Cardiopulmonary Physical Therapy

Haneul Lee, DSc, PT

Airway ClearanceTechniques Breathing Exercise Special Considerations for MechanicallyVentilated Exercise Injury Prevention and Equipment provision Patient Education Discharge Planning

Physical therapists providing therapeutic interventions for patients with acute cardiopulmonary conditions must appreciatethe unique circumstances and patient responses that occur in the hospital environment.

Acute cardiopulmonary conditions can be defined asdisease or states in which the patient’s oxygen transportsystem fails to meet the immediate demands.

The failure may result in significant periods of bed rest forthe patient.

The loss of muscle strength and endurance for patients with low-level baseline functional mobility can have significant consequences.

The loss of small amount of functional mobility may mean the difference between going home and to a nursing home.

System Effects

Cardiovascular system Increased basal heart rate

Decreased maximal heart rate

Decreased maximal oxygen uptake

Orthostatic hypotension

Increased venous thrombosis risk

Decreased total blood volume

Decreased hemoglobin concentration

Respiratory system Decreased vital capacity

Decreased residual volume

Impaired ability to clear secretions

Essentials of Cardiopulmonary Physical Therapy, 3rd edition, Ellen Hillegass, Elsevier

Ischemic cardiovascular diseasesChronic obstructive pulmonary diseasesPostoperative pulmonary complicationsComplications of hypertension

Diabetes and obesity are perhaps the common conditions associated with acute cardiopulmonary dysfunction

Patient in the acute care setting can present with multiple cardiopulmonary impairments regardless of the primary diagnosis.

Demonstrate difficulty performing effective airway clearance, cough, or achieving enough inspiratory effort to support functional activities.

May also demonstrate deconditioning as a result of the primary medical condition, prolonged bedrest, or a combination of both.

Manual or mechanical procedures that facilitate mobilization of secretions from the airways. Postural drainage

Percussion

Vibration

Cough techniques

Manual hyperinflation

Airway suctioning

Physical Therapist can facilitate the mobilization ofsecretions by using one or more airway clearancetechniques with acutely ill patients.

Body substance precautions such as gowns, masks, gloves, and goggles apply to the performance of airway clearance techniques.

Patient examination before, during, and after treatment provides the clinician with important information by which to judge the patient’s tolerance and the treatment’s effectiveness.

Should be performed before or at least 30 minutesfollowing the end of a meal or tube feeding.

Optimal pain control allows the patient to have the greatest comfort and offer fullest cooperation during the procedure.

Inhaled bronchodilator medications given prior to airway clearance procedure enhance the overall intervention outcome.

Take care to observe proper body mechanics whileperforming airway clearance techniques to avoid self-injury.

Goal Optimize airway patency

Promote alveolar expansion and ventilation

Increase gas exchange

Indications Excessive pulmonary secretions

Ineffective or absent cough

Impaired mucociliary transport

Duration and frequency of the techniques are based onpulmonary reevaluation at each session.

Often family members will be trained to continue the airway clearance techniques following hospital discharge.

Intervention is discontinued when the goals have been met or the patient can independently perform their own airway clearance techniques.

One or more body positions that allow gravity to assist withgraining secretions from each of the patient’s lung segments.

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Essentials of Cardiopulmonary Physical Therapy, 3rd edition, Ellen Hillegass, Elsevier

Essentials of Cardiopulmonary Physical Therapy, 3rd edition, Ellen Hillegass, Elsevier

Postural drainage may be used exclusively or in combination withother airway clearance techniques.

If PD is used exclusively, each position should be maintained for 5 to 10 minutes or longer, if tolerated.

Clinical approach to adding additional airway clearance maneuvers such as percussion and vibration during postural drainage should be performed if needed.

Priority should be given to treating the most affected lung segments first, and the patient should be encouraged to take deep breaths in the PD position and cough between positions as secretions mobilize.

Precautions Relative Contraindications

• Pulmonary edema

• Hemoptysis

• Massive obesity

• Large pleural effusion

• Massive ascites

• Increased intracranial pressure

• Hemodynamically unstable

• Recent esophageal anastomosis

• Recent spinal fusion or injury

• Recent head trauma

• Diaphragmatic hernia

• Recent eye surgery

Essentials of Cardiopulmonary Physical Therapy, 3rd edition, Ellen Hillegass, Elsevier

Chest percussion aimed at loosening retained secretions can be performed manually or with a mechanical device

Essentials of Cardiopulmonary Physical Therapy, 3rd edition, Ellen Hillegass, Elsevier

Manual percussion consists of a rhythmical clapping with cupped hands over the affected lung segment.

Mechanical percussion has been found to be similar in effectiveness to manual percussion.

Essentials of Cardiopulmonary Physical Therapy, 3rd edition, Ellen Hillegass, Elsevier

Percussion should be performed during inspiration andexpiration.

The hands essentially “fall”” on the chest in an even, steady rhythm between 100 and 480 times per minute.

The amount of force need not be excessive and should beadjusted to promote patient comfort.

Clapping on bony prominences should be avoided.

An airway clearance technique that can beperformed manually or with a mechanical device.

The palmar aspect of the hands are in full contract with the patient's chest wall or one hand may be overlapping the others

Essentials of Cardiopulmonary Physical Therapy, 3rd edition, Ellen Hillegass, Elsevier

At the end of a deep inspiration, the physical therapist exerts pressure on the patient’s chest wall and gently oscillates it through the end of expiration.

As with percussion, vibration is utilized in postural drainage positions to clear secretions from the affected lung segments.

Vibration may be a useful alternative to percussion in acutelyill patients with chest wall discomfort or pain.

https://youtu.be/ErMTXJLE5es

Precautions Relative Contraindications

• Uncontrolled bronchospasm

• Osteoporosis

• Rib fractures

• Metastatic cancer to ribs

• Tumor obstruction of airway

• Anxiety

• Coagulopathy

• Convulsive or seizure disorder

• Recent pacemaker placement

• Hemoptysis

• Untreated tension pneumothorax

• Unstable hemodynamic status

• Open wounds, burns in the thoracic

area

• Pulmonary embolism

• Subcutaneous emphysema

• Recent skin grafts or flaps on thorax

Coughing techniques are special ways of coughing that help move mucus up the airways.

The therapist hand(s) becomes the force behind the patient’s exhaled air. Assisted cough is used when the patient’s abdominal muscles cannot generate effective cough.

1. Position the patient against a solid surface; supine with head of bed flat or in aTrendelenburg position, or sitting with wheelchair against the wall or against the therapist

2. The therapist's hand is placed below the patient's xiphoid process3. Patient inhales deeply4. As the patient attempts to cough, the therapist's hand pushes

inward and upward, assisting the rapid exhalation of air

https://youtu.be/bCOmV_G0pkk

Inspiratory and expiratory mechanical aids are devices and techniques that involve the manual or mechanical application of forces to the body to assist inspiratory or expiratory muscle function

Mechanical cough assist devices deliver deep insufflations followed immediately by deep exsufflations.

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Airway suctioning is performed routinely for intubated patients to facilitate the removal of secretions and to stimulate the cough reflex.

The frequency of suctioning is determined by the amount of secretions produced in the airway.

Essentials of Cardiopulmonary Physical Therapy, 3rd edition, Ellen Hillegass, Elsevier

Pursed-lip breathing Diaphragmatic breathing Paced breathing Segmental breathing Inspiratory muscle training Sustained maximal inhalation

To reduced the respiratory rate, increase tidal volume, reduce dyspnea, decrease mechanical disadvantage of an impaired ventilator pump, improve gas change and facilitate relaxation.

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Indications Tachypnea Dyspnea

Precautions/Contraindications Forcing exhalation

Expected outcomes Decrease respiratory rate Relieve dyspnea Reduce arterial partial pressure of carbon dioxide (PaC02) Improve tidal volume Improve oxygen saturation Prevent airway collapse in patients with emphysema Increase activity tolerance

To increase ventilation, improvegas exchange, decrease work of berating, facilitate relaxation,improve mobility of chest wall.

http://www.buzzle.com/images/exercises/breathing-exercises/diaphragmatic-breathing-exercise-while-sitting.jpg

Indications Post-surgical patient with pain in the chest wall or abdomen, or restricted mobility Dyspnea at rest or with minimal activity Inability to perform ADLs due to dyspnea or inefficient breathing pattern

Precautions/Contraindications Moderate to severe COPD and marked hyperinflation of the lungs without

diaphragmatic movement Patients with paradoxical breathing patterns, or who demonstrate increased

inspiratory muscle effort, and increased dyspnea during DB

Expected outcomes Decrease respiratory rate Decrease use of accessory muscles of inspiration Increase tidal volume Decrease respiratory flow rate Subjective improvement of dyspnea Improve tolerance for activity

Breathing in coordination with your activity. Paced breathing prevents or decreases shortness of breath during activities,such as, when you walk or lift light objects.

This can combined with pursed-lib breathing ordiaphragmatic breathing.

http://www.growthguided.com/wp-content/uploads/2013/07/Exhale.jpghttp://www.growthguided.com/wp-content/uploads/2013/07/Inhale.jpg

Indications Patients with dyspnea at rest or with minimal activity Inability to perform activity due to pulmonary limitation Inefficient breathing pattern during activity

Precautions/Contraindications AvoidValsalva maneuver during activity

Expected outcomes Complete activity without dyspnea Decrease patient’s fear of becoming short of breath during

activity

Segmental breathing, also known as localized breathing or thoracic expansion exercise, is intended to improve regional ventilation and prevent and treat pulmonary complications after surgery.

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Indications Decreased intrathoracic lung volume Decreased chest wall lung compliance Increased flow resistance from decreased lung volume

Precautions/Contraindications None

Expected outcomes Increase chest wall mobility Expand collapsed alveoli via airflow through collateral

ventilation channels Assist with secretion removal

To increase the ventilator capacity and decrease dyspnea.An IMT program has tow parts: strengthening and endurancetraining

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Indications Impaired inspiratory muscle strength and/or a ventilatory

limitation to exercise performance

Precautions/Contraindications Clinical signs of inspiratory muscle fatigue

▪ Tachypnea▪ Reduced tidal volume▪ Increased PaC02▪ Bradypnea and decreased minute ventilation

Expected outcomes Increase inspiratory muscle strength and endurance Decrease dyspnea at rest and during exercise Increase functional exercise capacity

To increase inhaled volume, sustain or improve alveolarinflation, maintain or restore functional residual capacity.

SMI is also called incentive spirometry when using a device that provides visual or other feedback to encourage the patient to take long, slow, deep inhalations

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Indications Decreased intrathoracic lung volume Decreased chest wall lung compliance Increased flow resistance from decreased lung volume Atelectasis or risk of atelectasis due to thoracic and upper abdominal

surgery Restrictive lung defect associated with quadriplegia and/or

dysfunctional diaphragm

Precautions/Contraindications Patient is not cooperative or is unable to understand or demonstrate

proper use of the incentive spirometer Patient is unable to deep breathe effectively Patients with moderate to severe COPD with increased respiratory

rate and hyperinflation

Expected outcomes Absence of or improvement in signs of atelectasis

Decreased respiratory rate

Resolution of fever

Normal pulse rate

Normal chest x-ray

Improved Pa02

Increased forced vital capacity

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