Respiratory physiotherapists

Physiotherapy (or physical therapy) is primarily concerned with developing, maintaining and restoring an individual’s maximum movement and functional ability. It includes examination/assessment, evaluation, diagnosis, prognosis/ planning of treatment, intervention/treatment, and re-examination. The conceptual framework most frequently used by physiotherapists is the international classification of function; the main goal of this classification is to enhance the patient’s participation in everyday life. In patients with respiratory conditions, physiotherapy includes, but is not limited to, chest physiotherapy or clearance of secretions, and breathing exercises. In recent years, the evidence base for the use of physiotherapy in the form of exercise training has grown in many areas, ranging from intensive care to chronic respiratory conditions (see chapter 29).

Physiotherapy services can be used at all ages and at all stages of disease, from early diagnosis, through chronic illness, to acute episodes and care at the terminal stage. As such, physiotherapists have a clear and specific role in most clinical care pathways. The physiotherapist’s role in patient care includes assessment, advice, education and hands-on intervention. Traditionally, respiratory physiotherapists aid the mobilisation and removal of secretions. However, this is only one of the many problems physiotherapists can address. They aim to:

  • maintain or improve exercise tolerance

  • improve functional abilities (i.e. carrying out daily tasks)

  • maintain and improve physical activity, coaching patients toward improving healthy behaviour

  • reduce breathlessness and the work of breathing

  • improve the efficiency of ventilation

  • support weaning from mechanical ventilation and set up noninvasive mechanical ventilation

  • mobilise and aid the expectoration of secretions (coughing up of mucus)

  • improve knowledge and understanding

  • reduce (thoracic) pain

Physiotherapists who specialise in treating patients with respiratory disease have a background in respiratory physiology, exercise and muscle physiology, exercise training, and the principles of behaviour change. Further subspecialisation may include particular expertise in mechanical ventilation, aerosol delivery and pulmonary rehabilitation.

A physiotherapist should achieve the above aims with the goal of evidence-based practice in mind, i.e. they should know the most effective intervention, based on the evidence, and integrate this knowledge and its application with clinical judgment and patient preference. Recently, evidence-based treatment guidelines have summarised and endorsed the role of physiotherapy in the treatment of patients with respiratory conditions. A patient’s contact with their physiotherapist is often frequent and of a relatively long duration. This means the physiotherapist is ideally placed to help relieve anxiety, boost confidence and deliver appropriate information or advice.

Physiotherapy typically commences with a comprehensive assessment of the patient’s respiratory function, breathing pattern, respiratory muscle function and exercise capacity. Assessment of skeletal muscle function is particularly important, as this forms a major barrier to normal functioning in many respiratory patients. Based on this information, an evidence-based therapy plan is developed.

Physiotherapists often use mechanical devices, such as intermittent positive-pressure and CPAP equipment; tools that have been used in the profession since the mid-20th century. With the resurgence of interest in, and greater sophistication of, noninvasive ventilation techniques, physiotherapists have a greater armoury to turn to. Many individuals with life-threatening respiratory failure can be successfully managed in this way, avoiding intubation. Similarly, carefully selected devices can assist in mucus clearance. Exercise equipment has long been used in pulmonary rehabilitation programmes; however, physiotherapists may also use supplementary oxygen, noninvasive mechanical ventilation, complex training modalities or neuromuscular electrical stimulation to enhance the effectiveness of exercise training in respiratory patients. One specialised technique in particular is specific inspiratory muscle training using resistive breathing, which is used to alleviate breathlessness in patients with inspiratory muscle weakness.

Physiotherapists are important clinical team members in intensive care units, respiratory wards, outpatient clinics and palliative care services. The role of physiotherapists is widening as health services place a greater emphasis on chronic disease management and the maintenance of patient independence and function: where appropriate, patients are increasingly managed in the primary care setting, with the advent of domiciliary and hospital-at-home services.

Like their colleagues in other professions, physiotherapists should have greater involvement in tackling unhealthy behaviour (smoking, inactivity) in all aspects of healthcare. Ensuring that these skills are acquired is an important educational aim in the years to come.

Training

Like nurses, respiratory physiotherapists are often nonspecialised. However, in many European countries, increasing numbers specialise in respiratory physiotherapy and rehabilitation. The ERS has encouraged such specialisation by launching the HERMES respiratory physiotherapy programme, which aims to provide a standardised postgraduate programme of education and training. In a survey conducted to support this initiative, 64% of 107 respondents from over 30 countries reported that physiotherapy training is organised as an academic training programme in their country; 43% of these respondents reported that undergraduate training takes 3 years to complete and 32% reported that training modules are spread over 4 years.

See the entire Allied respiratory professionals Chapter