Pulmonary PT Chapter

CHAPTER 4

PULMONARY PHYSICAL THERAPY Julie Ann Starr

I. Pulmonary Anatomy and Physiology A. Bony Thorax

1. Anterior border is the sternum: manubrium, body, xiphoid process. The lateral borders of the trachea run perpendicularly into the suprasternal notch. The Angle of Louis (sternal angle), the bony ridge between the manubrium and body, is point of anterior attachment of the 2nd rib and tracheal bifurcation.

2. Lateral border is the ribcage. Ribs 1-6, termed true or costosternal ribs, have a single anterior costochondral attachment to the sternum. Ribs 7-10, termed false or costochondral ribs, share costochondral attachments before attaching anteriorly to the sternum. Ribs 11 and 12 are termed floating or costovertebral ribs, as they have no anterior attachment.

3. Posterior border is the vertebral column, Tl through TI2.

4. Shoulder girdle can affect the motion of the thorax. Provides attachments for accessory muscles of ventilation.

B. Internal Structures I. Upper airways.

a. Nose or mouth: entry point into the respiratory system. The nose filters, humidifies and warms air.

b. Pharynx: common area used for both respiratory and digestive systems.

c. Larynx: connects the pharynx to trachea, including the epiglottis and vocal cords.

2. Lower airways. a. The conducting airways, trachea to terminal

bronchioles, transport air only. No gas exchange occurs.

b. The respiratory unit: respiratory bronchioles, alveolar ducts, alveolar sacs and alveoli. Diffusion of gas occurs through all of these structures.

3. Lung structures. a. Right lung divides into 3 lobes by the oblique

and horizontal fissure lines. Each lobe divides into segments, totaling 10 segments.

b. Left lung divides into 2 lobes by a single oblique fissure line. Each lobe divides into segments, totaling 8 segments.

4. Pleura. a. Parietal pleura covers the inner surface of the

thoracic cage, diaphragm and mediastinal border of the lung.

b. Visceral pleura wraps the outer surface of the lung including the fissure lines.

c. Intrapleural space is the potential space between the two pleura that maintains the approximation of the ribcage and lungs, allowing forces to be transmitted from one structure to another.

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c. Muscles of Ventilation 1. Primary muscles of inspiration produce a normal

resting tidal volume. a. Primary muscle of inspiration is the

diaphragm. The diaphragm is a made of two hemidiaphragms, each with a central tendon. When the diaphragm is at rest, the hemidiaphragms are arched high into the thorax. When the muscle contracts, the central tendon is pulled downward, flattening the dome. The result is a protrusion of the abdominal wall during inhalation.

b. Additional primary muscles of inspiration are portions of the intercostals.

2. Accessory muscles of inspiration are used when a more rapid or deeper inhalation is required or in disease states. The upper 2 ribs are raised by the scalenes and sternocleidomastoid. The rest of the ribs are raised by levator costarum and serratus. By fixing the shoulder girdle, the trapezius, pectorals, and serratus, can become muscles of inspiration.

3. Expiratory muscles of ventilation. a. Resting exhalation results from a passive relax

ation of the inspiratory muscles and the elastic recoil tendency of the lung. Normal abdominal tone holds the abdominal contents directly under the diaphragm, assisting the return of the diaphragm to the normal high domed position.

b. Expiratory muscles , used when a quicker and/or fuller expiration is desired, as in exercise or in disease states. These are quadratus lumborum, portions of the intercostals, muscles of the abdomen, and triangularis sterni.

4. Special populations: patients who lack functional abdominal musculature, e.g. patients with spinal cord injury. Due to the lack of abdmonial musculature, the resting position of the diaphragm is lower in the thorax decreasing inspiratory reserve. The more upright the body position, the lower the diaphragm and the lower the inspiratory capacity. The more supine, the more advantageous the position of the diaphragm. An abdominal binder may be helpful in providing support to the abdominal viscera thereby assisting ventilation. Care must be taken not to constrict the thorax with the abdominal binder.

D. Mechanics of Breathing 1. Forces acting upon the rib cage.

a. Elastic recoil of the lung parenchyma pulls the

lungs, and therefore, visceral pleura, parietal pleura, bony thorax into a position of exhalation (inward pull).

b. Bony thorax pulls the thorax, and therefore parietal pleura, visceral pleura and lungs into a position of inspiration (outward pull).

c. Muscular action pulls either outward or inward, depending of the muscles used.

d. Resting End Expiratory Pressure (REEP) is the point of equilibrium where these forces are balanced. Occurs at end tidal expiration.

E. Ventilation: refers to the movement of gas in and out of the pulmonary system 1. Volumes. (Figure 4-1).

a. Tidal volume (TV): volume of gas inhaled (exhaled) during a normal resting breath.

b. Inspiratory reserve volume (lRV): volume of gas that can be inhaled beyond a normal resting tidal inhalation.

c. Expiratory reserve volume (ERV): volume of gas that can be exhaled beyond a normal resting tidal exhalation.

d. Residual volume (RV): volume of gas that remains in the lungs after ERV has been exhaled.

2. Capacities: two or more lung volumes added together. a. Inspiratory capacity (IRV + TV): the amount of

air that can be inhaled from REEP.

r -- -ll~M .. m. "h""," --- --- -----1--·

~: __ .(-- -::j TLC

FRC ~r --------------~';aximal-exiicilatiOn

l RV ___ J _______________________________ _

Figure 4-1: Lung volumes and capacities. IRV = inspiratory reserve volume;TV = tidal volume; ERV = expiratory reserve volume; RV = residual volume; IC = inspiratory capacity; FRC = functional residual capacity. VC = vital capacity; TLC = total lung capacity. From. O'Sullivan S. Schmidt T: Physical Rehabilitation: Assessment and Treatment. 4th ed. F. A. Davis. 200 I. pg 447, with permission.

b. Vital Capacity (IRV + TV + ERV): the amount of air that is under volitional control, conventionally measured as a forced expiratory vital capacity (FVC).

c. Functional Residual Capacity (ERV + RV): the amount of air that resides in the lungs after a normal resting tidal exhalation.

d. Total lung capacity (IRV + TV + ERV + RV): the total amount of air that is housed within the thorax during a maximum inspiratory effort.

3. Flow Rates. a. Forced Expiratory Volume in one second

(FEV,): the amount of air exhaled during the first second of FVC. In the healthy, at least 75% of the FVC is exhaled within the fust second (FEV,IFVC x 100> 75%).

b. Forced expiratory flow rate (FEF 25% to 75%) is the slope of a line drawn between the points 25% and 75% of exhaled volume on a forced vital capacity exhalation curve. This flow rate is more specific to the smaller airways, and shows a more dramatic change · with disease than FEV! .

F. Respiration: the diffusion of gas across the alveolarcapillary membrane 1. Arterial oxygenation: the ability of arterial blood

to carry oxygen. a. Partial pressure of oxygen in the atmosphere

(Pa02) at sea level is 760 rrunHg (barometric pressure) x 21 %=159.6 mmHg.

b. The partial pressure of oxygen in the arterial blood, Pa02, depends on the integrity of the pulmonary system, the circulatory system and the Pa02. In health, Pa02 at room air is 95-100 mmHg. Hypoxemia: Pa02 less than 90. Hyperoxemia: Pa02 greater than 100.

c. Fraction of oxygen in the inspired air (Fi02) is the percentage of oxygen in air based on a total of 1.00. The Fi02 of room air, approximately 21 % oxygen, is written as .21. Supplemental oxygen increases the percentage (greater than 21 %) of oxygen in the patient's atmosphere. Supplemental oxygen is usually prescribed when the Pa02 falls below 55-60 mmHg.

2 . Alveolar ventilation: ability to remove carbon dioxide from the pulmonary circulation and maintain pH. a. pH indicates the concentration of free floating

hydrogen ions within the body. Normal range for pH is 7.36-7.44.

Pulmonary Physical Therapy 167

b. PaC02: the partial pressure of carbon dioxide within the arterial blood, in health, 36 to 44 rrunHg. Hypercapnea is a PaC02 greater than 44 rrunHg. Hypocapnea is a PaC02 below 36 rrunHg. Removal or retention of CO2 by the respiratory system alters the pH of the body with an inverse relationship. An increase in the PaC02 decreases the body's pH. A decrease in the PaC02 raises the body's pH.

c. HC03-: amount of bicarbonate ions within the arterial blood, normally 23-30meq/ml. Removal or retention of HC03 - alters the pH of the body with a direct relationship. An increase in bicarbonate ions increase the body's pH. A decrease in bicarbonate ions decreases the body's pH.

G. Ventilation (V E) and Perfusion (blood flow or Q). Optimal respiration occurs when ventilation and perfusion (blood flow to the lungs) are matched. Different ventilation and perfusion relationships exist: 1. Dead Space: anatomical (conducting airways) or

physiological (diseases such as pulmonary emboli) dead space is a space that is well ventilated but no respiration (gas exchange) occurs.

2. Shunt: no respiration occurs because of a ventilation abnormality. Complete atelectasis of a respiratory unit allows the blood to travel through the pulmonary capillary without gas diffusion occurring.

3. Effects of body position on ventilation perfusion relationship. Gravity affects the distribution of ventilation and perfusion. a. Upright position.

(1) Perfusion is gravity dependent, i.e. , more pulmonary blood is found at the base of the lung.

(2) Ventilation. At the static point of REEP, the apical alveoli are fuller than those at the base. During the dynamic phase of inspiration, more air will be delivered to the less filled alveoli at the bases, making the greater change in V E at the bases.

(3) Ventilation perfusion ratio (V/Q ratio): the ratio of pulmonary alveolar ventilation to pulmonary capillary perfusion. In the upright position, the apices are gravity independent, having the lowest blood flow or Q. Although there is a relatively low VE,

there is still more air than blood, resulting in a high V/Q ratio (dead space). The rnid-

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dle zone of the lung have a more evenly matched the amount of perfusion and ventilation. The bases are gravity dependent and therefore have the most Q. Although there is a relatively high VE, there is more blood than air, resulting in a (relatively) low V/Q ratio (shunt) .

b. Other body positions. Every body position creates these zones: gravity independent, middle, and gravity dependent. The gravity independent area of the lung, despite the position of the body, will act as dead space. The gravity dependent area of the lung will act as a shunt. Body positions can be used for a variety of treatment goals: draining secretions, increasing ventilation, or to optimize ventilation perfusion relationships.

H. Control of Ventilation. A complex system controls the cycle of ventilation 1. Receptors (baroreceptors, chemoreceptors, irritant

receptors, stretch receptors) within the body assist in adjusting the ventilatory cycle by sending information to the controller.

2. Central control centers (cortex, pons, medulla, and autonomic nervous system) evaluate the receptors' information and send a message out to the ventilatory muscles to alter the respiratory cycle in order to maintain adequate alveolar ventilation and arterial oxygenation.

3. Ventilatory muscles institute the changes deemed necessary by the central controllers.

II. Physical Therapy Examination A. Patient Interview: Information from the patient, the

patient's family, and the medical record 1. Chief complaint usually involves the loss of func

tion (decreased ability to perform activities of daily living [ADLs]) or discomfort (shortness of breath [dyspnea]).

2. Present illness. a. Initial onset (sudden vs insidious) and progres

sion of primary problem. b. Anything that worsens or improves condition:

positions, rest, medications. 3. Review the patient's history.

a. Occupational history. Past occupational exposures for diseases such as asbestosis, silicosis, and pneumoconiosis. Present occupational exposure to antigens within the workplace (hypersensitivity pneumonitis).

b. Past medical history that would alter physical exam or treatment plans, such as heart disease, long term steroid use.

c. Current medications that can mask (steroids) or alter (beta blockers, bronchodilators) vital signs.

d. Social habits. (1) Smoking in pack years (number of packs

per day x number of years smoked). (2) Alcohol consumption. (3) Street drugs.

e. Functional and exertional activity level during periods of wellness, as well as with present illness.

f. Cough and sputum production. Record any changes from baseline because of present illness.

g. Family history of pulmonary disease (e.g., cystic fibrosis).

B. Tests and Measures 1. Vital signs. See Table 4-1 for normal values.

a. Temperature: normal (afebrile) 98.6°F, (37°C). Core temperature increase indicates infection.

b. Heart rate (HR): normal 60 to 100 bpm; tachycardia: HR greater than 100 bpm; bradycardia: HR less than 60 bpm.

c. Respirations. (1) Rate: in health is 12-20 breaths per minute.

Tachypnea is a rate greater than 20 br/min. Apnea means no respirations.

(2) Rhythm: regular or irregular. (3) Amplitude: shallow, deep.

d. Blood pressure. 2. Observation.

a. Peripheral edema seen in gravity dependent areas and jugular venous distension indicates possible heart failure. Right ventricular hypertrophy and dilation (cor pulmonale) are common sequelae to chronic lung disease.

b. Body positions. Stabilizing the shoulder girdle places the thorax in the inspiratory position and

TABLE 4-1 - NORMAL VALUES FOR INFANTS AND ADULTS

PARAMETER INFANT ADULT

Heart Rate 120 bpm 60-100 bpm

Blood Pressure 75/50 mmHg <120/80 mmHg

Respiratory Rate 40 br/min 12-20 br/min

Pa02 75-80 mmHg 80-100 mmHg

PaC02 34-54 mmHg 35-45 mmHg

pH 7.26-7.41 7.35-7.45

Tidal Volume 20 ml 500 ml

allows the additional recruitment of muscles for inspiration (pectorals).

c. Color: cyanosis, an acute sign of hypoxemia, is a bluish tinge to nail beds and the areas around eyes and mouth.

d. Digital clubbing: a sign of chronic hypoxemia. The configuration of the distal phalanx of fingers or toes becomes bulbous.

3. Inspection and palpation: standard precautions should be used any time the therapist may come in contact with a patient's body fluids. Refer to Table 6-1. Gloves are usually all that is needed during a routine physical exam. a. Neck.

(1) Observe the trachea: it should be in midline, superior to the suprasternal notch.

(2) Note the use of accessory muscles of ventilation.

b. Thorax. (1 ) Changes in bony thorax (pectus excavatum,

carinatum). (2) Observe anterior-posterior:lateral dimen

sion. In health, there is a 1:2 ratio. With obstructive pulmonary disease, the lung recoil force is decreased, resulting in a barreled chest and an increase in the A-P dimension.

(3) The right and left thorax should be symmetrical. (a) Symmetry, static and or dynamic, may

be altered by changes in the bony thorax (scoliosis, scapular immobility,


pain), changes in the underlying lung and pleura (a patient with pleuritic pain or pneumothorax), or changes in the overlying skin (thoracic burn).

(b) Thoracic excursion in health, measured at the base of the lungs from full inspiration to full expiration, is between 2 and 3 inches.

(c) Inspect for scars, indicating potential adhesions to underlying soft tissue or surgical removal of structures within the thorax.

4. Auscultation. a. Intensity of inspiration and expiration will be

quieter at the bases than the apex. (1) Vesicular (normal breath sound): a soft

rustling sound heard throughout all of inspiration and the beginning of expiration.

(2) Bronchial: a more hollow, echoing sound normally found only over the right superior anterior thorax. This corresponds to an area over the right main stem bronchus. All of inspiration and most of expiration are heard with bronchial breath sounds.

(3) Decreased: a very distant sound not normally heard over a healthy thorax; allows only some of inspiration to be heard. Often associated with obstructive lung diseases.

b. Adventitious (extra) sounds. According to the American Thoracic Society, there are only two adventitious breath sounds (1) Crackles (also termed rales, crepitations): a

TABLE 4-2 - INTERPRETATION OF ABNORMAL ACID-BASE BALANCE

TYPE pH PaCO,

Respiratory alkalosis t

Respiratory acidosis t

Metabolic alkalosis t WNL

Metabolic acidosis ,l. WNL

HCO,- CAUSES

WNL Alveolar hyperventilation

WNL Alveolar hypoventilation

t Bicarbonate ingestion, vomiting,

diuretics, steroids, adrenal disease

,l. Diabetic, lactic, or uremic acidosis,

prolonged diarrhea

SIGNS AND SYMPTOMS

Dizziness, syncope, tingling,

numbness, early tetany

Early: anxiety, restlessness,

dyspnea, headache

Late: confusion, somnolence,

coma

Vague symptoms: weakness, mental

dullness, possibly early tetany

Secondary hyperventilation

(Kussmaul breathing), nausea,

lethargy, and coma

From, The four basic conditions of acid-base balance. Rothstein J, Roy S, and Wolf S: The Rehabilitation Specialist's Handbook, 2nd ed FA Davis, Philadelphia, 1998, pg 529, with permission.

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crackling sound heard usually during inspiration that indicates pathology (atelectasis, fibrosis, pulmonary edema).

(2) Wheezes: a musical pitched sound, usually heard during expiration caused by airway obstruction (asthma, COPD, foreign body aspiration). With severe airway constriction, as with croup, wheezes maybe heard on inspiration as well.

c. Vocal sounds. (1) Normal transmission of vocal sounds.

(a) As with breath sounds, vocal transmission is loudest near trachea and mainstem bronchi.

(b) Words should be intelligible, though softer and less clear at the more distal areas of the lungs.

(2) Abnormal transmission of vocal sounds may be heard through fluid filled areas of consolidation, cavitation lesions or pleural effusions. (a) Egophony is a nasal or bleeting sound

heard during auscultation. "E" sounds are transmitted to sound like "A".

Restrictive Normal Obstructive

k IRV III l]l l ~ ve Ie IRV Ie IRV

~ ! JJf N J~~ N J~ L RV ERV ERV

FRC

ERV = Expiratory reserve volume FRC = Functional residual capacity IC = Inspiratory capacity IRV = Inspiratory reserve volume

RV = Residual volume TLC = Total lung capacity TV = lidal volume

Figure 4-2: Lung volumes of a healthy pulmonary system compared with the lung volumes and capacities found in restrictive and obstructive pulmonary disease. From Rothstein J, Roy S, and Wolf S: The Rehabilitation Specialist's Handbook, 2nd ed F.A. Davis, Philadelphia, 1998, pg 509, with permission.

TABLE 4-3 - CLASSES OF RESPIRATORY IMPAIRMENT

CLASS I CLASS 2 CLASS 3 CLASS 4 0% IMPAIRMENT 20·30% IMPAIRMENT 40·50% IMPAIRMENT 60-90% IMPAIRMENT

Roentgenographic Usually nonmal but there May be nonmal or abnonmal May be nonmal but usually Usually is abnonmal appearance may be evidence of healed is not

or inactive chest disease including, for example, minimal nodular silicosis or pleura scars

Dyspnea When it occurs, it is Does not occur at rest and Does not occur at rest but Occurs during such activities consistent with the seldom occurs during the does occur during the usual as climbing one flight of stairs cln::.l.Lr)')$J®c.ll_S_ oJ aJ;JiYitY, q.esfosmanc.ll_ of the_ usual activities of daily' Iivinq, or walkinq. 1 00 y'ards on level

activities of daily living. However, the patient can ground, on less exertion, or The patient can keep walk a mile at his own pace even at rest pace with persons of without dyspnea although same age and body build he cannot keep pace on on level ground without level ground with others of breathlessness but not the same age and body build on hills or stairs

Tests of ventilatory function

FEV 1, FCV, MMV Not less than 85% of 70-85% of predicted 55-70% of predicted Less than 55% of predicted predicted

Arterial oxygen Not applicable Not applicable Usually 88%* or greater Usually less than 88% at saturation at rest and after exercise rest and after exercise

*88% saturation corresponds to an arterial Po. of 58mmHg, assuming the arterial pH is in the normal range.

From Guides to the Evaluator of Permanent Impairment;The Respiratory System,JAMA, 1965, 194: 919, with permission.

(b) Bronchophony characterized by an intense, clear sound during auscultation, even at the lung bases.

(c) Whispered pectoriloquy occurs when whispered sounds are heard clearly during auscultation.

5. Radiographic examination. a. Chest X-rays (CXR): a two dimensional radi

ographic film to detect the presence of abnormal material (exudate, blood) or a change in pulmonary parenchyma (fibrosis, collapse).

b. Computerized axial tomography (CAT scan): a computer generated picture of a cross sectional plane of the body.

c. Ventilation perfusion (V IQ) scan: matches the ventilation pattern of the lung to the perfusion pattern to identify the presence of pulmonary emboli.

d. Fluoroscopy: continuous X-ray beam allows observation of diaphragmatic excursion.

6. Laboratory tests: See Table 4-1 for normal values. a. Arterial blood gas (ABG) analysis indicates the

adequacy of: (1) Alveolar ventilation by determining pH,

bicarbonate ion and partial pressure of carbon dioxide. Table 4-2 presents the four basic conditions of acid-base balance and the PaC02, pH and HC03 - values that accompany each condition.

(2) Arterial oxygenation by determining the

TABLE 4-4 - GRADED EXERCISE TEST TERMINATION CRITERIA

1. Maximal shortness of breath.

2. A fall in PaO, of greater than 20 mmHg or a PaO, less than 55 mmHg.

3. A rise in PaCO, of greater than 10 mmHg or greater than 65 mmHg.

4. Cardiac ischemia or arrhythmias.

5. Symptoms of fatigue.

6. Increase in diastolic blood pressure readings of 20 mmHg, systolic hypertension greater than 250 mmHg, decrease in blood pressure with increasing workloads.

7. Leg pain.

8. Total fatigue.

9. Signs of insufficient cardiac output.

10. Reaching a ventilatory maximum.

From Brannon, F, et al: Cardiopulmonary Rehabilitation: Basic Theory and Application, 3rd ed FA Davis, 1998, p 300, with permission.


partial pressure of oxygen in relation to the fraction of inspired oxygen.

b. Electrocardiogram: see Chapter on Cardiovascular Physical Therapy for discussion.

c. Sputum studies. (1) Gram stain: immediate identification of the

category of bacteria (Gram negative or Gram positive) and its appearance (pairs, chains, etc.).

(2) Culture and sensitivity: identifies the specific bacteria as well as the organism's susceptibility to various antibiotics. Results available within a few days.

(3) Cytology: reports the presence of cancer cells in sputum.

d. Pulmonary function tests (PFTs): evaluate lung volumes, capacities, and flow rates. Used to diagnose disease, monitor progression, and determine the benefits of medical management. Refer to Figure 4-2 for changes with disease states. Refer to Table 4-3 for classification of respiratory impairments including PFT predicted values.

e. Blood values. (I) White blood cell count (WBC) normal val

ues: 4,000 to 11,000. (2) Hematocrit (Hct) normal values: 35 to 48. (3) Hemoglobin (Hgb) normal values: 12.0 to

16.0. 7. Bronchoscopy: endoscope used to view, biopsy,

wash, suction and/or brush the interior aspects of the tracheobronchial tree.

8. Exercise tolerance tests (ETT) (Graded Exercise Test). See also chapter on Cardiovascular Physical Therapy. a. Evaluates an individual's cardiopulmonary

response to gradually increasing exercise. b. Determines the presence of exercise induced

bronchospasm by testing pulmonary function, particularly FEV 1 before and after ETT.

c. Documents the need for supplemental oxygen during an exercise program by analyzing arterial blood gas values throughout the ETT. ABGs also provide a criterion for test termination. If arterial blood sampling is unavailable, pulse oximetry can be used to monitor the percent saturation of oxygen within the arterial blood. Table 4-4 presents criteria for test termination for patients with pulmonary disease.

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ID. Physical DysfunctionJImpairments A. Acute Diseases

1. Bacterial Pneumonia. a. Description: An intra-alveolar bacterial infec

tion. Gram positive bacteria is usually acquired in the community. Pneumococcal pneumonia (streptococcal) is the most common type of gram positive pneumonia. Gram negative bacteria usually develops in a host who has underlying chronic debilitating conditions, severe acute illness, and recent antibiotic therapy. Gram negative infections result in early tissue necrosis and abscess formation. Common infecting organisms: Klebsiella, Haemophilus Influenza, Pseudomonas Aeruginosa, Proteus, Serratia.

b. Pertinent physical findings. (1) Shaking chills. (2) Fever. (3) Chest pain if pleuritic involvement. (4) Cough becoming productive of purulent,

blood streaked, or rusty sputum. (5) Decreased or bronchial breath sounds

and/or crackles. (6) Tachypnea. (7) Increased white blood cell count. (8) Hypoxemia, hypocapnea initially, hyper

capnea with increasing severity. (9) CXR confirmation of infiltrate.

2. Viral Pneumonia. a. Description: An interstitial or intra-alveolar

inflammatory process caused by viral agents (influenza, adenovirus, cytomegalovirus, herpes, parainfluenza, respiratory syncytial virus, measles).

b. Pertinent physical findings. (1) Recent history of upper respiratory infection. (2) Fever. (3) Chills. (4) Dry cough. (5) Headaches. (6) Decreased breath sounds and/or crackles. (7) Hypoxemia and hypercapnea. (8) Normal white blood cell count. (9) CXR confirmation of interstitial infiltrate.

3. Aspiration Pneumonia. a. Description: aspirated material causes an acute

inflammatory reaction within the lungs. Usually found in patients with impaired swallowing (dysphagia), fixed neck extension,

intoxication, impaired consciousness, neuromuscular disease, recent anesthesia.

b. Pertinent physical findings. (1) Symptoms begin shortly after aspiration

event (hours). (2) Cough may be dry at the onset, progress to

producing putrid secretions. (3) Dyspnea. (4) Tachypnea. (5) Cyanosis. (6) Tachycardia. (7) Wheezes and crackles with decreased

breath sounds. (8) Hypoxemia, hypercapnea in severe cases. (9) Chest pain over the involved area. (lO)Fever. (ll)WBC count shows varying degrees of

leukocytosis. (12)CXR initially shows pneumonitis. Chronic

aspiration shows necrotizing pneumonia with cavitation.

4. Tuberculosis (TB). a. Description: Mycobacterium tuberculosis

infection spread by aerosolized droplets from an untreated infected host. Incubation period: 2 to 10 weeks. Primary disease lasts approximately 10 days to 2 weeks. Post-primary infection is reactivation of dormant tuberculous bacillus which can occur years after the primary infection. Two weeks on appropriate anti tuberculin drugs renders the host non-infectious. During the infectious stage, the patient must be isolated from others in a negative pressure room. Anyone entering the room must wear a protective TB mask and follow universal precautions. If the patient leaves the negative pressure room, then the patient must wear the specialized mask to keep from infecting others. Medication is taken for prolonged periods, 3-12 months. There is an increased incidence of TB in the patient population infected by HIV.

b. Pertinent physical findings of primary disease can be unnoticed as it causes only mild symptoms: slight non-productive cough, low grade fever, and possible CXR changes consistent with primary disease.

c. Pertinent physical findings of post primary infection are characterized by: (1) Fever. (2) Weight loss.

(3) Cough. (4) Hilar adenopathy: enlargement of the

lymph nodes surrounding the hilum. (5) Night sweat. (6) Crackles. (7) Hemoptysis: blood streaked sputum. (8) WBC shows increased lymphocytes. (9) CXR shows upper lobe involvement with

air-space densities, cavitation, pleural involvement, and parenchymal fibrosis.

5. Pneumocystis Carinii pneumonia. a. Description: pulmonary infection caused by a

protozoan in immunocompromised hosts. Most often found in patients following transplantation, neonates, or patients infected with HIV.

b. Pertinent physical findings. (1) Insidious progressive shortness of breath. (2) Non productive cough. (3) Crackles. (4) Weakness. (5) Fever. (6) Chest X-ray shows interstitial infiltrates. (7) Complete blood count (CBC) shows no

evidence of infection. 6. SARS- Severe Acute Respiratory Syndrome.

a. Definition: An atypical respiratory illness caused by a coronovirus. Initial outbreak in southern Mainland China with world-wide spread to other areas such as Singapore, Toronto, Vietnam, and Hong Kong.

b. Pertinent physical findings. (1) High temperature. (2) Dry cough. (3) Decreased white blood cells, decreased

platelets, decreased lymphocytes. (4) Increased liver function tests. (5) Abnormal CXR with borderline breath

sounds changes. 7. Refer to Table 6-2, Transmission-Based Precautions.

B. Chronic Obstructive Diseases 1. Chronic obstructive pulmonary disease (COPD).

a. Description: according to the Global Initiative for Obstructive Lung Disease (GOLD): COPD is a disease state characterized by airflow limitation that is not fully reversible. The airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases.

b. Stages. (1) Stage 0 (at risk).


(a) Normal spirometry. (b) Chronic symptoms (cough, sputum

production). (2) Stage 1 (mild).

(a) FEV /FVC < 70%. (b) FEV,> = 80% predicted. (c) With or without chronic symptoms.

(3) Stage 2 (moderate). (a) FEV\IFVC < 70%. (b) 50% <FEV,< 80% predicted. (c) With or without chronic symptoms.

(4) Stage 3 (severe). (a) FEV \IFVC < 70%. (b) 30% <FEV\< 50%. (c) With or without chronic symptoms.

(5) Stage 4 (very severe). (a) FEV,IFVC < 70%. (b) FEV, < 30% predicted. (c) FEV \ < 50% with chronic respiratory

failure symptoms. (d) Pa02<60. (e) PaC02 > 50. (f) Cor pulmonale. (g) Increased jugular venous distention.

c. Physical findings: findings increase in severity as the stage of disease advances. (1) Cough/sputum production! hemoptysis. (2) Dyspnea on exertion. (3) Breath sounds decreased with adventitious

sounds. (4) Increased RR. (5) Weight loss/anorexia. (6) Increased A-P diameter of chest wall. (7) Cyanosis. (8) Clubbing. (9) Postures to structurally elevate shoulder

girdle. (lO)CXR showing hyperinflation, flattened

diaphragms, hyperlucency. (11)ABG changes of hypoxemia, hypercapnea. (12)PFTs showing obstructive disease, such as

decreased FEV " decreased FVC, increased FRC and RV and decreased FEV,IFVC ratio.

2. Asthma. a. Description: increased reactivity of the trachea

and bronchi to various stimuli (allergens, exercise, cold) and manifests by widespread narrowing of the airways due to inflammation, smooth muscle constriction and increased

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secretions, that is reversible in nature. Even during remission, some degree of airway inflammation is present.

b. Pertinent physical findings during exacerbation. (1) Wheezing, possible crackles, and decreased

breath sounds. (2) Increased secretions of variable amounts. (3) Dyspnea. (4) Increased accessory muscle use. (5) Anxiety. (6) Tachycardia. (7) Tachypnea. (8) Hypoxemia. (9) Hypocapnea. Responding to hypoxemia,

there is an increased respiratory rate and minute ventilation. This will decrease PaC02. With severe airway constriction, an increase in minute ventilation cannot occur and hypercapnea can be found.

(lO)Cyanosis. ( ll)PFrs show impaired flow rates. (12)CXR shows hyperlucency and flattened

diaphragms during exaccerbation. 3. Cystic fibrosis (CF).

a. Description: a genetically inherited disease characterized by thickening of secretions of all exocrine glands, leading to obstruction (pancreatic, pulmonic, gastrointestinal, etc.). CF may present as an obstructive, restrictive, or mixed disease. Clinical signs of CF include: meconium ileus, frequent respiratory infections, especially Staph Aureus and Pseudomonas Aeruginosa, inability to gain weight despite adequate caloric intake. Diagnosis is made by a positive sweat electrolyte test.

b. Pertinent physical findings with exacerbation of disease. (1) Onset of symptoms usually in early child-

hood. (2) Dyspnea, especially on exertion. (3) Productive cough. (4) Hypoxemia, hypercapnea. (5) Cyanosis. (6) Clubbing. (7) Use of accessory muscles of ventilation. (8) Tachypnea. (9) Crackles, wheezes, and/or decreased breath

sounds. (lO)Abnormal PFrs showing an obstructive

pattern, restrictive pattern or both.

(ll)CXR shows increased markings, findings of bronchiectasis, and/or pneumonitis.

4. Bronchiectasis. a. Description: a chronic congenital or acquired

disease characterized by dilatation of the bronchi and excessive sputum production.

b. Pertinent physical findings. (1) Cough and expectoration of large amounts

of mucopurulent secretions. (2) Frequent secondary infections. (3) Hemoptysis. (4) Crackles, decreased breath sounds. (5) Cyanosis. (6) Clubbing. (7) Hypoxemia. (8) Dyspnea. (9) CXR which shows increased bronchial

markings with interstitial changes. Bronchograms can outline bronchial dilatation but are rarely needed.

5. Hyaline membrane disease (also Respiratory Distress Syndrome or RDS). a. Description: alveolar collapse in a premature

infant resulting from lung immaturity, inadequate level of pulmonary surfactant.

b. Pertinent physical findings within a few hours of birth. (1) Respiratory distress. (2) Crackles. (3) Tachypnea. (4) Hypoxemia. (5) Cyanosis. (6) Accessory muscle use. (7) Expiratory grunting, flaring nares. (8) CXR shows a classic granular pattern

("ground glass") caused by distended terminal airways and alveolar collapse.

c. Physical therapy considerations: The increased work of breathing that handling a premature infant might cause must be carefully weighed against any possible benefit that physical therapy might have.

6. Bronchopulmonary dysplasia. a. Description: an obstructive pulmonary disease,

often a sequela of premature infants with respiratory distress syndrome; results from high pressures of mechanical ventilation, high fractions of inspired oxygen (Fi02) and/or infection. The lungs show areas of pulmonary immaturity and dysfunction due to hyperinflation.

b. Pertinent physical findings. (1) Hypoxemia, hypercapnea. (2) Crackles, wheezing, and/or decreased

breath sounds. (3) Increased bronchial secretions. (4) Hyperinflation. (5) Frequent lower respiratory infections. (6) Delayed growth and development. (7) Cor pulmonale. (8) CXR shows hyperinflation, low diaphragms,

atelectasis, andlor cystic changes. C. Chronic Restrictive Diseases: different etiologies

typified by difficulty expanding the lungs causing a reduction in lung volumes 1. Restrictive disease due to alterations in lung

parenchyma and pleura. a. Description: fibrotic changes within the pul

monary parenchyma or pleura, as a result of idiopathic pulmonary fibrosis, asbestosis, radiation pneumonitis, oxygen toxicity.

b. Pertinent physical findings. (1) Dyspnea. (2) Hypoxemia, hypocapnea (hypercapnea

appears with severity). (3) Crackles. (4) Clubbing. (5) Cyanosis. (6) PFfs reveal a reduction in vital capacity,

functional residual capacity, and total lung capacity.

(7) CXR show reduced lung volumes, diffuse interstitial infiltrates, andlor pleural thickening.

2. Restrictive disease due to alterations in the chest wall. a. Description: restricted motion of bony thorax,

with diseases such as ankylosing spondylitis, arthritis, scoliosis, pectus excavatum, arthrogryposis or the integumentary changes of the chest wall such as thoracic burns or scleroderma.

b. Pertinent physical findings. (1) Shallow, rapid breathing. (2) Dyspnea. (3) Hypoxemia, hypocapnea (hypercapnea

with increasing severity). (4) Cyanosis. (5) Clubbing. (6) Crackles. (7) Reduced cough effectiveness. (8) PFfs show reduced vital capacity, func-


tional residual capacity, and total lung capacity.

(9) CXR show reduced lung volumes, atelectasis 3. Restrictive disease due to alterations in the neuro

muscular apparatus. a. Description: decreased muscular strength

results in an inability to expand the rib cage, with mUltiple sclerosis, muscular dystrophy, Parkinson's disease, spinal cord injury, or CVA.

b. Pertinent physical findings. (1) Dyspnea. (2) Hypoxemia, hypocapnea (hypercapnea

with increasing severity). (3) Decreased breath sounds, crackles. (4) Clubbing. (5) Cyanosis. (6) Reduced cough effectiveness. (7) PFfs show reduced vital capacity, and total

lung capacity. (8) CXR show reduced lung volumes, atelectasis.

D. Bronchogenic Carcinoma: refers to a tumor which arises from the bronchial mucosa 1. Characteristics: smoking and occupational expo

sures are the most frequent causal agents. a. Cell types are: Small cell carcinoma (oat cell)

and non-small cell carcinoma (squamous cell, adenocarcinoma, and large cell undifferentiated).

b. Secondary changes due to the tumor include obstruction or compression of an airway, blood vessel, or nerve.

c. Local metastases are found in the pleura, chest wall, mediastinal structures. Common distant metastases are found in lymph nodes, liver, bone, brain, and adrenals.

2. Pertinent physical findings with pulmonary involvement. a. Unexplained weight loss. b. Hemoptysis. c. Dyspnea. d. Weakness. e. Fatigue. f. Wheezing. g. Pneumonia with productive cough due to air

way compression. h. Hoarseness with compression of the laryngeal

nerve. I. Atelectasis or bacterial pneumonia with non

productive cough due to airway obstruction. 3. Management of bronchogenic cancer.

a. Chemotherapy.

176

b. Radiation therapy. c. Surgical resection if possible.

4. Physical therapy considerations. a. Pneumonias that develop behind a completely

obstructed bronchus cannot be cleared with physical therapy techniques. Hold treatment until palliative therapy reduces the tumor size and relieves the bronchial obstruction.

b. Possible fractures from thoracic bone metastasis with chest compressive maneuvers and coughing.

c. Ecchymosis (bruising) in patients with low platelet count.

d. Fatigue which restricts other necessary activities. E. Trauma

1. Rib fracture, flail chest. a. Description: fracture of the ribs usually due to

blunt trauma. Flail chest is two or more fractures in two or more adjacent ribs.

b. Pertinent physical findings. (1) Shallow breathing. (2) Splinting due to pain (especially with deep

inspiration or cough). (3) Crepitation may be felt during the ventila

tory cycle over fracture site. (4) Paradoxical movement of the flail section

during the ventilatory cycle (inspiration, the flail section is pulled inward; exhalation, the flail moves outward).

(5) Confirmation by chest x-ray. 2. Pleural Injury.

a. Pneumothorax. (1) Description: air in the pleural space, usual

ly through a lacerated visceral pleura from a rib fracture or ruptured bullae.

(2) Pertinent physical findings all increase with the severity of injury. (a) Chest pain. (b) Dyspnea. (c) Tracheal and mediastinal shift away

from injured side. (d) Absent or decreased breath sounds. (e) Increased tympany with mediate per-

cussion (f) Cyanosis. (g) Respiratory distress. (h) Confirmation by CXR.

b. Hemothorax. (1) Description: blood in the pleural space usu

ally from a laceration of the parietal pleura.

(2) Pertinent physical findings: all increase with the severity of injury. (a) Chest pain. (b) Dyspnea. (c) Tracheal and mediastinal shift away

from side of injury. (d) Absent or decreased breath sounds. (e) Cyanosis. (f) Respiratory distress. (g) Confirmation by CXR. (h) May have signs of blood loss.

3. Lung contusion. a. Description: Blood and edema within the alve

oli and interstitial space due to blunt chest trauma with or without rib fractures.

b. Pertinent physical findings: all increase with the severity of injury. (1) Cough with hemoptysis. (2) Dyspnea. (3) Decreased breath sounds and/or crackles. (4) Cyanosis. (5) Confirmation by CXR of ill defined patchy

densities. F. Miscellaneous

1. Pulmonary Edema. a. Description: excessive seepage of fluid from

the pulmonary vascular system into the interstitial space; may eventually cause alveolar edema. (1) Cardiogenic: results from increased pres

sure in the pulmonary capillaries associated with left ventricular failure, aortic valvular disease, or mitral valvular disease.

(2) Non-cardiogenic: results from an increased permeability of the alveolar capillary membranes due to inhalation of toxic fumes, hypervolemia, narcotic overdose, or adult respiratory distress syndrome (ARDS).

b. Pertinent physical findings. (1) Crackles. (2) Tachypnea. (3) Dyspnea. (4) Hypoxemia. (5) Peripheral edema if cardiogenic. (6) Cough with pink, frothy secretions. (7) CXR shows increased vascular markings,

hazy opacities in gravity dependent areas of the lung showing a typical butterfly pattern. Atelectasis is possible if the surfactant lining is removed by alveolar edema.

UPPER LOBES Apical Segments

Bed or drainage table flat.

Patient leans back on pillow at 30' angle against therapist.

Therapist claps with markedly cupped hand over area between clavicle and top of scapula on each side.

RIGHT MIDDLE LOBE

Foot of table or bed elevated 16 inches.

Patient lies head down on left side and rotates 1/4 tum backward. Pillow may be placed behind from shoulder to hip. Knees should be flexed.

Therapist claps over right nipple area. In females with breast development or tendemess, use cupped hand with heel of hand under armp~ and fingers extending forward beneath the breast.

LOWER LOBES Lateral Basal Segments


Patient lies on abdomen, head down, then rotates ~ tum upward. Upper leg is flexed over a pillow for support.

Therapist claps over uppermost portion of lower ribs. (Position shown is for drainage of right lateral basal segment. To drain the left lateral basal segment, patient should lie on his right side in the same posture).

UPPER LOBES Posterior Segments


Patient leans over folded pillow at 30' angle.

Therapist stands behind and claps over upper back on both sides.

LEFT UPPER LOBE Lingular Segments


Patient lies head down on right side and rotates 1/4 tum backward. Pillow may be placed behind from shoulder to hip. Knees should be flexed.

Therapist claps with moderately cupped hand over left nipple area. In females w~ breast development or tenderness, use cupped hand with heel of hand under armprt and fingers extending forward beneath the breast.

LOWER LOBES Posterior Basal

Segments


Patient lies on abdomen, head down, wrth pillow under hips. Therapist claps over lower ribs close to spine on each side.

PuJmonary Physical Therapy 177

UPPER LOBES Anterior Segments


Patient lies on back with pillow under knees.

Therapist claps between clavicle and nipple on each side.

LOWER LOBE Anterior Basal Segments


Patient lies on side, head down, pillow under knees.

Therapist claps w~h slighHy cupped hand over lower ribs. (Pos~ion shown is for drainage of left anterior basal segment. To drain the right anterior basal segment, patient should lie on his left side in same posture).

LOWER LOBES Superior Segments

Bed or table flat.

Patient lies on abdomen with two pillows under hips.

Therapist claps over middle of back at tip of scapula on either side of spine.

Figure 4-3: Positions used for postural drainage. From Rothstein J, Roy S, and Wolf S:The Rehabilitation Specialist's Handbook. 2nd ed FA Davis, Philadelphia, 1998. pg 534-535. with permission.

178

2. Pulmonary Emboli. a. Description: a thrombus from the peripheral

venous circulation becomes embolic and lodges in the pulmonary circulation. Small emboli do not necessarily cause infarction.

b. Pertinent physical findings without infarction. (1) History consistent with pulmonary emboli:

deep vein thrombosis, oral contraceptives, recent abdominal or hip surgery, polycythemia, prolonged bed rest.

(2) Sudden onset of dyspnea. (3) Tachycardia. (4) Hypoxemia. (5) Cyanosis. (6) Auscultatory findings may be normal or

show crackles and decreased breath sounds.

(7) Ventilation-perfusion scan showing perfusion defects with concomitant normal ventilation.

c. Added pertinent physical findings consistent with pulmonary infarction. (1) Chest pain. (2) Hemoptysis. (3) CXR shows decreased vascular markings,

high diaphragm, pulmonary infiltrate, and/or pleural effusion.

3. Pleural Effusion. a. Description: excessive fluid between the vis

ceral and parietal pleura. The main causes of pleural effusion are increased pleural permeability to proteins from inflammatory diseases (pneumonia, rheumatoid arthritis, systemic lupus), neoplastic disease, increased hydrostatic pressure within pleural space (CHF), decrease in osmotic pressure (hypoproteine-

TABLE 4-5 . CONSIDERATIONS PRIOR TOTHE USE OF POSTURAL DRAINAGE

Precautions to the use of Trendelenburg position (Head of bed tipped down 15 to 18 degrees)

Circulatory system Pulmonary edema, congestive heart failure, hypertension.

Abdominal problems Obesity, ascnes, pregnancy, hiatal hernia, nausea and vomiting, recent food consumption.

Neurologic system

Pulmonary system

Recent neurosurgery, increased intracranial pressure, aneurysm precautions.

Shortness of breath.

Precautions to the use of side lying position

Circulatory system Axillo-femoral bypass graft

Musculoskeletal system Humeral fractures, need for hip abduction brace, other snuaijons that make sidelying uncomfortable, e.g., arthritis, shoulder bursitis.

mia), peritoneal fluid within the pleural space (ascites, cirrhosis) or interference of pleural reabsorption from tumor invading pleural lymphatics.

b. Pertinent physical findings . (1) Decreased breath sounds over effusion;

bronchial breath sounds may be present around the perimeter of the effusion . Pleural friction rub may be possible with inflammatory process.

(2) Mediastinal shift away from large effusion. (3) Breathlessness with large effusions. (4) CXR shows fluid in the pleural space in

gravity dependent areas of the thorax if greater than 300ml.

(5) Pain and fever only if the pleural fluid is infected (empyema).

4. Atelectasis. a. Description: collapsed or airless alveolar unit,

caused by hypoventilation secondary to pain during the ventilatory cycle (pleuritis, postoperative pain, or rib fracture), internal bronchial obstruction (aspiration, mucus plugging), external bronchial compression (tumor or enlarged lymph nodes), low tidal volumes (narcotic overdose, inappropriately low ventilator settings) or neurologic insult.

b. Pertinent physical findings. (1) Decreased breath sounds. (2) Dyspnea. (3) Tachycardia. (4) Increased temperature. (5) CXR with platelike streaks.

IV. Physical Therapy Intervention Refer to Table 3-4 for Preferred Cardiopulmonary Practice Patterns.

A. Manual Secretion Removal Techniques 1. Postural drainage: placing the patient in varying

positions for optimal gravity drainage of secre-

TABLE 4-6 • CONSIDERATIONS PRIOR TOTHE USE OF PERCUSSION AND SHAKING

General guidelines

Circulatory system

Pain made worse by the technique.

Aneurysm precautions, hemoptysis.

Coagulation disorders Increased partial thromboplastin time (PTT), increased prothrombin time (Pl), decreased platelet count (below 50,000), or medications that interfere with coagulation.

Musculoskeletal system Fractured rib, flail chest, degenerative bone disease, bone metastases.

tions and increased expansion of the involved segment. (Figure 4-3). a. Indications for the use of postural drainage.

(1) Increased pulmonary secretions. (2) Aspiration. (3) Atelectasis or collapse.

b. Considerations prior to the use of the postural drainage positions, (Table 4-5). These considerations are not intended to imply absolute danger with their use, but rather a possible need for position modification.

c. Procedure. (1) Explain procedure to the patient. (2) Place patient in the appropriate postural

drainage position. (3) Observe for signs of intolerance. (4) Duration of procedure can be up to 20 min

utes per postural drainage position. Typically, the duration equals the duration of the other manual techniques which are being used in conjunction with postural drainage.

2. Percussion: a force rhythmically applied with the therapist's cupped hands to the specific area of the chest wall that corresponds to the involved lung segment. Percussion is used to increase the amount of secretions cleared from the tracheobronchial tree. It is usually used in conjunction with postural drainage. a. Indications for the use of percussion.

(1) Excessive pulmonary secretions. (2) Aspiration. (3) Atelectasis or collapse due to mucous plug

ging obstructing the airways. b. Considerations to weigh the possible benefits

of percussion against possible detriments prior to the application of this technique are listed in Table 4-6. Modification of the technique may be necessary for patient tolerance.

c. Procedure. (I) Explain procedure to the patient. (2) Place patient in the appropriate postural

drainage position. (3) Cover the area to be percussed with a light

weight cloth to avoid erythema. (4) Percuss over area of thorax which corre

sponds to the involved lung segment. The duration of percussion depends on the patient's needs and tolerance. Three to five minutes of percussion per postural drainage


position with clinically assessed improvement is a guideline.

(5) The force of percussion is one that causes the patient's voice to quiver.

3. Shaking (Vibration): following a deep inhalation, shaking is a bouncing maneuver applied to the rib cage throughout exhalation Shaking hastens the removal of secretions from the tracheobronchial tree. Commonly used following percussion in the appropriate postural drainage posltIOn. Modification of this technique may be necessary for patient tolerance. a. Indications for the use of shaking.

(1) Excessive pulmonary secretions. (2) Aspiration. (3) Atelectasis or collapse of an airway from

mucus plugging. b. Considerations prior to the application of

shaking are similar to those of percussion. (Table 4-6).

c. Procedure. (1) Explain procedure to the patient. (2) Place patient in the appropriate postural

drainage position. (3) Perform percussion, if appropriate. (4) As the patient inhales deeply, the thera

pist's hands are placed so that fingers are parallel to the ribs.

(5) As the patient exhales, the therapist's hands provide a jarring, bouncing motion to the ribcage below.

(6) The duration of shaking depends on the patient's needs, tolerance, and clinical improvement. Five to ten deep inhalations with the shaking technique is generally acceptable practice. Any more than ten would risk hyperventilation (increased V E

resulting in decreased PaC02) and less than five might be ineffective.

4. Airway clearance techniques. a. Cough: the patient should be asked to cough in

the upright sitting position, if possible, after each area of lung has been treated. Coughing is effective in clearing secretions from the major central airways.

b. Huff: huffing is more effective in patients with collapsible airways, such as patients with chronic obstructive diseases; it prevents the high intrathoracic pressure which causes premature airway closure.

180

(1) Ask patient to inhale deeply. (2) Immediately, the patient forcibly expels the

air saying "ha, ha". c. Assisted cough: the therapist's hand(s) (or fist)

becomes the force behind the patient's exhaled air. Assisted cough is used when the patient's abdominal muscles cannot generate effective cough (e.g. spinal cord injury). The amount of force by the therapist is dependent upon patient tolerance and abdominal sensation. (1) Position the patient against a solid surface;

supine with head of bed flat or in Trendelenburg, or sitting with wheelchair against the wall or against the therapist.

(2) The therapist's hand is placed below the patient's subcostal angle (similar to hand placement for the Heimlich Maneuver) .

(3) The patient inhales deeply. (4) As the patient attempts to cough, the thera

pist's hand pushes inward and upward, assisting the rapid exhalation of air.

(5) Any secretions raised should be removed by a suction catheter if expectoration is problematic.

d. Tracheal stimulation: used with patients who are unable to cough on command, such as infants, patients following brain injury or stroke. (1) The therapist's finger or thumb is placed

just above the suprasternal notch and a quick inward and downward pressure on the trachea elicits the cough reflex.

e. Endotracheal suctioning: used only when the above airway clearance techniques fail to adequately remove secretions. (1) Standard Precautions are employed since

contact with a patient's body fluid is expected.

(2) Equipment: suction catheters come in sizes of 14 French gauge (Fr), usually for an adult, 10 Fr for older children, 8 and 5-6 Fr for young children and infants. Suction system set at approximately 120 mrnHg of suction. Sterile glove/clean glove.

(3) Procedure: the catheter is fed through either an artificial airway, oral airway, or the nares through the pharynx, larynx to the carina. When resistance is felt at the carina, the catheter is rotated and withdrawn. Suction is applied intermittently so as not

to damage the inner lining of the trachea. The usual suctioning time is between 10 and 15 seconds.

(4) Complications associated with suctioning include: hypoxemia, bradycardia or tachycardia, hypotension or hypertension, increased intracranial pressure, atelectasis, tracheal damage, infections.

B. Independent Secretion Removal Techniques 1. Active cycle of breathing: an independent program

used to assist in the removal of the more peripheral secretions that coughing alone may not clear. a. Breath in a controlled diaphragmatic fashion. b. Perform thoracic expansion exercises (with or

without percussion and shaking). These are deep inhalations with a hold at the top if possible.

c. Controlled diaphragmatic breathing. (the patient is now to decide what is needed next. If there are no secretions felt to be mobilized at this time, then the patient returns to step b, then c and re-assesses their situation. If the patient believes there to be secretions that can be cleared, the patient moves on to step d, e, and f.

d. Inhale a resting tidal volume. Contracting the abdominal muscles to produce one or two forced expiratory huffs from mid to low lung volume to raise secretions.

e. Huff from high lung volume or cough to clear. f. Controlled diaphragmatic breathing. g. Repetition of these cycles are continued until

secretions are in large airways. 2. Autogenic drainage: an independent program used

to sense peripheral secretions and clear them without the tracheobronchial irritation from coughing. The amount of time spent in each of the following phases is determined by where the patient feels the secretions. a. The unstick phase: quiet breathing at low lung

volumes to affect peripheral secretions. b. The collect phase: breathing at mid lung vol

umes to affect secretions in the middle airways. c. The evacuation phase: breathing from mid to

high lung volumes to clear secretions from central airways. This pha e replaces coughing as the means to clear secretions.

d. Repeat the steps which correspond to the area of retained secretions until all secretions are removed from the airways.

3. The FLUTTER device: an independent program using an external device that vibrates the airways

on exhalation to improve airway clearance. a. The patient breathes in through their nose or

around the mouthpiece of the flutter device. b. A three second hold at the top of inhalation. c. Rapid forced exhalations through the Flutter

device. d. Repeat between 4 and 10 times. e. Huff or cough to clear secretions. f. Repeat until all secretions are removed from

the airways. 4. Low pressure positive expiratory pressure (PEP)

mask: an independent exercise program that uses positive expiratory resistance via face mask to assist in the removal of airway secretions. Low pressure PEP measures 10 to 20 cm H20. a. Seated, the patient breathes at tidal volumes

with mask in place. b. After approximately 10 breaths, the mask is

removed for coughing and clearing of secretions. c. The sequence is repeated until all secretions are

removed from the airways. 5. High pressure positive expiratory pressure (PEP)

mask: an independent exercise program for patients with unstable airways that uses the high expiratory pressures via face mask to assist in the removal of airway secretions. High pressure PEP uses the point of PEP between 50-120 cm H20 where the patient is able to exhale a larger FVC with the mask than without. a. Seated, the patient breathes at tidal volumes

with mask in place. b. After approximately 10 breaths, huffing from

high to low lung volumes is performed with the mask in place.

c. The sequence is repeated until all secretions are removed from the airways.

C. Breathing Exercises I. Diaphragmatic breathing is used to increase venti

lation, improve gas exchange, decrease work of breathing, facilitate relaxation, maintain or improve mobility of chest wall, prevent pulmonary compromise. a. Used with postoperative patients, post trauma

patients, and patient's with obstructive or restrictive pulmonary lung diseases.

b. Procedure. (1) Explain procedure to patient. (2) Position the patient semi-reclined (e.g.,

Semi-Fowler's position). (3) Place the therapist's hand gently over the


subcostal angle of the patient's thorax. (4) Apply gentle pressure throughout the exha

lation phase of breathing. (5) Increase to firm pressure at the end of exha

lation. (6) Ask the patient to inhale against the resist

ance of the therapist's hand. (7) Release pressure allowing a full inhalation. (8) Progress to independence of therapist's

hand, in upright sitting, standing, walking, and stair climbing.

2. Segmental breathing is used to improve ventilation to hypoventiJated lung segments, alter regional distribution of gas, maintain or restore functional residual capacity, maintain or improve mobility of chest wall and prevent pulmonary compromise. a. Used with patients who have pleuritic, incision

al, or post trauma pain that is causing a decreased movement in a portion of the thorax (splinting) and are at risk for developing atelectasis .

b. Segmental breathing is inappropriate in cases of intractable hypoventilation until the medical situation is resolved (palliative therapy to reduce bronchogenic tumor size or a chest tube to reduce a pneumothorax).

c. Procedure. (1) Explain procedure to the patient. (2) Position the patient to facilitate inhalation

to a certain segment, such as postural drainage positions, upright sitting.

(3) Apply gentle pressure to the thorax over the area of hypoventilation during exhalation.

(4) Increase to firm pressure just prior to inspiration.

(5) Asks the patient to breathe in against the resistance of the therapist's hands.

(6) Release resistance allowing a full inhalation.

3. Sustained maximal inspiration (SMI) is used to increase inhaled volume, sustain or improve alveolar inflation, maintain or restore functional residual capacity. a. Used in acute situations for patients with post

trauma pain, post-operative pain, acute lobar collapse.

b. Procedure. (1) Inspire slowly through nose or pursed lips

to maximal inspiration. (2) Hold maximal inspiration for three seconds. (3) Passively exhale the volume.

182

(4) Incentive spirometers (devices used to measure and encourage deep inspiration) can assist the patient in achieving maximal inspiration during SMI.

4. Pursed lip breathing is used to reduce the respiratory rate, increase tidal volume, reduce dyspnea, decrease mechanical disadvantage of an impaired ventilatory pump, improve gas mixing at rest for patients with COPD, and facilitate relaxation. a. Primarily used for patients with obstructive

disease who experience dyspnea at rest or with minimal activity/exercise, or who use an ineffective breathing pattern during activity/exercise.

b. Procedure. (1) Slowly inhale through nose or mouth. (2) Passively exhale through pursed lips (posi

tion the mouth as if blowing out candles). Increases intrabronchial pressure.

(3) Additional hand pressure from the therapist applied to abdomen can be used to gently prolong expiration.

(4) Abdominal muscle contraction can be used judiciously to increase exhaled volume. Care must be taken not to increase intrathoracic pressure which might produce airway collapse.

5. Abdominal strengthening can be used when abdominal muscles are too weak to provide an effective cough. Abdominal splinting can be used when the abdominal muscles cannot provide the necessary support for the abdominal contents needed for passive exhalation, with high thoracic and cervical spinal cord injuries. It is important to ensure that the binder does not restrict inspiration. a. Glossopharyngeal breathing (air gulping) can

also be taught to assist coughing. D. Pre and Post Surgical Care

1. Preoperative teaching and treatment decreases the number and severity of postoperative pulmonary complications. a. Goals and outcomes.

(1) Determine baseline cardiopulmonary function. (2) Treat any existing condition which may

alter postoperative course. (3) Educate patient and family regarding post

operative course and physical therapy treatment.

(4) Enhance compliance postoperatively. b. Physical therapy considerations.

(1) Familiarize the patient with the therapist

and department. (2) Extract pertinent patient information from

medical record and physical examination. (3) Demonstrate secretion removal techniques

used postoperatively. (4) Teach breathing exercises, splinting, incen

tive spirometry. (5) Describe postoperative course, for exam

ple, site of incision, monitoring and therapeutic devices, levels of discomfort, treatment times, hospital guidelines for visitors. Information is tailored to the patient's inquiries and level of understanding.

(6) Perform secretion removal techniques as required.

2. Postoperative physical therapy sessions decrease the number and severity of pulmonary complications. a. Description: prevent postoperative pulmonary

complications. (1) Remove any residual secretions. (2) Improve aeration. (3) Gradually increase activity. (4) Return to baseline pulmonary functioning.

b. Pertinent physical findings of postoperative pulmonary complications. (1) Increased temperature. (2) Increase in white blood cell count. (3) Change in breath sounds from the preoper-

ative evaluation. (4) Abnormal chest X-ray. (5) Decreased expansion of the thorax. (6) Shortness of breath. (7) Change in cough and sputum production.

c. Physical therapy considerations. (1) Determine need for pain management. (2) Choose appropriate intervention based on

the individual patient's needs. (a) Secretion removal techniques~ (b) Breathing exercises to improve aera

tion, incentive spirometry. (c) Early mobilization.

E. Activities for Increasing Functional Abilities 1. General conditioning. A prescription for exercise

can be written to improve cardiopulmonary fitness based on the results of an exercise tolerance test. Refer to Chapter 3 for more in-depth discussion. a. Mode. Any type of aerobic activity which

allows a graded workload can be used. Usually, a circuit program of multiple activities (bike, walking, arm ergometry, etc.) is used because

patients with pulmonary disease may be quite deconditioned. Patient preference should enter into the decision making process for mode of exercise.

b. Intensity. Using the test data in Karvonen's formula [(Maximum Heart Rate - Resting Heart Rate) (40%-85%) + Resting Heart Rate] results in safe range for exercise intensity. Most patients with pulmonary disorders will work in the upper end of the target heart rate range. Ratings of Perceived Exertion scale is also used to monitor exercise intensity.

c. Duration. Using a high intensity for exercise, the patient may need an intermittent exercise program with rest periods for tolerance. Progression is directed fIrst towards a duration of 20 to 30 minutes of continuous exercise before an increase in intensity is considered.

d. Frequency. The goal is 20 to 30 minutes of exercise 3 to 5 times per week. If the duration is less than 20 to 30 minutes, exercise must be performed more frequently (5 to 7 times per week).

2. Inspiratory muscle trainers (IMTs) load the muscles of inspiration by breathing through a series of graded aperture openings. By increasing strength and endurance of muscles of ventilation, the patient will have increased efficiency of ventilatory muscles , decreased work of breathing, decreased possibility of respiratory muscle fatigue , Whether or not this translated into improved functional abilities has been cause for debate and has yet to be conclusively proven. a. IMT is appropriate for patients with decreased

compliance, decreased intrathoracic volume, resistance to airflow, alteration in length tension relationship of ventilatory muscles, decreased strength of the respiratory muscles.

b. Procedure. (1) Explain procedure to patient with emphasis

on maintenance of respiratory rate and tidal volume during training sessions.

(2) Determine maximum inspiratory pressure (MlP).

(3) Choose an aperture opening which requires 30% to 40% of MIP (intensity), and allows 15 to 30 minute training per session.

(4) Ask patient to breathe through device while maintaining respiratory rate and tidal volume for at least 15 minutes.


(5) Progression initially focused on increasing duration to 30 minutes, then increasing intensity by using smaller apertures.

3. Paced breathing (activity pacing) is used to spread out the metabolic demands of an activity over time by slowing its performance. a. Used with patients who becomes dyspneic dur

ing the performance of an activity or exercise. b. Procedure.

(1) Break down any activity into manageable components that can be performed within the patient's pulmonary system's abilities.

(2) Inhale at rest. (3) Upon exhalation with pursed lips, complete

the fIrst component of the desired activity. (4) Stop the activity and inhale at rest. (5) Upon exhalation with pursed lips, complete

next component of activity. (6) Repeat steps (4) and (5) until activity is

accomplished in full without shortness of breath. For example, stair climbing can be done ascending one or more stairs on the exhalation phase of breathing, cease activity and breathe in at rest, then more stairs on exhalation, followed by another inhalation at rest and so on.

4. Energy conservation. The energy consumption of many activities of daily living can be decreased with some careful thought and planning, making seemingly impossible tasks possible. For example, showering is difficult for the patient with pulmonary disease given the activity and the hot humid environment that accompanies the task. With a shower seat, hand held shower and use of a terry cloth robe after showering, the patient does not have to stand, hold their breath as often, nor dry off in the humid environment, thus reducing the energy cost of the activity.

V. Medical and Surgical Management of Pulmonary Disease

A. Surgical Management 1. Types of surgeries to remove diseased lung por

tions. a. Pneumonectomy: removal of a lung. b. Lobectomy: removal of a lobe of a lung. c. Segmental resection: removal of a segment of a

lobe. d. Wedge resection: removal of a portion of a seg

ment of a lobe.

184

e. Lung volume reduction surgery (LVRS) or pneumectomy, removes large emphysematous, non-functioning areas of the lung in order to restore more normal thoracic mobility and improve gas exchange of the healthier remaining lung.

2. Types of incisions. a. Midsternotomy. The sternum is cut in half

lengthwise and the ribcage retracted. Used in most heart surgeries. The sternum is wired together at the close of surgery; therefore, physical therapy should encourage full upper extremity range of motion postoperatively.

b. Thoracotomy. Used for most lung resections. The incision follows the path of the fourth intercostal space. Full range of motion should be encouraged postoperatively.

B. Medical Management 1. Bronchodilator agents.

a. Beta-2 agonists (sympathomimetics): rrurrucs the activity of the sympathetic nervous system which will produce bronchodilation. Also can cause increase in heart rate and blood pressure. Given topically through a metered dose inhaler (MDI), unwanted systemic effects are reduced. Most of the drugs in this category are termed rescue drugs as they are to be used primarily for immediate relief of breakthrough symptoms of chest tightness, wheezing and shortness of breath. Examples of rescue Beta 2 agonists are Ventolin, Alupent, Maxair, Albuterol. Newer treatment options include a Beta-2 agonist for maintenance. They are long acting inhaled bronchodilators that may decrease the need for rescue drugs, and decrease the need for inhaled anti-inflammatories. An example of this type of Beta-2 maintenance drug is Serevent.

b. Anticholinergics: inhibit the parasympathetic nervous system. Inhibiting the parasympathetic system can also cause an increase in heart rate and blood pressure along with bronchodilation. Side effects can include lack of sweating, dry mouth and delusions. These drugs are administered by MDI with minimal side effects. They should be used on a regular schedule to maintain bronchodilation. An example of this category of drug is Atrovent.

c. Methylxanthines: produce smooth muscle relaxation but their use is limited due to the serious toxicity of increased blood pressure, increased

heart rate, arrhythmias, gastrointestinal distress, nervousness, headache and seizures. Blood levels need to be drawn to ensure medication effect without causing toxicity. Examples are aminophylline and theophylline.

2. Anti-inflammatory agents: used to decrease mucosal edema, decrease inflammation, reduce airway reactivity. a. Steroids: These drugs are used for maintenance

of airway and should be taken on a regularly scheduled basis. They are not to be used for the acute onset with breakthrough symptoms. These drugs can be administered systemically or topically (MDI). Side effects of systemic administration are increased blood pressure, sodium retention, muscle wasting, osteoporosis, GI irritation, and hypercholesteremia. The main side effect of inhaled steroids is thrush, a fungal infection of the mouth and throat. Examples are Vanceril (MDI) , Azmacort (MDI), Prednisone (po) [by mouth] and Solumedral (IV).

b. Leukotriene Receptor Antagonist: blocks leukotrienes that are released in an allergic reaction. Inhibits airway edema and smooth muscle contraction without being a steroid. It has additive benefits when used in conjunction with other anti-inflammatories. An example of this drug is Montelukast - Singulair.

c. Cromolyn Sodium: an antiallergic drug. Prevents release of mast cells (i.e., histamine) after contact with allergens. Used prophylactically to prevent exercise-induced bronchospasm and severe bronchial asthma via oral inhalation. It is not to be used as a rescue drug during acute situations. Frequent inhalation can result in hoarseness, cough, dry mouth and bronchial irritation. Symptoms of overdosage include paradoxical bronchospasm. Brand names include Intal.

3. Antibiotics: to control infection. a. Categories: culture and sensitivity results are

used to prescribe the most effective antibiotic. (1) Penicillins. (2) Erythromycins. (3) Tetracyclines. (4) Cephalosporins. (5) Aminoglycosides.

b. Side effects. (1) Allergic reactions, stomach cramps, nausea,

vomiting and diarrhea.

VI. Intensive Care Unit Management: Physical therapy is employed in the ICU for pulmonary care (secretion removal or improved aeration) and early mobility (range of motion, positioning, therapeutic exercise, transfers, ambulation). The followi ng provides a brief description of some equipment frequently encountered when treating a patient in the ICU.

A. Mechanical Ventilation: maintain an adequate V E

for patients who cannot do so independently. Requires intubation with an endotracheal (oral), nasotracheal (nasal) or tracheal (through a tracheostomy directly into the trachea) tube. Endotracheal and nasotracheal tubes are only taped into place. Tracheal tube may be sutured in place. Tubes or mechanical ventilation pose no contraindications to physical therapy treatment. A patient who is intubated can ambulate using a mechanical resuscitator bag to maintain ventilation. It is sometimes easier to use a stationary device, e.g., peddler, to exercise a patient who needs a ventilator. When moving a patient who is intubated, care should be taken that excessive tension is not placed on the tube. Alteration in the placement of the tube (either a drop inward or a pull outward) could be detrimental to optimal ventilation. If tube movement is suspected, a nurse or respiratory therapist should check the placement of tube. If the tube is dislodged, a physician, often an anaesthesiologist, needs to replace the tube.

B. Chest Thbes: used to evacuate air or fluid trapped in the intrapleural space. The chest tubes are sutured in place, making them secure. There are no contraindications to physical therapy treatment with a chest tube. If the chest tube is connected to a suction device mobility is limited only by the length of the tubing: Portable suction machines can be used to allow increased mobility. If the tube is dislodged during treatment, cover the defect and seek assistance.

C. IVs: Intravenous catheters used to deliver medications. There are no contraindications to physical therapy treatment with IV lines; however, the upper extremity should not be raised above the level of the IV medication for any length of time or backflow of blood may occur. Rolling IV poles allow for mobility. Most IV pumps have a battery back up system to allow the patient to be mobile.

D. Arterial Lines: catheters that are placed within the arterial system, usually the radial artery. The tubing is connected to a pressure pack that exceeds arterial pressure so the line does not back up with blood. Caution to maintain patency during moving is war-


ranted. These lines limit mobility only by the length of the tubing. If this line becomes dislodged, immediate firm pressure needs to be applied to or above the arterial insertion site to stop bleeding.

E. Monitors/Oscilloscopes 1. Continuous EKG with a reported heart rate. 2. Blood pressure reading either periodic using non

invasive cuff (NIBP) or continuous using a transducer attached to the arterial line (ABP).

3. Continuous oxygen saturation (Sa02) with pulse wave. Sa02 is the percent saturation of oxygen in the arterial blood. It is a non-invasive measurement that relates to the Pa02 on the S-shaped curve called the oxyhemoglobin desaturation curve. Normal levels are 98% to 100% saturated. The pulse oximeter utilizes a finger sensor (or an ear sensor) to obtain a consistent reading.

F. Supplemental Oxygen: increases the Fi02 (up to 1.0) of the patient's environment. A portable oxygen cylinder attached to the oxygen delivery device, (cannula, mask or even a manual resuscitator bag attached to the endotracheal tube) can be used during mobility training to provide supplemental oxygen for the patient. Supplemental oxygen is indicated if Sa02 is less than 88% or Pa0 2 is less than 55 mmHg regardless of activity level. Monitor the patient's Sa02 to assure adequate oxygenation with increased activity. Oxygen must be prescribed by a physician. It is considered a form of medication.

Portions of the review of pulmonary anatomy and physiology have been preViously published in Starr, J. Pulmonary System (Ch.7) in Meyers, R (ed): Saunders Manual of PhYSical Therapy Practice, WB Saunders Co, Philadelphia, 1995.

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