NHH Respiratory Rehabilitation

|RESPIRATION AS A LIMITING FACTOR|

2. Blood stealing 🩸

Diaphragmatic breathing positively affects blood shifting between the trunk and the extremities during exercise.

At sustained high intensities the diaphragm fatigues; demanding up to 14%–20% of cardiac output and 10%–16% of VO2, on top of concurrent accessory and expiratory muscle fatigue.

Ventilatory muscle fatigue at high intensities triggers the metaboreflex, which ensures that the ventilatory pump maintains adequate perfusion, by shunting blood from the working muscles.

This competition for oxygen-rich blood is termed “blood stealing.”

|PHYSIO 🤝🏻 BIO|

We had a blast chatting to yesterday, about cardiorespiratory physiotherapy, what we do and our role in the breathless patient. Such great questions and stimulating clinical conversations. Thanks for having us 🩺👩🏻‍💻

has created such a unique space where the multidisciplinary team comes together, with the main aim of patient-centered care, always. Fantastic to share this space with such like-minded clinicians and clinical teams 🫶🏻

|RESPIRATION AS A LIMITING FACTOR|

📈 Dynamic Hyperinflation

Exercise breathing pattern (BP) may fail to provide the “just right” response in the presence of flow limitation.

During high intensity exercise, large increases in ventilatory flow may cause narrowing of the airway.
This is termed “exercise-induced largyngeal obstruction,” and it is particularly common in elite athletes who generate large minute ventilations (VE) at high intensities.

Up to 20% of elite athletes, females, adolescents and overweight individuals may experience this during low-intensity activity. Dysfunctional breathing (DB) phenotypes, including upper-thoracic-dominant breathing and core muscle hypertonicity (such as in low back pain compensation) are also risk factors.

Flow limitation could lead to “breath stacking,” a negative consequence when subsequent breaths have slightly larger inspiratory than expiratory flow. Breath stacking causes end-inspiratory lung volume (EILV) and end-expiratory lung volume (EELV) to progressively increase, leading to dynamic hyperinflation. At these higher lung operating volumes, the lungs are stiffer, less compliant and require more muscle work to expand.

Unfortunately, dynamic hyperinflation places the diaphragm in a suboptimal length for expanding the lungs and managing intrathoracic pressures, further fatiguing the ventilatory musculature 🫁🏃🏻‍♀️🌬

|RESPIRATION AS A LIMITING FACTOR| 😮‍💨

At exercise around or above 80%–85% VO2max, 3 primary mechanisms cause the respiratory system to limit performance:
1. Exercise-induced arterial oxyhemoglobin desaturation
2. Excessive ventilatory muscle work
3. Intrathoracic pressure effects on cardiac output

Specific scenarios (e.g., hypoxia and cold/dry climates) expose respiratory system vulnerabilities at submaximal intensities, and certain populations (e.g., elite athletes, females and elderly) are especially susceptible. While the exact limiting mechanisms differ (structural / functional), these situations and individuals bring the respiratory system close to its physiological limits. However, physiological limits do not fully explain the prevalence of exercise-induced breathlessness (a.k.a dyspnoea, EID).

An estimated 20%–40% of otherwise healthy runners experience EID even at low absolute exercise intensities. This could be because deconditioned individuals may approach high levels of exertion and experience limb fatigue at low absolute workloads. It could also be related to mouth breathing, since mouth-only breathing at submaximal intensities causes airway irritation and possibly subsequent exercise-induced laryngeal obstruction (EILO).

While the majority of EID prevalence may be explained by physiological limitations and deconditioning, the other most likely cause is dysfunctional breathing. Distinct from pathology, dysfunctional breathing (DB) can cause otherwise healthy runners to experience premature onset of fatigue and subsequent EID.

Whether caused by physiological or psychological limits, fatigue and EID could contribute to cessation of exercise, increased rating of perceived exertion (RPE) or negative emotional states.

The study by Harbour et.al aims to identify 3 important shared phenomena that lead to respiration limiting exercise performance, tolerance and enjoyment:
1. Dynamic hyperinflation 📈
2. Blood stealing 🩸
3. Hyperventilation 🫁

*to be continued
📸
📝 A Synthesis of Evidence-Based Breathing Strategies to Enhance Human Running (Harbour et al.)

|HANDHELD DYNAMOMETRY| (HHD)

HHD is increasingly utilized as part of the pulmonary rehabilitation initial assessment process. The aim is to determine peripheral muscle strength, which is crucial for overall physical function and exercise tolerance.

Benefits of using HHD:
📈 Objective Measurement: HHD provides objective and quantitative measurements of muscle strength in peripheral muscles. This helps in identifying muscle weakness and monitoring changes over time.

🤸🏻‍♀️ Functional Relevance: Peripheral muscle strength is vital for activities of daily living and exercise capacity. Assessing strength using HHD allows clinicians to target specific muscle groups that may be weak, due to deconditioning or disease-related factors.

👩🏻‍💻 Tailored Exercise Prescription: Based on HHD results, rehabilitation programs can be customized to include targeted strengthening exercises for peripheral muscles. This enhances overall physical function and endurance, which are essential for improving quality of life and reducing symptoms in pulmonary patients.

📊 Tracking Progress: Regular HHD assessments enable clinicians to track rehabilitation progress objectively. Improvement in peripheral muscle strength translates to better exercise tolerance and reduced fatigue during daily activities.

📝 Comprehensive Assessment: Incorporating HHD alongside other assessments, such as exercise capacity, provides a comprehensive view of a patient’s functional status and response to rehabilitation interventions.

🤝🏻 Patient Engagement: Objective data from HHD can motivate patients by showing measurable improvements in muscle strength, which encourages adherence to the rehabilitation program.

🧠 Research and Clinical Applications: HHD findings contribute to research on rehabilitation outcomes and guide evidence-based practice in pulmonary rehabilitation.

We are excited to join the team, enabling us to take our HHD assessments to the next level. Do you assess peripheral muscle strength using HHD, as part of your pulmonary rehabilitation program?

Last week, the hosted an intensive two day advanced pulmonary rehabilitation course. And it was phenomenal 🤓👩🏻‍💻🧠

The course content was world-class and presented by international experts in the field of pulmonary rehabilitation. What a privilege to have access to such relevant, cutting-edge research, as well as the opportunity to ask questions and engage in challenging discussions.

Following each day, we were allocated to small break out rooms to analyze case presentations. These discussions were facilitated by one of the expert panelists😅 Fantastic to hear how international colleagues in the field approach complex cohorts, as the case presentations were anything but straight forward (but that's how we like it!)

Learnt an incredible amount and cannot wait to put it all into practice. Honoured to be certified by the ERS Advanced Pulmonary Rehabilitation Academy 🫁

|GENE'S DAY| 👖🫁

May is Cystic Fibrosis awareness month and today is Gene's Day. A day where we grab the opportunity to shine a bright light on Cystic Fibrosis, creating as much awareness around the condition as we can.

"Cystic Fibrosis is an inherited disorder affecting mainly the lungs, and occurs across all race groups.
Early diagnosis and proper treatment is critical and improves quality of life and survival age significantly."

So much has happened in the South African Cystic Fibrosis space over the last while. It has been incredible to see our patients finally gain access to the life-saving medication that EVERY patient with Cystic Fibrosis deserves. Still much to be done, but so proud of the massive strides that have been made!

Gain more insight and support the initiative by visiting 🌹🌬

|AWARENESS| 🫀🫁

A few weeks ago, our respiratory rehabilitation team were approached by Netcare Christiaan Barnard Hospital, to deliver a talk on what we do as physiotherapists with a special interest in the field of cardiorespiratory physiotherapy.

Yesterday morning, we got to speak to a room (and online audience) filled with nurses, doctors, and specialists. What a privilege to raise awareness on what we can offer the breathless cohort, both in the in-patient and out-patient setting.

The main section of the talk was on a big passion field of ours, complex breathlessness. We, as cardiorespiratory physiotherapists, have a key role in the assessment, treatment, and ongoing management of these patients. It was a fantastic opportunity to make that known!

Honoured to have a fantastic team by my side 🥰

|TWO OCEANS MARATHON|

It's that time of year again, and you can feel the vibes! Especially here at 🔥
GOODLUCK to all our athletes and everyone else taking part in the EPIC Two Oceans Marathon weekend ⛰️ 🏃🏻‍♀️ 👟

We'll take this opportunity for a shameless plug on respiratory health and efficient breathing in athletes. It's a big passion field of ours here at the Cardiorespiratory Unit, so big in fact, that we joined the dynamic duo from to chat about it!

Links below (and in linktree in bio), if you're keen for a listen ahead of your big race.
Let us know what you think 👇🏻
https://podcasts.apple.com/za/podcast/how-to-breathe-better/id1461719225?i=1000577832970
OR
https://open.spotify.com/episode/3MikdxoCJa1FTbFwHPZDzP?si=o6RMB_u3T2KSWh0nrUXBEQ&utm_source=whatsapp

Breathe strong 🫁 🌬

|THE RESPIRATORY SYSTEM × SPORT|

VERY excited for this six part webinar series starting next week, hosted by the 🫁🤓

"Participation in vigorous exercise or sport is now recognised to play an important role in many people’s lifestyle. Sporting activity is associated with a broad range of benefits, including for pulmonary, cardiovascular, metabolic and mental health. For some individuals, however, the ability to participate in and enjoy sporting activity may be curtailed by the presence of respiratory symptoms. Indeed, it is estimated that at least one in four individuals report troublesome exercise-related respiratory issues and pulmonary conditions, such as asthma, are a highly prevalent and impactful problem in people partaking in endurance sport.

Despite respiratory issues being a prevalent issue in sport, clinicians often feel unclear as to the best way to proceed when faced with this problem. There is a lack of clear guidance regarding the best way to investigate pulmonary issues in athletic individuals and this can lead to uncertainty regarding the best way to proceed. There is also a need for pulmonary clinicians to consider how sporting activity interacts with environmental conditions and thus how to protect pulmonary health in the context of undertaking exercise, in potentially noxious environments. Pulmonary clinicians may also be faced with questions from individuals with chronic lung disease wishing to safely engage in and enjoy sport."

Registration is still open 👇🏻
https://www.ersnet.org/events/the-respiratory-system-and-sport-from-bench-to-bedside-in-an-olympic-year-webinar-series/

📝 Development and feasibility of an exercise training program in primary care for patients with COPD experiencing an acute exacerbation

🩻 Starting rehabilitation soon after an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is crucial to diminish the detrimental effects of this acute event on muscle function. However, uptake in outpatient pulmonary rehabilitation is low.

🫁 This paper provides a feasible, acceptable and accessible exercise training program (ETP) developed for patients recovering from a moderate or severe AECOPD. This is the first ETP developed for implementation in primary care in patients suffering from an AECOPD.

Open access: https://www.physiotherapyjournal.com/article/S0031-9406(23)00056-1/fulltext

|RE-ASSESSMENT|

This week is all about re-assessment in our pulmonary rehabilitation unit (and initial assessments of course, for all the new patients).

Re-assessments are so important, to ensure you maintain an individualized and focused approach to treatment, for each and every patient.

In our unit, we assess exercise capacity, peripheral muscle strength, respiratory muscle strength, respiratory muscle endurance as well as questionnaires we feel are relevant.
In addition to these tests, we will also re-assess (where indicated), respiratory mechanics and efficiency, diaphragm ultrasound, capnography, airway clearance strategies, and medication use (i.e. inhaler technique) - to name a few adjuncts 🫁

What did we miss?
What do you feel is an important re-assessment tool in your pulmonary rehabilitation unit?
Let us know in the comments 💫

|ANXIETY & DEPRESSION|

"Up to 40% of persons with COPD have symptoms of depression or anxiety. The prevalence can be higher if disease is advanced and among those using supplemental oxygen.

Anxiety and panic can lead to alterations in breathing pattern that often result in severe progressive dynamic hyperinflation that can in turn, precipitate frequent emergency department visits and/or outright respiratory failure. Incorporation of breathing training and coping strategies for recognition and management of anxiety/panic in PR has the potential to reduce such events and improve patient outcome."

The way these ladies have supported one another through the ups and downs of their clinical journeys has been pretty amazing to watch.
It takes a village 🫶🏻

|BREATHLESSNESS| 😮‍💨

Breathlessness on exertion is one of the leading causes of chronic suffering and disability and the cardinal symptom in people with cardiorespiratory disease. The symptom trajectory is often progressive, leading to a vicious cycle of impaired activity, deconditioning and worsening of breathlessness at progressively lower degrees of exertion. As people reduce their physical activity to avoid the symptom, exertional breathlessness should be measured in relation to a given symptom stimulus, such as at a standardized degree of exertion or ventilation.

This study provides the first reference equations to predict the normal breathlessness intensity response at any standardized relative or absolute power output, VO2, and VE during CPET and quantify the degree of abnormal exertional breathlessness.

🔗 https://www.atsjournals.org/doi/epdf/10.1513/AnnalsATS.202305-394OC?role=tab

|WE'RE BACK| 👋🏻

Our Cardiorespiratory (outpatient) Unit is back to full capacity today, and we are so excited 🎉

For our new followers, we'll be sure to include an update on the services we provide, as well as who and how we can help. If you have any questions in the meantime, please pop them in the chat!

Let's go, 2024 🙌🏻😅

|IN-SERVICE|

Over the last few months, we've been doing some upskilling in our cardiorespiratory field 🫀🫁
This is to ensure that each of our physiotherapists with a special interest in this space, is equipped with the knowledge to perform an unmatched assessment and treatment of the patient in our care.

Our respiratory team spent an afternoon refining their assessment skill set - looking at lung function screening, capnography, diaphragm strength and endurance () and the principles of respiratory mechanics.

Our hospital team had a deeper look at diaphragm imaging - specifically diaphragm thickness and excursion. This is a unique technique in physiotherapy practice, that has the potential to add a great value to clinical decision making.

Never stop learning 🤓

|WORLD COPD DAY|
“Breathing is Life - Act Earlier"

Today is WORLD COPD DAY 🌎 🫁

World COPD Day is organized by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) in collaboration with health care professionals and COPD patient groups throughout the world. Its aim is to raise awareness, share knowledge, and discuss ways to reduce the burden of COPD worldwide.

This year's theme is “Breathing is Life - Act Earlier" and aims to highlight the importance of early lung health, early diagnosis and early interventions. Keeping lungs healthy is an integral part of future health and it is now more important than ever to act sooner.

We now know that there are many other factors besides to***co smoking that can contribute to COPD and that it can start early in life and effect young individuals. In addition, we have now identified precursor conditions that can provide new opportunities for early diagnosis and prompt treatment.

This campaign will focus on highlighting the importance of early lung health and how we can expand the horizon of COPD prevention and treatment by acting earlier. This can include preventing early risk factors, monitoring lung health from birth, diagnosing COPD in a precursor state and providing treatment promptly.
.foundation

|PULMONARY HYPERTENSION|

A wholesome morning spent raising awareness around Pulmonary Hypertension at one of our local trail events 🥳🙌🏻

Attending the event was the initiative of one of our patients, , who decided to take part in the 5km walk, after months of training and dedicated hard work. He convinced us and a fellow patient to join in the fun, so of course, we did!

So incredibly proud of them for walking strongly, safely and bravely. An emotional finish, culminating a tough year and a lot of challenging pulmonary rehabilitation sessions leading up to the day!

Exercise in Pulmonary Hypertension is safe, if you are medically optimized, symptom free and have completed structured and supervised rehabilitation with a respiratory physiotherapist who is familiar with the condition 🫁🫀

Today is WORLD LUNG DAY 🫁

Today we unite to promote better lung health for all.
This year's theme: Access to prevention and treatment for all. Leave no one behind.

Let's raise awareness of the importance of lung health and take action to ensure everyone has access to the care they need.

🔗https://ow.ly/McPK50POerw

10 years working together, side by side 🫶🏻

Problem solving, learning, growing, challenging and encouraging!
The future looks bright, and we're so ready for it ☀️

|BREATHING RETRAINING|

Hypertonicity and weakness of respiratory muscles might contribute to dysfunctional breathing patterns, neuromechanical uncoupling and increased dyspnoea.

Hypertonic respiratory muscles tend to be weaker due to the laws of the length–tension relationship. Relaxation of hypertonic respiratory muscles is important for increasing functional strength of respiratory muscles. Manual therapy that aims to relax respiratory muscles and improve mobility of the rib cage has been found to increase peak flow and improve dyspnoea symptoms associated with a sense of unsatisfied respiration, and might be a useful addition to breathing retraining.

A study by Courtney et al. (2011) found that improved breathing pattern was a necessary condition for reduction of dyspnoea symptoms 🫁
📖 https://openres.ersjournals.com/content/3/4/00065-2017 -61

Last chance for Level 1 in August 🫶🏻

Bradcliff Level 1 registrations closing 27th August - grab your space now! - https://mailchi.mp/b2bca544ab1c/x2h3j748hg-20267612

Sam () is a director at Nel, Housego, Holtzhausen Physiotherapists Inc. () and the clinical lead of the Cardiorespiratory Rehabilitation division.

Together with the exciting branch opening at Sports Science Institute this week (), Sam's division has also undergone a restructuring, to ensure the evidence based services offered are clear to all who might need them.

The specialized units operating under the umbrella of Cardiorespiratory Rehabilitation include:
🫁 Pulmonary Rehabilitation Unit
🫀Cardiac Rehabilitation Unit (acute)
🌬 Breathing Rehabilitation Unit
😷 Airway Clearance Unit
🏃🏻‍♀️ Athletic Performance Unit

Each unit requires a unique skill set, to ensure best practice management standards are met. We'll elaborate on each unit over the next few weeks.

If you have any questions in the mean time, we're always happy to talk heart and lungs 🥰

|NEW LOCATION|

We are INCREDIBLY excited to announce the opening of our new Respiratory Rehabilitation Unit in Newlands, Cape Town 🎉🫁

We are now also located at:
📍Sports Science Institute of South Africa (SSISA )

We have had some fun restructuring the Respiratory Rehabilitation division and will share these updated services soon 🫶🏻
In the mean time, if you're in the area, come pop in. Otherwise, join us for our launch at the end of the month!

|TREATABLE TRAITS|

"Interstitial lung disease (ILD) is a diverse group of inflammatory and fibrotic lung conditions causing significant morbidity and mortality.
🫁
A multitude of factors beyond the lungs influence symptoms, health-related quality of life, disease progression, and survival in patients with ILD.
Despite an increasing emphasis on multidisciplinary management in ILD, the absence of a framework for assessment and delivery of comprehensive patient care poses challenges in clinical practice.
🩺
The treatable traits approach is a precision medicine care model that operates on the premise of individualised multidimensional assessment for distinct traits that can be targeted by specific interventions."
📝 https://erj.ersjournals.com

|EXERCISE TRAINING|

"Exercise training is a potent intervention to reverse several non-respiratory physiological consequences. When fine-tuned, exercise training can have profound effects on the skeletal muscle, cardiovascular,
metabolic, bone and mental health consequences of chronic diseases.
🫁
Skeletal muscle dysfunction and impaired cardiorespiratory fitness contribute to the burden of COPD as it is experienced by patients. Muscle dysfunction contributes to excess pulmonary ventilation and early contractile muscle fatigue. Along with reduced ventilatory capacity, dynamic hyperinflation and poor gas exchange further contribute to exercise intolerance.
🌬
Improving skeletal muscle function delays fatigue and reduces the ventilatory requirements during exercise, and hence reduces dynamic hyperinflation and symptoms."

|BREATHING BUDDIES|


Samantha Diedericks, one of our incredible senior physiotherapists, completed the Breathing Buddies course a few months ago, and this is what she had to say about it 🫶🏻

"In our Pulmonary Rehabilitation Unit, we mainly assist adults with managing their breathing patterns and lung conditions, with the aim of improving their quality of life. This lead to me wanting to find ways to teach the same concepts to children in order for them to better manage their breathing patterns and lung conditions.

The Breathing Buddies course is a fantastic guide, encouraging the practical and fun implementation of conscious breathing in children. This allows them to manage their emotions and self-regulation through breathing awareness, empowering them to use these techniques to manage their health."

We cannot wait to use Sam's unique skill set in a new and exciting division coming soon 👀

|EXERCISE & ASTHMA|
Trigger or Treatment?

"It is common for individuals with asthma, particularly those with severe or difficult-to-treat disease, to report activity limitation, and impaired exercise capacity.
🫁
It has previously been argued that exercise intolerance in people with asthma may occur due to factors other than cardiovascular limitation, such as persistent airway narrowing (i.e., contributing to impaired oxygen delivery), alveolar wall thickening and/or loss of elastic recoil.
🏃🏻‍♀️
However, evidence from studies conducted in physically active or athletic cohorts indicate that well-trained individuals with evidence of moderate expiratory airflow limitation (i.e., FEV1 60 mL kg− 1.min− 1) or at least values consistent with healthy non-asthmatic individuals."
https://www.sciencedirect.com/science/article/pii/S095461112300135X

|PHYSICAL ACTIVITY|

》Physical activity recommendations for patients with Chronic Obstructive Pulmonary Disease 👣🚶🏻‍♀️🫁

Physical inactivity is an important treatable trait in patients with Chronic Obstructive Pulmonary Disease (COPD). Physical activity (PA) management is a recommended component of the non-pharmacological treatment of patients with COPD.

"PA levels of patients with COPD are lower as compared to healthy peers and the activity level lowers with increasing disease severity. Low PA levels are related with increased mortality and risk of comorbidity, and from a patient centered perspective, the ability to engage in PA is an important component in the psychosocial well-being of patients."
📝https://www.thoracic.org