Cardiopulmonary Physical Therapy. Haneul Lee, DSc, PT

Transcription

1 Cardiopulmonary Physical Therapy Haneul Lee, DSc, PT

2 Airway ClearanceTechniques Breathing Exercise SpecialConsiderations for MechanicallyVentilated Exercise Injury Prevention and Equipment provision Patient Education Discharge Planning

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

4 Acute cardiopulmonary conditions can be defined as disease or states in which the patient s oxygen transport system failsto meet theimmediate demands. The failure may result in significant periods of bed rest for the 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.

5 System Cardiovascular system Effects 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, 3 rd edition, Ellen Hillegass, Elsevier

6 Ischemic cardiovascular diseases Chronic obstructive pulmonary diseases Postoperative pulmonary complications Complications of hypertension Diabetes and obesity are perhaps the common conditions associated with acute cardiopulmonary dysfunction

7 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, prolongedbedrest, or a combination of both.

8 Manual or mechanical procedures that facilitate mobilization of secretions from the airways. Postural drainage Percussion Vibration Cough techniques Manual hyperinflation Airway suctioning

9 Physical Therapist can facilitate the mobilization of secretions by using one or more airway clearance techniques 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.

10 Should be performed before or at least 30 minutes following 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 while performing airway clearance techniques to avoid self-injury.

11 Goal Optimize airway patency Promote alveolar expansion and ventilation Increase gas exchange Indications Excessive pulmonary secretions Ineffective or absent cough Impaired mucociliary transport

12 Duration and frequency of the techniques are based on pulmonary 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.

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

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

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

16 Postural drainage may be used exclusively or in combination with other 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.

17 Precautions Pulmonary edema Hemoptysis Massive obesity Large pleural effusion Massive ascites Relative Contraindications 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, 3 rd edition, Ellen Hillegass, Elsevier

18 Chest percussion aimed at loosening retained secretions can be performed manually or with a mechanical device Essentials of Cardiopulmonary Physical Therapy, 3 rd edition, Ellen Hillegass, Elsevier

19 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, 3 rd edition, Ellen Hillegass, Elsevier

20 Percussion should be performed during inspiration and expiration. 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 be adjusted to promote patient comfort. Clapping on bony prominences should be avoided.

21 An airway clearance technique that can be performed 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, 3 rd edition, Ellen Hillegass, Elsevier

22 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 acutely ill patients with chest wall discomfort or pain.

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24 Precautions Uncontrolled bronchospasm Osteoporosis Rib fractures Metastatic cancer to ribs Tumor obstruction of airway Anxiety Coagulopathy Convulsive or seizure disorder Recent pacemaker placement Relative Contraindications 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

25 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 process 3. Patient inhales deeply 4. As the patient attempts to cough, the therapist's hand pushes inward and upward, assisting the rapid exhalation of air

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27 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.

28 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, 3 rd edition, Ellen Hillegass, Elsevier

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

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

31 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

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

33 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

34 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 breathingor diaphragmatic breathing.

35 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

36 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.

37 Indications Decreased intrathoracic lung volume Decreased chest wall lungcompliance Increased flow resistance from decreased lungvolume Precautions/Contraindications None Expected outcomes Increase chest wall mobility Expand collapsed alveoli via airflow through collateral ventilation channels Assist with secretion removal

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

39 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

40 To increase inhaled volume, sustain or improve alveolar inflation, 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

41 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

42 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

43 1. National Physical Therapy Examination, O sullivan&siegelman, TherapyEd 2. Essentials of Cardiopulmonary PhysicalTherapy, 3 rd edition, Ellen Hillegass, Elsevier 3. Cardiovascular and pulmonary PhysicalTherapy Evidence to Practice, 5 th edition, Donna Frownfelter, Elizabeth Dean, Elsevier 4. Cardiopulmonary PhysicalTherapy Management and Case Studies, 2 nd edition, W.Darlence Reid, Frank Chung, Kylie Hill,SLACK Inc. 5. Steele, Joel Dorman Hygienic Physiology (NewYork, NY: A. S. Barnes & Company, 1888) 6. PTEXAM the complete study guide, Scott M Giles, Scorebuilders 7. Khan academy,