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P.T. Plan of Care for Cardiac and Pulmonary Conditions—PTP 673 –Handout I
Pulmonary Practice Patterns, Physics, Physiology, &
Physical Therapy-Occupational Therapy
Barb Bernard Butler, PT, MS PT, DPT,
(“Lung Whisperer” per Keri Hutchins, 1976-2010)
University of Michigan-Flint
July 11, 2013
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Our Job: Improve O2 Transport
• Pulmonary History? Red Flags: “If you can’t breathe, you can’t function” & “Function trumps structure”.
• “Screen Cardio-Vascular-Pulmonary Systems first!– imaging, labs, meds, tests
• i.e., CT scan, vent/perf. scan, blood glucose, coagulation, bronchodilator, ECG, PFT
– identify the “hidden impairments”
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The Guide to Practice APTA
• Musculoskeletal Screens– ROM– Strength– Posture
• Neuromuscular Screens– Tone, Reflex, Coordination– Balance– Sensation– Communication &
Cognition
• Integumentary Screens– Superficial Skin– Partial-thickness Skin– Full-thickness Skin– Extension into Fascia or
deeper
• Cardio-vas-pulm screens– Deconditioning / Demand– Airway Clearance– Heart Pump / Lung Pump– Gas Exchange– Lymphatic
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Cv-P Preferred Practice Patterns
• A. Prevention / Risk Reduction
• B. Aerobic Capacity / Endurance
• C. Airway Clearance
• D. Cardiovascular Pump
• E. Ventilatory Pump
• F. Respiration / Gas Exchange• G. Neonatal Respiration
• H. Lymphatic System
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Physics and Physiology Principles
• Iron lung / human lung model
• References: – John B. West’s texts
• Respiratory Physiology: use of + and – pressure to fill lungs, “iron lung”
• Respiratory Pathophysiology
– Mary Massery, PT, DPT course• “If You Can’t Breathe, You Can’t Function”
• Barb’s Drawings
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Normal Mechanics—L Lung: gas will preferentially flow to the dependent region
first.
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Midlung Field: critical for ventilation
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Closing Volume: R lung – more WOB (work of breathing)
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Modifying Your Intervention:for lesions / optimizing results / etc.
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Malignant pleural effusion
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Oxygen Titration: at rest / with activity
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1 airway: ~27 generations glottis to alveoli
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Coughing and Secretions:(Cohesive secretions
vs. Adhesive secretions)
but only from mid-upper airways!
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Stressed set / Calmed set(sympathetic / parasympathetic)• Forced exhalations• Secretions rattling
around, but not coming out
• Many ineffective small coughs
• Increased RR
• Relaxed, controlled exhalation with minimal force
• (? Pursed lip breathing if it comes naturally)
• Hold inflation 2-3 seconds• Suppress small coughs /
facilitate only strong, effective cough
• Decreased RR, large, controlled inspiration
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Pop Can / Steel Can Model(from Mary Massary)
Intact trunk: •integrated, •strong, •flexible, •coordinated
powerful
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Postural Muscles = Breathing Muscles
• Diaphragm: – an amazing muscle
• costal vs. central
– a “pressure regulator”
– a skeletal muscle with length : tension ratio
– Length = “radius of curvature”
• Normal
• Lengthened
• Shortened – flat dome, barrel chest
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HOW DO YOU KNOW YOU DID YOUR JOB? (EFFECTS OF O2 TRANSPORT FOR THE BETTER?)
• Changes in heart rate• Changes in blood pressure• Changes in O2 saturation• Changes in ECG (rhythm & pattern)• Changes in blood gases• Changes in respiratory rate & pattern• Changes in symptoms
– (e.g., measures of the hidden impairments)
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Pulmonary Common Hierarchy “Screen the Hidden Impairments First”
• 1. Activity & exercise• 2. Body positioning• 3. Breathing control
maneuvers• 4. Coughing
maneuvers• 5. Relaxation &
energy conservation maneuvers
• 6. Exercise throughout the ROM
• 7. Gravity assisted postural drainage
• 8. Manual / device airway clearance modalities
• 9. Suctioning(--adapted from Dean &
Frownfelter 3rd study guide)
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“Caring for your Lungs”
Frequent position change– In bed, include prone, ¼ from prone, ¼ from supine
Stretch, twist, bend• Swallow correctly; avoid reflux• Aerobic exercise; lots of fluids; good diet• Avoid aerosols; avoid airway infections• No smoking; avoid / prevent air pollution• Avoid hard exhalation / cough spasms
– emphasize relaxed in-breaths
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Key Findings
Pattern A
• Prevention / Risk Reduction– Functional work capacity– Max. aerobic capacity– Dyspnea on exertion– Sedentary job / role– Client knowledge– Central vs. peripheral
impairments
Pattern H
• Lymphatic System Disorders– Perceived body image– Difficulty dressing– Edema– Skin integrity– Pain
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Key Findings – Pattern B
• Aerobic Capacity / Endurance – Deconditioning– Exercise / Activity Tolerance– Perceived Exertion– HR, BP, SpO2– RR, Breathing Pattern
• “Ventilation”—organ level – “Respiration”—tissue level
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Key Findings – Pattern C
• Airway clearance– Difficulty mobilizing secretions– Breath sounds
• Normal• Abnormal (rubs, absent, distant/diminished,artifact)• Adventitous (crackles/rales, rhonchi, wheeze)
– Airway protection• Swallow• Aspirations • Huff/cough quality
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Key Findings – Pattern D
• Cardiovascular Pump Dysfunction, or Failure of Increased O2 Demand (during activity)– HR, RR, SpO2, &/or resp. pattern changes– Change in baseline breath sounds– Flat / falling BP (“failure”)– Hypertensive (“dysfunction”)– METS (<4-5 = “failure”), (<5-6 = “dysfunction”)
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Key Findings – Pattern E
• Ventilatory Pump Function– Ventilatory muscles– Thoracic bony structures– Airway patency– Inspiratory force– FEV1 (forced exp vol in 1 sec) >80% pred.– VC (vital capacity) >70%
pred.– I:R ratio 1:2 (inspi : expi time)– RR (resp rate) & pattern 12-20
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Key Findings: Pattern F
• Respiratory Dysfunction / Gas exchange– ABGs
• PaO2 80-100% (or age predicted norm)• PaCO2 35-45% “ “• pH 7.35-7.45
– SaO2• WNL 95-100% on x% FiO2• Usually adequate >90% on x% FiO2• CO2 retainer: “adequate”=88% on x% FiO2;
“severe”=<85% on x% FiO2