Joint BTS/ACPRC guideline Guidelines for the physiotherapy management of the Thorax: first published as 10.1136/thx.2008.110726 on 30 April 2009. Downloaded from adult, medical, spontaneously breathing patient J Bott, S Blumenthal, M Buxton, S Ellum, C Falconer, R Garrod, A Harvey, T Hughes, M Lincoln, C Mikelsons, C Potter, J Pryor, L Rimington, F Sinfield, C Thompson, P Vaughn, J White, on behalf of the British Thoracic Society Physiotherapy Guideline Development Group c Additional Appendices are GUIDELINE DEVELOPMENT GROUP Section 3—Cystic fibrosis published online at http://thorax. On behalf of the Association of Chartered bmj.com/content/vol64/ Steering group Physiotherapists in Cystic Fibrosis issueSupplI and http://www. Julia Bott (Chair), support to Section 6, Consultant brit-thoracic.org.uk Physiotherapist, Surrey PCT NW Locality Penny Agent, Service Lead Physiotherapist, Royal Brompton & Harefield NHS Trust Sheric Ellum, support to Section 5, Consultant Physiotherapist, Guy’s & St Thomas’ NHS Trust, Gillian Davie, Senior I Physiotherapist, Cystic Correspondence to: London Fibrosis Team, Aberdeen Royal Infirmary [email protected] Dr Rachel Garrod, support to Section 1, Reader, Mary Dodd, Consultant Physiotherapist in School of Physiotherapy, Faculty of Health and Cystic Fibrosis, University Hospital of South Social Care Sciences, Kingston University and St Manchester NHS Foundation Trust Received 19 November 2008 Dr Sarah Elkin, Respiratory Physician, St Mary’s Accepted 15 February 2009 George’s, University of London. Dr Jennifer Pryor, support to Sections 3 and 4, Hospital, London Senior Research Fellow in Physiotherapy, Royal Tracey Hughes (Chair), Senior I Physiotherapist, Brompton & Harefield NHS Trust Leeds Regional Adult Cystic Fibrosis Unit, Leeds Dr Lesley Rimington, support to Section 2, Teaching Hospitals NHS Trust Lecturer School of Health and Rehabilitation, Margaret MacLeod, Senior I Physiotherapist, Keele University Cystic Fibrosis Team, Aberdeen Royal Infirmary Nicola Mills, Senior I Physiotherapist, Adult Cystic Fibrosis Unit, University Hospitals of Section 1—COPD Leicester Sharon Baines, Clinical Specialist Physiotherapist, http://thorax.bmj.com/ Chronic Lung Disease Service, NHS Central Lancashire Section 4—Non-cystic fibrosis-related Amanda Dryer, Physiotherapy Clinical Lead in bronchiectasis Respiratory Care, Central Manchester and Alex Harvey (Co-Chair), Lecturer in Manchester Children’s University Hospital Physiotherapy, Brunel University Robert Goddard, Superintendent Physiotherapist, Fran Sinfield (Co-Chair), Superintendent County Durham and Darlington NHS Foundation Physiotherapist, Oxford Centre for Respiratory Medicine, The Churchill Hospital, Oxford Trust on September 24, 2021 by guest. 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Catherine Thompson, Senior Lecturer, York St Dr Robert Wilson, Respiratory Physician, Royal John University Brompton & Harefield NHS Trust Dr John White (Chair), Respiratory Physician, York Hospitals NHS Trust Section 5—Non-obstructive/restrictive lung diseases Section 2—Asthma and disordered breathing Debbie Dykes, Clinical Specialist Respiratory Caroline Falconer (Co-Chair), Senior Physiotherapy, St. Richards Hospital, Royal West Physiotherapist, Papworth Hospital NHS Sussex NHS Trust, Chichester Foundation Trust Katie Ford, Team Lead, Respiratory Lianne Jongepier, Respiratory Specialist Physiotherapy, Bristol Royal Infirmary, Bristol Physiotherapist, Service Lead COPD Team, Rachael Mitchell, Specialist Respiratory Primary Care Centre, Colchester Physiotherapist, Luton and Dunstable Hospital Melanie Lincoln (Co-Chair), Team Leader NHS Foundation Trust Physiotherapist, Papworth Hospital NHS Catherine Potter (Chair), Specialist Respiratory Foundation Trust Physiotherapist, The Whittington Hospital NHS Christine Mikelsons, Consultant Respiratory Trust, London Physiotherapist, Royal Free Hospital Fiona Rushmer, Physiotherapy Manager, Dr Mike Thomas, General Practitioner, Asthma Ashtead Hospital, Surrey UK Senior Research Fellow, University of Dr Paul Tate, Respiratory Physician, St. Richards Aberdeen Hospital, Royal West Sussex NHS Trust, Jo Williams, Senior Pulmonary Rehabilitation Chichester Specialist Glenfield Hospital, University Hospitals Jennifer Tomkinson, Respiratory Specialist of Leicester NHS Trust Physiotherapist, Bristol Primary Care Trust Thorax 2009;64(Suppl I):i1–i51. doi:10.1136/thx.2008.110726 i1 Joint BTS/ACPRC guideline c Section 6—Neuromuscular diseases and chest wall disorders Assess the effectiveness of a gutter rollator frame in the Thorax: first published as 10.1136/thx.2008.110726 on 30 April 2009. Downloaded from Dr Steve Banham, Respiratory Physician, Glasgow Royal acute setting, for patients with COPD severely disabled by Infirmary breathlessness, especially the elderly. (Grade B) Sharron Blumenthal (Co-Chair), Lecturer in Physiotherapy, c Teach individualised energy conservation techniques to help Glasgow Caledonian University reduce dyspnoea during activities of daily living. (Grade D) Caroline Brown, Principal Physiotherapist, Hospital of North Staffordshire NHS Trust Breathing techniques Rebekah Hooker, Advanced Physiotherapist, University Recommendations Hospital of North Staffordshire NHS Trust c Teach patients with COPD breathing control at rest to see if Lisa Morrison, Clinical Specialist Physiotherapist, Gartnaval it helps relieve dyspnoea. (Grade D) Hospital, Glasgow c Diaphragmatic breathing should not be taught routinely to Pamela Vaughn (Co-Chair), Clinical Specialist patients with severe COPD. (Grade C) Physiotherapist, Stobhill Hospital, Glasgow Nicola Williams, Specialist Physiotherapist, Blackpool, Fylde c Teach pursed lips breathing during exertion as a potential and Wyre Hospitals NHS Trust. strategy to reduce respiratory rate and aid recovery in patients with COPD. (Grade C) c Section 7—Workforce issues Teach exhalation on effort (‘‘blow as you go!’’) as a potential strategy to reduce dyspnoea in patients with Maria Buxton, Consultant Physiotherapist, Central Middlesex COPD. (Grade D) Hospital and Brent PCT c Christine Mikelsons, Consultant Respiratory Physiotherapist, Teach relaxed, slower, deeper breathing as a potential Royal Free Hospital strategy to facilitate more effective ventilation during exertion in patients with COPD. (Grade D) c Teach paced breathing as a strategy to maintain control of SUMMARY OF RECOMMENDATIONS breathing and reduce dyspnoea during exertion in patients Introduction with COPD. (Grade D) Physiotherapy should be offered to patients with a variety of medical respiratory conditions, with the aim of breathlessness Ventilation feedback training management and symptom control, mobility and function improvement or maintenance, and airway clearance and cough Recommendation c enhancement or support. Strategies and techniques include: Ventilation feedback training is not indicated in patients rehabilitation, exercise testing (including for ambulatory oxygen with COPD. (Grade C) assessment), exercise prescription, airway clearance, and posi- tioning and breathing techniques. Physiotherapy may be helpful Managing anxiety and panic http://thorax.bmj.com/ for postural and/or musculoskeletal dysfunction and pain, and Recommendation provide help in improving continence, especially during cough- c Teach patients with COPD positioning, breathing and ing and forced expiratory manoeuvres. Physiotherapists are relaxation strategies to help manage anxiety and panic usually central to the delivery of pulmonary rehabilitation and attacks. (Grade D) may be instrumental in the non-invasive ventilation service. Physiotherapists are frequently involved in the delivery of Pulmonary rehabilitation oxygen and some nebulised substances, as well as providing Recommendations vital monitoring of, for example, ventilatory function and cough c Pulmonary rehabilitation should include exercise training of on September 24, 2021 by guest. Protected copyright. effectiveness. Some complementary therapies may be appro- the muscles of ambulation. (Grade A) priate in some situations (Web Appendix 1). c Pulmonary rehabilitation should incorporate strength train- Recommendations are listed for each diagnostic group. A ing of both upper and lower limbs. (Grade A) concise version of this guideline is available on the BTS website. c Information, advice and education should be integral to pulmonary rehabilitation. (Grade A) Chronic obstructive pulmonary disease (COPD) c Pulmonary rehabilitation should be made available to all Management of breathlessness appropriate patients with COPD. (Grade A) Positioning Recommendations c Advise on passively fixing the shoulder girdle for optimising Field exercise tests ventilatory muscle efficiency and relief of breathlessness. Recommendation (Grade D) c The recommended number of practice walks must be c Assess the effectiveness of forward lean sitting on relief of included when assessing exercise tolerance with a field breathlessness in all patients with COPD, in both the exercise test for the prescription of either exercise or chronic and acute settings. (Grade C) ambulatory oxygen. (Grade C) c Advise modification of the forward lean position for use in standing and lying, for patients for whom forward lean Peri- and postexacerbation pulmonary rehabilitation sitting is effective. (Grade D) Recommendations c Consider pulmonary rehabilitation soon after exacerbation Walking aids for patients with COPD. (Grade B) Recommendations c Consider some form of rehabilitation during exacerbation to c Assess the effectiveness