Cardiopulmonary Physical Therapy. Haneul Lee, DSc, PT

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1 Cardiopulmonary Physical Therapy Haneul Lee, DSc, PT

2 Airway Clearance Techniques Breathing Exercise Special Considerations for Mechanically Ventilated Exercise Injury Prevention and Equipment provision Patient Education Discharge Planning

3 Intubation and mechanical ventilation are required for most patients with acute respiratory failure. One of main goals for these patients is to return to spontaneous breathing. The process of discontinuing mechanical ventilation is called weaning. The benefit of weaning from mechanical ventilation Minimizing iatrogenic complications Minimizing the duration of ICU stay Preventing atrophy of the inspiratory muscles

4 From the physical therapist s perspective An assist device capable of performing a wide range of support for the act of breathing Coordinating physical therapy interventions with the weaning process is critical for the patient to receive optimal benefit and successfully progress toward the goal of continuous spontaneous breathing.

5 The patient s status should be maximized in regard to nutrition, metabolic stability, fluid and electrolyte balance, hemodynamic stability, and cardiac function. The patient must manage respiratory secretions. Preferably the patient is alert and cooperative, but at the minimum he or she should be initiating breaths spontaneously.

6 Physical therapy interventions facilitate the weaning process by optimizing airway clearance and pulmonary function. Balancing the patient s energy expenditure during the weaning process with the added energy required for performing functional mobility activities or exercise is a challenge for the physical therapist. Communication between therapist, patient, and clinical care team is critical to the success of the weaning process for patients requiring prolonged mechanical ventilation (more than 5 days).

7 Developing communication system difficult but important Use of written communication Lip reading Eye blinks - simple means Head nods simple means Gestures Facial expression Whatever methods are deemed effective must be utilized consistently to further enhance communication, and they must be reinforced by all staff.

8 Airway clearance techniques are an important part of the weaning process. Biofeedback for increasing tidal volume and relaxation have been shown to reduce weaning time. Inspiratory resistance training has been demonstrated to improve respiratory muscle strength and endurance in patients with reparatory failure and has facilitated increased weaning success. Timing of the physical therapy treatment is essential for optimizing patient success and meeting functional goals.

9 In the acute care setting, Patients often have limitations in strength and endurance that prevent optimal functional mobility and efficient breathing patterns. Neuromyopathy most common peripheral neuromuscular disorder see in the ICU -> presents as profound extremity and respiratory muscle weakness Systemic inflammation, hyperglycemia, corticosteroid use and deconditioning associated with prolonged bedrest -> Neuromuscular weakness Exercise, in the form of both endurance and strength training, should be used to in an effort to both prevent and treat the negative neuromuscular sequelae of critical illness

10 Goal of endurance training in acute care Maximize the independence and efficiency by which the patient performs ADLs and functional mobility. Indications Acute Conditions That Are Indications for Mobilization and Exercise Alveolar hypoventilation Pulmonary consolidation Pulmonary infiltrates Inflammation of bronchioles and alveoli Pleural effusions Acute lung injury and pulmonary edema Systemic effects of immobilization (see lecture 7) National Physical Therapy Examination, O sullivan&siegelman, TherapyEd

11 The acute care patient s response to activity or exercise is dependent on the body s ability to meet the oxygen transport demand. Monitoring cardiopulmonary parameters before, during, and after activity allows the therapist to provide the safest and most effective treatment intervention. Signs and symptoms of exercise intolerance that occur during physical therapy treatment indicate that the intervention needs to be stopped or modified.

12 The PT needs to be aware of the patient s current medications and their effect on exercise response. National Physical Therapy Examination, O sullivan&siegelman, TherapyEd Abnormal Responses to Exercise Heart rate increases more than 20 to 30 bpm above resting heart rate Heart rate decreases below resting heart rate Systolic blood pressure increases more than 20 mmhg above resting level Systolic blood pressure decreases more than 10 mmhg below resting level Oxygen saturation drops below prescribed level Patient becomes short of breath or respiratory rate increases to a level not tolerated by the patient ECG changes Nonverbal/nonvital signs of possible exercise intolerance: Color changes Diaphoresis Increased accessory muscle use Agitation, nonverbal signs of pain

13 Acute care patients response to exercise intensity can be measured in several ways Borg rate of perceived exertion (RPE) Warm-up and cool-down 9 to 11 range Peak activity 13 to 15 range RPE 12 to 13 = approximately 60% of maximum HR RPE 16 = 85% of maximum HR Some medications reduce HR can reduce maximum HR by 20-30% Levels of shortness of breath using dyspnea Index (DI) DI A patient takes a deep breath and then counts to 15 slowly The number of breaths the patient requires to count to 15 is the dyspnea index Warm-up and cool-down 1 to 2 breaths to reach 15 Peak activity 3 breaths

14 Monitoring patient for subjective complaints of angina Angina correlates with ECG changes ST-segment depression or elevation Stages of Stable Angina Stage Description 1 Initial perception of discomfort 2 Increase in the intensity of Level 1 or the radiation of pain to other areas ( jaw, throat, shoulders, arms, or other body parts) 3 Relief is obtained only through cessation of activity 4 Infraction pain National Physical Therapy Examination, O sullivan&siegelman, TherapyEd

15 Duration is the amount of time that a patient can tolerate performing a certain activity. The patient's cardiovascular response will help determine the desired duration of activity during the inpatient exercise or mobility session. May progress a patient from 5 minutes on a lower extremity ergometer to 15 minutes at a time within 3 or 4 days. This can be repeated 2 or 3 times per day as tolerated and should be performed 6 or 7 times per week. Nearing end of the hospital stay 6 minute walk test may be performed. Progress is measured by increases in the distance walked.

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16 Usually, in the acute care patient population, multiple short intervals of exercise followed by rest periods are tolerated better than one long session of exercise on a given day. The therapist may accomplish this by performing airway clearance techniques first in the morning and then using the afternoon treatment session for functional mobility or other exercise.

17 Most patient have limited exercise capacities because of their medical or surgical conditions. In order to maximize independence, PT often choose functional activities as the preferred mode of exercise for patients in acute care ( In hospital setting) Bed mobility Standing Transfers Ambulation Stairs Stationary bike, pedal exerciser Upper body ergometer In the acute setting, a patient may not bale to complete a 6-minute walk test. A 3-minute walk test may be used instead.

18 Functional mobility training may be initiated as soon as the patient can roll bilaterally in the bed and maintain blood pressure and oxygenation parameters.

19 Beginning an exercise program often starts at the patient s bedside with the first level of functional mobility, bed mobility. Bridging Rolling Sitting

20 Bridging The act of bridging helps with placement and removal of the bedpan, linen changes, and positioning in bed. Can be first step of independence.

Critically ill patients show a 40-50% increase in oxygen consumption during chest

21 Rolling If PT is using airway clearance techniques, the PT can instruct the patient in rolling to position for this technique. Critically ill patients show a 40-50% increase in oxygen consumption during chest physical therapy combined with rolling.

22 Sitting (at the edge of the bed) The PT should be mindful of proper body mechanics during this stage of functional mobility. May want the assistance of other staff or may raise the bed up to a level that prevents a forward flexed posture. The thorax can move in all planes and the patient has the opportunity to stretch the muscles of the thorax. The patient s tidal volume increases, as well as reparatory rate.

Once patient is able to sit at the edge of the bed unsupported for 5 minutes with acceptable responses in vital signs, the patient may progress to standing and ambulating.

23 Once patient is able to sit at the edge of the bed unsupported for 5 minutes with acceptable responses in vital signs, the patient may progress to standing and ambulating. The use of the four-wheeled walker allows the patient to walk with support and the availability of a fold-down seat it is needed.

An intubated patient is ready to use the walker, the PT must arrange for sufficient amounts of

24 If needed, the patient should be educated on how to use the walker, complete with verbal and visual instructions, as well as demonstration. An intubated patient is ready to use the walker, the PT must arrange for sufficient amounts of assistance. One assist the patient physically during ambulation Another responsible for bagging the patient with a selfinflating bag connected to supplemental oxygen.

25 A portable ventilator may also be used, if available. A gait belt is warranted for the safety for both patient and therapist. The patient does not need to be extubated to start ambulation training. Once the patient is extubated, the PT may continue with the wheeled walker or progress the patient to the next least restrictive assistive devise as indicated. Contraindications or Precautions for Advancing Functional Mobility Untreated deep-vein thrombosis Unstable vital signs Patient not able to follow commands High ventilator support Other orthopedic, vascular, Or neurologic injury that requires alternative bed activities National Physical Therapy Examination, O sullivan&siegelman, TherapyEd

26 If a patient depends on supplemental oxgen during rest, then oxygen saturation levels need continued monitoring before, during, and after ambulation. All vital signs should be monitored before, during, and after ambulation. The PT and patient work toward goals of increasing ambulation distance and decreasing the levels of assistance. Goal of the patient to ambulate independently without an assistive device or oxygen.

to determine how the patient is responding to physical therapy interventions.

27 Patient safety is paramount in all areas of physical therapy. PT and PTA working in acute setting with patients who have cardiovascular and pulmonary impairments must monitor patients closely to determine how the patient is responding to physical therapy interventions. The patient with cardiovascular and pulmonary impairments often have multiple comorbidities. By starting at a low level of exercise, progressing slowly, and monitoring the patient s response, the clinician can progress the patient safely and effectively.

28 Patient and caregiver education is an important physical therapy intervention in the acute care setting. Patient education has been shown to decrease length of stay, decrease patient anxiety, increase quality of life, increase adherence with medical advice, and increase the patient s participation as an active member of the health care team.

29 3 main factors contributing to noncompliance The barriers that patients perceive Lack of time Fatigue Pain Lack of motivation Difficulty fitting exercise into a daily routine Lack of positive feedback Perceived helplessness The PT should evaluate the effectiveness of the education program.

30 During the initial physical therapy evaluation, the patient s current level of function is evaluated and a prognosis is made regarding his or her potential abilities. It helps patient to prepare for discharge home or for the next level of care. However, since patient s status may change on a daily basis, discharge plan must be frequently reassessed and modified according to the patient s improvement.

31 1. In acute care settings, physical therapy interventions for patients at any age, with primary or secondary cardiopulmonary dysfunction, is aimed at optimizing the patient's oxygen transport system. 2. Therapeutic interventions designed to meet this goal include airway clearance techniques, therapeutic positioning, breathing and chest wall exercise, patient education, and functional mobility exercise. 3. Patients with multiple medical problems and acute respiratory failure may require prolonged periods of mechanical ventilation. Physical Therapy interventions for theses patients need to be coordinated with the weaning process in order to balance the patient s energy expenditure for breathing with that which would be required for participation in therapy activities.

4. Monitoring patient tolerance to physical therapy treatment using parameters such as HR, BP, SO2, RR, and ECG is crucial to safe and effective activity progression for acutely ill patients. 5.

32 4. Monitoring patient tolerance to physical therapy treatment using parameters such as HR, BP, SO2, RR, and ECG is crucial to safe and effective activity progression for acutely ill patients. 5. The primary role of the acute care physical therapist is shifting from providing treatment to acting as a consultant, offering recommendations based on the patina's functional status and rehabilitation potential, and assisting with determining discharge destination and equipment needs.

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

Cardiopulmonary Physical Therapy. Haneul Lee, DSc, PT

Cardiopulmonary Physical Therapy Haneul Lee, DSc, PT A comprehensive pulmonary rehabilitation program should incorporate the following components : Patient assessment and goal-setting Exercise and functional