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Cited by 451Chronic Obstructive Pulmonary Disease (COPD) ResearchRespiratory Support and MechanismsClinical practice guidelines implementation

Guidelines for the physiotherapy management of the adult, medical, spontaneously breathing patient

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Bott, J, Blumenthal, S, Buxton, M, Ellum, S, Falconer, C, Garrod, R, Harvey, A, Hughes, T +10 more·2009·Thorax
DOI 10.1136/thx.2008.110726
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Abstract

IntroductionPhysiotherapy should be offered to patients with a variety of medical respiratory conditions, with the aim of breathlessness management and symptom control, mobility and function improvement or maintenance, and airway clearance and cough enhancement or support.Strategies and techniques include: rehabilitation, exercise testing (including for ambulatory oxygen assessment), exercise prescription, airway clearance, and positioning and breathing techniques.Physiotherapy may be helpful for postural and/or musculoskeletal dysfunction and pain, and provide help in improving continence, especially during coughing and forced expiratory manoeuvres.Physiotherapists are usually central to the delivery of pulmonary rehabilitation and may be instrumental in the non-invasive ventilation service.Physiotherapists are frequently involved in the delivery of oxygen and some nebulised substances, as well as providing vital monitoring of, for example, ventilatory function and cough effectiveness.Some complementary therapies may be appropriate in some situations (Web Appendix 1).Recommendations are listed for each diagnostic group.A concise version of this guideline is available on the BTS website. Chronic obstructive pulmonary disease (COPD) Management of breathlessness PositioningRecommendations c Advise on passively fixing the shoulder girdle for optimising ventilatory muscle efficiency and relief of breathlessness.(Grade D) c Assess the effectiveness of forward lean sitting on relief of breathlessness in all patients with COPD, in both the chronic and acute settings.(Grade C) c Advise modification of the forward lean position for use in standing and lying, for patients for whom forward lean sitting is effective.(Grade D) Walking aids Recommendations c Assess the effectiveness of a rollator frame for patients with COPD disabled by breathlessness.(Grade B) c Assess the effectiveness of a gutter rollator frame in the acute setting, for patients with COPD severely disabled by breathlessness, especially the elderly.(Grade B) c Teach individualised energy conservation techniques to help reduce dyspnoea during activities of daily living.(Grade D) Breathing techniques Recommendations c Teach patients with COPD breathing control at rest to see if it helps relieve dyspnoea.(Grade D) c Diaphragmatic breathing should not be taught routinely to patients with severe COPD.(Grade C) c Teach pursed lips breathing during exertion as a potential strategy to reduce respiratory rate and aid recovery in patients with COPD.(Grade C) c Teach exhalation on effort (''blow as you go!'') as a potential strategy to reduce dyspnoea in patients with COPD.(Grade D) c Teach relaxed, slower, deeper breathing as a potential 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 breathing and reduce dyspnoea during exertion in patients with COPD.(Grade D) Ventilation feedback training Recommendation c Ventilation feedback training is not indicated in patients with COPD.(Grade C) Managing anxiety and panic Recommendation c Teach patients with COPD positioning, breathing and relaxation strategies to help manage anxiety and panic attacks.(Grade D) Pulmonary rehabilitation Recommendations c Pulmonary rehabilitation should include exercise training of the muscles of ambulation.(Grade A) c Pulmonary rehabilitation should incorporate strength training of both upper and lower limbs.(Grade A) c Information, advice and education should be integral to pulmonary rehabilitation.(Grade A) c Pulmonary rehabilitation should be made available to all appropriate patients with COPD.(Grade A) Field exercise tests Recommendation c The recommended number of practice walks must be included when assessing exercise tolerance with a field exercise test for the prescription of either exercise or ambulatory oxygen.(Grade C) Peri-and postexacerbation pulmonary rehabilitation Recommendations c Consider pulmonary rehabilitation soon after exacerbation for patients with COPD.(Grade B) c Consider some form of rehabilitation during exacerbation to maintain mobility and function in patients with COPD.(Grade D) Joint BTS/ACPRC guideline i2

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  • Respiratory rehabilitation may reduce the need for artificial ventilation.

    “It may improve oxygen exchange, prevents the lungs from collapsing, reduce psychological stress and the need for artificial ventilation [10–12].”

    From Effects of short-term breathing exercises on respiratory recovery in patients with COVID-19: a quasi-experimental study (2022) · cites this paper as [10]

    The Non-invasive ventilation section (page unavailable) reports that NIV reduced tracheal intubation rates in patients with community-acquired pneumonia. That supports a narrower claim about avoiding invasive ventilation, but NIV is itself a form of assisted ventilation; the Pulmonary rehabilitation peri-and postexacerbation section does not report reduced need for artificial ventilation from rehabilitation. (LLM, conf=0.83)

    Experimental — accuracy not yet measured

  • Respiratory rehabilitation may improve oxygen exchange.

    “It may improve oxygen exchange, prevents the lungs from collapsing, reduce psychological stress and the need for artificial ventilation [10–12].”

    From Effects of short-term breathing exercises on respiratory recovery in patients with COVID-19: a quasi-experimental study (2022) · cites this paper as [10]

    The ‘Relaxed, slower, deeper breathing’ section recommends a breathing technique as a potential way to improve ventilation during exertion in patients with COPD and reports reduced arterial carbon dioxide with slow, controlled breathing. That supports a possible respiratory benefit, but the guideline does not establish that respiratory rehabilitation generally improves oxygen exchange. The retrieved passages do not provide a page number for this section. (LLM, conf=0.78)

    Experimental — accuracy not yet measured

  • Respiratory rehabilitation should be considered when there are no signs of progressive deterioration and patients are hospitalised, as recommended by Chinese, the Netherlands, Italian, and UK rehabilitation professionals [6, 10, 15, 17, 33].

    “Respiratory rehabilitation should be considered when there are no signs of progressive deterioration and patients are hospitalised, as recommendations by Chinese, the Netherlands, Italian, and UK rehabilitation professionals [6, 10, 15, 17, 33].”

    From Effects of short-term breathing exercises on respiratory recovery in patients with COVID-19: a quasi-experimental study (2022) · cites this paper as [10]

    The “Pulmonary rehabilitation peri-and postexacerbation” section recommends considering rehabilitation during an exacerbation for patients with COPD and describes inpatient rehabilitation during admission. It does not give absence of progressive deterioration as a criterion or extend that recommendation to hospitalised patients generally. The passages provided do not give a page number. (LLM, conf=0.85)

    Experimental — accuracy not yet measured

  • The clinical community acknowledges physiotherapy as an effective treatment for HVS and, more broadly, for chronic dysfunctional breathing.

    “However, the clinical community acknowledge physiotherapy as an effective treatment for HVS and, more broadly, for chronic dysfunctional breathing.”

    From Physiotherapy Education and Breathing Retraining for Patients With Hyperventilation Syndrome: An Observational Study (2026) · cites this paper as [40]

    In the Breathing techniques section, the guideline reports benefits of physiotherapy and breathing retraining for hyperventilation syndrome (HVS); its recommendation section says breathing retraining should be offered as first-line treatment for HVS. It also reports improvement in dysfunctional breathing symptoms in a cohort with asthma, but does not establish physiotherapy as effective for chronic dysfunctional breathing more broadly. Page numbers were not available in our copy. (LLM, conf=0.83)

    Experimental — accuracy not yet measured

  • In France, the treatment regimen led by a trained physiotherapist is the only therapeutic intervention prescribed to HVS patients.

    “In France, the treatment regimen proposed above and led by a trained physiotherapist is the only therapeutic intervention prescribed to HVS patients.39,40”

    From Physiotherapy Education and Breathing Retraining for Patients With Hyperventilation Syndrome: An Observational Study (2026) · cites this paper as [40]

    The Level of evidence 1+ Recommendation section recommends breathing retraining as a first-line treatment for hyperventilation syndrome, and the Breathing techniques section describes retraining by a physiotherapist. Neither section says that physiotherapy is the only intervention prescribed or describes prescribing practice in France. Page numbers are unavailable in our copy. (LLM, conf=0.88)

    Experimental — accuracy not yet measured

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Authors
Bott, J., Blumenthal, S., Buxton, M., Ellum, S., Falconer, C., Garrod, R., Harvey, A., Hughes, T., Lincoln, M., Mikelsons, C., Potter, C., Pryor, J., Rimington, L., Sinfield, F., Thompson, C., Vaughn, P., White, J., & on behalf of the British Thoracic Society Physiotherapy Guideline Development Group
Affiliations
University of London (GB)
ORCID
Venue
Thorax
Publisher
BMJ
Published
2009-04-30
Volume
64
Issue
Suppl 1
Pages
i1-i52
ISSN
0040-6376 (ISSN-L)
DOI
10.1136/thx.2008.110726
OpenAlex
W2150691143
Cited by
451
References
4
Citations by year
2026: 14 · 2025: 16 · 2024: 21 · 2023: 26 · 2022: 33 · 2021: 45 · 2020: 24 · 2019: 31 · 2018: 28 · 2017: 35 · 2016: 26 · 2015: 28 · 2014: 31 · 2013: 36 · 2012: 22
FWCI
16.05
Type
journal article
Language
en
Open access
Locations
  • Thorax (publishedVersion)
  • PubMed (publishedVersion)
Topics
  • Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Chronic Obstructive Pulmonary Disease (COPD) Research
  • Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Respiratory Support and Mechanisms
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Clinical practice guidelines implementation
Keywords
physiotherapy, chronic obstructive pulmonary disease, breathlessness management, pulmonary rehabilitation, airway clearance, cough, exercise prescription, oxygen therapy, non-invasive ventilation, breathing exercises, pursed-lip breathing, diaphragmatic breathing, positioning, walking aids, energy conservation, postural dysfunction, continence, complementary therapy, dyspnea
MeSH terms
Administration, Inhalation, Adrenergic beta-Agonists, Adult, Asthma, Bronchiectasis, Cystic Fibrosis, Exercise Therapy, Humans, Humidity, Hyperventilation, Neuromuscular Diseases, Oxygen, Respiratory Therapy, Sodium Chloride, Physical Therapy Modalities, Pulmonary Disease, Chronic Obstructive

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