to reduce work of breathing  (WOB), to control minute volume, the higher the FIO2. The nasal cannula
breathlessness, to assist in the removal of secretions, to can be used in AECOPD in those intolerant to Venturi
reduce the amount and viscosity of secretions, and to mask, and after the acute phase of the exacerbation.[1,6,16]
facilitate accessory muscles. Amount and viscosity of
secretions can be reduced by hydration, humidification, Arm exercise
and nebulization. To reduce WOB, strategies such as Supported arm exercise training is given during
positioning and oxygen therapy are administered. acute exacerbation of COPD. During supported arm
Breathing techniques such as breathing control, training  (the distal end of the extremity is fixed) this
Innocenti, and PLB control the breathlessness. To facilitate muscle can work as accessory muscles, and hence,
accessory muscles, supported arm exercise can be given. there is less load on diaphragm muscles and hence
To remove the excess secretions modified postural less dyspnea. Supported arm training is commonly
drainage, active cycle breathing technique (ACBT), and done with arm ergometer with training done at 60%
huffing techniques are administered.[15] of maximal work capacity, increase workload every
5 th  session as tolerated. The patient should do the
Hydration exercise for 30 min.[16,18]
Dehydration reduces mucus transport by 25%. If a
patient is well hydrated, the secretions will be easily Modified postural drainage
loosened up so it is better to advice the patient to drink Sometimes true postural drainage cannot be given in
warm water before chest physiotherapy.[8,16] some conditions because they may desaturate or may
develop orthopnea. In this case, modified postural
Nebulization drainage is adopted. For draining lower lobes, a pillow
It is done to generate aerosol particles  (suspension under the pelvis in supine may drain anterior basal
of liquid particles in a gaseous state). It is of two segments, and a pillow under the pelvis in prone lying
types: bland aerosol and therapeutic aerosol. The may drain posterior basal etc.[16,19]
bland aerosol is the administration of saline which is
commonly done to loosen the secretions before postural Huffing
drainage. The therapeutic aerosol is the administration Huffing techniques are preferred compared to coughing
of the therapeutic dose of selected agents such as techniques as coughing may further aggravate
bronchodilators and mucolytics.[6,8,10,16] bronchospasm. Always huffing technique is interspersed
with breathing control technique. One of the active
Humidification coughing techniques such as pump coughing is also
It is the method by which humidified  (warming and used as it facilitates secretion clearance in patients with
moistening) air can be introduced into the respiratory air trapping.[16,20]
system. In a COPD patient, humidification is done to
humidify Oxygen while administering through cannula Electrical stimulation for peripheral muscle
or through mask, to treat bronchospasm caused by cold dysfunction
air and to overcome humidity deficit when the upper Weakness, atrophy, structural, and metabolic changes
airway is bypassed as in case of intubation.[6,8,16] have been observed in limb muscles, which, in turn,
can have a negative impact on exercise tolerance. This
Facilitation of accessory muscles may initiate dyspnea deconditioning cycle. To break
During acute exacerbation of asthma or COPD, the this, electrical stimulation can be applied. Studies have
patient’s accessory muscles should be facilitated. An shown that electrical stimulation improves muscle
anterior pelvic tilt facilitates accessory muscle use. This function, exercise performance  (increased walking
can be achieved by placing a towel roll vertically along distance and increased time to exhaustion in a constant
the spine in supine. Keeping hands on outstretched work rate cycling test) and muscle size peak torque.[16,21,22]
position in sitting also relieves breathlessness as it
facilitates accessory muscles.[16,17] TENS to reduce breathlessness
Studies have shown that the effect of single session of
Oxygen therapy bilateral application of TENS for 45 min in patients with
Oxygen therapy is administered in case of documented COPD showed increase in FEV1, 6‑min walk distance
hypoxemia. The goal of inpatient oxygen therapy is to and decrease in dyspnea. An improvement in FEV1 and
maintain PaO2 ≥60 mmHg or SpO2 ≥90% to prevent dyspnea score at the end of Acu‑TENS treatment was
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Solomen: Physiotherapy management of COPD

associated with a concurrent increase in b‑endorphin BP, RR, Borg  rate of perceived exertion (RPE) scale for
level in patients with COPD.[16,23,24] breathlessness and fatigue has to be checked prior,
immediately, and after 3  min of exercise testing.
At the Time of Discharge Commonly, these tests are performed at the time of
discharge.[16]
An exercise testing is done at the time of discharge to
prescribe exercise for the patient to perform in the home. Other airway clearance technique
A  history of smoking history is noted, and smoking Either ACBT or autogenic drainage  (AD) is taught to
cessation therapy is administered at this time. This can the patient as home exercise at the time of discharge.
minimize the future risk of disease progression. ACBT consists of three phases breathing control, thoracic
expansion, and FET. FET consists of low huffs and high
Pacing huffs interspersed with breathing control. AD is a method
Pacing can be taught to get control of breathing during of controlled breathing in which the patient adjust the
exercise. This is normally taught to patients at the rate location and depth of respiration. It is divided into
time of discharge. This can decrease WOB and relieve three phases such as unsticky phase, collecting phase,
dyspnea during activity. Subject and therapist simply and evacuating phase, whereas German approach has
test different I:E ratios with various activities such as only one phase.[16,25]
cycling, walking, stair climbing until they find the rate
and pattern that lower RR, relieves dyspnea, and possibly
Physiotherapy Management in Stable Phase
improves SaO2. For example, while walking; for every
two steps patient should exhale followed by the next The goals in managing stable COPD include techniques
step with patients inspiration.[16,25] to inhibit accessory muscles, to strengthen inspiratory
muscles, to improve posture, to increase chest expansion,
Smoking cessation to improve the mobility of thorax, to improve the patients
A smoking history, including pack‑years or smoking
breathing pattern, prevention of exacerbations, and to
index  (number of bidis/cigarettes smoked per day
reduce energy demand.[15]
multiplied by number of years smoked; mild, moderate,
and heavy smokers are defined as having a smoking
Diaphragmatic breathing and incentive spirometry
index of <100, 100–300, and >300, respectively should
Diaphragmatic breathing exercise and incentive
be documented for all patients with COPD. Smoking
spirometry are only given during stable phase not in
cessation is the most effective method to prevent
the acute exacerbation as it may provoke the symptoms.
COPD. The 5A strategy: ask (about tobacco use), assess
Care should be taken that an inspiratory hold should not
the status and severity of use advice to stop, assist in
be given, as bullae may open up with inspiratory hold
smoking cessation, and arrange follow‑up program
should be adopted. In addition to a reduction in the rate which can result in pneumothorax.
of decline of FEV1 in stable COPD, smoking cessation
is also associated with a reduction in the frequency Other breathing techniques
of exacerbations. Nicotine replacement therapies; Breathing control is synonymous with diaphragmatic
forms such as gums, tablets, patches, and inhalers, breathing. However, the only difference is that in
drugs  (varenicline or bupropion), are administered diaphragmatic breathing, it is done with maximal
by physician to people who are planning to stop inspiration whereas in breathing control technique is
smoking.[26] performed at normal tidal volume. PLB exercise stresses on
expiration, therefore, it can be used to control breathlessness
Exercise testing and to reduce WOB. It keeps airways open by creating back
The parameters of exercise prescription for the patient pressure in the airways. The procedure is such that subject
with chronic cardiopulmonary dysfunction are loosely purse the lips and exhale (like blowing out a match
determined from a clinical exercise test. The purpose of stick or candle). PLB decrease RR, increase tidal volume,
this test is to determine how a patient exercise response improves exercises tolerance. Innocenti technique aimed
differs from the normal and to diagnose the specific to prevent forceful expiration thereby reduction of excess
limitations to exercise. Exercise testing has to be done energy consumption and improves expiratory flow. The
for both the upper limb and lower limb. In the lower procedure is that at each breath instructs the subject to
limb, most commonly a 6‑min walk test or shuttle inhale just before abdominal muscle recruitment. This
walk test is preferred. However, in case of the upper allows a smooth transition from inspiration to expiration
limb, a supported upper limb exercise test with bicycle practice first with physiotherapist’s voice then without. It
ergometer or unsupported upper limb endurance test helps to prevent airway shutdown consumes less energy
to be performed. Whatever the tests administered, HR, than PLB, thereby improving PaO2.[16,25]

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Solomen: Physiotherapy management of COPD

Techniques to inhibit accessory muscles rate they can manage for 15–30 min. High‑pressure low
One of the techniques to inhibit the accessory muscle flow loading can be of two types; inspiratory resistive
is that to give the accessory muscle its primary action training or inspiratory threshold training. Studies have
rather than assisting in respiration. Hence that these shown that it can decrease breathlessness, increase
muscles cannot take part in respiration and there will exercise tolerance, and increase nocturnal saturation.
be shift of the respiratory work toward the diaphragm. Even diaphragmatic training using weights can help in
For example, keeping the hand elevated overhead while ventilatory muscle training.[16‑18]
breathing. Another way to inhibit accessory muscle
is to keep the muscle either in fully lengthened or Endurance training
fully shortened position. Keeping the muscle in these Aerobic endurance training can be performed at high
positions cannot effectively actively part in respiration. or low intensity. High‑intensity training  (70%–85% of
For example, perform breathing with the neck in an maximal work rate) improves aerobic fitness such as
elevated position. While performing breathing, give VO2 max, delays anaerobic threshold, decreased HR for a
facilitatory techniques for lower thorax and inhibitory given workload, increases oxidative enzyme capacity, and
techniques for the upper thorax. This also inhibits the more capillarization of the muscle. It also improves exercise
accessory muscle use. Applying the Myofascial release to endurance. Low‑intensity training improves the exercise
accessory muscle also inhibits the muscle use. Positioning endurance, but it does not improve aerobic fitness.[16,18]
and unsupported arm exercises are the other ways to
inhibit the accessory muscle, which is described below. Strength training
Strength training in stable phase of COPD leads to
Positioning improvements in muscle strength, increased exercise
During the stable phase, the pelvis should be posteriorly endurance, and fewer symptoms during ADL.
tilted pelvis to facilitate diaphragmatic muscle. This can Lower‑extremity strengthening may be augmented
be achieved by placing a pillow under the knees.[17,20] through aerobic training itself. Upper limb strengthening
can be done with low resistance of light weights (dumbbells,
Arm exercise pulleys, and elastic bands) and progressed first by
Unsupported arm training is given during the stable
increasing repetitions (starting with 10–20) before adding
phase. During unsupported arm exercise, (the distal end
additional weight. During training physical therapist
is not fixed) the participation of the accessory muscles in
should monitor breathing pattern and pulse oximetry.[16,18]
ventilation decreases, and there is a shift of respiratory
work to the diaphragm. This is associated with
Flexibility training
thoracoabdominal dyssynchrony, severe dyspnea, and
Patients with progressive chronic respiratory disease
termination of exercise at low workloads, especially in
loose range of motion (ROM) of the shoulder, rib cage,
patients with more severe bronchial obstruction. Studies
and rib cage. This results in significant changes in posture
have shown that that upper limb exercise training for
patients with COPD increases upper limb work capacity, and reduced mobility. Flexibility exercise can also be
improves strength and endurance, and reduces oxygen given in stable phase as it improves posture, increases
consumption at a given workload. The most common ROM, decreases stiffness and prevents injury. Gentle
types of upper limb exercises are throwing a ball against stretching with body movements should be coordinated
the wall with arms above horizontal in sitting position, with breathing exercises. For example, movements
passing a beanbag over the head in sitting position, that bring full shoulder flexion, back extension, and
Exercises on overhead pulleys in sitting position, moving inspiration should be performed with trunk flexibility.
a ring across a wire without touching the wire, while Exercise with forward reaching and trunk flexion or with
the arm was above horizontal. Each exercise should be unilateral or bilateral hip flexion should be combined
performed for 40 s followed by 20 s rest. Exercises have with expiration. Flexibility exercise is also incorporated
to be repeated four times in 4 min.[16,18] in warm up and cool down period in the aerobic exercise
to relieve muscle tension and anxiety.[16,18]
Inspiratory muscle training
Inspiratory muscle training can be done by either through Buteyko technique
inspiratory threshold training or inspiratory resistive The Buteyko technique is performed by slowing RR with
training. Inspiratory muscle training can be classified breath counting and at night, lying on the left side and
as low‑pressure high flow loading or high‑pressure low taping mouth closed. The hold at the end of expiration
flow loading. In low‑pressure high flow loading also elevates PaCO2 which helps in bronchodilatation during
called as normocapneic hyperpenic training increase the stable phase. This technique reverses the symptoms,
rate of breathing without altering PaCO2 value. In this lessens the need for medication, and prevents attack on
technique, subjects were asked to breath at the highest acute exacerbation.[8,16]
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Solomen: Physiotherapy management of COPD

Postural correction exercise Financial support and sponsorship

A COPD patient typically exhibits a poked chin Nil.
posture  (flexion of the lower cervical column with
the extension of the upper cervical column), rounded Conflicts of interest
shoulder with kyphosis and sitting on an outstretched There are no conflicts of interest.
hand. Exercises such as chin tuck, neck extension,
shoulder retraction, and back extension are prescribed References
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72 Physiotherapy ‑ The Journal of Indian Association of Physiotherapists ‑ Volume 13, Issue 2, July-December 2019