Cardiopulmonary Physical Therapy

Meghan Lahart PT, DPT

Cardiovascular and Pulmonary Resident Ann Arbor VA

What is Cardiopulmonary PT?

What is a normal hemodynamic response to exercise?

What are some negative effects of immobilization?

Name some positions for dyspnea relief Name a few breathing strategies

What is Cardiopulmonary PT?

Entry level vs Advanced practice Acute cardiopulmonary conditions are

defined as disease in which the patient’s oxygen transport system fails to meet the demands placed on it.

This failure may result in prolonged bed rest and adverse effects such as loss of muscle strength and endurance.

Why is it CP PT important in the acute care setting?

Prolonged effects of bed rest:– Cardiovascular effects: decreased max HR,

decreased max oxygen uptake, increased basal HR, orthostatic hypotension, increased risk for venous thrombosis, decreased total blood volume, decreased Hgb concentration

– Respiratory effects: decreased vital capacity, decreased Pa02, impaired ability to clear secretions, decreased residual volume, increased ventilation-perfusion mismatch

Airway Clearance Techniques

Manual or mechanical procedures that facilitate mobilization of secretions from the airways.

Indications:– Impaired mucociliary transport– Excessive pulmonary secretions– Ineffective or absent cough

Airway Clearance Techniques

Goals of airway clearance:– Optimize airway patency– Increase ventilation and

perfusion matching– Promote alveolar

expansion and ventilation

– Increase gas exchange

Interventions: – Postural drainage– Percussion– Vibration– Cough Techniques and

Assists– Active Cycle of breathing– Mechanical Aids for

coughing– Manual hyperinflation

and Airway suctioning

Breathing Strategies, Positioning, and Facilitation

Used to assist with the progression to independence with mobility and breathing

Techniques are used for patient with weakness, inefficiency, or inhibition of the diaphragm muscle

Paired movement and breathing Positions for dyspnea relief when dyspnea is

caused by pulmonary dysfunction

Breathing Exercises

Pursed lip breathing: used to relieve dyspnea, improve activity tolerance and reduce wheezing

Diaphragmatic breathing: used to improve oxygen saturation, resolution of atelectasis, lower anxiety, mobilize secretions

Lateral costal breathing: used to improve symmetrical chest wall expansion, mobilize secretions and improve posture– Hands on ribs

Breathing Exercises

Inspiratory hold technique: used to improve ventilation and perfusion matching, resolve atelectasis, and improve cough effectiveness

Stacked breathing: used to improve ventilation and perfusion matching, resolve atelectasis, reduce pain, and improve cough effectiveness (take breath in and hold, take a breath in and hold, etc…then breath out)

Paced breathing: used to increase activity tolerance, reduce dyspnea, reduce fatigue, and lower anxiety (breath in/out in 1:4 ration)

Upper chest inhibiting technique: used to reduce accessory muscles overuse (prevent upper chest from moving manually)

Trunk counter rotation techniques: used to increase chest wall mobility, increase ventilation and perfusion matching, improve trunk muscle length, and improve cough effectiveness

Special Considerations for Mechanically Ventilated Patients

Weaning is the process of discontinuing mechanical ventilation and the main goal of a patient requiring mechanical ventilation is the return to spontaneous breathing

Benefits of weaning from mechanical ventilation– Minimize iatrogenic complications– Minimize duration of ICU stay– Prevent atrophy of the inspiratory muscles

Special Considerations for Mechanically Ventilated Patients

Weaning Criteria– FiO2 < 50% (% of O2 in air, typical air is 20%) and

SaO2 >90% with PEEP (pressure that keeps lungs open so they don’t collapse) of less than 5cm H2O

– Negative inspiratory force of 20 to 30 cm H2O– Respiratory rate < 35 breaths per minute– Minute ventilation <15L/min

Assessing Dyspnea

Dyspnea is a clinical manifestation of work of breathing

Yes or no…are you short of breath? Dyspnea can be measured rating on a

numerical scale of 0-10, with 0 being no shortness of breath and 10 indicated the worst imaginable shortness of breath

Exercise

Neuromuscular weakness results from systemic inflammation, hyperglycemia, corticosteroid use (proximal muscle weakness) and deconditioning associated with bedrest

Critical illiness neuromyopathy often presents as profound extremity and respiratory muscle weakness and is the most common peripheral neuromuscular disorder seen in the ICU

Goal of endurance training is to maximize the independence and efficiency of patients to perform ADLs and functional mobility

Normal Cardiopulmonary Values at Rest

Heart Rate: 50-100bpm Systolic BP: 85-140mmHg Diastolic BP: 40-90mmHg Respiratory Rate: 12-20 breaths per minute Oxygen Saturation >95%

Abnormal Responses to Exercise

HR increase of greater than 20-30bpm HR decreasing below resting HR Increase of SBP >20-30mmHg Decrease of SBP >10mmHg Oxygen saturation dropping below prescribed level RR increases beyond a level tolerated by patient ECG changes Color changes, diaphoresis, agitation, increased

accessory muscle use

Exercise Intensity

RPE scale 6-20– Warm up 9-11 range, peak activity 13-15

Dyspnea index– 1-2 breaths at rest, 3 breaths with peak activity

Count to 15, number of breaths it takes

Stages of Stable Angina– 1-4, monitor with ECG changes

Exercise Duration and Frequency

Duration is the amount of time that a patient can tolerate performing a certain activity which is determined by the patient’s cardiovascular response

Frequency is usually multiple short intervals of exercise followed by rest periods, which is shown to be better tolerated in the acute care patient population

Injury Prevention and Equipment Provision

Parameters to monitor: BP, HR, ECG, RR, and oxygen saturation

Signs and Symptoms: shortness of breath, chest pain, dizziness, lightheadedness, cyanosis, pallor, diaphoresis, nausea, and headaches

Progress low level activity and utilize assistive devices in order to conserve energy and increase endurance training.

Discharge Planning

Determining the patient’s rehabilitation potential directly effects the discharge plan

During the initial physical therapy evaluation the patient needs to evaluate the current level of function and prognosis

Acute rehabilitation, sub acute rehablitation, long term care, home with assistance

Practice Patterns

Conditions associated with acute cardiopulmonary dysfunctions and associated preferred practice patterns

6A: Primary prevention/risk reduction for cardiovascular/pulmonary disorders

Conditions: obesity, smoking, hypertension, hyperlipidemia, DMII

Clinical Findings: hypoventilation, atelectasis (lung collapsing), C02 retention, resting SBP >140mmHg

6B: Impaired aerobic capacity/endurance associated with deconditioning

Conditions: sedentary lifestyle, prolonged immobilization

Clinical findings: elevated resting HR, early fatigue, dyspnea on exertion

6C: Impaired Ventilation, Respiration/Gas Exchange, and Aerobic Capacity/Endurance Associated with Airway Clearance Dysfunction

Conditions: Cystic fibrosis, bronchiectasis, acute bronchitis, pneumonia, lung abscess, asbestosis, inhalation burns, asthma, pulmonary fibrosis

Clinical Findings: productive cough of >30mL of secretions per 24 hours, fever, SOB, hypoxemia, C02 retention, respiratory acidosis, decreased FEV1

6D: Impaired Aerobic Capacity/endurance associated with Cardiovascular Pump Dysfunction or Failure

Conditions: CHF, CAD, disease of aortic or mitral valves, cardiomyopathy, endocarditis (young IV drug use), shock, PAD, congenital heart anomalies

Clinical Findings: SOB, jugular venous distension, S3 heart sound (heart failure), crackles on auscultation (heart failure), decreased ejection fraction (heart failure), cyanosis, dependent edema, claudication

6E: Impaired Ventilation and Respiration/Gas Exchange Associated with Ventilatory Pump Dysfunction or Failure

Conditions: chest trauma, Guillain-Barre syndrome, SCI, multiple sclerosis, muscular dystrophy, post-polio syndrome, emphysema, burns to upper body, Parkinson disease

Clinical Findings: paradoxical breathing, inability to cough, dyspnea, reduced peak expiratory flow rate, reduced tidal volume and peak inspiratory pressure

6F: Impaired Ventilation and Respiration/Gas Exchange Associated with Respiratory Failure

Conditions: acute respiratory distress syndrome, pneumonia, pulmonary edema, sepsis

Clinical Findings: hypoxemia, abnormal chest radiograph, increased respiratory rate, mechanical ventilation, fever, hypoxemia

6G: Impaired Ventilation, Respiration/Gas Exchange, and Aerobic Capacity/Endurance Associated with Respiratory Failure in the Neonate

Conditions: bronchopulmonary dysplasia, CMV pneumonia, asthma, meconium aspiration

Clinical Findings: intercostal retraction, stridor, wheezing, physiological intolerance of routine care, impaired airway clearance

Cardiovascular and Pulmonary Risk Factors

Family History– Father/male relative before

55 years old– Mother/female relative

before 65 years old Cigarette Smoking Hypertension

– > 140/90 Dyslipidemia

– LDL >130, HDL <40, total >200

Impaired fasting glucose– >100

Obesity– BMI >30, waist girth

>102cm men and >88cm women

Sedentary lifestyle– Not participating in regular

exercise program