Transcript Cardiopulmonary Physical Therapy

Cardiopulmonary Physical
Therapy
Meghan Lahart PT, DPT
Cardiovascular and Pulmonary
Resident Ann Arbor VA
What is Cardiopulmonary PT?
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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?
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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?
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Prolonged effects of bed rest:
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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
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Manual or mechanical procedures that
facilitate mobilization of secretions from the
airways.
Indications:
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Impaired mucociliary transport
Excessive pulmonary secretions
Ineffective or absent cough
Airway Clearance Techniques
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Goals of airway
clearance:
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Optimize airway patency
Increase ventilation and
perfusion matching
Promote alveolar
expansion and
ventilation
Increase gas exchange
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Interventions:
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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
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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
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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
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Hands on ribs
Breathing Exercises
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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
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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
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Minimize iatrogenic complications
Minimize duration of ICU stay
Prevent atrophy of the inspiratory muscles
Special Considerations for
Mechanically Ventilated Patients
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Weaning Criteria
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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
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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
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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
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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
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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
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RPE scale 6-20
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Warm up 9-11 range, peak activity 13-15
Dyspnea index
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1-2 breaths at rest, 3 breaths with peak activity
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Count to 15, number of breaths it takes
Stages of Stable Angina
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1-4, monitor with ECG changes
Exercise Duration and Frequency
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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
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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
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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
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Conditions associated with acute
cardiopulmonary dysfunctions and
associated preferred practice patterns
6A: Primary prevention/risk reduction for
cardiovascular/pulmonary disorders
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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
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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
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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
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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
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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
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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
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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
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Family History
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Cigarette Smoking
Hypertension
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Father/male relative before
55 years old
Mother/female relative
before 65 years old
> 140/90
Dyslipidemia
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LDL >130, HDL <40, total
>200
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Impaired fasting glucose
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Obesity
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>100
BMI >30, waist girth
>102cm men and >88cm
women
Sedentary lifestyle
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Not participating in regular
exercise program