Cardiopulmonary Physiotherapy

M Jones PhD MCSP, F Moffatt MSc MCSP, M Jones, PhD, MCSP, F Moffatt, MSc, MCSP

• Publisher: Routledge
• Year: 2002
• eBook ISBN: 9781135319847
• Edition: 1
• Topic: Medicine
• Subtopic: Cardiology

Starting with patient assessment, the authors explain the physiological basis of all major cardiopulmonary problems before describing the physiotherapy interventions possible - this ensures the reader understands why the problems occur and not just how to treat them. The book concludes with a detailed glossary, an appendix describing all the treatm

Section 1: ASSESSMENT TOOLS

ASSESSMENT TOOLS

Introduction

Respiratory examination must form part of a multisystem assessment, as physiologically no body system works in isolation. The clinician should review available medical/nursing documents and charts to insure that any overall ‘trends’ are identified, as this will prevent findings being taken out of context. Early detection of physiological changes may prevent catastrophic patient deterioration. Liaison with members of the multidisciplinary team will insure a holistic examination is performed.

This section provides all the core tools necessary for the physiotherapy assessment of any patient with a respiratory system disorder, from a simple pre-operative examination to the complex assessment of the critically ill patient. The physiotherapist must use their clinical judgment to select the appropriate assessment tools.

Assessment is an on-going procedure and should be performed before, during and after every treatment.

Subjective examination

• HPC including onset, progression, signs and symptoms, treatment/response, identification of problems as seen by the patient.
  DOES THE CURRENT CONDITION REPRESENT A CHANGE FROM NORMAL AND IF SO, HOW?

During assessment of the following signs and symptoms, identify the nature, precipitating factors, methods of relief, effect of treatment, diurnal variations, severity and associated symptoms:

• SOB: mild/moderate/severe (visual analog scale, Borg scale), orthopnea, and paroxysmal nocturnal dyspnea.
• Wheeze: PEFR ↑↓.
• Cough: productive, dry, nocturnal.
• Sputum: quantity, color, consistency, and hemoptysis.
• Exercise tolerance and functional limitations: descriptive terms (distance, pain, dyspnea, fatigue), stair climbing.
• Pain: body chart, visual analog scale, descriptive terms.
• Relevant PH, DH, SH, FH.

Objective examination

Central nervous system

	Intracranial pressure	Cerebral perfusion pressure
Normal value	< 10 mmHg	> 70 mmHg
Critical value	>25 mmHg	<50 mmHg

• Level of consciousness (Glasgow coma scale), orientation (time, person, place).
• Pupil size/reactivity/equality.
• Ability to maintain a patent airway.
• Sensorimotor loss, speech disturbances.
• Level of pain/agitation.
• Note results from interventions: transcerebral Doppler, CT scans, MRI scans, EEGs, cerebral function activity monitor.
• Note the presence and location of ventricular drains, bone flaps, jugular bulbs.
• Pharmacological support: muscle relaxants, sedatives, anxiolytic agents, antidepressant agents, anesthetic agents, analgesics, osmotic diuretics, cerebral artery vasodilators, anticonvulsing agents and cortical steroids.

Cardiovascular system

	Heart rate (HR)	Arterial blood pressure (BP)	Central venous pressure (CVP)	Pulmonary artery pressure (PAP)	Pulmonary capillary occlusion pressure (PCOP)
Normal range	50-100	95-120/60-90 mmHg	3-15 mmHg	10-20 mmHg	6-15 mmHg
	bradycardia <50 bpm tachycardia >100 bpm		Note palpable JVP

• Rhythm (normal sinus rhythm, abnormal, e.g. atrial fibrillation/flutter, ventricular tachycardia, ectopic beats, ventricular fibrillation, heart block).
• Note presence and severity of peripheral edema.
• Note presence and quality of peripheral pulses or signs of peripheral circulatory insufficiency.
• Note results of cardiac output studies: cardiac index, systemic/pulmonary vascular resistance, calculated values of right/left atrial pressure.
• Note presence of pulmonary artery catheter, central and arterial lines.
• Note presence and rate of drainage in mediastinal drains.
• Review relevant tests: 12-lead ECG, angiogram, echocardiogram, cardiac enzymes, exercise test (Bruce protocol).
• Pharmacological support: inotropes, antihypertensive agents, anti-arrhythmic agents, ACE inhibitors, vasodilators, diuretics, crystalloid, colloid, antithrombolytic and anticoagulant agents.
• Mode of mechanical support: ventricular assist devices, intra-aortic balloon pumps, pacemakers and inplantable defibrillators.

Respiratory system

• Mode of ventilation: spontaneous, assisted, intubated and ventilated, NIPPV.
• Level of PEEP, CPAP or pressure support.
• Respiratory rate: normal spontaneous 10–15 breaths per minute. In a ventilated patient respiratory rate may be widely manipulated to achieve different clinical objectives, e.g. hyperventilation with acute head injury. N.B. Respiratory rate change is commonly the most sensitive indicator of physiological deterioration.
• Respiratory pattern: work of breathing (at rest and with exercise), use of accessory muscles, pursed lip breathing, intercostal recession, paradoxical movement, Cheyne-Stokes respiration, apneustic breathing.
• Inspiration:expiration ratio (may be manipulated with mechanical ventilation to achieve different clinical objectives, e.g. prolonged inspiration to increase oxygenation, or prolonged expiration to minimize air trapping in obstructive lung disease).
• Airway pressures (peak and mean).
• Fraction of inspired oxygen (FiO2) and delivery device.
• Type of humidification device.
• Use of pulse oximetry or capnography.
• Presence and rate of drainage in intercostal drains.
• Shape of thorax: barrel, kyphosis, scoliosis, thoracoplasty and pectus cavinatum/excavatum.
• Color (e.g. cyanosis), nicotine stains and finger clubbing.
• Palpation: thoracic expansion, tracheal position and mobility, secretions, bony crepitus and surgical emphysema.
• Cough and sputum (nature of cough, color, viscosity, quantity and odor of sputum).
• Pharmacological support: oxygen, bronchodilator agents, mast-cell stabilizers, steroids, inflammatory cell antagonists, mucolytic agents, inhaled pulmonary vasodilators, inhaled antibiotics, respiratory stimulants and surfactant.
• Mechanical support: ECMO, ECCO₂R.

Auscultation

• Where possible always fully expose the thorax.
• Listen to a full inspiration and expiration (normal ratio 1:2).
• Note where in respiratory cycle any abnormality occurs, inspiration/expiration.
• Note where in inspiration/expiration abnormality occurs, early, middle or late.
• Listen over the trachea and main bronchi.
• Work down the lung fields comparing both sides:
  • upper lobe: apical, anterior and posterior segments;
  • middle/lingula lobes: medial and lateral/superior and inferior segments;
  • lower lobe: apical, medial, lateral, anterior and posterior segments.
• Breath sounds: normal, reduced or added.
• Normal: equal and bilateral.
• Reduced: consider atelectasis, collapse, pleural effusion, empyema, pneumothorax, hypoventilation, hyperinflation and absence of lung tissue.
• Added sounds:
  • Crackles: generated by opening of previously closed alveoli and small airways. Fine or coarse: fine, consider fibrosis or pulmonary edema, coarse, consider sputum.
  • Wheeze: musical note generated by air vibrating a narrowed airway. Initially heard in expiration, can progress to inspiration. Monophonic or polyphonic; monophonic denotes single airway obstruction, consider sputum plug; polyphonic, denotes widespread airway involvement, consider bronchospasm.
  • Pleural rub: creaking noise generated with articulation of inflamed pleura.
  • Bronchial breath sounds: normal breath sounds heard over the trachea and main bronchi. However, can be transmitted and heard over airless areas of lung. Loud noise with harsh quality. Heard equally through inspiration and expiration with a short pause between the two phases. Consider consolidation, or a large area of obstruction.
  • Stridor: upper airway or laryngeal obstruction. Potentially life-threatening situation. Physiotherapy contraindicated. Discuss with doctor immediately.
  • Transmitted noise and artefact: note sounds occurring due to movement of stethoscope bell against bed sheets or skin. Mechanical sounds may be transmitted from a ventilator, nebulizer, intercostal drains or humidification device.
• Percussion note: generated by percussing the chest with one finger, to produce vibration of underlying chest wall and tissues. ...

Table of contents

• COVER PAGE
• TITLE PAGE
• COPYRIGHT PAGE
• ACKNOWLEDGMENTS
• ABBREVIATIONS
• HOW TO USE THIS BOOK
• SECTION 1: ASSESSMENT TOOLS
• SECTION 2: PATHOPHYSIOLOGY
• SECTION 3: PHYSIOTHERAPY TECHNIQUES AND ADJUNCTS
• SECTION 4: CASE STUDIES AND SELF-ASSESSMENT