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Respiratory physiotherapy – it is more than breathing exercises and expectoration


Respiratory physiotherapy – it is more than breathing exercises and expectoration

  • This article was prepared by experts in the field of respiratory physiotherapy - Dr. Agnieszka Lewko and Dr. Anna Pyszora. It discusses the scope of such practices in the context of current scientific evidence and latest clinical recommendations.

Physiotherapy incorporates various branches of clinical specialism, e.g. neurology, trauma and orthopaedics or cardiology. In some countries, respiratory physiotherapy is one of the three most important areas of physiotherapy, while in other countries it is still undervalued. Respiratory physiotherapy is commonly associated with airway clearance techniques, postural drainage or breathing exercises. However, these techniques only constitute a fragment of its therapeutic scope and respiratory physiotherapy is de facto much more! Physiotherapists who specialize in this field work with range of people e.g. after thoracic surgery, with ineffective cough or ventilation due to neuromuscular diseases or spinal cord, with ventilation dysfunction during exacerbations of chronic diseases, mechanically ventilated in intensive care units, hospitalized due to pneumonia or acute airway infections in all ages (including children). Physiotherapists also play an important role in the management of patients with functional disorders of the respiratory system, e.g. hyperventilation syndrome or hypoventilation in advanced obesity. Respiratory physiotherapy is also invaluable for neonates with respiratory dysfunction. This article aims to explain the scope of respiratory physiotherapy in the context of current medical knowledge and latest clinical recommendations.

Not just patients with pulmonary diseases    

The general goal of physiotherapy is to provide an optimal level of physical and emotional functioning for patients in all phases of disease process [1]. This principle applies to the early period after the diagnosis, both in acute and chronic conditions (when stable and during exacerbation), as well as at the end of a patient’s life. Respiratory Physiotherapists practice in intensive care units [2], on hospital wards, in outpatient clinics and increasingly in the community [1,3]. Respiratory physiotherapists are responsible for comprehensive subjective and objective patient assessment , in relation to the respiratory and other systems. The process of clinical reasoning involves careful analysis of assessment findings and consideration of patients’ goals based on their individual needs ad including consideration of psycho-social     elements. This enables to plan effective and safe physiotherapeutic  intervention.  It is important to emphasise that respiratory physiotherapy  does not limit itself to treating only patients  with pulmonary conditions. Naturally, this  specialty of physiotherapy is crucial in comprehensive  treatment of patients living with diseases such  as cystic fibrosis (CF), chronic obstructive pulmonary  disease (COPD), asthma, bronchiectasis or pulmonary  fibrosis. In therapy of the above-mentioned groups  of patients, implementation of the following methods  plays an essential role: airway clearance techniques  (called “chest therapy” in literature), non-invasive  ventilation (both in exacerbations during hospitalization  and at home), ambulatory oxygen therapy or,  physical training as a part of pulmonary rehabilitation  programmes.  Furthermore, respiratory physiotherapy is also important  in treating other disorders which are associated  or may lead to respiratory complication, such  as difficulties in expectoration in patients with neuromuscular  diseases or spinal cord injuries, patients  who have undergone surgical procedures, as well as  critically ill or obese patients.  Appropriate assessment, patient evaluation and  adequate intervention often prevent serious complications,  which could potentially lead to permanent  disability or premature death.

Only scientific evidence  

Methods utilised by respiratory physiotherapy are  based on research evidence. There is a significant  number of publications in this field of physiotherapy  – there are numerous textbooks for respiratory physiotherapy  [4, 5] clinical guidelines [2, 6, 10] and recommendations  prepared in accordance with strong  scientific evidence and experts’ opinions [7-9]. Techniques  used in respiratory physiotherapy aim to: clear  bronchial secretions, reduce work of breathing or  increase reduced lung volume [5]. While these techniques  are extensively described in professional literature,  the decision about their implementation and  effectiveness must be based on an individual patient  assessment, evaluation of mechanisms which led  to the problem such as secretion retention, as well  as evaluating its clinical effectiveness [2, 4, 5, 6, 11].  For instance, Active Cycle of Breathing Techniques  (ACBT) is a method widely applied airway diseases,  whereas cough assist using mechanical insufflation  exsufflation (MIE) is mostly used in patients with  neuromuscular diseases and manual hyperinflation  (MHI) is recommended for intubated and mechanically  ventilated patients in intensive care units. Respiratory  physiotherapists also actively participate  in the care of patients who use non-invasive ventilation  in order to support respiratory muscle [12, 13],  using techniques to relieve symptoms such as dyspnoea  [4, 6, 14]. These physiotherapists also have general  knowledge and skills about physical training  and improving patients’ exercise capacity and muscle  strength. Respiratory physiotherapy specialists are  an integral part of pulmonary rehabilitation teams  and often they lead the team. Pulmonary rehabilitation  is a comprehensive and economically effective  program of sessions which last several weeks and  involve: physical training, education, health behaviour  change and self-management [15]. This form  of therapy is recognised as a standard of health management  in patients with chronic respiratory diseases,  especially with COPD [16-18].


The scope and areas of respiratory physiotherapy are  broad, which is why professionals who specialize in  this field should be an integral part of every therapeutic  team – especially the teams working in hospitals,  outpatient clinics, in long-term, palliative care,  and in the community. Nevertheless, there are huge  differences in clinical practice, workforce training  and accessibility to these specialists, even among the  European Union countries and despite the fact that  the education systems in Europe follow the Bologna  agreement.  In 2012, an international task force group was created  to define the scope and to develop a postgraduate  training programme in for respiratory physiotherapy  specialists.  This group was established in association with the  European Respiratory Society (ERS) education program  under the name “HERMES” (Harmonised Education  in Respiratory Medicine for European Specialists).  Hundreds of specialists from 30 countries,  including Poland, have taken part in consultations.  Using the Delphi process, a consensus was agreed  and used to prepare the syllabus and a structured  postgraduate curriculum for respiratory physiotherapists  all around the world. The syllabus was published  in 2015 [19], while the complete curriculum  with detailed learning outcomes was published in  2019 [20]. This project is not only important as an  indicator of post-graduate education standards but   also as a tool for evaluation of the level of knowledge, skills and attitudes expected from physiotherapists who work with patients affected by various respiratory dysfunctions. These problems may appear in different stages of life, in the course of various diseases, after surgical treatment or as a result of serious injuries, as has been mentioned before. A well-trained physiotherapist is able to conduct an independent patient assessment, define their therapeutic problems by means of clinical reasoning and create an adequate physiotherapy plan. In order to make sure that physiotherapists are ready to perform complex assessment and provide appropriate therapy, we ought to take a closer look at undergraduate teaching programs and evaluate – according to the HERMES curriculum – whether we are offering sufficient preparation for Polish physiotherapists. The standard of education at undergraduate level and the quality of practice education often determine which career pathway junior physiotherapists are going to choose. It is also critical to ensure continuous professional development opportunities and create a team of specialists in this field, who will become mentors and experts for other physiotherapists and will also lead among other healthcare professionals. Without properly trained and experienced specialists in respiratory physiotherapy, a large group of patients do not have access to the treatment which could help with their recovery, prevent dangerous complications, improve quality of life or even prolong life.

Respiratory physiotherapy and COVID-19

This year a pandemic of a virus attacking the respiratory system has revealed disparities in the level of training, skills and preparation of physiotherapists for treating patients with acute respiratory failure. It became transparent that some recommendations and guidelines prepared according to current scientific knowledge and international expertise cannot be implemented in many countries, including Poland. This period has allowed physiotherapists themselves to gain more knowledge about what opportunities respiratory physiotherapy may offer. Now comes the time to evaluate and reflect on the needs and goals of respiratory physiotherapy in our country, as well as to discuss how such goals can be achieved.


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