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

1. 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

2. 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”

3. 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

4. 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

5. 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

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

7. Midlung Field: critical for ventilation

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

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

12. Malignant pleural effusion

13. Pulmonary Function Test

15. Oxygen Titration: at rest / with activity

16. 1 airway: ~27 generations glottis to alveoli

17. Coughing and Secretions:(Cohesive secretionsvs. Adhesive secretions)but only from mid-upper airways!

18. 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 Stressed set / Calmed set(sympathetic / parasympathetic)

19. Pop Can / Steel Can Model(from Mary Massary) Intact trunk: • integrated, • strong, • flexible, • coordinated  powerful

20. 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

21. 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)

22. 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) Pulmonary Common Hierarchy “Screen the Hidden Impairments First”

23. “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

24. I Love you with both of my lungs!

25. Key Findings Pattern A Pattern H Lymphatic System Disorders Perceived body image Difficulty dressing Edema Skin integrity Pain • Prevention / Risk Reduction • Functional work capacity • Max. aerobic capacity • Dyspnea on exertion • Sedentary job / role • Client knowledge • Central vs. peripheral impairments

26. 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

27. 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

28. 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”)

29. 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

30. 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