cardiovascular/pulmonary systems physical therapy

Cardiovascular/pulmonary systems physical therapy

interventions and their applications for rehabilitation, health

promotion, and performance according to current best

evidence

Cardiac rehabilitation (4 Phases) is now outdated but may still be on the NPTE.

The major concerns are how the patient is monitored, where the patient is located.

Other concerns are the workload measured in metabolic equivalents and the patient’s

functional goal.

Contraindications to cardiac rehabilitation and active exercise:1

Unstable angina

Resting systolic blood pressure > 200 mm Hg.

Resting diastolic pressure > 110 mmHg.

Orthostatic blood pressure drop > 20 mm Hg.

Critical aortic stenosis

Acute systemic illness or fever

Unstable blood sugar level due to uncontrolled diabetes

Uncontrolled high thyroid level

Uncontrolled hydration level or electrolyte imbalances

Recent embolism

Thrombophlebitis

Severe orthopedic conditions that prevent exercise

Other severe or uncontrolled medical conditions

Active pericarditis or myocarditis

Uncontrolled cardiac arrhythmia:

o Uncontrolled atrial or ventricular arrhythmia

o Uncontrolled tachycardia with rates over 120 at rest

o Third degree atrial-ventricular (AV) blocks

o Third degree AV block without a functioning pacemaker

o Resting ST-segment depression or elevation of greater than 2 mm on the ECG

Initial inpatient care: Most of the time the first few visits are in the ICU/CCU or NNICU.

Indications:

Medically stable patients with post myocardial infarction (MI) at rest. This should be

approved by the physician by a stable EKG at rest and blood enzyme levels declining.

Angina should be stable and not the unstable/uncontrolled form

Following open heart surgery such as coronary bypass graft surgery, heart transplant, or

implantation of a ventricular assist device.

Following a balloon angioplasty or coronary endarterectomy with stent placement of

the transmural coronary arteries.

Heart valve replacement surgery where the myocardium was cut through.

Surgery to correct congenital heart defects that involved incision through the

myocardium.

Sudden cardiac death syndrome

Phase I or with patients in the ICU,CCU or NNICU2

Patient monitoring: the patient is in the hospital intensive care unit (ICU) or coronary

care unit (CCU). They need to be monitored 24 hours a day, both during activity and at rest.

Electronic monitoring through telemetry or wall mounted ECG and other vital functions such as

O2 saturation and ventilation rate are used.

Goals: Minimal assistance levels with activities of daily living. Ideally to allow the patient

to go home (homebound level) with assistance. Ideally the patient should be able to tolerate a

stress level of 2.5 to 3 Mets. They need to be stable at rest to be released to phase II.

Activities: Therapeutic exercise, starting with the lower extremities and progressing to

the upper extremities to permit dressing. Exercise is focused on strength with active and active

assistive exercises. Few repetitions are used with frequent rest breaks. Use a low target 65-75%

of maximal effort. Transfer training bed to chair. Ambulation 10-20 ft. to permit bathroom use.

Patient education can be introduced during rest breaks.

Phase II or with patients that are not in intensive care, they are on a hospital floor such as the

subacute unit or in a skilled nursing facility or at home in a homebound status.3

Indications here can include:

Usually following an ICU stay for cardiac complications

Any cardiomyopathy, damage to the heart muscle by trauma or infection.

Patient monitoring: the patient is home in homebound status or in a subacute unit. The

length of this phase is 4-6 weeks to allow the muscle of the myocardium to heal. Cardiac

monitoring during exercise, not at rest. Vital signs are most often used to monitor, but a pulse

oximeter is now in use as well.

Goals: The patient should be able to tolerate 5-6 Mets by the end of this phase. This will

allow the patient to enter the community, get to outpatient cardiac rehabilitation. This is the

same level that is needed for sedentary work, such as an office job.

Activities: Exercise of both lower and upper extremities with a concentration on

strength. Ambulation of at least 200ft. by the end of this phase. Patient education on their

condition and lifestyle changes. Energy conservation and the solving of problems that are

concerned with their house are addressed during rest breaks.

Phase III Outpatient cardiac rehabilitation4

Indications:

After initial pacemaker insertion or implantable cardiac defibrillator insertion

Angiography or Balloon angioplasty not related to an acute myocardial infarction.

At high risk for coronary disease due to multiple or severe risk factors such as diabetes.

End stage renal disease

Peripheral vascular disease

Cardiac disease that cannot be medically or surgically corrected that is impacting the

patient’s function.

Patient monitoring: During exercise patients are closely monitored by a professional

(usually an exercise physiologist, specially trained nurse or physical therapist [often a

cardiopulmonary certified specialist]). Telemetry is commonly used. Monitoring is done prior to

exercise, during exercise and after exercise to determine recovery time.

Goals: The heart muscle (myocardium should be healed now. Goals here focus more on

improving endurance to enhance the patient’s quality of life. The patient should tolerate their

expected maximal heart rate. They should be able to tolerate the workload as indicated by

their employment or recreational activities that they have been doing. Self-monitoring of vital

signs. This phase terminates when a patient can reliably monitor their own vital signs and

demonstrate that they can increase workloads to an appropriate stress level and recognize

when they are exceeding a targeted training level.

Activities: Exercise (5 times a week) often takes the form of graded exercise testing. The

focus is on improving endurance. Upper and lower extremities are exercised with exercises that

incorporate both to achieve higher workload levels (elliptical trainers and ski machines). Patient

education focuses on teaching the patient to monitor their own vital signs to determine how

much exercise they can tolerate. Education on exercise and diet as a lifestyle change.

Phase IV5

This form of cardiac rehabilitation is not professionally supervised. Here the patient is

able to monitor their own heart rate before, during and after exercise. There are many classes

that a patient can attend or exercise on their own. The best choice is an activity that the patient

likes to do which is within their target training intensity level. This increases compliance with

regular exercise.

Patient monitoring: Here the patient is able to monitor themselves during exercise and

at rest. No professional monitoring is needed. They exercise at a health club or any facility.

Many cardiac rehabilitation programs allow patients that have graduated from phase III to

continue to come and use the equipment, although they are not monitored. The YMCA has

developed programs for this phase of cardiac rehabilitation.

Goals: are to maintain (3 times a week) or improve (5 times a week) cardiac muscle

function. Improvement may be needed if a patient cannot tolerate a workload, or stress level

that is required by either a job or recreational activity that they need to or want to participate.

Activities: are focused on aerobic activities that are integrated into a patient’s lifestyle.

They may be seasonal sport activities or cross training types of exercise programs that interest

a patient. Compliance is a major factor in selecting good activities. When a patient participates

in the activity their heart rate should be within a training level for at least 20 minutes.

(Reference: ACSM, (2010), ACSM’s Guidelines for Exercise Testing and Prescription, 8th edition.

P. 209)

The NPTE will focus more on phase I and II cardiac rehabilitation as entry level

therapists are commonly involved in these phases. To treat a patient with cardiac precautions,

even with another diagnosis, the phase II of cardiac rehabilitation should be used to ensure a

safe and effective treatment. Geriatric patients, infants and those with anemia, neurological

impairments and pulmonary dysfunction should use this concept. Aerobic and anaerobic

elements should be addressed in all treatment plans.

Calculations:

The maximal heart rate is calculated by computing 220- the patient’s age.

A target heart rate is calculated by using Karvonen formula

Target heart rate = [(heart rate maximal - heart rate at rest) X % intensity] + heart rate

at rest. Generally, for most patients that are in the early phases of cardiac rehabilitation an

intensity percentage of 60-70 % is used. In outpatient rehabilitation with professional

monitoring a higher 80-95% can be used, this causes endorphin production that will reward the

patient for their effort and lead to better compliance and more likely a lifestyle change.6

Graded exercise:

Principles to follow:

Initially use low intensity work load

o Start with smaller muscle groups and progress to larger muscle groups

o Start with lower extremity exercise first as this does not affect the barrow

receptors as greatly so vital signs will elevate more slowly

o Start in supine and progress to sitting then standing

Functional activities have lesser and greater workloads

o Start in supine with bed mobility progress to sitting then standing and finally

walking

Give at least 5 minutes before increasing the workload to allow them to adjust to the

demand on the cardiopulmonary system.

o Monitor vital signs and O2 saturation levels at least every 5 minutes during a

treatment session

o Use current vital signs to make the decision to advance to the next level of

workload

o Use Karvonen formula to calculate a target heart rate

Conducting a treatment session with cardiac precautions:

Initial baseline vital signs (heart rate, respiratory rate, blood pressure and sometimes

oxygen saturation) should be measured.

Make decision to exercise if vital signs are within parameters that will allow for safe

exercise.

Calculate target heart rate for the exercise session.

o Initial intensity should be low. Duration to steady state (5-7 minutes of

contentious exercise). Patient history should indicate what intensity has been

tolerated previously which serves as a guide on what intensity to start. It is

recommended that the intensity should be at least a level below the level that

the patient previously tolerated.

Observe the patient during exercise for signs of intolerance (Stridor, the use of

accessory muscles of respiration, skin color or diaphoresis (excessive sweating)

decreasing level of consciousness or complaints of chest and/or arm pain).

Retake the vital signs to determine patient tolerance.

o Make a decision to increase exercise intensity if the vital signs are within

expected parameters.

This process is repeated until the goal of the treatment has been achieved.

Low target intensity levels (65-75% of maximal effort) are safer in that it is unlikely to

exceed maximal heart rate that is determined through calculation of the maximal expected

heart rate or better from a maximal stress test.

High target intensity levels are 85-95% of maximal effort. Using this level will gain

better patient compliance, but are not as safe to use.

Monitoring a Patient

The therapist needs to know how to monitor a patient’s vital signs and what is expected

as a normal and abnormal reaction to a stressful work load. This is used to adjust the work

load so that an effective treatment is accomplished.

An example is initial ambulation or a patient immediately after a myocardial infarction.

GUIDELINES FOR HELPING PATIENTS RESUME WALKING SOON AFTER

MYOCARDIAL INFARCTIONS7

Before Exercise

Ask about chest discomfort, dyspnea, and faintness (if present, check with physician before

proceeding).

Measure blood pressure and heart rate (if greater than160/100 or less than 90/60 mm Hg or if

heart rate is greater than110 or less than 60 bpm, check with physician before starting)

Check orthostatic blood pressure before beginning standing range-of-motion exercise or

walking. If blood pressure falls more than 20 mm Hg or if fall is associated with symptoms of

faintness, have patient lie down and notify physician.

During Exercise

Ask patient to report symptoms, particularly chest discomfort, dyspnea, or faintness. If

symptoms occur, discontinue exercises until checking with physician.

Ask for rating of perceived exertion.

Immediately After Exercise

Ask patient about symptoms.

Measure heart rate, blood pressure, and rating of perceived exertion. If symptoms occur,

blood pressure falls more than 20 mm Hg, or heart rate rises more than 20 bpm over resting

rate, check with physician before continuing.

Response to Stress/Exercise

As a patient begins to exercise vital signs normally change. Accommodation to a

workload takes up to 3-5 minutes normally, but with debilitated patients it may take up to 7

minutes. If it is longer than 7 minutes it may mean that the patient should not be exercised.

After an exercise session, or functional mobility training, vital signs should be checked

again (5-7 minutes) to see if they tolerated the treatment. If their vital signs are not near the

starting vital sign levels after treatment it means that they did not tolerate the treatment.

Initially all patients with any cardiopulmonary involvement should be treated as if they

have a cardiopulmonary problem. If after several treatments, you see that the vital signs are

responding as expected you can just take vital signs before and after treatment.

Monitoring the cardiopulmonary status of a patient

To adequately monitor a patient using vital signs the therapist must know what changes

and when it changes in response to exercise or functional training. With this knowledge you can

spot if there is an abnormal response indicating that the intensity of the activity is too great for

it at this time.

Patients with cardiac precautions should have their vital signs taken before, during

treatment every time the intensity is to be increased or every 5 minutes and after exercise to

see if they tolerated the treatment.

All patients with diagnoses and secondary diagnoses that can lead to cardiopulmonary

problems should have their vital signs assessed at the beginning, and end of treatment.

All patients should have their vital signs assessed in their initial assessment.

Response to Exercise

Period Factor Expected

Response

to

Exercise

Normal

Maximum Values

Danger Signs

Initial 30

seconds

Increased

tidal

volume

Increases Facial grimace with

sub sternal retractions

May decrease when

other factors

accommodate



Response

to

Exercise

Normal

Maximum Values

Danger Signs

30-60 seconds Increased

respirations

Increases Adult

normal 12

Maximum 30

Infant 40- 60

Child under 3 years

20-30

Child over 3 years

15-20

Adult

Abnormal greater

than 30, less than 6

May slightly decrease

when other factors

(HR and cardiac

output)

accommodate to

workload

Infant

Abnormal high more

than 60

Abnormal low less

than 40

Child under 3 years

Abnormal high more

than 30

Abnormal low less

than 20

Child over 3 years,

less than 15 years

Abnormal more than

20

Abnormal less than

15



Response

to

Exercise

Normal

Maximum Values

Danger Signs

First Minute Ventilation

output

Increases Initially increases

then may slightly

decrease when other

factors

accommodate

60-120 seconds Increased

stroke

volume

Systolic

blood

pressure

increases

Adult

Rest 120 mmHg

Maximum 280

mmHg

Infant 60-90 mm

Hg

Child under 3 years

75-130 mm Hg

Child over 3

years 90-140 mm

Hg

Adult

Abnormal Less

than 100

mmHg

Greater than 280

mmHg

Falling with increased

work load

Infant

Abnormal high more

than 90 mmHg

Abnormal low less

than 60 mmHg

Child under 3 years

Abnormal high more

than 130 mmHg

Abnormal low less

than 75 mmHg

Child over 3 years

Abnormal more than

140 mmHg

Abnormal less than

90 mmHg



Response

to

Exercise

Normal

Maximum Values

Danger Signs

Over 1 minute Increased

heart rate

Increases Adult normal 80

BPM

Maximum 220

BPM

Infant 120-200

BPM

Child under 3

years 100-180

BPM

Child over 3 years

70-150 BPM

Adult

Greater than 220

BPM

Less than 60 BPM

Infant

Abnormal high more

than 200 BPM

Abnormal low less

than 120 BPM

Child under 3 years

Abnormal high more

than 180 BPM

Abnormal low less

than 100 BPM

Child over 3 years

Abnormal more than

150 BPM

Abnormal less than

70 BPM

Pulse

Stroke

volume +

Heart Rate

Increases

pulse

pressure =

systolic BP

-diastolic

Adult

40 mmHg

All patients Falling

with increased work

over 10 mmHg is

significant

BP



Response

to

Exercise

Normal

Maximum Values

Danger Signs

Steady state:

at 2.5 - 3

minutes

Diastolic

blood

pressure

No change Adult 80 mmHg

Infant 30-60

mmHg

Child under 3

years 45-90 mmHg

Child over 3

years 50-80

mmHg

Maximum 100

mmHg

Abnormal

CNS response is

falling or elevating

Over 90-100 mmHg

Change greater than

10 mm Hg

Abnormal Adult less

than 50 mmHg

greater than 90

mmHg

Infant

Abnormal high more

than 60 mmHg

Abnormal low less

than 30 mmHg

Child under 3 years

Abnormal high more

than 90 mmHg

Abnormal low less

than 45 mmHg

Child over 3 years

Abnormal more than

80 mmHg

Abnormal less than

50 mmHg

Target Range:

Target ranges are used to maintain a specific training intensity or workload. Active

exercises should have the intensity level set to a target range. The target is 65% to 90% of a

patient’s maximal effort. To determine a specific level a maximal effort must be first

determined. Studies have shown that there is not a significant difference in the adaptation of

tissue (gains) due to training at either 65 or 90% of a patient’s maximal effort. Since 65 to 90 %

is a large range the consideration of safety or motivation needs to be considered.

Training at 65% is safer (debilitated patients can be started at as little as 40% of maximal

effort) in that there is a considerable range that would have to be bridged for a patient to

exceed 100% and cause additional tissue damage. The problem is that training at 65% is not

motivating to the patient as little stress is felt by the patient, thus they would not gain a sense

of accomplishment.

Physiologically there is little to no additional endorphin release in response to this low

intensity level of exercise. Exercising at 90% of maximal level does provide the patient with a

sense of accomplishment of overcoming a stress, thus is motivating. In addition a significant

amount of endorphins are produced so that the patient is better satisfied with their

performance.

Aerobic activities that are popular among people with heart failure are walking and

stationary cycling. Remember to first exercise at low intensity. They can gradually increase the

intensity and duration of the exercise sessions as long as the tolerance improves with no

symptoms. Teach patients to listen to their body.

An example of a walking and cycling program for people with heart failure is shown below.

Aerobic Exercises8

Mode Intensity Duration Frequency Progression

Walking Slow to moderate

pace

RPE: 11 to 14

THR: 40% to

70% of HR max

Until tolerance if

asymptomatic

Interval training

Exercise 1 to 6

min.

Rest 1 to 2 min.

Total exercise

time

10 to 20 min.

3 to 7 days a

week

5 -7 times a week

to improve

aerobic capacity.

3 times a week to

maintain aerobic

capacity

Gradual increase

in duration starts

at 7-15 minutes

and increases to

20-30 minutes

Gradual increase

in intensity; RPE:

11 to 14

Aerobic Exercises

Mode Intensity Duration Frequency Progression

Cycling

(stationary)

Little to moderate

resistance

Comfortable revs

per min. RPE: 11 to

14

THR: 40% to

70% of HR max

Until tolerance if

asymptomatic

Interval training

Exercise 1 to 6

min.

Rest 1 to 2 min.

Total exercise

time

10 to 20 min.

3 to 7 days a

week

5 -7 times a week

to improve

aerobic capacity

3 times a week to

maintain aerobic

capacity

Gradual increase

in duration

Gradual increase

in resistance;

RPE: 11 to 14

Stop exercising if the patient experience angina (chest pain or discomfort), shortness of

breath, unexplained dizziness, or significant pain or discomfort.

GUIDELINES FOR EXERCISE and EXERCISE TESTING

Metabolic equivalents (METs) are workloads. This is the stress that is put upon a patient

to do an activity or exercise.

1 MET=3.5 ml O2 / ml per minute

1 MET= 1 kcal / kg per minute

1 L O2 / min = 5 kcal

MET VALUES OF COMMON PHYSICAL ACTIVITIES CLASSIFIED AS LIGHT, MODERATE, OR

VIGOROUS INTENSITY8

LIGHT (<3 METs) MODERATE (3-6 METs) VIGOROUS (> 6 METs)

Walking Walking Walking, jogging, and

running

Walking slowly around

home, store or office =

2.0a

Household level ambulation

Walking 3.0 mph = 3.0a

Walking at very brisk pace (4

mph) = 5.0a

Community level ambulation

Walking at very, very brisk

pace (4.5 mph) =

6.3a

Walking/hiking at

moderate pace and grade

with no or light pack (<10

pounds) = 7.0

LIGHT (<3 METs) MODERATE (3-6 METs) VIGOROUS (> 6 METs)

Household and occupation Household and occupation Household and

occupation

Sitting - using computer,

work at desk, using light

hand tools = 1.5

Standing performing light

work, such as making bed,

washing dishes, ironing,

preparing food or store

clerk = 2.0 - 2.5

Cleaning, heavy washing -

windows, car, clean garage =

3.0

Sweeping floors or carpet,

vacuuming, mopping = 3.0 -

3.5

Carpentry - general = 3.6

Carrying and stacking wood =

5.5

Mowing lawn - walk power

mower = 5.5

Shoveling sand, coal, etc.

= 7.0

Carrying heavy loads, such

as bricks = 7.5

Heavy farming, such as

bailing hay = 8.0

Shoveling, digging ditches

= 8.5

Leisure time and sports Leisure time and sports Leisure time and sports

Arts and crafts, playing

cards = 1.5

Billiards = 2.5

Boating - power = 2.5

Croquet = 2.5

Darts = 2.5

Fishing - sitting = 2.5

Playing most musical

instruments = 2.0 - 2.5

Badminton - recreational = 4.5

Basketball - shopping around =

4.5

Bicycling on flat - light effort

(10-12 mph) = 6.0

Fishing from riverbank and

walking = 4.0

Dancing - ballroom slow = 3.0.

ballroom fast = 4.5

Golf - walking pulling clubs =

4.3

Sailing boat, wind surfing =

3.0

Swimming leisurely = 6.0b

Table tennis = 4.0

Tennis doubles = 5.0

Volleyball - noncompetitive =

3.0 - 4.0

Basketball game = 8.0

Bicycling on flat

moderate effort (12-14

mph) = 8 fast (14-16

mph) = 10

Skiing cross country slow

(2.5 mph = 7.0) fast (5.0 -

7.9 mph = 9.0)

Soccer - casual = 7.0

competitive = 10.0

Swimming -

moderate/hard = 8 - 11b

Tennis singles = 8.0

Volleyball – competitive at

gym or beach = 8.0

MET metabolic equivalent, MPH miles per hour

*On flat, hard, surface

*MET values can vary substantially from person to person during swimming as result of

different strokes and skill level.

Pulmonary system

The pattern of

distribution of the lobes

is important in

pulmonary and thoracic

surgery along with

drainage of specific

lobes of the lung.

Breathing Strategies

Coughing - Clearing of sputum from the trachea, bronchus and bronchioles.

Huffing - Clearing of the larynx.

Pacing - The rate and depth of respiration affecting both gas exchange and the clearing of

sputum.

Positions to Improve Ventilation and Oxygenation:9

Positioning of the patient is used to improve either ventilation (air), with that area positioned

upwards or perfusion (blood flow) with the area to be treated positioned downwards.

RESPIRATORY DISEASES: Positional Treatment

Disease Lung Tissue

Involved

Pathology Treatment and Position

Bronchitis Membrane lining

bronchial tubes

Inflammation of

lining of the bronchus

Removal of mucus

Gravity independent to increase ventilation.

Gravity dependent to facilitate drainage (removal of mucus).

Bronchiectasis Bronchial tubes

(bronchi or air

passages)

Bronchial dilation with inflammation.

Action of the cilia to

move mucus is

decreased.



Pneumonia Alveoli (air sacs) Causative agent

invades alveoli with

resultant outpouring

from lung capillaries

into air spaces and

continued healing

process

Acute phase: Gravity independent position during acute infection.

Sub-acute phase: Gravity

dependent to facilitate

drainage during the

subacute phase, when

the patient’s body

temperature is not

elevated.

Emphysema Air spaces beyond terminal bronchioles

(alveoli)

Breakdown of

alveolar walls.

Air spaces are

enlarged.




Disease Lung Tissue Involved Pathology Treatment and Position

Asthma Bronchioles (small

airways)

Bronchioles obstructed by: Muscle spasm

Swelling of mucosa

Thick secretions

In a gravity independent position.

The patient should use

purse lipped breathing.

Cystic

Fibrosis

Bronchioles Bronchioles become

obstructed and obliterated.

Later, larger airways

become involved.

Plugs of mucus cling to

airway walls, leading

to:

Bronchitis

Bronchiectasis

Atelectasis

Pneumonia

Pulmonary abscess




Disease Lung Tissue

Involved

Pathology Treatment and Position

Atelectasis Lung Rupture of pleural sac causing collapse of the lung

This causes air to escape

into the pleural space.

Chest tube on the involved side to allow air to escape out of the pleural space to the environment.

Position the patient on

the uninvolved side to

allow air to escape. This

allows the lung to

gradually heal and seal

(48-72 hours), then

inflate.

Pneumothorax Lung Air entering the pleural

space collapsing the

lung.

Chest tube on the involved side to allow air to escape out of the plural space to the environment.



allow air to escape. This

allows the lung to

gradually heal and seal

(48-72 hours), then

inflate.

Hemothorax Lung Fluid enters the pleural

space and puts pressure

on the lung, decreasing

its ability to inflate.

Chest tube on the involved side to allow fluid to escape out of the pleural space.



allow fluid to escape. This

allows the lung that is

pressured to gradually re-

inflate.

Structural Weakness:

Diastasis recti (also known as abdominal separation) is commonly defined as a gap of around

2.7 cm or greater between the two sides of the rectus abdominis muscle.

The distance between the right and left rectus abdominis muscles is created by the stretching

of the linea alba, a connective collagen sheath created by the aponeurosis insertions of the

transverse abdominis, internal oblique, and external oblique.

This follows pregnancy or abdominal surgery that is in midline. Ventral hernias may occur

anywhere in the abdominal walls. Inguinal hernias are also common, and are often caused by

lifting. Male patients may also herniate into the scrotum. With all of these conditions lifting is

contraindicated as is anything that increases abdominal pressure.

Significant separation is 2.5 cm. This is a contraindication for abdominal exercises. Problems

are a weak cough and decreased support of the spine.

Coughing is less effective in tracheal intubated patients; coughing ability can be improved by

manual support of the patient’s incision; stomas following tracheal tube removal should be

covered with an airtight dressing to improve cough efficiency; an effective cough must be

preceded by a large inspiration. Some methods of cough stimulation, including “huffing,”

vibration (of larynx), summed breathing, external tracheal compression and oral pharyngeal

stimulation (gag), are used.

Steps:

Inspiratory gasp.

Closing of the glottis.

Contraction of expiratory muscles. The internal intercostal muscles and the abdominal

muscles.

Opening of the glottis.

The patient should be cautioned to avoid bronchospasm that can be induced by

repetitive coughing.

Patients need strong muscles to produce a productive cough.

Huffing

Huffing is clearing the throat by low

frequency vibration of the larynx. This

propels mucus past the vocal cords through

the epiglottis to the esophagus.

This is accomplished by the muscles that

control the vocal cords along with the

muscles involved in the latter phases of

swallowing.

Bronchial Drainage Techniques

Pulmonary Drainage

Pulmonary drainage is used to remove secretions that the patient cannot remove on

their own.

Pulmonary Drainage Precautions:

Hemorrhage- Especially involving the lungs

In the presence of pulmonary edema including edema from left side heart failure.

Uncontrolled blood pressure or cerebral spinal pressure including intra-cranial swelling

(gravity dependent position of the head is contraindicated). Even with controlled

conditions vital signs must be monitored.

Untreated or Undiagnosed Conditions Contraindications

Left side CHF (congestive heart failure)

Pulmonary embolism

Pneumothorax

Hemothorax.

If these conditions are present:

Any condition where a cough is an irritant such as a vertebral disk lesion

Any condition where blood pressure elevation is a problem- heart or neurological

Any condition that the bones of the thorax are at risk

Tumor in the lungs or, fracture, osteoporosis, surgery in the thorax.

To prepare to perform postural drainage:

First auscultate the lungs to:

Identify the lobes that are congested but mobile. You should hear rhonchi to indicate

mobile secretions

Listen for rales that indicate pulmonary edema, if heard postural drainage should not be

done.

Contraindications:

The Trendelenburg Position with the head lower than the trunk are termed and are

contraindicated in the presence of:

Pulmonary edema, and increased blood pressure or increased inter-carinal pressure.

Gastrointestinal problems such as esophageal reflux and hiatal hernia or nausea

eliminate use of this position. Pulmonary drainage should not be done on a patient with

a full stomach.

Side lying positions may also be cautioned in patients with vascular or skeletal

problems.

The pulmonary drainage position places a patient in a position that improves ventilation

of the lobe that is specified, because it is placed in a gravity independent position.

This position also increases the perfusion of the lobes that are placed into a more

dependent position.

Pulmonary Drainage

Area to be Drained Supporting

Surfaces

Patient Position Contact Area for

manual/mechanic al

techniques

1. Upper Lobes

Apical segments

Bed or drainage table

flat

Displaced 30 deg.

Posterior

Percussion between top of scapula and clavicle

2. Upper Lobes

posterior segments

Bed or drainage table

flat

Displaced 30 deg.

Anterior Percussion over

upper back, both

sides

3. Right Middle

Lobes

Foot Elevated 1530

deg

Side lying Left

Roll 1/4 turn posterior

Percussion over

Right Nipple, or

lateral with female

4. Left Upper

Lobes

Lingulae segments

Foot Elevated 1530

degrees. 16 inches

Side lying right, 1/4

turn posterior

Percussion over left

nipple, or lateral

under armpit

5. Lower Lobes

lateral Basal

segments

Foot elevated 3045

degrees. 20 inches

Prone, 1/4 turn

posterior, support

upper leg with a pillow

Percussion over the

upper part of the

lower ribs, both

sides

6. Lower Lobes

posterior basal

segments

Foot elevated 3045

degrees, 20 inches

Prone, pillow support

under hips

Percussion over

lower ribs close to

spine, both sides

7. Upper lobes

anterior segments

Flat Supine with pillow

under knees

Percussion between

clavicle and nipple

8. Lower lobes

anterior basal

segments

Foot elevated 3045

degrees, 20 inches

Side lying, head down,

involved hip in neutral

Percussion over the

lower lateral ribs

9. Lower lobes

superior segments

Flat Prone, arms above

head, and 6 inch

support under hips

Percussion over upper to middle back t the tip of the

scapula

The goal of pulmonary drainage is to position the pulmonary tree, the bronchus, to

allow gravity to drain that lobe.

Techniques:

Gravity is used by positioning the patient appropriately to facilitate the lobe involved.

Pulmonary drainage may be augmented with manual/mechanical techniques:

Percussion, vibration, or shaking to loosen secretions within the airways.

If the patient uses a Nebulizer, this treatment should be given just prior to pulmonary

drainage. Positions may sometimes be substituted if a patient cannot assume the normal

position for a specific lobe.

To drain the anterior lobes a supine position could be used. When doing this the time of

drainage needs to be doubled to compensate for the decreased drainage angle.

To drain the posterior lobes a prone position could be substituted.

To drain the apical lobes standing against a support such as a tilt table could be

substituted for sitting.

Manual/Mechanical Techniques

Mechanical Devices to Loosen Secretions

Percussion and Vibration are used to loosen secretions from the walls of the

bronchioles, bronchus and tracheae.

Installation

The NPTE may ask questions dealing with the introduction of medications to the

pulmonary tree. Not a huge favorite, but there are always one to three questions from this

area on each exam.

Suctioning is used to remove sputum from the trachea and main stem bronchus

Medications are introduced through aerosol, vaporizer or Nebulizer treatments. These

medications that a physical therapist might use in conjunction with other pulmonary

treatments either thin secretions or relax airway restrictions.

Nebulizer treatments use a medication (steroids, beta blockers or thrirozides)

suspended in a saline mist, which also adds moisture to the secretions.

Positive Expiratory Pressure (PEP) Positive Expiratory Pressure, or PEP, is a small device that a patient exhales into, using a mask. PEP is

also called PEP Therapy, PEP Mask or TheraPEP.

These devices use a face mask that provides 20-30 mmHg of resistance pressure to expiration.

This pressure expands the airway diameter thus letting secretions flow better. Usually 8 to 10

breaths are used followed by a cough or huff to clear the airway.

Percussion

These devices can be set a specific pressure and frequency. The pressure needs

to be less than 20 psi or pounds per square inch to prevent damage to the skin

or ribs.

Thicker the secretions the lower the frequency of percussion should be. The

frequency range is from 10 to 40 cycles per second.

These devices or techniques are employed when coughing or suctioning,

breathing exercises, and patient mobilization are not adequate to clear retained

secretions.

They are used as an adjunct to postural drainage for mobilization of secretions.

They may not be performed in the presence of rib fractures, chest tubes and

subcutaneous emphysema; should produce a hollow sound; should not cause

undue pain; does not need to be forceful to be effective if performed properly.

Cautions and Precautions:

The manual technique uses rhythmic clapping of cupped hands

over bare skin or thin material covering the skin in the area of lung

involvement; performed during inspiration and expiration.

Avoid redness or petechial of skin (which indicates improper hand

or device positioning by therapist or patient coagulopathy).

The use on patients with rib, thoracic vertebral pathology is

contraindicated.

The use in the treatment of patients that are taking blood thinning

medications or have a decrease in blood clotting time are strongly

cautioned.

Vibration

These devices can be set to a specific pressure and frequency.

The pressure needs to be less than 20 psi or pounds per square inch to prevent damage

to the skin or ribs. The thicker the secretions the lower the frequency of percussion

should be.

The frequency range is from 10 to 40 cycles per second.

These devices or techniques are employed when coughing or suctioning, breathing

exercises, and patient mobilization are not adequate to clear retained secretions.

They are used as an adjunct to postural drainage for mobilization of secretions.

This may not be performed in the presence of rib fractures, chest tubes and

subcutaneous emphysema; should produce a hollow sound; should not cause undue

pain; does not need to be forceful to be effective if performed properly.

Suctioning

Suction is used to remove secretions

from the larger airways. In intubated

patients, suctioning is performed routinely

and is an integral part of chest therapy;

frequency of suctioning is determined by the

quality of secretions.

Tracheal suctioning are used only on

patients who have an artificial airway in

place.

The suctioning procedure should be

limited to a total of 15 seconds; the suction

catheter can reach only to the level of the

main-stem bronchus; it is more difficult to

cannulate the left main-stem bronchus than

the right due to its angle and relative

distance from the carina.

Nasotracheal suctioning should be

avoided.

To perform suctioning use aseptic technique. Sterile technique is preferred as it reduces the

risk of inducing infection into the lungs.

Steps:

Provide supplemental oxygen

Insert suction catheter without applying suction, as fully as possible; be gentle.

Apply suction only while withdrawing the catheter.

Let the lungs re-expand by letting the patient breath for a minute or re-expand lung

with mechanical ventilator or manual inflation by resuscitator with a bag attached to

tracheal tube.

Avoid hypoxemia (cyanosis and significant changes in vital signs) and cardiac

dysrhythmia, mechanical trauma and bacterial contamination of tracheobronchial tree,

and increase in intracranial pressure.

Breathing Strategies

Cough

Cough is the most important function relating to the hygiene of the pulmonary system.

The processes that cleanse the lung are first sputum production by glands within the lungs,

then movement of this sputum upwards from the alveoli to the trachea then a cough to clear

the larynx. Obstructive pulmonary disease is caused by failure of these systems and or

narrowing of the airways. The scope of practice of a physical therapist focuses on treatment of

musculoskeletal system. This is the focus of questions on the NPTE.

A productive cough is a cough that produces an expectorant (sputum). Nonproductive coughs

occur when the sputum is either too thin (pulmonary edema) or too thick (cystic fibrosis) to be

removed.

The muscles that provide a cough are the muscles of forced expiration. A lack of a

strong or ineffective cough prevents the patient from effectively clearing secretions allowing

for an increased risk of infection.

Muscles of Expiration:

R

Rectus Abdominis

Acts to flex the trunk,

especially the lumbar area

(posterior pelvic tilt), and

stabilize the trunk for cervical

flexion.

Transverse Oblique

Acts bilaterally to flex the

trunk and unilaterally to side

bend the trunk to the

ipsilateral side.

Internal Oblique

Acts bilaterally to flex the trunk and unilaterally to side bend the trunk and rotate to the same

side.

External Oblique

Acts bilaterally to flex the trunk and unilaterally to side bend the trunk and rotate to the

opposite side.

Surgical procedures that affect the delivery of therapy

Thoracotomy is a surgical incision into the chest wall. It is used to access the heart and is done

in patients who have:

Coronary artery bypass graft

Lung, heart or lung and heart transplant

A left ventricular pump installed

Here the sternum is divided and usually several ribs are fractured during surgery. The

therapist should use sternal precautions for at least the first 4 weeks. These patients also will

have chest tubes for a pneumothorax for the first few days until the lungs inflate and for a

hemothorax for about 2 weeks after surgery.

Rib fractures. Flail chest and a patient that had closed chest compressions (CPR) are likely to

have rib fractures so sternal precautions are indicated.

Arterial incisions. Patients that have undergone a balloon angiogram or angioplasty

(endarterectomy and stint placement) have had an incision to access a major artery. In this

case the location of the incision should not be moved for 72 hours to allow the wound to heal.

Also blood pressure should not be raised. This means exercise, except passive range of motion

should be held along with functional training.

Medications

Cardiac medications often have effects both on the heart and the arteries so you need to be

aware of all the effects. You are likely to see either a generic or trade name, what is common

on a patient’s medication bottle or list.

Calcium channel blockers

These decrease blood pressure quickly and also decrease the irritability of the heart, thus

control fast arrhythmia. When a patient has first started these medications they may

experience orthostatic hypotension, which can lead to syncope and falls. They also can cause

slight muscle weakness.

Side effects:

Cardiovascular: o Palpitations which is a sign of arrhythmia o Swollen ankles which is a sign of right sided heart failure

Gastrointestinal o Constipation

Neuromuscular These are also symptoms of cerebral hypotension that can lead to syncope

o Headache o Dizziness

Generic name Common brand names

Amlodipine besylate Norvasc*, Lotrel*

Bepridil Vasocor*

diltiazem hydrochloride Cardizem CD*, Cardizem SR*, Dilacor XR*, Tiazac*

Felodipine Plendil*

Isradipine DynaCirc*, DynaCirc CR*

Nicardipine Cardene SR*

Nifedipine Adalat CC*, Procardia XL*

Nisoldipine Sular*

verapamil hydrochloride Calan SR*, Covera HS*, Isoptin SR*, Verelan*

Beta blockers

Beta blockers such as Inderal is used to prevent sudden increase in blood pressure. They also

prevent a sudden rise in heart rate. When exercising a patient on these medications will not

experience a rise in heart rate or systolic blood pressure. Since heart rate is the major way of

showing the intensity of exercise, other ways need to be used to show the tolerance of exercise

or functional training. The rate of perceived exertion and the BORG scale will provide you with

a subjective picture of the intensity of a treatment. It is better to look at the oxygen saturation

level because it is a more objective measure in most patients unless they have undergone

training on the subjective scales. The therapist should still check vital signs as a decrease in

blood pressure or heart rate still indicate intolerance.


Acebutolol Sectral*

Atenolol Tenormin*

Betaxolol Kerlone*

Bisoprolol fumarate Zebeta*

Carteolol hydrochloride Cartrol*

Metoprolol tartrate Lopressor*

Metoprolol succinate Toprol-XL*

Nadolol Corgard*

Penbutolol sulfate Levatol*

Pindolol* Visken*

propranolol hydrochloride* Inderal*

Solotol hydrochloride Betapace*

Timolol maleate* Blocadren*

Combination beta-blocker/diuretic Side effects:

Neuromuscular o Insomnia o Tiredness or depression

Cardiovascular o Cold hands and feet, a symptom of left sided heart failure o Slow heartbeat, bradycardia o Impotence may also occur

Pulmonary o Symptoms of asthma

If they have diabetes and are taking insulin, their responses to therapy should be monitored closely.

Pregnancy. If they have been prescribed beta-blockers, they should consult their healthcare provider as soon as possible to determine the safest medication at this time.

Hydrochlorothiazide and bisoprolol Ziac*

Ace inhibitors

These medications gradually lower blood pressure, but it can take 6-9 months to start to be

effective. They relax and allow the arterial walls to atrophy which undoes some of the damages

that the high blood pressure caused. To be maximally effective it may take 2 years or more.

Usually they are started along with a calcium channel blocker to initially control the

hypertension thus decreasing the damage and decreasing the associated risk factors for stroke,

myocardial infarction and renal failure.

The therapist treating a patient should always monitor blood pressure at the start of

each therapy session as they are at risk for developing hypotension. If they are found to

develop hypotension they should be referred to a physician.


Benazepril hydrochloride Lotensin*

Captopril Capoten*

Enalapril maleate Vasotec*

Eosinophil sodium Monopril*

Lisinopril Prinivel*, Zestril*

Moexipril Univasc*

Perindopril Aceon*

quinapril hydrochloride Accupril*

Ramipril Altace*

Trandolapril Mavik*

Side effects often prevent their continued use in many patients:

Pregnancy: These drugs have been shown to be dangerous to both mother and baby

during pregnancy. They can cause low blood pressure, severe kidney failure, excess

potassium and even death of the newborn.

Most common problems:

Skin rash

Loss of taste

Chronic dry, hacking cough

In rare instances, kidney damage

Diuretics

For a therapist there are two classes, those that are not potassium sparing, where you need to

be checking for signs of abnormal potassium levels (usually too low) and those that spare the

potassium. These drugs lower blood pressure and are used to decrease excess water to treat

edema, commonly from heart failure.

If the patient is taking digitalis and a diuretic, they have a significant chance of heart failure. In

this case you should decrease the intensity of treatments that increase the cardiac work load. It

is also unlikely that they will progress to the point that they can tolerate an age appropriate

work load.

These drugs cause the kidneys to excrete excess sodium and usually potassium as well. They

remove water thus placing a patient at risk for dehydration.


Chlorthalidone Hygroton*

Chlorothiazide Diuril*

Furosemide Lasix*

Hydrochlorothiazide Esidrix*, Hydrodiuril*, Microzide*

Indapamide Lozol*

Metolazone Mykrox*, Zaroxolyn*

Potassium sparing diuretics, there is no increased risk of hypokalemia

Amiloride hydrochloride Midamar*

Spironolactone Aldactone*

Triamterene Dyrenium*

Side effects:

Neuromuscular and musculoskeletal system: Some of these drugs may decrease your

body's supply of potassium. Symptoms such as weakness, leg cramps or fatigue may

result. Eating foods containing potassium may help prevent significant potassium loss.

Many patients are also placed on a potassium supplement to prevent potassium loss.

Diuretics such as amiloride (Midamar)*, spironolactone (Aldactone)* or triamterene

(Dyrenium)* are called "potassium sparing" agents. They don't cause the body to lose

potassium. They might be prescribed alone, but are usually used with another diuretic.

Some of these combinations are Aldactazide*, Dyazide*, Maxzide* and Moduretic*.

Musculoskeletal system: Some patients may suffer from attacks of gout after prolonged

treatment with diuretics. This is a side effect of dehydration.

Endocrine system: Patients with diabetes may find that diuretic drugs increase their

blood sugar level. Again this is a side effect of dehydration. A change in medication,

diet, insulin or oral anti-diabetic dosage corrects this in most cases.

Vascular due to low blood pressure Impotence may occur.

Nitroglycerine (nitrates)

This is used as a vasodilator to relieve chest pain (angina), reduce blood pressure and the work

load on the heart. A therapist needs to understand the two common forms.

The short acting form which is a tablet that the patient should be carrying with them.

o When they start to feel chest pain they should stop activity and sit.

o If the chest pain continues, over 5 minutes, they should place a tablet under the

tongue, while seated with adequate support.

o The effect of the nitroglycerine peaks within 2-3 minutes and their chest pain

should be relieved.

o If the pain is not relieved after 5 minutes they should take another nitroglycerine

tablet.

o If they have used 4 tablets and still have chest pain it is considered to be a

myocardial infarction instead of angina so activate the emergency medical

system.

Nitroglycerine effect on vital signs.

o Vasodilation should cause a drop in the diastolic blood pressure, they can

experience dizziness and syncope with this.

o The heart rate should increase significantly which decreases the cerebral

hypotension and the dizziness.

o They should develop a headache. This is a normal side effect of the

nitroglycerine.

Patch or cream nitroglycerine is used for long term administration of nitroglycerine. It

can be used to treat unstable angina. The most common side effect is a skin rash.

o If a patient wearing a patch develops chest pain when exercising, do not use the

activity intensity that caused the chest pain until you consult with the physician.

References

1. Cardiac Rehabilitation: Overview, History and Definition of Cardiac Rehabilitation, Patient Selection and Risk Stratification. March 2016. http://emedicine.medscape.com/article/319683-overview?pa=v1Jn6oFFsNcZo0bY7AAcAChI2Jn1uLsRz0CsEUtMfcC%2Ba%2BSJfhX%2Fp%2Bu7TTF9a295LCEJNCrbkqLWYvqLrhntWA%3D%3D. Accessed November 11, 2016.

2. de Macedo RM, Faria-Neto JR, Costantini CO, et al. Phase I of cardiac rehabilitation: A new challenge for evidence based physiotherapy. World J Cardiol. 2011;3(7):248-255. doi:10.4330/wjc.v3.i7.248.

3. Pinto BM, Goldstein MG, Papandonatos GD, et al. Maintenance of exercise after phase II cardiac rehabilitation: a randomized controlled trial. Am J Prev Med. 2011;41(3):274-283. doi:10.1016/j.amepre.2011.04.015.

4. Seki E, Watanabe Y, Shimada K, et al. Effects of a phase III cardiac rehabilitation program on physical status and lipid profiles in elderly patients with coronary artery disease: Juntendo Cardiac Rehabilitation Program (J-CARP). Circ J Off J Jpn Circ Soc. 2008;72(8):1230-1234.

5. Woolf-May K, Bird S, MacIntyre P. Physical activity levels during phase IV cardiac rehabilitation in a group of male myocardial infarction patients. Br J Sports Med. 2005;39(3):e12. doi:10.1136/bjsm.2003.010983.

6. PT SHRS, FAHA SLWPPF, OCS DASPP. The Rehabilitation Specialist’s Handbook. 4 edition. Philadelphia, PA: F.A. Davis Company; 2012.

7. Antman EM, Hand M, Armstrong PW, et al. 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee. Circulation. 2008;117(2):296-329. doi:10.1161/CIRCULATIONAHA.107.188209.

8. Ainsworth BE, Haskell WL, Whitt MC, et al. Compendium of physical activities: an update of activity codes and MET intensities. Med Sci Sports Exerc. 2000;32(9 Suppl):S498-504.

9. Chung F, Mueller D. Physical Therapy Management of Ventilated Patients with Acute Respiratory Distress Syndrome or Severe Acute Lung Injury. Physiother Can. 2011;63(2):191-198. doi:10.3138/ptc.2010-10.

cardiovascular/pulmonary systems physical therapy

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