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Conventional chest physical therapy for obstructive lung disease

Chest physical therapy (CPT) is a widely used intervention for patients with airway diseases. The main goal is to facilitate secretion transport and thereby decrease secretion retention in the airways. Historically, conventional CPT has consisted of a combination of forced expirations (directed cough or huff), postural drainage, percussion, and/or shaking. CPT improves mucus transport, but it is not entirely clear which groups of patients benefit from which CPT modalities. In general, the patients who benefit most from CPT are those with airways disease and objective signs of secretion retention (eg, persistent rhonchi or decreased breath sounds) or subjective signs of difficulty expectorating sputum, and with progression of disease that might be due to secretion retention (eg, recurrent exacerbations, infections, or a fast decline in pulmonary function). The most effective and important part of conventional CPT is directed cough. The other components of conventional CPT add little if any benefit and should not be used routinely. Alternative airway clearance modalities (eg, high-frequency chest wall compression, vibratory positive expiratory pressure, and exercise) are not proven to be more effective than conventional CPT and usually add little benefit to conventional CPT. Only if cough and huff are insufficiently effective should other CPT modalities be considered. The choice between the CPT alternatives mainly depends on patient preference and the individual patient's response to treatment.

Tourism's impact on climate change and its mitigation challenges : how can tourism become 'climatically sustainable'?

At the Heart of Art and Earth

In today’s technological world, human intertwinement with the rest of nature hasbeen severely diminished. In our digital culture, many people hardly have any direct experience of and sense of connection with “the real” of the natural world. The author assumes that when we want to find ways to mend this gap, arts-based environmental education (AEE) can play a meaningful role. In AEE, artmaking is regarded as itself a way of potentially gaining new understandings about our natural environment. As a reflective practitioner, the author facilitated three different AEE activities, at several times and at diverse locations. On basis of his observations, memories, written notes, audio-visual recordings and interviews with participants, teachers and informed outsiders, he interpreted the experiences both of participants and himself. To this end he employed interpretative phenomenological analysis paired with autoethnography.The artmaking activities researched here aimed to bring about a shift in focus. Participants were encouraged to approach natural phenomena not head-on, but in an indirect way. Moreover, the artmaking process aspired to heighten their awareness to the presence of their embodied self at a certain place. The research questions that the author poses in this study are: (1) What is distinctive in the process of the AEE activities that I facilitate?; (2) Which specific competencies can be identified for a facilitator of AEE activities?; and (3) Does participating in the AEE activities that I facilitate enhance the ability of participants to have a direct experience of feeling connected to the natural world?In this explorative study, the author identifies facilitated estrangement through participating in AEE as an important catalyst when aiming to evoke such instances of transformative learning. In undergoing such moments, participants grope their way in a new liminal space. Artmaking can create favorable conditions for this to happen through its defamiliarizing effect which takes participants away from merely acting according to habit (on “autopilot”). The open-ended structure of the artmaking activities contributed to the creation of a learning arena in which emergent properties could become manifest. Thus, participants could potentially experience a sense of wonder and begin to acquire new understandings – a form of knowing that the author calls “rudimentary cognition.” The research further suggests that a facilitator should be able to bear witness to and hold the space for whatever enfolds in this encounter with artistic process in AEE. He or she must walk the tightrope between control and non-interfering.The analysis of the impacts of the AEE activities that were facilitated leads the author to conclude that it is doubtful whether these in and of themselves caused participants to experience the natural environment in demonstrable new and deep ways. He asserts that most of their awareness was focused on the internal level of their own embodied presence; engagement with place, the location where the AEE activity was performed, seemed secondary. The findings show that AEE activities first and foremost help bring about the ignition and augmentation of the participants’ fascination and curiosity, centered in an increased awareness of their own body and its interactions with the natural world. The present study can be seen as a contribution to efforts of envisaging innovative forms of sustainable education that challenge the way we have distanced ourselves from the more-than-human world.

Exploring a 1-Minute Paced Deep-Breathing Measurement of Heart Rate Variability as Part of a Workers’ Health Assessment

Low heart rate variability (HRV) is related to health problems that are known reasons for sick-leave or early retirement. A 1-minute-protocol could allow large scale HRV measurement for screening of health problems and, potentially, sustained employability. Our objectives were to explore the association of HRV with measures of health. Cross-sectional design with 877 Dutch employees assessed during a Workers’ Health Assessment. Personal and job characteristics, workability, psychological and mental problems, and lifestyle were measured with questionnaires. Biometry was measured (BMI, waist circumference, blood pressure, glucose, cholesterol). HRV was assessed with a 1-minute paced deep-breathing protocol and expressed as mean heart rate range (MHRR). A low MHRR indicates a higher health risk. Groups were classified age adjusted for HRV and compared. Spearman correlations between raw MHRR and the other measures were calculated. Significant univariable correlations (p < 0.05) were entered in a linear regression model to explore the multivariable association with MHRR. Age, years of employment, BMI and waist circumference differed significantly between HRV groups. Significant correlations were found between MHRR and age, workability, BMI, waist circumference, cholesterol, systolic and diastolic blood-pressure and reported physical activity and alcohol consumption. In the multivariable analyses 21.1% of variance was explained: a low HRV correlates with aging, higher BMI and higher levels of reported physically activity. HRV was significantly associated with age, measures of obesity (BMI, waist circumference), and with reported physical activity, which provides a first glance of the utility of a 1-minute paced deep-breathing HRV protocol as part of a comprehensive preventive Workers’ Health Assessment.Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creat ivecommons .org/licen ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate redit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

A multidimensional inquiry into Chinese outbound tourism to Western Europe: the visitation of Chinese millennial students to the Netherlands