P.T. Plan of Care for Cardiac and Pulmonary Conditions—PTP 673 –Handout I

Pulmonary Practice Patterns, Physics, Physiology, &

Physical Therapy-Occupational Therapy

Barb Bernard Butler, PT, MS PT, DPT,

(“Lung Whisperer” per Keri Hutchins, 1976-2010)

University of Michigan-Flint

July 11, 2013

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Our Job: Improve O2 Transport

• Pulmonary History? Red Flags: “If you can’t breathe, you can’t function” & “Function trumps structure”.

• “Screen Cardio-Vascular-Pulmonary Systems first!– imaging, labs, meds, tests

• i.e., CT scan, vent/perf. scan, blood glucose, coagulation, bronchodilator, ECG, PFT

– identify the “hidden impairments”

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The Guide to Practice APTA

• Musculoskeletal Screens– ROM– Strength– Posture

• Neuromuscular Screens– Tone, Reflex, Coordination– Balance– Sensation– Communication &

Cognition

• Integumentary Screens– Superficial Skin– Partial-thickness Skin– Full-thickness Skin– Extension into Fascia or

deeper

• Cardio-vas-pulm screens– Deconditioning / Demand– Airway Clearance– Heart Pump / Lung Pump– Gas Exchange– Lymphatic

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Cv-P Preferred Practice Patterns

• A. Prevention / Risk Reduction

• B. Aerobic Capacity / Endurance

• C. Airway Clearance

• D. Cardiovascular Pump

• E. Ventilatory Pump

• F. Respiration / Gas Exchange• G. Neonatal Respiration

• H. Lymphatic System

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Physics and Physiology Principles

• Iron lung / human lung model

• References: – John B. West’s texts

• Respiratory Physiology: use of + and – pressure to fill lungs, “iron lung”

• Respiratory Pathophysiology

– Mary Massery, PT, DPT course• “If You Can’t Breathe, You Can’t Function”

• Barb’s Drawings

Normal Mechanics—L Lung: gas will preferentially flow to the dependent region

first.

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Midlung Field: critical for ventilation

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Closing Volume: R lung – more WOB (work of breathing)

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Modifying Your Intervention:for lesions / optimizing results / etc.

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Malignant pleural effusion

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Pulmonary Function Test

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Oxygen Titration: at rest / with activity

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1 airway: ~27 generations glottis to alveoli

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Coughing and Secretions:(Cohesive secretions

vs. Adhesive secretions)

but only from mid-upper airways!

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Stressed set / Calmed set(sympathetic / parasympathetic)• Forced exhalations• Secretions rattling

around, but not coming out

• Many ineffective small coughs

• Increased RR

• Relaxed, controlled exhalation with minimal force

• (? Pursed lip breathing if it comes naturally)

• Hold inflation 2-3 seconds• Suppress small coughs /

facilitate only strong, effective cough

• Decreased RR, large, controlled inspiration

Pop Can / Steel Can Model(from Mary Massary)

Intact trunk: •integrated, •strong, •flexible, •coordinated

powerful

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Postural Muscles = Breathing Muscles

• Diaphragm: – an amazing muscle

• costal vs. central

– a “pressure regulator”

– a skeletal muscle with length : tension ratio

– Length = “radius of curvature”

• Normal

• Lengthened

• Shortened – flat dome, barrel chest

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HOW DO YOU KNOW YOU DID YOUR JOB? (EFFECTS OF O2 TRANSPORT FOR THE BETTER?)

• Changes in heart rate• Changes in blood pressure• Changes in O2 saturation• Changes in ECG (rhythm & pattern)• Changes in blood gases• Changes in respiratory rate & pattern• Changes in symptoms

– (e.g., measures of the hidden impairments)

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Pulmonary Common Hierarchy “Screen the Hidden Impairments First”

• 1. Activity & exercise• 2. Body positioning• 3. Breathing control

maneuvers• 4. Coughing

maneuvers• 5. Relaxation &

energy conservation maneuvers

• 6. Exercise throughout the ROM

• 7. Gravity assisted postural drainage

• 8. Manual / device airway clearance modalities

• 9. Suctioning(--adapted from Dean &

Frownfelter 3rd study guide)

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“Caring for your Lungs”

Frequent position change– In bed, include prone, ¼ from prone, ¼ from supine

Stretch, twist, bend• Swallow correctly; avoid reflux• Aerobic exercise; lots of fluids; good diet• Avoid aerosols; avoid airway infections• No smoking; avoid / prevent air pollution• Avoid hard exhalation / cough spasms

– emphasize relaxed in-breaths

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Key Findings

Pattern A

• Prevention / Risk Reduction– Functional work capacity– Max. aerobic capacity– Dyspnea on exertion– Sedentary job / role– Client knowledge– Central vs. peripheral

impairments

Pattern H

• Lymphatic System Disorders– Perceived body image– Difficulty dressing– Edema– Skin integrity– Pain

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Key Findings – Pattern B

• Aerobic Capacity / Endurance – Deconditioning– Exercise / Activity Tolerance– Perceived Exertion– HR, BP, SpO2– RR, Breathing Pattern

• “Ventilation”—organ level – “Respiration”—tissue level

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Key Findings – Pattern C

• Airway clearance– Difficulty mobilizing secretions– Breath sounds

• Normal• Abnormal (rubs, absent, distant/diminished,artifact)• Adventitous (crackles/rales, rhonchi, wheeze)

– Airway protection• Swallow• Aspirations • Huff/cough quality

Key Findings – Pattern D

• Cardiovascular Pump Dysfunction, or Failure of Increased O2 Demand (during activity)– HR, RR, SpO2, &/or resp. pattern changes– Change in baseline breath sounds– Flat / falling BP (“failure”)– Hypertensive (“dysfunction”)– METS (<4-5 = “failure”), (<5-6 = “dysfunction”)

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Key Findings – Pattern E

• Ventilatory Pump Function– Ventilatory muscles– Thoracic bony structures– Airway patency– Inspiratory force– FEV1 (forced exp vol in 1 sec) >80% pred.– VC (vital capacity) >70%

pred.– I:R ratio 1:2 (inspi : expi time)– RR (resp rate) & pattern 12-20

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Key Findings: Pattern F

• Respiratory Dysfunction / Gas exchange– ABGs

• PaO2 80-100% (or age predicted norm)• PaCO2 35-45% “ “• pH 7.35-7.45

– SaO2• WNL 95-100% on x% FiO2• Usually adequate >90% on x% FiO2• CO2 retainer: “adequate”=88% on x% FiO2;

“severe”=<85% on x% FiO2