2040 Full Notes

PHTY2040- CARDIOPULMONARY PHYSIOTHERAPY I
LECTURE 1- AN INTRODUCTION TO CP PHYSIOTHERAPY

33yAt42JnkxG5z
e Understand the concept of cardiopulmonary dysfunction and where dysfunction

mayoccur in the CP system.
o Functions of the cardiopulmonary system;
=" Pulmonaryventilation
e Central control (medulla)
e Respiratory pump (mm, bones)
e Alveoli
=" Gas exchange 1

e §=6@alveoli
e =Ventilation/perfusion
e Matching of V/Q
=" Transport
e Hb, cardiac output
=" Gas exchange 2

e Exchange of gas between capillary and tissue.
e Capillaries.
e Dependent upon tissue characteristics.
= Lung defence (ciliary clearance, cough, upper airways)

=" Metabolism and detox — activates angiotensin | to angiotensin II (ACE,
vasoconstrictor), deactivates — serotonin, prostaglandins.
e Relate CP dysfunction to identifying respiratory problems amenable to

physiotherapy.
-
|
TRANSPORT
1
33yAt42JnkxG5z
GAS EXCHANGE 2
33yAt42JnkxG5z
>
PPthinkswap
1627123981
Find more study resources at https://www.thinkswap.com
e Differentiate between a cause, a sign/symptom,an effect and a problem.
o Cause- The pathophysiological background
Respiratory problems- ventilation, secretion clearance, other (ex tol, WOB)
0
Signs and symptoms- SOB, cough, sputum, chest pain, wheeze

0
Effects
Oo
=" Pathophysiological
=" On activity and participation i.e. overall functioning.
33yAt42JnkxG5z
e Identify commonly encountered respiratory problems amenable to physiotherapy

treatment.
o Pulmonary ventilation
=" Gas exchange and lung volumes
o Secretion clearance
= Increased secretions
=" Reduced clearance
=" Reduced exercise tolerance

= Increased work of breathing /dyspnea
=" General debility and reduced mobility
=" Thoracic pain
e Discuss the impact of CP problemson the patient in termsofactivity limitations

and participation restrictions.
o Limitations and restrictions (disability and handicap)
o E.g unable to work, unable to attend school.
LECTURE 2- CARDIOPULMONARY ASSESSMENT: MEDICAL INFORMATION
e Describe and list possible sources of information in the clinical setting.

33yAt42JnkxG5z
o Ward board (patient name,bed #, status, investigations planned).

Hospital computer system (demographic, ward, bed #, investigations).
0
Progress notes (admission details, reports)

0
Old notes (particularly useful for chronic conditions)

0
Other staff (doctors, nurses, allied health).

33yAt42JnkxG5z
Oo
33yAt42JnkxG5z
e Describe the structure, contents and abbreviations of the medical assessment.

33yAt42JnkxG5z
o Initial information — name,age etc

o History of presenting illness / condition - HPI / HPC
33yAt42JnkxG5z
=" Summaryof current problem

=" Details of why the patient presented
"Elective or emergency
= Any relevant history relating to this admission
pH
> thinkswap Find more study resources at https://www.thinkswap.com

1627123982
o Past history (PHx, PMH)
Medical
Surgical
o Family history
o Social history
ETOH
33yAt42JnkxG5z
Smoking
Living situation
Employment
33yAt42JnkxG5z
Medications
Relevant system reviews;
CVS (e.g. BP, pulse rate & rhythm)
Respiratory (auscultation, palpation, observation).
CNS (LOC, pupils, GCS, reflexes, sensation, power).
33yAt42JnkxG5z
GIT (tenderness, guarding, masses).

MS (ROM, strength)
o Investigations
Venous blood
e Cultures
e FBC
e Hb
o M14-16 g/100ml
o F12-15g/100ml)
e WCC (4-11 x 10%litre)
e Pits (150-400 x 10° / litre)
e £UC (electrolytes, urea, and creatinine)
e _BGL (blood glucoselevels- resting or fasting. 4 - 6mmol/I)
e Cardiac enzymes (e.g. troponin, CK-MB, LDH)
33yAt42JnkxG5z
e Clotting times (APT, APTT)

e Liver function tests (bilirubin, ALT, AST)
e Druglevels (e.g. digoxin)
Arterial blood (arterial blood gases- ABGs)

MSU (mid-stream urine)
Sputum (MC&S- microbiology, culture & sensitivity).
Radiology (CXR, CT, MRI)
33yAt42JnkxG5z
Lung function (e.g. spirometry)

Cardiac function (ECG, echo, radioisotope).
e Recognise the importanceof differentiating relevant from irrelevant information.

o Ask yourself about any piece of information...
Does it relate directly to the current presenting condition or is it a peripheral
issue
Is it recent?
Could it relate to, or affect, the respiratory or cardiovascular system?
Did it significantly affect the patient?
o Inthe beginning regard all information as relevant! This will become a much
easier process.
pH
P thinkswap Find more study resources at https://www.thinkswap.com

1627123983
LECTURE3, 4, 5- CP PHYSIOTHERAPY ASSESSMENT
e Outline the general contents and overall structure of the physiotherapy

assessmentof a CP patient.
o Medical information — all sources
o Subjective assessment — patient history
o Objective assessment — physical examination
33yAt42JnkxG5z
o Analysis of assessmentfindings — problems
e Describe in detail the structure and possible contents of the patient history in CP.
o General History
= If the full medical record is available
= If no medical record is available:
e Brief review of major systems
e Ask if any major health problems
o History of respiratory disease
= Course of respiratory disease
33yAt42JnkxG5z
= How long they have had the disease?

= Howit was diagnosed?
o Behavior of the disease
= Find out:
e History in terms of exacerbations
e Hospitalizations
e Change in function over time (anything you could do last year that
you can’t do now?)
o Respiratory
= E.g. cough, SOB, sputum, ex tol, wheeze, haemoptysis
= Establish baseline 33yAt42JnkxG5z
= Compare present condition to “norma

|”
= Relieving and aggravating factors

o Managementof respiratory disease
= Usual treatment
= Respiratory physician?
= Previous physiotherapy treatment?
= Respiratory medications
= Oxygen therapy at home?
= Pulmonary rehab?
o Exercise tolerance
= Any regular exercise? If so — what, how often, how long
= Limiting factors- what might limit patients in terms of exercise?
Smoking history
0
ETOH
0
Living and home situation

0
Understanding of disease /condition

oO
33yAt42JnkxG5z
pH
PPthinkswap Find more study resources at https://www.thinkswap.com

1627123986
e Describe in detail the structure and contents of the objective examination
including observation, palpation, investigations (CXR, ABGs, PFTs, pulse oximetry)
and listening (auscultation/cough).
o Physical examination
=" Look- observation of;
e Color, posture, clubbing, breathing pattern, attachments, LOC, chest
33yAt42JnkxG5z
shape, accessory muscle use.

= Listen
e Breath sounds/pattern, distress, stridor, gurgling, cough type.
= Feel (palpate)
e Accessory muscles, tracheal position, chest expansion
o 33yAt42JnkxG5z
Investigations
= Pulmonary function tests 33yAt42JnkxG5z
33yAt42JnkxG5z
= CXR
33yAt42JnkxG5z
=" ABGs
= Pulse oximetry
=» Exercise test
e Discuss the situations in which modifications to the physiotherapy assessment may

need to be made.
o Patient setting — e.g. pre op vs. chronic lung disease vs ICU 33yAt42JnkxG5z
o Patient condition
=" Level of consciousness
=" Respiratory status
= SOB
=» Pain
=" Contraindications
33yAt42JnkxG5z
LECTURE 6: TREATMENT FOR PULMONARYVENTILATION, GAS EXCHANGE, AND LUNG

VOLUME.
e Discuss the concepts of reduced alveolar ventilation / lung volume and understand
the clinical situations in which these problems might occur.
o Functional residual capacity (FRC

= The amount left in the lung at the end of normal expiration. Keeps the
alveoli open and continually exchanging gas.
o Tidal volume (Vt)
=" The amount of gas moving in and out with each breath.
o Vital capacity (VC)
= Ability to take a deep breath abovetidal volume.
33yAt42JnkxG5z
33yAt42JnkxG5z
pH

1627123989
o Reduced volumes may be caused by
= Reduced central drive
= Airway obstruction
= Compression of lung e.g. pleural effusion
= Surgery
33yAt42JnkxG5z
= Lung parenchymal disease (E.g. collapse)

33yAt42JnkxG5z
=" Thoracic / chest wall disorders

=" Reduced resp mm function — posture, disease
o Small airways tend to close towards the end of expiration as lung volumes decrease
> alveoli are then likely to collapse.
o Closing volume — the volume at which small airways start to close.
33yAt42JnkxG5z
o Normal lungs prevent alveolar closure or recruit recently collapsed lung units by
periodic sighs.
o Healthy young - breathe deeply (twice tidal volume) once every 5 mins.
o Breathing constantly at small volumes reduces lung compliance — may lead to lung
collapse.
e Describe the consequencesof reducedalveolar ventilation and lung volume on the

33yAt42JnkxG5z
respiratory system in terms of:

© lung compliance- Reduced
o distribution of ventilation- 7 airway resistance, J expiratory airflow
© gas exchange- ventilation/perfusion matching
o atelectasis- Lung collapse - Usually implies subsegmental collapse
33yAt42JnkxG5z
REDUCED LUNG VOLUME

(consequence1)
q
Reduced lung compliance
increased airway resistance
4 Closure of small lung units and small airways sy
V/Q mismatch LUNG COLLAPSE / ATELECTASIS Reduced alveolar

ventilation
33yAt42JnkxG5z
Ne
PaO, tPaCO,
33yAt42JnkxG5z
33yAt42JnkxG5z
pH
P thinkswap 33yAt42JnkxG5z

1627123988
REDUCED LUNG VOLUME
(consequence2)
g
increased airway resistance, reducedairflow
g§
Increased workof breathing
/ sy
Dyspnoea (SOB) Increased O, demand
and consumption
33yAt42JnkxG5z
REDUCED LUNG VOLUME

(consequence3)
§
increased airway resistance, reducedairflow
33yAt42JnkxG5z
Reduced cough effectiveness
u
Reducedsecretion clearance
“a Na
Potential for respiratory Further effects on compliance,
Infection - pneumonia airway resistance etc
33yAt42JnkxG5z
p>

1627123991
o Causes ofatelectasis
o Lack of distending forces on lung

=" Weak diaphragm
=" Reduced lung volume
= (less negative pleural pressure) Surfactant
- Vining
= CNS dysfunction Negative 7, Elastie rece
= Weak resp mms ge
33yAt42JnkxG5z
33yAt42JnkxG5z
o Localised airway obstruction

=» Sputum '
Collateral
= Small airway collapse

.
ventilation
. Absorption of gas occurs and A. Forces in the normal B. Lack of distending C. Localized airway
lung. forces on the lung. obstruction.
alveoli collapses -P
o Insufficient surfactant
33yAt42JnkxG5z
=" Prematurity
= Lack of lung stretch (sigh)
= Anesthesia
=" High FiO2
. E. Negative sirway F. Increased lung elastic
= Persistent collapse Insufficient surfactant. ressure, recoil.
°
33yAt42JnkxG5z
33yAt42JnkxG5z
o Negative airway pressure

= Suctioning
o “Lung elastic recoil
=" Decreased compliance
= Low lung volumes 33yAt42JnkxG5z
= Interstitial fibrosis
o Most patients have degree of atelectasis post-surgery, clinical course varies

but mild casesare self-limiting. Significantif:
= Results in respiratory dysfunction/compromise
=" Has potential to become more serious respiratory pathology
e Outline the assessmentofalveolar ventilation and lung volume.

o Subjective examination (SOB,difficulty breathing, unable to clear secretions).
Investigations (CXR, ABGs, pulmonary function tests [PFT] e.g. FVC, FEV1).
0
Observation (7. RR, shallow breathing, |. chest expansion).

0
33yAt42JnkxG5z
Palpation (poor LBE/local chest expansion).

0
Listen (auscultation- reduced, absent, BBS, crackles, weak/ineffective cough).

Oo
e Describe (in terms of physiological background, practical performance, evidence of

effectiveness, precautions and contraindications), the physiotherapy techniques
which can be used to treat disorders of alveolar ventilation and lung volume.
o Rx for | ventilation aimed at improving lung volume and optimising
ventilation/perfusion matching.
o Canbe global (J) PaO2 7. PaCO2) or regional (J) PaO2, 7S PaCO2 if large area).
pH

1627123994
e Breathing exercises
o Aims to:
= “inhaled volume and promote expansion of alveoli by interdependence and
collateral ventilation.
=» Tidal volume (to increase alveolar ventilation and stretch-
preventing/reversing atelectasis).
o Canadd sustained maximal inhalation or inspiratory hold.
o Needs to be:
= Slow
e More contribution from abdominal/diaphragmatic component
rather than costal / rib cage.
e Ventilation may be preferentially distributed to the dependent lung.
=" Deeper than tidal volume

e Increased lung volume, better lung compliance.
e Hand position on lateral chest wall to encouragecorrect pattern of
33yAt42JnkxG5z
breathing — diaphragm/abdominal.
=" Sustained inspiration or inspiratory hold

e time for "slow" alveoli to open
e Collateral ventilation / interdependence
e Don’t encourage contraction of abdo mms or closing ofglottis.
33yAt42JnkxG5z
o Contraindications/precautions:
=" Hyperinflation
=" Undrained pneumothorax
= Respiratory distress
o Indications:
=» J Alveolar ventilation (from reversible
pathology- global or regional).
= J Lung volumes from reversible pathology.
= E.g. post-op patient, lung collapse/consolidation,
post- effusion drainage.
Hand position on thorax

0
33yAt42JnkxG5z
Relaxed shoulders
0
Concentrating on slow LBE

oO
Improved pattern of breathing — not encouraging

increased volume at all costs
o Evidencefor effectiveness is physiology based- verylittle research evaluating

33yAt42JnkxG5z
breathing exercises as used by physiotherapists.

o Should be combined with appropriate positioning.
33yAt42JnkxG5z
p>
P thinkswap
33yAt42JnkxG5z

1627123995
e incentive spirometry
o Mechanical device to promote inspiration and increase in lung volume
Similar in principle to breathing exercises
0
0 Useful in serving as reminder to do exercises.
No evidence they do anything morethan physio
0
Tends to encouragerapid inspiration

0
May encourageincorrect pattern of breathing

O00
Indications & contraindication same as DB.

Recommendations:
= If you don't have to use one then don't!
33yAt42JnkxG5z
= Ifthe patient already has one - ensure correct use

=" Get one that has low flow rates (e.g. cliniflo)
e Positioning
33yAt42JnkxG5z o 1% thing that should be considered. Meanheight = 1.68 m
o Affects lung volumes,alertness, . ; Q Q
distribution of ventilation/perfusion, S73 D397 Door s\. t
resp. mm efficiency, and ability to
Functional residual capacity (L [BTPS}}
33yAt42JnkxG5z
3.5 [-
cough.
oO Upright sitting
33yAt42JnkxG5z
=" Improves FEV (forced exp. Volume)

= Improves overall lung volumes
(particularly FRC) 2.5 [-
= Best > worstpositions for
volumes:
2.0 [-
1. Sitting
2. Side-lying Barsindicate + 1 standard deviation
3. Slumped 1.5
4. Supine
5. Head down
o When combined with slow LBE may increase ventilation to dependent lung-
but remember distribution of ventilation at low lung volumes. 33yAt42JnkxG5z
o Side-lying
Changes distribution of ventilation (and perfusion)
0
Better than supine and slumped for FRC

0
Can affect unilateral lung pathology

oO
Expansion of uppermostalveoli due to stretch of alveoli

o. Affected side uppermost
o Indications:
o Reduced lung volume — global or regional
o Reduced alveolar ventilation — global or regional
o Also has effects on secretion clearance
o Contraindications/Precautions:
33yAt42JnkxG5z
o Unstable cardiac conditions

o Unstable or uncontrolled BP
o Obese 33yAt42JnkxG5z
pH

1627123995
o Pregnant
o SOB (in side-lying)
o MSSK issues e.g. recent THR
o Usually used in combination with other physiotherapy treatment techniques.
o Little research on positioning used as a physiotherapy treatment technique.
33yAt42JnkxG5z
e Mobilisation
o Often used with the aim of increasing pulmonary ventilation (as well as for
mobility reasons).
Not a treatmentfor specific lung pathology- usually used for global problems.
33yAt42JnkxG5z
How does mobilization affect the respiratory system?

= Increased demand for O2 > increased minute ventilation to meet demand
(VT and freq)
= Better V/Q matching (due to increased cardiac output)
=" Upright position — increases FRC
o Important to incorporate slow deep breathing exercises during mobilization if
33yAt42JnkxG5z
we wantto achieve the aim of increasing alveolar ventilation via increasing

33yAt42JnkxG5z
Vr.
o Indications:
=" Reduced alveolar ventilation - global
= Also may achieve gait and musculoskeletal aims (eg mm length, strength,
balance)
=" E.g. post-op, long term disability, post long term ICU stay.
o Precautions/contraindications
=" Benefits vs costs (O2) - e.g. acuteillness, fever, recent cardiac ischemia, CHF.
=" Unstable cardiac conditions
= MSK 33yAt42JnkxG5z
=" Safety — balance, attachments etc.
oO Research:
=" Cardiac surgery
e No need for breathing exercises on top of a program of early
mobilisation (Dull and Dull 1983, Jenkins et al 1989, Stiller et al
1994, Brasher et al 2003)
= Upper abdominal surgery - Orfanos etal (1999)
e Mobilisation resulted in an increase in minute ventilation — mainly
via increasing RR rather than tidal volume
e If using mobilisation to improve ventilation patients need to be
33yAt42JnkxG5z
encouraged to take deep breaths
33yAt42JnkxG5z
33yAt42JnkxG5z
pH
® thinkswap Find more study resources at https://www.thinkswap.com

1627123996
LECTURE 7: PHYSIOTHERAPY Rx FOR SECRETION CLEARANCE
e Describe the concepts of impaired secretion clearance/increased secretions and

understand the clinical situations in which these problems might occur.
o “Sputum production (e.g. CF, bronchiectasis).
o Impaired/weak cough (e.g. pain).
o Anaesthetic
e Describe the consequencesof impaired secretion clearance and increased

secretions on the respiratory system.
o “Airway resistance- dyspnoea, 7’ WOB
33yAt42JnkxG5z
o J Alveolar ventilation/gas exchange- exercise intolerance, 7’ WOB

o Potential for infection
e Outline the assessmentof secretion clearance.

o Laboratory techniques
=" Radio-aerosol tracers
33yAt42JnkxG5z
= Sputum volume & weight (‘wet weight’- with saliva, ‘dry weight’- without).
33yAt42JnkxG5z
= Sputum culture, MC&S (microscopy, culture, and sensitivity).

o Subjective history
=" Patient reporting of secretions
=" Amount of sputum
=" Characteristics — colour, thickness
=" Ease of clearance
=" Clearance techniques
=" SOB —- mayrelate to increased WOB due toairway obstruction.
o Observation
=" Fever, temperature, HR.
o Cough
= Productive / non productive
=" Moist / dry 33yAt42JnkxG5z
= Strong / weak 33yAt42JnkxG5z
= “tight”
Noisy breathing (gurgl 33yAt42JnkxG5z
Auscultation
= Wheezes
=" Crackles
= URTNs (upper respiratory tract noises)
= Reduced BS
o Chest expansion
= May be normal
33yAt42JnkxG5z
= LBE may be reduced or an abnormal pattern of breathing may be present

= May feel the secretions through the chest wall (only if in large airways)
o ABGs
=» J PaO2 and 7 PaCO2 — only if resulting in reduced ventilation or gas
exchange.
pH
P thinkswap 33yAt42JnkxG5z
1627123997
o CXR
=" May havesigns collapse/consolidation.
O PFTs
= May have reduced FEV1 due to obstruction ofairflow
=" Not always useful clinically
e Describe (in terms of physiological background, practical performance, evidenceof

effectiveness, precautions and contraindications), the physiotherapy techniques
which can be used to treat disorders of secretion clearance/increased secretions.
o When planning a treatment consider whether the technique is aimedat;
33yAt42JnkxG5z
= General tracheobronchial/airway clearance

=" More specific clearance from lung lobes/segments
=" Both
o Improving alveolar ventilation lung volume

= Important to consider if the problem with secretions is initially caused by
reduced ventilation.
=" More volume > better flow
= Air behind secretions
=" Better mechanical advantage for resp. muscles
=" Clearance of airways - not specific
33yAt42JnkxG5z
= Gamsu et al (1976)- secretion clearance did not improve until ventilation to

33yAt42JnkxG5z
the area improved (post-operative patients).
=" Normal clearance mechanism used to clear secretions from the main
airways (up to about 6th -7th generation of airway branching).
=" Requires;
33yAt42JnkxG5z
e ability to increase lung volume (flow rate is higher from high lung
volumes)
e ability to close the glottis
e sufficient respiratory and abdominal mm strength
e Ability to maintain airway calibre during cough (l.e. airways that
don’t collapse on forced expiration)
e Clearance of secretions from large airways
33yAt42JnkxG5z
e Commonly used in combination with other secretion clearance
mechanisms e.g. P&V
e Considerations
o High pressures > morelikely to be dynamic airway collapse
33yAt42JnkxG5z
o Pain (postop patients)

o Fatigue and SOB
e Remember wound support whereindicated.
e Assisted cough for muscle weakness (manually or machine).
e Stimulate cough (tracheal rub, drink water,
percussion/shaking).
pH

1627123998 33yAt42JnkxG5z
o Huff
=" Forced expiration with an open glottis
= Developed to overcome the negative aspects of the cough (Hietpas et al
1979)
e Airway compression
e Pain, exhausting
= The aim is to have good airflow with minimal dynamic airway collapse /
compression.
= Less effort, less fatigue, less painful but equally good clearance to cough.
=" Can be taught with spirometry mouthpiece — stops closing glottis.
= Effect of lung volume;
e Huffing from high lung volumes clears secretions from more proximal
(central, larger) airways.
e Huff from mid or lower lung volume has a more peripheral (distal) effect.
e Generally a huff is used from a medium sized inspiration.
= Length of expiration 33yAt42JnkxG5z
e If the expiratory time is too short the huff may be ineffective

e If clearance from back of throat and trachea is required a rapid short huffis
appropriate.
e If the expiration is too long paroxysmal coughing and bronchospasm may
result.
= Evidence based on physiological understanding- equal pressure point.
= Usually used in combination with other techniques.
o FET
=" FET = Forced expiration technique
=" Huff combined with relaxed diaphragmatic breathing (breathing control)
=" BC 1-2 huffs > BC
=" Breathing control 33yAt42JnkxG5z
e Slow relaxed breathing (not deep breathing, no inspiratory hold)

e Physiotherapist provides manual feedback — as for LBE.
e Time of breathing control will be variable depending on the patient
— until they feel relaxed and have recovered.
=" Breathing control is advocated to reduce the possibility of dynamic airway
collapse from huffing and to minimize energy expenditure and desaturation.
33yAt42JnkxG5z
= Addition of thoracic expansion exercises (TEE) to FET

= Useful for clearing secretions from major airways and from lung
= TEE -increased volume +/- insp. hold
= Aimed at maintaining alveolar volume, preventing collapse of airways and
alveoli.
=" TEE
e Added with the aim of improving alveolar ventilation via collateral
channels and thus maintaining/ increasing lung volume.
e Value of the TEE in the ACBT has been questioned (White et al 1996)
e Probably best to include when alveolar ventilation or lung volume is
also a problem e.g. postoperative
pH

1627123999
e Not appropriate to include TEE with hyperinflation (COPD).
= Example ACBT;
e Breathing control
e 3-4TEE
e BC
e@ 3-4TEE
e BC
e 1-2 huffs
e BC
e Repeat in which ever combination appropriate
33yAt42JnkxG5z
= Indications- Secretion clearance +/- alveolar ventilation.

= Precautions- care with hyper inflated patients.
=" Shown to be effective in enhancing the clearance of secretions in patients
33yAt42JnkxG5z
with CF - As effective as conventional forms of therapy e.g. P&V, PD (Pryor
and Webber 1979).
oO Percussion
= Application of force to the chest wall with a cupped hand — transfer of
mechanical energy.
= Mechanism remains poorly understood.
= Indications;
e Secretion clearance - excessive secretions and difficulty clearing
e Effective with large volume of secretions
e Not effective with little or no secretions
e Does not resolve lung consolidation.
=" Contraindications/precautions
e Fractured ribs or other thoracic injury or pain e.g. burns, pleuritic
pain, surgical wounds.
e Frank hemoptysis (coughing up fresh blood)
e RibCa
e Bronchospasm (?) 33yAt42JnkxG5z
e Hemodynamic instability
e Severe osteoporosis
e Low platelet levels
e Raised ICP
=" Frequently combined with other techniques (e.g. postural drainage).
o Vibrations
=. Application of oscillatory force to the patient’s thorax during expiration -
consists of both oscillation and compression components.
=" Commonly used technique — often used with other techniques e.g.
percussion, PD, ACBT.
= Indications & contraindications as per percussion.
=" Transmission of mechanical energy to the airway thought to assist with
secretion clearance.
33yAt42JnkxG5z
=" May increase / augment expiratory airflow (McCarren, 2003)
= =? Reduces sputum viscosity
pH

1627124003
= Stimulate cough
=" There is some thought that the vibrations on expiration cause the next
breath in to be larger in volume. This is possibly because vibrations push the
chest wall down closer to RV and so the next breath will be from a lower
lung volume and therefore may look larger.
=" Very little research into use independently- use in combination.
o Postural drainage
= Uses gravity to assist the clearance of secretions from lung segments.
=" Segment to be drained is placed non-dependent with the orientation of the
bronchus such that secretions will be drained towards the main airways 33yAt42JnkxG5z
where theycan be cleared via a huff or cough.

33yAt42JnkxG5z
=" Indications;
e Secretion clearance - Excessive secretions and difficulty clearing. Can be
used for global or regional secretion clearance E.g. whole lung or specific
segment.
=" Contraindications/precautions 33yAt42JnkxG5z
e High ICP, recent neuroinjury

e CVS instability
e Hypertension
33yAt42JnkxG5z
e Pulmonary oedema / heartfailure
e Orthopnoea — SOB when lying flat
e Respiratory distress — extreme SOB
33yAt42JnkxG5z
e Post pneumonectomy (don’t lie with affected side uppermost)

e Upper GIT surgery (oesophagectomy, gastrectomy, hiatus hernia repair
e Eye surgery, Head and neck surgery
e Severe abdominal distension, Obesity, Late in pregnancy
e If patient is distressed or distressed by the position
e Hiatus hernia, Vomiting, reflux, GORD
e Recent meal
=" Usually included with other techniques e.g. percussion.
o PEP
=" Mechanical device that increases resistance to airflow > positive expiratory
pressure in the airways during expiration.
= Initially used to re-inflate lung post operatively via collateral ventilation
(1979).
33yAt42JnkxG5z
33yAt42JnkxG5z
= The positive pressure acts to “splint” the airway open during expiration and
prevent dynamic collapse of airways - Allows greater expiratory airflow and
therefore better secretion clearance.
= FRCis increased during tidal volume breathing using the PEP mask.
= Residual volume (trapped gas) is decreased.
=" More air enters the collateral channels during inspiration than escapes
during expiration.
= This results in better lung volume, better alveolar ventilation, recruitment of
atelectatic lung units and allowsair to get behind secretions and assist in
clearance (better expiratory flow).
33yAt42JnkxG5z
= Low pressure PEP application:
pH
® thinkswap
33yAt42JnkxG5z

1627124003
e In sitting (or PD)
e Via face mask or mouthpiece
e Small valveis fitted into mask — reduced expiratory diameter.
e Positive pressure measured with manometer — should be 10-20cm H20 at
mid-expiration.
e Ratio of inspiration to exhalation =1:3-4
e Breathing is tidal (or slightly greater in recent reviews), slightly active
exhalation.
e Number of breaths = 5-10, cycle concluded with FET
e Rx duration =15-20 minutes
e Finish with huff
= Indications:
e Secretion clearance - Excessive secretions and difficulty clearing
e Persistent lung collapse / atelectasis
e Particularly useful with patients who havesignificant reflux
=" Contraindications / precautions
e Undrained pneumothorax
e Frank haemoptysis 33yAt42JnkxG5z
e Recent lung surgery (anastomosis)

e Recent upper GIT, eye or face / head / neck surgery
e Increased ICP
e Unstable CVS
e Undrained pneumothorax
e ~=Gross hyperinflation with bullae
e Recent facial surgery (using mask)
=" High pressure PEP therapy
e High PEP therapy (HiPEP)
o Oberwaldner, sustained expiratory pressures of 40 — 100 cmH20
generated
o Documented as safe (PTx, haemoptysis)
e Can makewith simple tools — eg O2 tubing and water
e Good for independent treatment
= Research:
e Shown to be as effective as conventional treatment for patients with
excess secretions (CF) (Falk et al 1984, Lannefors et al 1992, Mcllwaine et
al1997).
33yAt42JnkxG5z
e Beneficial effect on lung function (Oberwaldner et al 1986, Darbee et al

2004).
e Reduction in RV and increase in gas mixing in the lung -indicating opening
of previously closed small airways (Darbee et al 2004).
e Well accepted by patients (Mclilwaine et al 1997).
o Oscillating PEP (Flutter/acapella)

= The flutter is a mechanical device that applies a variable resistance to
expiratory airflow
= The oscillation is angle dependent (patient upright), adjusted to create the
highest frequency for the individual 8-26Hz.
= This causes an oscillation of the air within the airways, intermittent
acceleration of expiratory airflow and also creates a positive expiratory
33yAt42JnkxG5z
pressure.
pH

1627124004
=" Approximates the “pulmonary resonance”or cilia ‘beat’ frequencyof 8-
16Hz, to maximize vibration of the bronchial walls.
= Improves gas-liquid interaction.
=" May reduce sputum viscosity by mechanically rupturing the rigid mucus gel,
rearranging crosslinks and reducing molecular size.
= Flutter:
e Device held at best angle for oscillations
e Breathe in slightly deeper than normal, brief hold
e Expire through device
e 5-10 breaths out through flutter then a forced expiration
through the flutter
e Continue as appropriate — 15 mins
33yAt42JnkxG5z
=" Acapella
e Similar to Flutter but allows a variable resistance and can be
33yAt42JnkxG5z
used at any angle

e Indications and contraindications as per PEP.
= Weak, mixed research.
= Recommendations- not to replace conventional methods, may
be used as an adjunct where suitable.
o Autogenic drainage
=" Secretion clearance technique developed in Europe (Belgium and Germany).
= Utilises breathing exercises at different lung volumes to enhanceexpiratory
airflow and therefore secretion movement.
=" 3 phases — unstick, collect and evacuate.
= Aims to achieve maximum expiratory flow without airway collapse.
= Indications- secretion clearance, unstable airways.
=" No contraindications
= Evidence suggests equally effective as other Rx (PD, P&V, ACBT, PEP).
33yAt42JnkxG5z
= Not many people know howto perform the technique effectively.

33yAt42JnkxG5z
= Difficult to teach.
=" Takes time to learn.
=" Hard to breathe at low lung volumes.
o Hypertonic saline
=" Hypertonic saline can be used to aid in secretion clearance
33yAt42JnkxG5z
= Usually 9% saline
=" Shown toincrease clearance in CF, chronic bronchitis
= Main issue — may cause bronchoconstriction
33yAt42JnkxG5z
=~ Mark Elkins — current research
33yAt42JnkxG5z
e Discuss issuesrelating to patient education and self-managementof secretion

clearance.
o Many patients with chronic secretion production need ongoing clearance techniques
o Most are equally effective
o Consider;
p>

1627124005
33yAt42JnkxG5z
=" Specific pathology — eg area of lung
=" Patient preference
= Ability to perform technique
= Outcomes
LECTURE 8: PHYSIOTHERAPY Rx FOR WOB, DYSPNOEA & OTHER PROBLEMS
33yAt42JnkxG5z
e Understand the loads placed on therespiratory system.

o Work= weight x vertical distance moved.
o Work is required for the respiratory system to movegas in and out of the
lungs.
o Work of breathing: the amountof effort that the respiratory muscles have to
exert during the respiratory cycle.
o Inthe lung it is most convenient to measure work as the pressure required
to move a certain volume.
o Loads:
=" Gas properties
= Elastic load
e Lung
e Chest wall
e Static property of respiratory system
e Elastic forces of the lung and chest wall have to be overcome by the
respiratory muscles in order to move gas.
e In the lung elastic load is referred to as ‘compliance’- volume change per
unit change in pressure.
e Compliance of lung tissue determined by componentsof lung tissue
(elastin, collagen) and the surface tension ofalveoli.
e Lung less compliant at high volumes.
e §=Chest wall less compliant at low volumes.
e =Chest wall tends to spring outwards- pulled back in by lungs.
e Compliance of chest wall determined by joints/ligaments.
e §=Point at which pressures are equal & opposite is FRC.
= Resistive
e Dynamic properties of respiratory system.
e 2types of resistance;
oO Inertial
o Inertial resistance is generated when an object with a given mass
33yAt42JnkxG5z
33yAt42JnkxG5z
is accelerated into motion

o Inertial resistance is generated in the respiratory system by
gas/lungs/chest wall when they start moving.
33yAt42JnkxG5z
o Very small and can be ignored in tidal breathing. 33yAt42JnkxG5z
©. Frictional
o Pulmonaryand chestwall tissue resistance.
o Stretching and movement of the lung and chest wall causes
friction as the tissues move against and over one another.
o E.g. lung tissue, bones, muscles, joints, abdomen.
33yAt42JnkxG5z
pH

1627124005
o ©Normally about 15-20% oftotal frictional resistance during quiet
breathing.
o Frictional resistance- airways (Raw)
o Represents about 80% of total frictional resistance during resting
breathing
o Influenced by;
=" Driving pressure
= Airway radius
=" Tube length
=" Gas viscosity
33yAt42JnkxG5z
Normal Edema Mucusretention Collapsed

or bronchospasm
O Oninspiration mainly resistive (airway) and elastic load (lung).

© Onexpiration mainly resistive load. 33yAt42JnkxG5z
e Describe the conceptsof increased respiratory workload and dyspnoea and

understand the clinical situations in which these problems might occur.
o Rate and depth of breathing normally occur in a combination that is the most
efficient i.e. takes the least work.
oO Increased elastic load
=" E.g. J compliance (e.g. significant collapse)
= Shift to J vol, T rate
oO Increased Resistive load 33yAt42JnkxG5z
=" E.g. bronchospasm

= Shift to T vol, J rate
o At rest O2 consumption byrespiratory system is 1-2% of total metabolic rate — ie
33yAt42JnkxG5z
breathing is low cost

o When respiratory activity increases (eg chronic lung disease) — metabolic cost of
breathing mayrise to 30% of total metabolic rate > hypoxia of other tissues.
o Work of breathing may be increased due to:

= Increase in elastic and/or resistive load
=" Reduced lung compliance
= Reduced chest wall compliance
=" Increased airway resistance
= Increased tissue resistance 33yAt42JnkxG5z
pH

1627124007
33yAt42JnkxG5z
o Reduction in ability to meet the load — usually due to respiratory muscle
dysfunction.
o The ability of the muscle to generate force can be measured by measuring
change in pressure at the mouth — MIPS and MEPS.
o Maximum inspiratory (MIP) and expiratory pressure (MEP) generated by the
respiratory muscles can be measured by a manometer during insp/exp
maximal effort against a closed valve.
o Respiratory muscle dysfunction may be due to;
=" Neuromuscular disease (e.g. ALS, polio, MS, CVA-hemiparesis).
=" Change length tension relationship (e.g. kyphoscoliosis).
= Myopathy (e.g. steroid induced).
=" Connective tissue disorders
= Hypoxia
= Malnutrition/electrolyte disturbance.
33yAt42JnkxG5z
o Hyperinflation
= Increasing static lung volume (FRC, RV)
= Initially a compensatory mechanism to overcome T Raw — however leads to
alterations in mechanics
=" People with COPD will dynamically hyperinflate to overcome increased
airway resistance — flow is better at increased volume
o Dynamic hyperinflation worsens if:
= Airway resistance is increased
= Time for expiration is reduced (eg exercise)
o Advantages;
=" Distends airways and prevents them collapsing so readily during expiration.
= Reduces resistance and increasesairflow.
o Disadvantages;
=" Changes length- tension relationship of resp mms
= Flattened diaphragm — reduced force generating ability
= Shortening other resp muscles — reduced force generating ability.
33yAt42JnkxG5z
e Describe the consequencesof increased respiratory workload and dyspnoeain

33yAt42JnkxG5z
terms of:
o Dyspnoea
=" Term generally applied to sensation of unpleasant or unusual respiratory
sensations.
= E.g. breathlessness, suffocating, unable to catch breathe.
=" Feedback mechanisms throughout the body serve to allow the respiratory
centre to alter level and pattern of breathing to maintain blood gases and
acid-base balance.
= When there is a mismatch between the respiratory centre command and
the incoming afferent feedback then the sensation of dyspnoea will occur —
33yAt42JnkxG5z
33yAt42JnkxG5z
changes in resp. pressure, airflow or lung / chest wall movement are not
appropriate for the level of resp. command output then dyspnoea will occur.
pH

33yAt42JnkxG5z
1627124008
=" Occurs with;
e Resp mm abnormalities
e Increased elastic or resistive work
e Blood gas abnormalities
e §=6Anxiety
= MRC (British Medical Research Council)
e Links dyspnoeato activities
= BDI (Baseline Dyspnoea Index)
33yAt42JnkxG5z
=" Modified Borg dyspnoea scale

e 10 point scale with verbal expressions anchoredto specific numbers.
e Used most commonly in Australia.
alveolar ventilation - respiratory failure

33yAt42JnkxG5z
0
33yAt42JnkxG5z
respiratory muscle fatigue

0
secretion clearance
O00
exercise tolerance
Quality oflife - anxiety and depression.
Oo
e Outline the assessmentof increased respiratory workload and dyspnoea.

o Subjective;
33yAt42JnkxG5z
=" Dyspnoea scales.

= Difficulty breathing
o Objective
=" Abnormal breathing pattern
= Rate
=" Paradoxical
= Rib indrawing
= Upper chest pattern of breathing — reduced LBE
= Accessory muscle use
=" Weak cough
= Investigations (e.g. ABGs, FEV1, MIPS/MEPS)
e Describe the physiotherapy techniques which can be used totreat increased

respiratory workload and dyspnoeaincluding:
o Medical management: pharmacology(e.g. opiates-depressresp. drive),

behavioural therapy, 02 therapy.
Physiotherapy Rx
33yAt42JnkxG5z
o Breathing control
=" Relaxed, quiet breathing.
=" Pursed lip breathing (prevents airway collapse by maintaining PEP).
=™ Reduces 02 consumption.
o Energy conservation, relaxation 33yAt42JnkxG5z
o Positioning
pH

1627124008
33yAt42JnkxG5z
=" Lean forward (length tension relationship of diaphragm).
=" Arm bracing (fixation of accessory muscles).
O Exercise trainin
o Supplementary oxygen
oO Respiratory muscle trainin
33yAt42JnkxG5z
33yAt42JnkxG5z
33yAt42JnkxG5z
33yAt42JnkxG5z
33yAt42JnkxG5z
e Understand other problems which CP patients may present with and discuss
33yAt42JnkxG5z
clinical situations in which these problems might occur.

o Thoracic pain
o Reduced mobility
o Reduced exercise tolerance
e Consequencesof reduced mobility, thoracic pain and reduced exercise tolerance:

o Respiratory system ( volumes, \) cough (pain), |) secretion clearance).
o Other body systems (J) MS strength, endurance)
o Outcome
o Activity limitation and participation restriction
33yAt42JnkxG5z
e Outline the physiotherapy assessment of mobility, thoracic pain and exercise

tolerance.
oO Gait, STS analysis.
o Exercise stress tests.
o Musculoskeletal assessment
e Briefly describe the physiotherapy techniques which can be usedto treat reduced
mobility, thoracic pain and reduced exercise tolerance.
o Mobility and gait training
p>

1627124011
o Musculoskeletal techniques for the thoracic spine
o Exercise training
LECTURE 9- HOSPITALISATION, BED REST, & ACQUIRED RESPIRATORYDISEASE.
e Describe the effects of hospitalization and bed rest on:

o The severity of the effects of bed rest vary depending on;
The prior condition of the patient.
Length of time of the condition
33yAt42JnkxG5z
Amount of the reduction of the effects of gravity
33yAt42JnkxG5z
o Respiratory system
Less dramatic consequences to other systems
Usually worse if combined with pathology e.g. surgery.
Loss of mm strength — resp. mms
Recumbent position
e Reduced lung volume (particularly FRC)
e Risk of atelectasis
Not moving around — reduced clearance
Clinical implications
e Increased risk of collapse, infection
e Increased risk of soutum retention and pneumonia
33yAt42JnkxG5z
o Cardiovascular system
Responds quickly to changesin activity levels — within a few days
As well as immediate changes, chronic inactivity is a risk factor for CVS
disease e.g. IHD.
Increased HR at rest and submaximal exercise
Reduced SV
Reduced VO» max
Fluid losses occur with bed rest
Changes in fluid regulating mechanisms
e ~=Diuresis (occurs quickly)
e Reduced plasma volume
Hypovolaemia
Increased blood viscosity
Increased fibrinogen and platelets — risk of clotting
Venous stasis — lack of mm pump- 7 risk DVT
Orthostatic hypotension- reduced blood volume, dysfunction of
baroreceptors. 33yAt42JnkxG5z
When patient assumes upright position;

e Pooling of blood in lower extremities
e Drop in BP > dizziness, syncope
Can occur within 3-4 days of starting bed rest
33yAt42JnkxG5z
Clinical implications;
e Heart less able to meet increased demand- Fatigue, SOB.
e Orthostatic hypotension- falls risk, reduced mobility.
33yAt42JnkxG5z
33yAt42JnkxG5z
pH
® thinkswap
33yAt42JnkxG5z

1627124012
o Musculoskeletal system
=" Muscles require regular stimulation by motor nerves. Decrease in activity >
deconditioning (atrophy and J) strength).
= Postural muscle strength declines quickly. 33yAt42JnkxG5z
= Total losses of slow twitch muscle mass is greater but the loss of cross
sectional area is also very large in fast twitch mms e.g. quads.
= Reported drop in strength : 1-1.5% per day
=" Upper body affected < lower body.
= Mm endurance is also reduced
e J 15-20% knee extensor endurance after 4 weeks suspension
=" Contractile protein lost — not muscle fibres (therefore reversible).
33yAt42JnkxG5z
"Inefficient use of oxygen (78 demand, poor use).
=" Changes in muscle length (affecting force generation).
= Loss of muscle strength and size can be prevented by pre-training — i.e. more
mm bulk and strength to start with.
= Clinical implications
e Patients on prolonged bed rest have reduced muscle strength and
endurance
e Increased difficulty in transferring, standing, walking
e Reduced balance and increasedrisk offalling
=" Alack of weight-bearing stress on the bone leads to greater bone absorption
than formation and a resultant loss in density. 33yAt42JnkxG5z
33yAt42JnkxG5z
= Loss of minerals eg calcium from the bone - hypercalcaemia

e systemic symptoms eg fatigue, weakness, cardiac arrhythmias
33yAt42JnkxG5z
= Loss of bone density is not uniform.

=" Moresignificant with long term bed rest and inactivity.
= Clinical implications
e Renal calculi (more calcium in blood)
e Greater risk of # due to reduced bone density
e Development of osteoporosis
o Neurological system
= Not as much research (mainly space)
= Bed rest has negative effects on neural firing rate and motor unit
recruitment
= Evidence that bed rest / microgravity may have effects on:
e Postural control
e Gait
e Proprioception
=" Sensory deprivation may lead to anxiety, depression, and fear ofactivity.
"Clinically; may be reluctant to be active and/or unmotivated.
° Integumentary system (skin)

=" Prolonged bed rest and lack of movement can affect skin integrity.
= Pressure on one area of tissue or shearing forces applied to tissue can cause
pressure ulcers/bed sores/decubitus ulcers.
=" Common around sacrum, ischial tuberosity, heels, greater trochanter, lateral
malleolus.
pH

1627124014
=" Stage 1: Non blancheable erythema of the intact skin.
= Stage 2: Partial thickness skin loss. Skin broken.
=" Stage 3: Full thickness skin loss. Extension into subcutaneous fat.
= Stage 4: Extensive destruction damaging muscle, bone or tendon.
=" Can lead to serious infection.
= Prevention essential;
e Improve general health
e Positioning to relieve pressure
33yAt42JnkxG5z
e Manage moisture
e Manage nutrition
e Never drag patients
e Understand the risk factors for developing respiratory and cardiovascular

33yAt42JnkxG5z
dysfunction during hospitalization/bed rest.
o Nosocomial = pertaining to or originating in a hospital
© latrogenic = caused by medical intervention 33yAt42JnkxG5z
o Common nosocomial infections; UTI, Pheumonia, Wound infection.

o Contributing factors;
= Hospital setting (eg ICU)
=" Health status
=" Underlying disease / comorbidities
= Immune status
=" Skin integrity
= Presence of invasive devices eg IDC, IVC
= Antibiotic use and resistance
o Bacteria
33yAt42JnkxG5z = Staphylococci (eg Staph aureus)- 20% prolonged, 60% intermittent,
20% never colonized. Common in health care workers.
33yAt42JnkxG5z
= MRSA- wound infection.
= Enterobacteriaceae (e.g. ecoli)- UTI, diarrhoea, sepsis.
= VRE- generally harmless, in intestines of healthy people.
=" Pseudomonas- pneumonia, UTI (almost always in compromised host)
=" Acinetobacter- 25% adults have cutaneous colonisation. Common
33yAt42JnkxG5z
nosocomial- pneumonia, sepsis, UTI, wound infection.
33yAt42JnkxG5z
o Nosocomial pneumonia
=" Defined as pneumonia developing 2 or more days after admission for
another reason — a secondary infection
33yAt42JnkxG5z
= Nosocomial pneumonia accounts for 15% of all nosocomial infections

e 2°4 most common (1° = UTI)
= Affects 0.5-2% of all hospitalised patients
= Predisposing factors
e Mechanical ventilation > 48 hours
e Prior AB-use and resistance 33yAt42JnkxG5z
e Duration of hospital stay

Other health problems (Particularly chronic disease eg COPD)
pH

1627124014
e Malnutrition
e ETOH abuse
e Reduced immune defenses — immunocompromised
e Major surgery
e Reduced LOC
e Increased age
e Presence of NGT (nasogastric tube)
33yAt42JnkxG5z
=" Most commonly caused by gram negative bacteria (50-80%).
e Discuss the issuesrelating to preventative physiotherapy treatment and deciding

when this is appropriate and necessary.
O Early and regular activity and mobilization.
O All staff should be encouragedto assist patients to be as mobile as possible
and to maintain good positioning when bedrest is unavoidable.
Physio Rx aimed at optimal or independent mobility with or without
33yAt42JnkxG5z
33yAt42JnkxG5z
33yAt42JnkxG5z
assistance.
33yAt42JnkxG5z
Who to consider treating to prevent nosocomial pneumonia;

=" Mechanical ventilation > 48 hours
=" Prolonged bed rest
33yAt42JnkxG5z
"Post major surgery

= Past history of significant respiratory disease or increased secretions
=" Mobility disorders — eg restricted mobility, long ICU stay.
e Discuss self-management and education for the hospitalized patient.

O Pre training to minimize losses — not alwaysrealistic or possible.
O Optimise mobility so people can be independentin ambulating.
O Teach bed exercises to maintain strength and muscle length.
33yAt42JnkxG5z
O Teach simple respiratory exercises (should not be neededif actively

mobilizing)
=" Deep breathing
=" Coughing — huff, other secretion clearance as needed
Group treatment e.g. ward exercise classes.
LECTURE 10: GENERAL EFFECTS OF SURGERY, ANAETHESIA, & ANALGESIA
e Outline terms and abbreviations commonly usedin surgery.

—ectomy (Removal, excision, cutting out)
—otomy (Opening,cut into)
—oscopy(Look at)
—plasty (Changing, altering, repair, formation)
—desis (Fusion)
—olysis (Breaking down)
— ostomy (Making a hole in, a join)
> thinkswap 1627124015

33yAt42JnkxG5z

Laparotomy
33yAt42JnkxG5z
Thoracotomy Sternotomy
o Pre-op
= Patient should be assessed to determine fitness for surgery.
= Patient should be as well as possible.
e Describe the effects of surgery and anaesthesia on the body,particularly the

respiratory system.
o General anaesthesia- A drug-induced, reversible depression of the CNS that

results in the loss of physiologic response and perception toall external
stimuli.
o Components
= Pre-med (J stress/anxiety, 7S sedation- e.g. midazolam).
= Induction
e Aim to quickly initiate anaesthesia
e =IV short acting coma-inducing drug eg Propofol, barbiturates (Thiopental)
e Intubation and mechanical ventilation (or laryngeal mask airway in some
cases)
= Maintenance
e Maintaining anaesthesia for the duration of the surgical process.
e Type and format of anaesthesia will vary depending on the procedure,
patient, situation.
= Reversal
e Reduce concentration of anaesthetic agents.
e Drugs that reverse muscle blockade given.
e May need narcotic reversal to reduced respiratory depressive effects eg
naloxone.
33yAt42JnkxG5z
p>
PPthinkswap
33yAt42JnkxG5z

1627124016
o Effects of anaesthesia;
= CVS
e Periop cardiac morbidity is the primary cause of death after anaesthesia
and surgery
33yAt42JnkxG5z
e Affects all aspects of CVS physiology

e Responses to operative stress — Autonomic NS — fluctuation in HR, rhythm,
BP, CO
e CVS responseaffected by
o Baseline CVS status
oO Type of anaesthesia
o Surgical stress during the procedure (eg blood loss)
= Respiratory
e Significant effects.
e Heavily dependent on pre-op status.
= GIT
e Decrease in GIT function
e Reduced motility — may lead to ileus
e Compounded byeffects of opioids
o Regional anaesthesia 33yAt42JnkxG5z
= Regional/localised areas.
=" Faster recovery
=" Fewer effects on body systems
=" Fewer complications
= Ability to observe
= Commonly supplemented with sedatives/opioids.
33yAt42JnkxG5z
© Spinal/epidural anaesthesia
=" Catheter into subarachnoid or epidural space.
=" Motor, sensory, sympathetic and pain blockade.
=" Done for LAS or peripheral surgery particularly with patients who have
significant risk factors for surgery.
o Local anaesthesia
= (E.g. Lidocaine) may be used for short term peripheral procedures.
= May block a bundle of nerves e.g. brachial plexus.
e Understand the concept of postoperative pulmonary complications.
o Complications;
Local or general
o Early or late
oO Preop
o Intraop
33yAt42JnkxG5z
=" Haemorrhage
=" Opening ofbiliary, alimentary tract
=" CVS—AMI (recent AMI - TT risk)
= Respiratory — Resp failure (unable to extubate)
= Lapse in sterility (instruments/personnel)
pH

1627124017
=" Wound complications (e.g. dehiscence, infection).
= Pyrexia (Common in first 24 — 48 hours, >48 hours suspect infection)
= DVT (risk of pulmonary embolism, TED socks, calf compressors, heparin).
= Renal failure (Impaired renal function due to fluid loss — | renal perfusion).
= Nausea/vomiting (common, anaesthesia- risk of aspiration).
33yAt42JnkxG5z
= Peripheral nerve injury (due to surgical approach/position).
= Paralytic ileus ( bowel function- due to surgery/anaesthetics).
= Psychological (medication, sleep deprived, pain).
33yAt42JnkxG5z
© Postoperative pulmonary complications (PPC’s)

= Significant cause of mortality and morbidity
=" Delays discharge from hospital
= Rates - 20-30% after major UAS and CT surgery
Respiratory dysfunction of some kind is inevitable with most major surgery.
Significant PPCs include respiratory failure, pneumonia,
collapse/consolidation, secretion retention.
o Pre-op risk factors for PPC;
=» Age 60+
= Increased closing volume, may exceed FRC during resting breathing > 65
= Increased risk of small airway closure and lung collapse
=" Reduced mm strength
= Respiratory disease (acute or chronic)
33yAt42JnkxG5z
=" Smoking (recent- within last 8 weeks)

=" Obesity (7. load on diaphragm/lung- J FRC)
=" Nutritional status
=" Co-morbidities
= Impaired cognitive function (J ability to comply with Rx)
o Intra-op risk factors for PPC;
= Anaesthesia (30-40% \-FRC- dependent atelectasis, resp. depression).
=" Mechanical ventilation (preferentially ventilates dependent lung).
= Intubation (endotracheal tube- ETT.Irritates mucosa- “~* sputum J
clearance).
# Incision (size, muscle/bone? Changed mechanics).
= Patient position (supine- FRC)
=" Handling of abdominal contents (reflex inhibition of phrenic nerve >
diaphragmatic dysfunction- |) ability to generate pressure change).
o Post-op risk factors for PPC;

= Patient position (slumped/supine- | FRC)
= Analgesia (opiates- |) drive to breathe/cough, \ sensitivity to CO2).
=" Reduced mobility (reduced need for ventilation).
= Increased abdominal size (i.e. swelling- more respiratory work).
= NGT(risk of aspiration)
= Pain (changed breathing pattern, J ability to take deep breath/cough).
pH

1627124017
e Describe the general postoperative care for surgical patients including the concept
of high dependency.
o Pain control- significant issue. 33yAt42JnkxG5z
o Recovery warduntil obs stable and waking up

o Return to ward
o Postop location depends on
= Preop risk factors
= Type and length of surgery /anaesthetic
=" Need for monitoring
= Intraop complications
e Describe types, methods and effects of postoperative pain management.

o APS - Acute pain service
o Multimodality — combinations of drugs
o Options;
» IM
e Intramuscular morphine.
e inadequate analgesia for major procedures
e variable pain control
» IV
e Continuous or PCA
e PCA (patient controlled analgesia- never pressed button for patient).
e Systemic, base rate and “bolus” doseif increased pain.
e Variable pain control
e Requires patient to report pain to staff
33yAt42JnkxG5z
e Respiratory depression
e Sedation
33yAt42JnkxG5z
= Epidural
33yAt42JnkxG5z
33yAt42JnkxG5z
e Combination of local anaesthetic and opiate.
e Blockade depends on concentration and types of drugs. Smallest
fibres (pain and temp) blocked first then large fibres (motor).
e Sympathetic block — can lead to hypotension particularly if high
thoracic (above T4- extra care).
e If able to SLR both legs off the bed (one at a time) can generally
stand up.
e Should be able to walk, sit up out of bed — will depend on the spinal
level — lower (Lumbar) — more problems with mobility.
» NSAIDs
e Often added to pain control regimen to further improve pain relief
e.g. Tramadol.
=" Nerve blocks
= Pleural infusion/intercostal block
pH

1627124019
e Local anaesthetic into pleural space or intercostal, for thoracic
surgery, #ribs.
o Result of surgery is the developmentofa restrictive pattern

o Reduced lung volumes
= FRC — 30-40% + VC (IC) — 40-60%
=" Forced expiratory volumes — FEV:, FVC
= Preferential ventilation of non-dependent lung
o Changedpattern of breathing
= TRR, J tidal volume
= Shift toa more “rib cage” pattern of breathing, less abdominal contribution
to tidal volume — further compromise to dependent lung
33yAt42JnkxG5z
e Discuss the psychological needsof the surgical patient including issues relating to
preoperative education.
o Potential for global and regional alveolar hypoventilation > hypercapnia.
© Potential for atelectasis / lung collapse > V/Q mismatch, poor gas exchange
— hypoxaemia
=" Increased amount
=" Reduced ability to clear
e Outline the appropriate assessment, common respiratory problems and possible

physiotherapy treatmentstrategies for the surgical patient.
oO Pre-op
= Assessmentof respiratory status
= Treatment of respiratory pathologyif indicated
= Education about postop physio and self-management
e Early mobility
e Breathing exercises
e Wound support
e Incentive spirometry
33yAt42JnkxG5z
Who to pre-op:
e Major UAS or CT surgery
e Long anaesthetic duration
33yAt42JnkxG5z
e Lung disease
e Smoking
e Other systemic disease
e. Poor mobility
e Obese
e Age
o Post-op
o Assessment to determine
= Extent of postop respiratory dysfunction
pH

1627124019
"Clinically significant PPCs
o Identify respiratory problems amenable to treatment
o Treatment of identified respiratory problems
= E.g. poor ventilation — positioning, breathing exercises,
= .g. reduced secretion clearance — ACBT
LECTURE 11: UPPER ABDOMINAL SURGERY(UAS)
e Briefly describe common upper abdominal surgical proceduresin terms ofincision

site, technique, postop care and contraindications to physiotherapy treatment.
Laparotomy
0
Rooftop
0
Subcostal
0
Lower midline
O00
Transverse
Oesophagectomy
=" Cancer, ulceration
=" Thoracotomy and laparotomy
=" Very long surgical time
= Remove oesophagus, Pyloroplasty — stomach in thorax
= Usually intubated and ventilated in ICU for up to 7 days
=" Very high risk of complications
=" Gastrograffin swallow postop to check leaks 33yAt42JnkxG5z
= DONOT TIP
=" DO NOT SUCTION
33yAt42JnkxG5z
= DO NOTAPPLY POSITIVE AIRWAW PRESSURE eg. CPAP
o Gastrectomy
=" Cancer, ulceration.
=" Laparotomy
= Remove stomach — all or part
= Anastomose remains of stomach to small intestine.
=" Usually high dependency
=" NGT
=" Do not tip unless OK with surgeon
o Eundoplication
= Reflux, hiatus hernia
=" Often laparoscopic
= Fundus wrapped
=" around sphincter to reduce reflux
33yAt42JnkxG5z
= Post-op in general ward

=" May not need physio if laparoscopic and no risk factors
=" Do nottip unless OK with surgeon
o Small intestine resection
pH

1627124024
= E.g. duodenectomy
=" Usually due to obstruction, rarely cancer.
=» Laparotomy
=" General ward unless high risk
=" No specific physiotherapy precautions.
33yAt42JnkxG5z
o Large intestine
= E.g. Colectomy, hemicolectomy, abdominal peritoneal resection, Hartman’s.
=" Cancer, ulceration, diverticulitis
=" Laparotomy
=" Resection of part of colon and re anastomosis of remains
= After surgery a stoma may be required (ileostomy, colostomy). May be 33yAt42JnkxG5z
temporary or permanent.
= General ward unless high risk.
33yAt42JnkxG5z
o Hepatectomy
= Liver cancer, cysts, other pathologies.
=" High laparotomy — roof top, “mercedes benz”
=" High dependencypost-op.
=" High risk for resp. complications due to high incision
=~ Often (R) LL
o Cholecystectomy
33yAt42JnkxG5z
= Indicated in cases of cholecystitis, chloelithiasis.

= Lateral subcostal incision
=" Often laparoscopic
=" Combined with cholangiogram
33yAt42JnkxG5z
= Post-op in general ward.

=" Generally no physio intervention unless significant risk factors.
o Whipples
= Includes; Pancreaticoduodenectomy, cholecystectomy,
choledochojejunostomy, pancreaticojejunostomy, gastrojejunostomy.
=" Indicated; cancer of pancreas.
=" High laparotomy (“roof top”)
=" High dependencypost-op
= Usually high risk for PCCs
33yAt42JnkxG5z
= Usually R (LL)
Oo AAA repair
= Indicated in case of aneurysm.
=" Long midline incision
= Sometimes endoluminal 33yAt42JnkxG5z
= Aorta clamped off

= Usually HDU post op, if open ICU.
=" No specific physio precautions
o Carotid endarterectomy
pH

1627124025
=" Removal of obstruction from carotid artery
= Usually no requirement for physiotherapy
=" High dependency due to risks of surgery
o Nephrectomy
= Indicated; renal cancer, cysts.
=" Lateral laparotomy
=" General or renal ward post-op
= Nil specific physiotherapy points.
33yAt42JnkxG5z
o Renal transplant
= Most common organ transplant.
= Indicated; polycystic kidney disease, renal failure.
= Incision as for nephrectomy, lateral sub costal
=" Transplant attached on iliac artery
=" Cadaver or living donor
= Reverse barrier nursing post op.
=" Often not allowed to sit up in the early postop period — check before you
change the patient’s position.
=" Check protocol before Rx
o Cystectomy
=" Indications; TCC bladder. 33yAt42JnkxG5z
=" Midline laparotomy

=" Bladder removed
= |leum formed into conduit for urine to skin surface
= Post op- general or renal ward
= Nil specific physio precautions.
o Radical prostatectomy
= Prostate cancer or enlargement.
=" Midline laparotomy
= Usually done transurethral - TURP
=" Post-op in post-surgical or renal wards.
=" Nil specific physiotherapy precautions.
33yAt42JnkxG5z
e Describe the effects of upper abdominal surgery on the respiratory system.

o Shift of activity from the diaphragm to other respiratory muscles (rib cage
and abdominal).
o Changedpattern of breathing
=» tidal vol, T RR
= May be paradoxical abdominal movement
=» J MIPs (diaphragm)
= Shift in activity from diaphragm to other muscles (Rib cage & abdominals).
= Doesn’t happen with peripheral or LAS
o Voluntary diaphragmatic contraction can increase the diaphragmatic
contribution to tidal volume and improveventilation to the lower zones of
pH

1627124027
the lung (Chuter et al 1990) as possibly can coached deep breathing and TEE
(Blaney et al 1997).
o Use of incentive spirometer does not improve diaphragmatic function. 33yAt42JnkxG5z
33yAt42JnkxG5z
e Outline the physiotherapy assessment and common respiratory problems of the

patient pre and postop UAS.
o Outcome measures commonly used;
=" Rates of PPC
=" Restoration of mobility — length of time
= LOS (length of stay)
= Use of resources (e.g. O2, staff, drugs, investigations).
33yAt42JnkxG5z
e Discuss physiotherapy treatment strategies for patients’ pre and post UAS
including rationale for use, indications, contraindications and evidence of
effectiveness.
33yAt42JnkxG5z
o Evidence supporting use of physiotherapy in improving mobility and risk of

developing PPCs.
DB (improves mechanics & volumes).
0
Huffs (assists sputum clearance without explosiveness of cough)

0
FET (assists sputum clearance, splints open airways- J) risk of collapse)

00
PEP (assists sputum clearance, splints open airways- \ risk of collapse)

Coughs (combine with wound support).
OO
Walk (improves lung volumes).

33yAt42JnkxG5z
33yAt42JnkxG5z
LECTURE 12: CARDIOTHORACIC SURGERY
e Briefly describe common cardiothoracic surgical procedures in termsofincision

site, technique, postop care and contraindications to physiotherapy treatment.
33yAt42JnkxG5z
o Surgery in the thorax ie above the diaphragm e.g. Heart, lungs, pleura,
mediastinum.
o CT surgery can be open or closed.
oO Incisions; 33yAt42JnkxG5z
=" Median sternotomy

=" Thoracotomy (anterior, lateral, or posterolateral)
=" Thoracoscopy (VATS)
o Pleural surgery
= Repair of defects (e.g. stapling blebs PTx)

33yAt42JnkxG5z
= Pleuradesis
e Fusion of visceral and parietal pleura.
e Thorascopic or open
e Indications; recurrent effusion or PTx
e Material introduced into pleural space — sets up inflammatory
reaction (e.g. talc, abrasion, tetracycline).
pH

1627124027
=" Decortication
Stripping of thickened pleura off lung (allows lung to re-expand).
Indications; chronic pleuritic, empyema.
Thoracotomy or thoracoscopy
=" Physio key points

May not need to see (small procedures/low risk patients).
Very painful
33yAt42JnkxG5z
Lung compromised byrestriction (pain, mechanics).

Remember the shoulder
o Thoracic surgery
=" Very high risk for respiratory complications (Smoking, Thoracic incision, Pain,
Lung collapse).
=" Thorough preop essential. 33yAt42JnkxG5z
=" Lobectomy
33yAt42JnkxG5z
Removal of one or more lung lobes of the lung

Indications; cancer, chronic infection (e.g. bronchiectasis).
Thoracotomy. 2 chest drains (apical & basal).
Remaining lung fills space.
Physio commences ASAP
Lie affected side UP (7 ventilation, drainage, and re-expansion).
33yAt42JnkxG5z
DO NOTsuction or use PEP or CPAP

= Pneumonectomy
Removal of whole lung.
Indications; lung cancer.
Thoracotomy
Spacefills with blood > eventual fibrosis.
Physio commences ASAP
33yAt42JnkxG5z
Very high risk for respiratory complications (smoking, pain,
mechanics).
DO NOTlie affected side up (blood drain from post-pneumonectomy
space into good lung & wet stump).
DO NOTsuction or use PEP/CPAP.
Remember the shoulder 33yAt42JnkxG5z
=" Chest drainage

AKA. Chest tube, chest drain, intercostal catheter (ICC), underwater
seal drain (UWSD), pleurocath.
NOTin the lung- they are in the PLEURAL SPACE.
Removebuild-up of air or fluid without allowing air to return to the
pleural space (one-way valve).
Fluid drains via gravity (drains must be held below the thorax).
Suction may be applied to hasten drainage.
pH

1627124029
e Regularly observe- drain site, amount drained, bubbling, and swing
(Transmission of pleural pressure changes to the fluid in the tube).
e Consider when positioning, transferring, and mobilising patient.
o Cardiac Surgery
= Indications; coronary artery disease, valve disease, structural or
electrophysical abnormalities.
33yAt42JnkxG5z
33yAt42JnkxG5z
=" Percutaneous revascularisation

e Catheter introduced into arterial circulation and advanced to the
coronary arteries.
33yAt42JnkxG5z
e Stents- Scaffolds inserted into the diseased vessel (Maintain lumen

patency).
=" Cardiopulmonary bypass (CPB)

e The machine that temporarily takes over the role of the heart
(circulation) and lungs (gas exchange) during open cardiac surgery.
e Developed in 1950’s.
e Generally clinically called “the pump”. 33yAt42JnkxG5z
e Allows the heart to be stopped for surgery.

e Sometimes used in situations other than cardiac surgery e.g.
emergency cardiac situations, pre transplant, ECMO.
e Heparinised circuit.
e Venous cannule (removes blood from venous circulation).
e Oxygenator (bubble, membrane).
33yAt42JnkxG5z
e Reservoir (holds blood and allows things to be added e.g. extra fluid)
e Heat exchanger (cooling for surgery 28-32°C).
e Pump (propels blood into arterial circulation).
e Arterial cannulae.
e Complications;
o Release of vasoactive substances.
Activation of immune response.
o0006dC~OUWUdlCUO
Related to time spent on CPB

Renal failure (poor renal perfusion).
CVA (1-5%)
Cerebral effects (personality, depression).
Lung collapse (Predisposes to alveolar collapse postop)
=" Cardioplegia
e "The induction and maintenance of the heart in an arrested state
33yAt42JnkxG5z
33yAt42JnkxG5z
using a chilled solution infused into the coronaryartery circulation."

(Finkelmeier).
e Cardioplegic solution is a complex mixture of chemicals. Includes
electrolytes (mainly K+). Usually around 4-8° C.
e Causes cardiac arrest and protects the myocardium during surgery.
e Antegrade (through coronaryartery at aortic root) or retrograde
(through coronaryveins) infusion.
e Heart re-started by warming & reperfusion of heart.
pH

1627124029
e DC shock may be required.
=" Coronary artery bypass graft (CABG)

e Indications; coronary artery disease.
e GA, CPB, sternotomy
e Blocked CAsare bypassed using another vessel
e Graft options;
o Saphenous vein (LSV, SVG)

= Free graft
33yAt42JnkxG5z
= Attached to aorta
= Shorter lifespan than arterial graft
=" Patient also has leg wound
33yAt42JnkxG5z
o Internal mammary artery (RIMA, LIMA

=" Lasts longer than SVG
=" Left attached at subclavian artery
= Can generally only graft 1 CA (usually LAD)
=" Morerespiratory complications
o Radial artery
=" Free graft — benefits of artery graft but less pulmonary
complications
= Arm wound
© Gastroepiploic
33yAt42JnkxG5z
e MIDCAB
o Minimally invasive direct coronary artery bypass.
Usually only used LIMA — LAD (1 graft).
©
“Off pump” — beating heart.

©
33yAt42JnkxG5z
33yAt42JnkxG5z
“Octopus” used to hold heartstill for surgery.

Oo
Faster recovery and quicker discharge time.

33yAt42JnkxG5z
Oo
= Valve disease
e Indications; stenosis, prolapse, incompetence.
e May berepaired or replaced (annuloplasty, MVR, AVR).
e Can be replaced with tissue (less need for life long anticoagulation)
or mechanical grafts (lifelong anticoagulation required).
e Surgical procedure and post-op care as for CABG.
=" Cardiac Transplantation

33yAt42JnkxG5z
e Specialised area. Only 3-4 sites in Australia (St. Vincent’s NSW).

e Post op- mechanically ventilated & haemodynamically unstable.
e No time spent in recovery- straight to ICU.
e Extubated when haemodynamically stable, breathing spontaneously
and waking up. Usually 4 - 8 hours postop.
pH

1627124031
= Pacemakers
e Some arrhythmias may require PPM or AICD.
e PPM;
o Permanent pacemaker
o Generator implanted under the skin (shoulder)
o Wires fed IV into position in the heart
33yAt42JnkxG5z
o Automated implantable cardioverter-defibrillator

33yAt42JnkxG5z
33yAt42JnkxG5z
o Similar to PPM 33yAt42JnkxG5z
o Delivers DC shock in response to detection of arrhythmia

33yAt42JnkxG5z
e Describe the effects of cardiothoracic surgery on the respiratory system. 33yAt42JnkxG5z
o Fluid overload
= CPB effects
= Fluid resuscitation
=" Heart failure
33yAt42JnkxG5z
o Retraction of the lung
=" Particularly (L)LL
= Collapse / consolidation
= (L)LL collapse/consol. is seen as a normal complication of cardiac surgery
=" Generally self-resolving.
=" May not need, or respond to, physiotherapy.
o Pleural effusion
= Fluid in the pleural space (blood)
=" More common with IMA grafts
=" Compression of lung
o Pneumothorax
33yAt42JnkxG5z
= Common postop — breach of pleura during OT

= May occur or persist after drains removed
e Describe the effects of sternotomy and thoracotomy on the musculoskeletal

system.
© Sternal instability common postop. Infection may also occur
o Bone healing takes about 6 weeks
o Avoid aggravating movements(check instructions from surgeon).
33yAt42JnkxG5z
e Outline the physiotherapy assessment and common respiratory problems of the

patient pre and postop cardiothoracic surgery.
e Discuss physiotherapy treatment strategies for patients pre and post
cardiothoracic surgery including rationale for use, indications, contraindications
and evidenceof effectiveness.
o High risk of respiratory complications.
pH

1627124031
Assessment and treatment required pre and post cardiac surgery.
0
Preop as for other surgery (see previous lectures).
0
Commencepostop treatment once extubated — usually day 1
O00 Identify problems and treat as appropriate.
33yAt42JnkxG5z
Patients need assessment and treatment until independently mobile and no

Oo
significant resp compromise.

© (L)LL collapse/consolidation is a common postop complication — unless
associated with potential for more serious resp comps — does not require
specific intervention.
o CABG/AVR/MVR post-op care example
= DayO
33yAt42JnkxG5z
e Surgery
e Ventilated
e Extubated some time 4-8 hours postop
" Dayl
e Extubated 33yAt42JnkxG5z
e SOOB
e Drains out
33yAt42JnkxG5z
=» Day 2-5
e Progressive increase in mobility
e Transfer to step down ward
=" Day 5-7
e Discharge
33yAt42JnkxG5z
o Uncomplicated post cardiac surgical patients do not gain any additional

33yAt42JnkxG5z
benefits from the addition of DB to early mobility and supported FET, cough.
o Limitations to treatment:
=" Haemodynamic instability
=" Arrhythmias eg AF
= ~Sternal complications
=" Post op confusion
Review mobility and stairs prior to discharge
Musculoskeletal exercises (Start early).
o Home program — cardiac rehab 33yAt42JnkxG5z
33yAt42JnkxG5z
pH

1627124031
33yAt42JnkxG5z
LECTURE 14: INFLAMMATORY, INFECTIOUS, SUPPURATIVE, AND NEOPLASTIC LUNG
DISEASE.
e Describe common inflammatory, infectious, suppurative and neoplastic respiratory

diseases in termsof aetiology, pathogenesis, clinical presentation and medical
management.
o Inflammatory/infectious
URT
= Common cold
e “coryza” = common cold, “coryzal’— like those of the common cold.
e Acuteviral illness affecting the upper respiratory tract.
e Multiple viruses which prevents immunity.
33yAt42JnkxG5z
e Infection and inflammation of the nasopharyngeal mucosa
= Influenza
e Highly infectious acuteviral illness caused by the influenza virus
e Characterised by systemic features (pyrexia, fatigue, headache,
malaise).
e Highly infectious- droplets.
e High risk for those with co-morbidities.
e Management supportive and preventative.
33yAt42JnkxG5z
33yAt42JnkxG5z
" Other
e Epiglottitis (inflammation supraglottic region)
e Laryngotracheobronchitis (croup- subglottic region)
e Pertussis (whooping cough).
= Physiotherapy contraindicated in acute stage. Later in disease course

only if specific lung pathology (e.g. secondary pneumonia) and excess
secretions. 33yAt42JnkxG5z
LRT
=" Bronchiolitis
e Inflammation of the bronchioles caused by viral pathogen.
e Most common LRT disease of childhood.
e Aerosol or direct transmission.
e Airway oedema
e Increased mucous production
e Obstruction of small airways
e Respiratory distress
e Cough +/- secretions
e §6Auscultation signs
e CXR may show consolidation
e Ventilatory support as needed.
pH

1627124031
= Pneumonia
Inflammatory process affecting the lung parenchyma — gas
exchangeportion of the lung.
Caused by various agents
“typical” vs “atypical”
33yAt42JnkxG5z
Bacteria eg Streptococcus, Staphylococcus, Klebsiella,

Pseudomonas, Haemophilus, Legionella
33yAt42JnkxG5z
Viruses: Influenza, RSV

Mycoplasma pneumoniae (Small organisms which escapes
isolation by standardtests).
Varicella - Chicken pox
Rubella - Measles
Fungal infections: Aspergillus, Histoplasmosa, Candida.
Aspiration
Alveoli fill- serum, fluid, WBCs, RBCs > consolidation of lung.
Consolidation > V/Q mismatch > hypoxaemia.
Stages; 33yAt42JnkxG5z
1. Consolidative
2. Resolution (break up of consolidation, may produce secretions).
33yAt42JnkxG5z
33yAt42JnkxG5z
May affect pleura (Parapneumonic effusion, Empyema).
Complictions;
o Permanent lung damage
o Bronchiectasis, lung abscess
o Pleural effusion - “parapneumonic”, empyema
o Sepsis and multiorgan failure
o Respiratory failure
Physio ineffectivein initial consolidation phase.
Aim to preventor treat in resolution stage.
= Legionella
Legionella pneumophilia.
Gram — bacteria causing severe pneumonia.
Widely distributed in nature in water
Not transmissible from person to person- but by contaminated
water systems.
High mortality, systemic involvement.
Physio Rx- frequently non-productive. Treat problems found in
assessment.
=" Lung abscess

A localised collection of pus within a cavitated necrotic lesion in the
lung parenchyma.
33yAt42JnkxG5z
Caused by;
o Anaerobic bacteria entering lung (via aspiration).
o Other bacteria invading lung eg: Strep, Klebsiella, E-coli
pH

1627124034
Bronchial obstruction with secondaryinfection
0
Vascular obstruction eg PE.
oO000
Interstitial lung disease with cavity formation.
Blood borne infection — Sepsis, IVDU.
Infected bullae.
oO Transdiaphragmatic spread.
e As for pneumonia in early stages - lung consolidation.
33yAt42JnkxG5z
33yAt42JnkxG5z
e Progression to tissue necrosis and destruction of tissue - cavity

formation.
e Cavity filled with air and infected material.
e May be encapsulated in a pyogenic membrane.
e May rupture into a bronchus or into the pleural cavity >
compression of surrounding lung.
e Can be seen on CXR
e Medical management; surgery, antibiotics, biopsy, supportive
therapy (nutrition & fluids).
e Physio Rx- postural drainage (if abscess is draining). Affected area
UP.
BRONCHIECTASIS
° . M
=" Bronchiectasis lserakesentti
e Anatomically defined by chronic, Impaired
irreversible dilation and distortion of Inflammatory ciliary action
response Loss of
the bronchi caused by inflammatory
33yAt42JnkxG5z
ciliated cells
33yAt42JnkxG5z
destruction of the muscular and “Oey

elastic componentsof the bronchial Eset - ff Bacterial
walls (Georgeetal). inte a —
e Incidence in developed countries reas: a proliferation
unknown low. ——
e Prevalence in Indigenous Australians 33yAt42JnkxG5z
and Maori/Pacific Islanders among 33yAt42JnkxG5z
the highest in the world.

e Can be idiopathic, congenital or alin .
acquired.
e Acquired; chronic lung infection, chronic aspiration, subsequent to
childhood infections, immunodeficiency, distal to obstructed 33yAt42JnkxG5z
bronchus.
e Congenital; associated with range of autoimmune diseases.
e Initial insult and then ongoing inflammatory response >Damage
and destruction to airway.
e Reduced effectiveness of MCC > pooling of secretions.
33yAt42JnkxG5z
e Small airways closure — may lead to gas trapping or alveolar collapse

33yAt42JnkxG5z
e Scarring and fibrosis of airways.

e Both obstructive and restrictive
e Local or diffuse
e 3 anatomic varieties;
o Cylindrical (Dilated bronchi which fail to taper)
o Varicose (irregular dilation- like varicose veins)
o Cystic/saccular (bronchi dilated ending in cysts)
pH

1627124035
e Cough with secretions, Haemoptysis
e Ausc-— crackles, wheezes
e ABGs, PFTS
e CXR useful, HRCT (CT scan) gold standard diagnostic tool.
CT scans
as
, Cylindrical el Varicose Cystic
e Acute exacerbation;
o Increased cough with moresecretions, changed colour
Haemoptysis
0
Signs of resp compromise (observation, palp)

o0o000
Ausc — BBS,crackles, wheezes

Pleuritic pain
CXR — increased consolidation, secretions in bronchi, cysts.
33yAt42JnkxG5z
33yAt42JnkxG5z
e Maintenance;
o Antibiotics
33yAt42JnkxG5z
33yAt42JnkxG5z
© Respiratory medications as appropriate (inhaled steroids,

bronchodilators)
o Vaccinations
e Effective secretion clearance is the mainstay of the acute and chronic
management of bronchiectasis
e PD, P&V, ACBT, PEP, Flutter
e Self management education
e Patient
e Carers
e Exercise training / pulmonary rehabilitation
=" Tuberculosis
33yAt42JnkxG5z
e Infectious disease caused by mycobacteruim tuberculosis.

e >5 million new cases reported to WHO each year.
e 95% from developing countries.
e Incidence stable or slightly declining.
e Mortality decreasing in developed world since 1900.
e Effective antibiotics available in the 1940’s.
e Drug resistant strains have emerged.
e Droplet transmission.
e Can remain suspended in the air for several hours.
p>

1627124036
33yAt42JnkxG5z
e Initial lesion develops in the lung.
e Immune response causes a tubercle to surround the bacilli.
e Tubercle may eventually calcify and heal — scarring and fibrosis.
e 33yAt42JnkxG5z
Bacilli may escape tubercle and spread throughout the lungs >
consolidation, abscess, and bronchiectasis.
e May spread to other organs.
e May lie dormant for many years
e Can reactivate years later (due to reinfection, |. immune status).
e May be non-specific symptoms.
e Pulmonary, extrapulmonary and both
e Persistent cough
e Haemoptysis
e Fever
e Anorexia and weight loss
e Night sweats
33yAt42JnkxG5z
e CXR;
o Apical changes
o Cavities
33yAt42JnkxG5z
o Airspace pathology
e Medical management;
oO Sanitarium (rest & fresh air)
o Surgery
o Pharmacology(rifampicin, isoniazid).
e Physio Rx;
o Not indicated in acute stage as often non-productive
(hemoptysis).
o May need totreat if significant focal lung pathology and
excess secretions.
LECTURE 15: RESTRICTIVE LUNG DISEASE
e Differentiate between obstructive and restrictive lung disease.

o Restrictive characterised by reduced lung expansion.
o Obstructive characterised by reducedairflow.
o Combinations include CF, bronchiectasis.
e Describe common restrictive lung disorders in terms of aetiology, pathogenesis,

clinical presentation and medical management, including:
o Disorders of the lung parenchyma/interstitium (e.g. IPF)

= Surgery (lung and chest wall/abdo)
=" Ageing (stiffening/hardening of lung and chest wall structures).
= ~Pneumonia/bronchiectasis (Inflammatory processes result in reduced lung
compliance)
= Pulmonaryfibrosis (involves the lung parenchyma, interstitium of the lung
33yAt42JnkxG5z
and small airways).
pH

1627124037
=" The interstitium
e Includes alveolar walls, pulmonary microvasculature,interstitial cells
(e.g. macrophages, fibroblasts), extracellular matrix channels,
lymphatic drainage channels.
e Affected by 150 diseases.
e Characterised by inflammation and fibrosis.
e Non-infectious in most cases.
e Known causes; occupation, environmental, drugs, irradiation.
33yAt42JnkxG5z
e —IPF- idiopathic pulmonaryfibrosis- unknown origin. SET tel

es
e Infiltration and inflammation of the alveolar wall.
33yAt42JnkxG5z
e Inflammatory exudatein the alveoli.

e Smooth mm hypertrophy.
e Distortion and destruction of normal alveolar
architecture.
e reduced lung compliance
e FRC WOB
e J Gas exchange > hypoxaemia
e RR, rapid shallow breathing pattern
e SOB resting and on exertion.
e Ausc. Crackles and | BS
e Signs of cardiac failure (RVF)
e Do not usually have excess secretions (unless
coexisting infection).
e “Honeycombing” pattern on CXR. “Ground glass”
look on CT
e Chronic & deteriorating prognosis 5 years 50%.
e Sarcoidosis
e Enigmatic disease
e Often clinical diagnosis of exclusion
e Multisystem disease
e Granulomatomas tissue develops
e Lymph nodes, lungs, skin, eyes, liver, spleen
33yAt42JnkxG5z
e Unknown aetiology
e Hypersensitivity pneumonitis
e Extrinsic allergic alveolitis.
e Hypersensitivity reaction to inhaled organic dusts or or contaminant
it carries.
e.g. farmer’s lung, breeder’s lung, maple bark strippers’ lung.
e Pneumoconiosis
e Refers to Parenchymal lung disease caused byinhalation of
inorganic dusts and particles.
e Usually of environmental or occupational origin (usually long term
exposure).
pH

1627124039
e _E.g. Coal workers (coal dust), Asbestosis.
e Toxic lung injury — toxic pneumonitis

e Exposure to gases, fumes, mists may produceinflammatory lung
disease.
e E.g. ammonia, chlorine, metal gases.
e Connective tissue diseases

e E.g. RA, Scleroderma, SLE
e BOOP
e Bronchiolitis obliterans with organising pneumonia.
e Lymphangitis Carcinomatosa
e Lymphangitic spread of carcinoma tissue (usually adenocarcinoma)
through pulmonary system 33yAt42JnkxG5z
e E.g. secondary to breast, ovary, colon, stomach Ca.
e Other restrictive lung parenchymal diseases;

e Granulomatous diseases (e.g. Wegeners's granulomatosis, Churg
Strauss Syndrome)
e ARDS
e Cytotoxic drugs (e.g. chemo).
33yAt42JnkxG5z
e Radiation pneumonitis.
e Pulmonary oedema
e Eosinophilic syndromes
o Disordersof the pleura
= Effusion
=" Collection of fluid in the pleural space.
= Usually secondary/associated with other disease.
= Pleural space is a "potential" space
= Thin layer of fluid (2-10 um)
= Fluid is constantly entering and leaving the pleural space
33yAt42JnkxG5z
=" Dynamics are dependent on hydrostatic and oncotic pressures

across the pleural membranes.
33yAt42JnkxG5z
= Parietal pleura — perfused by systemic circulation. Lymphatic

vessels for drainage.
pH

1627124039
= Visceral pleura — perfused by low pressure pulmonary
circulation
= Fluid can enter the pleural space from either pleural surface
but tends to come from the parietal pleura (due to direction
of forces).
= Balance offorces results in no net build-up of pleural fluid
33yAt42JnkxG5z
(15ml/24hrs).
=" Causes;
e Rate of pleural fluid formation > pleural fluid removal.
e May result from a change in formation, filtration and/or
absorption of pleural fluid.
e Increased capillary pressure (eg LVF)
e Reduced oncotic pressure (hypoalbuminaemia)
33yAt42JnkxG5z
e Capillary permeability (pleural inflammation,

pneumonia)
e Lymphatic obstruction
e More negative intrapleural pressure (eg atelectasis)
= Typically yellow straw coloured (haemoserous)
=" Generally gravity dependent
= Classified as;
e Transudates (movement of fluids across capillaries
e.g. heart, renal failure, pulmonary oedema).
e Exudates (Associated with local factors - changes in
permeability of pleural surface)
= S/E-report SOB,difficulty breathing, chest pain.
= Effusions are normally "free“ and gravity dependent.
= If the fluid doesn't shift freely when the patient changes
position — the fluid is said to be "loculated".
= Adhesions between pleural surfaces- Thick fluid eg protein, blood.
= No physio Rx for actual effusion.
33yAt42JnkxG5z
= Effect on lung depends on size of effusion.
33yAt42JnkxG5z
= Empyema
=" Accumulation of pus in the pleural space
=" Develops as a result of inflammation and infection
=" Often secondary to pneumonia
=" Chylothorax
= Lymphatic fluid in the pleural space - chyle
=" Trauma to or obstruction of the thoracic duct
= Haemothorax
= Blood in the pleural space
= Trauma, surgery
=" Mesothelioma
= Pleural malignancy related to asbestos exposure
=" Thickening,fibrosis
p>

1627124039
= Pneumothorax
= Airin pleural space from;
e Lung
e Atmospherevia chest wall
e Oesophagus
= Loss of normal negative intrapleural pressure
= Separation of lung from chest wall
= Lung collapse inward (Lung unable to expand).
=" Unable to ventilate alveoli —V/Q mismatch
=" Takes up space in the thorax — compression of lung (and
heart)
=" Reduced expansion
=" Reduced lung volume
= Alveolar hypoventilation
= Atelectasis
= Potential for infection in lung (and pleural space)
= Spontaneous pneumothorax
e Suddenly with no apparent cause
e High mechanical stress in apices of lung
e Sub pleural “blebs”
=" Tension pneumothorax
33yAt42JnkxG5z
e Air into pleural space but not out

e Opening functions as a valve
e Medical emergency
e Compression of lungs, heart (cardiac tamponade)
= S/E-SOB,difficulty breathing, sharp chest pain
= Obs/palp
=" Hyperresonant percussion note
= Ausc.
=" No physio management but managethe underlying lung.
o Disorders of the chest wall/abdominal causes

=" Surgery
=" Obesity
e Reduction in thoracic compliance
e Less ability and more work for lung to expand- Alveolar hypoventilation.
33yAt42JnkxG5z
33yAt42JnkxG5z
=" Chest trauma

e #ribs (changed mechanics due to pain).
e Flail segment (more than 1# on more than 33yAt42JnkxG5z
1 rib).
e Lung contusion (bruising > bleeding into
lung).
=" Medical management; pain relief, respiratory
support(e.g. O2, ventilation).
=" Physio Rx- Treat problems identified.
33yAt42JnkxG5z
p>
PPthinkswap
33yAt42JnkxG5z

1627124040
=" Chest wall deformity
=" Kyphoscoliosis, anklylosing spondylosis, pectus excavatum.
=" Reduced chest wall compliance and altered mechanics.
=" Muscles changes in shape and therefore function.
=" May also change lung compliance.
=" Treat problems based on assessment.
o Neuromuscular disorders.
=" Diseases affecting the muscles of respiration or their nerve supply
=" Reduced respiratory muscle function > Reduced force generating capacity.
= E.g. SC injury, motor neurone disease, ALS, MS, muscular dystrophy.
= Medical treatment supportive rather than curative.
= Physio Rx based on problems found in assessment.
e Outline the appropriate assessment, common respiratory problems and possible

physiotherapy treatmentstrategies for the patient with restrictive lung disease.
o Position to optimise ventilation.
o Treat problems found in assessment- e.g. soutum clearance- huff, ACBT.
LECTURE 16: OBSTRUCTIVE LUNG DISEASE
e Understand the concept, the causes and the consequencesofairflow limitation.

o Spirometry is the gold standard in determining air flow limitation.
FEV, and /or FEV;/ FVC ratio
0
< 70% FEV: / FVC

0
< 80% FEV:

O00
Low peak flow is non-specific

Causes;
Oo
= Reduced lumen size

e Secretions
e Mucous glad hypertrophy, inflammation, oedema
33yAt42JnkxG5z
e Smooth muscle hypertrophy and bronchospasm

= Loss of radial traction of airway
e Loss of elastic supporting tissue
33yAt42JnkxG5z
=" Reduced driving pressure

e Alveolar destruction
e Reduced elastic recoil
o Consequences;
=" Prolonged expiratory time
=" Collapse of small airways
=" Gas trapping
=" Hyperinflation
=" Poor effective alveolar ventilation
=" Reduced secretion clearance
33yAt42JnkxG5z
pH

1627124042
o Max airflow not usually reached by healthy adults during breathing (even
with max exercise).
o Some people with COPD may reach max airflow during tidal breathing.
o "Scooped-out" appearance of flow volume curve — flow limitation early in
expiration. 33yAt42JnkxG5z
33yAt42JnkxG5z
Healthy normal Copp — es

] perro nnas ee predicted |
oe » ee — actual
Flow (L/s)
| Tc
33yAt42JnkxG5z
So er aeonnivel
Volume (L) Volume (L)
o Hyperinflation
= Increasing static lung volume (FRC, RV)
= Initially a compensatory mechanism to overcome 7 airway resistance —
expiratory flow is better at increased volume
= Results in altered mechanics
=" Dynamic hyperinflation worsens when;
33yAt42JnkxG5z
e Airway resistance is increased
e Time for expiration is reduced (E.g. exercise)
= Mechanism;
e Airflow limitation (causes above)> expiration takes longer > air trapping
and increased TLC/FRC/RV > changed mm mechanics.
e Compounded bythe patient increasing RR to compensate for reduced
inspiratory time/volume — further gas trapping.
= Advantages;
e Distends airways and prevents them collapsing so readily during expiration.
33yAt42JnkxG5z
e Reduces resistance and increases airflow.

=" Disadvantages; 33yAt42JnkxG5z
e Restricts further volume expansion (e.g. during exercise)

33yAt42JnkxG5z
e Additional burden on respiratory mms — increased elastic loading >

Altered respiratory muscle mechanics.
e Flattened diaphragm — reduced force generating ability
e Shortening other resp. muscles — reduced force generating ability
=" Consequences;
e Short term benefit (better flow rates)
e Alterations in pulmonary mechanics
e Increased work of breathing
e Reduced effective alveolar ventilation
e Reduced ability to clear secretions
pH

1627124045
e Reduced exercise capacity
e Dyspnoea
e Describe common obstructive lung diseases in terms of aetiology, epidemiology,

33yAt42JnkxG5z
pathogenesis and clinical presentation.
o COPD 33yAt42JnkxG5z
=" Acombination of emphysema and chronic bronchitis.

=» "asthmatic component"
= Reversibility- use of bronchodilators/corticosteroids may give limited relief.
=» “A disease state characterized by the presence of airflow limitation due to
chronic bronchitis or emphysema: the airflow limitation may be
accompanied by airway hyper-reactivity and may bepartially reversible”-
ATS.
=» “Reduced maximum expiratory flow and slow forced emptying of the lungs,
which is slowly progressive and mostly irreversible to present medical
treatment”- ERS.
= Difficult to collect accurate data (due to differing definitions).
= 4"leading cause of death in the world (GOLD).
=" Often poorly diagnosed (patients reluctant to seek help).
=" Most important cause of COPD is cigarette smoking- 80 - 90% have smoked.
=" Close relationship between amount of tobacco smoked and decline in FEV1.
=" About % ofall smokers develop some airflow limitation.
= Inhalation of smoke > Inflammation > Affects neutrophils, protease
inhibitors.
= 25-100mlI FEV1 lost per year.
= Air pollution- Effects remain contentious.
=" Occupational inhalation of dusts and fumes- Exposure to heavy dusts causes
a productive cough; unknownlong term effects.
= Low socioeconomic status correlates strongly with COPD. Nutrition,
respiratory infection in early life, environmental exposures, premature birth,
lower birth weight.
= Early childhood factors- Respiratory infections, Prematurity Cause — failure
=» Asthma
=" Early stages often not associated with symptoms.
=" Once symptoms develop the disease is often quite advanced
33yAt42JnkxG5z
=" Long “pre-clinical” course.

= Starts with small airways.
=~ Identifiable with spirometry.
= Slow progression of airflow limitation.
=" FEV: normally declines with advancing age (20-30ml/year).
=" Progression of disability.
= Exacerbations.
=" Factors associated with increased mortality;
e@ FEV:
e BMI
e 6MWT
pH

1627124046
e §=Chronic hypoxaemia
=" Severity based on FEV1
e Mild 60-79%
e Moderate 40-59%
e Severe < 40%
= Some havereversible component — some fixed obstruction.
= Assessment of reversibility helps plan optimal management.
= Type A- pink puffers
e Emphysema
e Cachetic (weak/wasted)
e Minimal cough / sputum
Breathless 33yAt42JnkxG5z
e Maintain ABGs at rest until advanced

e Responsiveto levels in CO2
=" Type B- blue bloaters
e Chronic bronchitis
e §=Chronic cough with sputum
VPaO2, TPaCO2
33yAt42JnkxG5z
Plethoric complexion
Reduced ventilatory drive
=" Complications of COPD

e Pneumonia
e Polycythaemia
e Nocturnal respiratory failure
e Sleep disorders
e Respiratory failure
e Cor pulmonale- (R) sided heart failure secondary to lung disease.
=» S/E
e SOB
e Cough
33yAt42JnkxG5z
e Wheeze
33yAt42JnkxG5z
e Reduced exercise tolerance
e ~=Acute vs chronic vs exacerbation
=" Observation:
e Chest shape
e =Posture
e Accessory mms
e PLB (pursed lip breathing)
e Reduced LBE 33yAt42JnkxG5z
e §=Clubbing
33yAt42JnkxG5z
e §=Cyanosis
= ABGs
e Maintained or abnormal
e Depends on presentation
e =May be chronically hypercapnic and/or hypoxaemic
e Obstructed
e Exacerbation vs usual
pH

1627124047
Figure 4.1. Mechanisms of airway obstruction. (A) The lumen is partly blocked,
for example, by excessive secretions. (8) The airway wall is thickened, for
example, by edema or muscle hypertrophy. (C) The abnormality is outside the
airway; in the example shown, the lung parenchyma is partly destroyed and the
airway has narrowed because of loss of radial traction.
= Management
Oo Not curable
oO TSANZ 4 step guideline;
= Assess and monitor disease
=~ Reducerisk factors
= Manage stable COPD 33yAt42JnkxG5z
= Manage exacerbations
Diagnose (PFTs, respiratory physician).

0
Ongoing monitoring (Spirometry, ABGs, resp physician, ex test.)

o0o00
Reducerisk factors (Smoking cessation)

Smoking cessation returns decline in lung function to the “normal” rate of decline.
|”
Patients with COPD previously thought unable to exercise - unable to exercise at

high enough intensity.
Now seen as an integral part of the management of patients with COPD.
33yAt42JnkxG5z
oO
Oxygen therapyis the only treatment (apart from stopping smoking) that has been
shown to reduce mortality in COPD.
Remember hypoxic drive to breathe!! 4 times when 02 may be used;
= Acute, during exacerbations- correct short term hypoxaemia.
= LTOT (domiciliary)- correct long term hypoxaemia.
= Short-burst therapy
= Ambulatory
Surgery- Lung volume reduction surgery (LVRS)- bullectomy.
Non invasive ventilation (NIV)
= Frequently used for acute exacerbations in hospital and for nocturnal respiratory
33yAt42JnkxG5z
failure.
=" Consider use during daytime or exercise.
Physiotherapy Rx considerations; 33yAt42JnkxG5z
= High WOB
=» Dyspnoea
= Respiratory mm mechanics
=" Floppy collapsible airways
= Poor expiratory flow 33yAt42JnkxG5z
=" Hyperinflation
= Weak mms
p>

1627124048
o If the patient has secretion clearance problems;
= Aim for best expiratory flow rate with least airway compression/collapse.
= Aim to remove secretions without increasing WOB / dyspnea.
=" Do not encourage lots of coughing — particularly if non productive
=" Do not tip head downif very breathless
=" Consider huff, FET, ACBT (+/-TEE), (autogenic drainage).
=" Passive treatment in a modified postural drainage position may be required
if the patient is acutely unwell and very breathless (P&Vs).
o If the patient has reduced alveolar ventilation;

= Is it something you can treat?
= No deep breathing — further encourages hyperinflation
= Aim for better effective alveolar ventilation.
=" Consider the effect of secretion clearance.
=" Encourage controlled breathing — dyspnoea relief
e Pursed lip breathing
33yAt42JnkxG5z
e Consider position/arm bracing
o Reducing work of breathing;

=" Working out when to treat and when notto!
33yAt42JnkxG5z
33yAt42JnkxG5z
=" Consider mm mechanics

=" Relaxed, controlled breathing techniques
= Pursed lip breathing, positioning
=" Exercise training 33yAt42JnkxG5z
= May need further help if dyspnea seems disproportional to the situation.
o Thoracic spine;
=" Neglected area
= Many patients with chronic lung disease have thoracic/shoulder/neck
pathology.
=" May worsen respiratory function and contribute to symptoms.
=" Consider assessing and treating thoracic cage/shoulder/neck.
o Emphysema
= Permanent enlargement of the airspaces distal to the terminal bronchiole
with destructive changes in the alveolar wall.
=. Destruction of the elastic fibre network in the lung.
o Chronic bronchitis
33yAt42JnkxG5z
=" Hyper secretory disorder.

=" Cough productive of sputum on mostdaysfor at least 3 months for at least
2 successive years (excluding other diagnoses e.g. bronchiectasis).
33yAt42JnkxG5z
pH
PPthinkswap
33yAt42JnkxG5z

1627124048
o Asthma
=" Obstructive lung disease characterised by airway hyper-responsiveness to
various stimuli.
=" Episodic occurrence of wheezing and dyspnoea.
= Airflow obstruction with a bronchodilator reversible component.
= Airway inflammation.
= Physio Rx
e Education
o Medication use
o Disease monitoring
o Health maintenance
o Secretion clearance if appropriate
e Secretion clearance
o Thick secretions - plugging of airways
o PEP, FET, autogenic drainage techniques
o Aim for good airflow without airway compression
e Exercise training
LECTURE 17: INTERPRETATION OF CHEST XRAYS
e Describe the features of a normal CXR in a systematic mann
Manubrium —
Talia)
Left
ventricle
33yAt42JnkxG5z
33yAt42JnkxG5z
Lateral view
Trachea
Re Saonavroan bP
1.0 ------
R main bronchus 2. Ascending aorta
L main bronchus 3. Aortic arch
aortic arch 4. Brachiocephalic vessels
33yAt42JnkxG5z
Azygos vein 5. Trachea

R pulmonary artery 6. RUL bronchus
L pulmonary artery 7. _LUL bronchus
R pulmonary artery 8. R Pulmonary artery
R pulmonary vein
33yAt42JnkxG5z
33yAt42JnkxG5z
9. _L Pulmonary artery
R atrium
ad
10. -----
L ventricle
33yAt42JnkxG5z
> thinkswap
1627124052
o Technical aspects
Heart will appear a bit bigger than it is in AP view- more normal in PA view.
PAs are done in the departments, Aps done in the ward (mobile).
White = 7 Density e.g. heart
Black = | Density e.g. Air
If exposed correctly SP’s clearly visible to T4
Insp. Phase: Normal = 6"rib ant, 9°" rib post.
Dissect the diaphragm in the mid clavicular line.
o Patient position
Patients can be erect, supine, or in lateral decubitus position (side).
Lateral decubitus usedto identify fluid around pleura.
Is the ray centred? If so, clavicles should be equal distances from SP.
o Anatomical details and structures

Visible soft tissue includes;
Breast tissue
Swelling
Subcutaneous emphysema
Air under the diaphragm
Mediastinum
Heart
SVC, (R) atrium, (L) atrium, (L) ventricle,
aorta
< % diameter of the chest.
Hilum Subcutaneous emphysema
Bronchi, arteries, veins, lymph nodes
Trachea
Midline, bifurcation should be visible.
Fractures
Joints 33yAt42JnkxG5z
Thoracic shape
Vertebral column
Osteoporosis
Diaphragm
Outline should be clear
33yAt42JnkxG5z
Right higher than left

Costophrenic angle & cardiophrenic angle
Elevated v Flattened
33yAt42JnkxG5z
Lung fields
Translucency symmetrical
Lung markings are evenly spaced and all the way out to the edgeofthe film
e.g. pneumothorax
Pleura should not be thickened e.g. Pleural effusion
Horizontal fissure approx 4" IC space
o Lines/drains
ETT/trache - T4 or 3-4 cm above carina
p>

1627124052
=" Central venous catheter- Just above RA in SVC
=" Swan Ganz Catheter- In PA outside RV
= ICC
= NGT
=" ECG dots
=" Watch for external lines lying on the chest wall
33yAt42JnkxG5z
e Identify on a CXR the following common pathologies and outline their radiological 33yAt42JnkxG5z
features:
o Airspace disease (collapse/consolidation)

33yAt42JnkxG5z
=" Opacityin interstitial space

= Fingerlike projections
= Peribroncial cuffing 33yAt42JnkxG5z
= Kerley B lines
= Causes;
e Cardiogenic
e ARDS -—leakycapillaries
e ~Hypervolaemia
Peribronchial cuffing
© Opacity in pleural space

= Veil like
"= Homogenous
=. Dependent if patient mobile
= Veil over entire lung if supine
= Pleural effusions (below)
33yAt42JnkxG5z
33yAt42JnkxG5z
33yAt42JnkxG5z
33yAt42JnkxG5z
>
PPthinkswap 1627124053
33yAt42JnkxG5z
33yAt42JnkxG5z
Pleural effusion
33yAt42JnkxG5z
O Opacity- alveolar space

Air bronchograms 33yAt42JnkxG5z
Patchy opacity
Limited by major fissures
Pus e.g. Infection
Blood e.g. Pulmonary contusion
Protein e.g. Alveolar proteinosis
Water e.g. Fluid overload 33yAt42JnkxG5z
Cells e.g. neoplastic

Often occurs simultaneously. 33yAt42JnkxG5z
Pure consolidation = signs of alveolar

Alveolar space opacity
opacity, no loss of volume.
Pure collapse = signs of alveolar opacity, loss of
volume + movementof fissures or diaphragm.
The “silhouette sign” refers to the loss of distinct Ae
borders between structures due to the presence of ra
TS
massor fluid.
Hyperinflation
Oo Flattened ribs
33yAt42JnkxG5z
- Per
Urata ECGi
TS
Elongated mediastium
0
Blackened lung fields

0
Increased number of ribs visible above the diaphragm

oO
Flattened diaphragm LeftLower
Silhouette sign
p>

1627124053
33yAt42JnkxG5z
33yAt42JnkxG5z
33yAt42JnkxG5z
o Pneumothorax
33yAt42JnkxG5z
33yAt42JnkxG5z
L Lung PTx R Lung collapse + PTx
>
PPthinkswap
1627124054
o Pleural effusion
33yAt42JnkxG5z
o Atelectasis
33yAt42JnkxG5z
R UL atelectasis
33yAt42JnkxG5z
>
> thinkswap
1627124055
o Collapse/consolidation
33yAt42JnkxG5z
33yAt42JnkxG5z
33yAt42JnkxG5z
33yAt42JnkxG5z
R ML collapse and/or consolidation
33yAt42JnkxG5z
33yAt42JnkxG5z
33yAt42JnkxG5z
33yAt42JnkxG5z
>
PSthinkswap 1627124057
33yAt42JnkxG5z

R LL collapse and/or consolidation
33yAt42JnkxG5z
33yAt42JnkxG5z
33yAt42JnkxG5z
L LL collapse and/or consolidation

ee ee
33yAt42JnkxG5z
>
PSthinkswap 1627124057
PORTABLE
Right ML & LL collapse and/or consolidation
R LL/ML + UL collapse
33yAt42JnkxG5z
33yAt42JnkxG5z
oe RS
Right LL aspiration pneumonia
33yAt42JnkxG5z
>
> thinkswap
1627124060 33yAt42JnkxG5z
33yAt42JnkxG5z
33yAt42JnkxG5z
Plate/bilateral atelectasis
o Chest trauma
33yAt42JnkxG5z
33yAt42JnkxG5z
e RPTx
e R#ribs 33yAt42JnkxG5z
33yAt42JnkxG5z
33yAt42JnkxG5z
eR basilar PTx
e Contusions
e subcut emphysema
e pneumomediastinum
>
> thinkswap
1627124062
LECTURE 18: BASIC CARDIOLOGY
e Describe common cardiovascular disorders in termsof aetiology, epidemiology,

pathogenesis, clinical presentation.
o Cardiac output= Stroke volume x HR
o Linearly related to oxygen consumption
o Stroke volume= Volume ejected per beat and is dependenton:
= End diastolic volume - Venous return (preload)
= Resistance against which it is pumping (afterload)
=" Force of ventricular contraction (contractility)
o Pre-load
=" Extent to which the ventricle is stretched before contraction.
=" Volume load - Venous return
=" What determines venous return?
e Blood volume
e Mm pump
e Body position
e Breathing
33yAt42JnkxG5z
e Ventricular stiffness
e Venous tone
o After-load
= Resistance that the heart works against during contraction
= Pressure load.
= The aorta distends when the bloodis ejectedintoit.
= When aortic pressure exceeds the pressure in the ventricle the valve
33yAt42JnkxG5z
shuts.
= The aorta compresses and actslike a second pump.
=" Determinants of afterload;
e Impedance created by aorta / PA
e Impedance of systemic / pulmonarycirculation
e Valvesize (aortic / pulmonary)
33yAt42JnkxG5z
o Contractility to affected by;

=" Starling mechanism
= Autonomic NS
=" Dynamics of preload and afterload
o Frank — Starling mechanism;
= Increased stretch of cardiac mm fibres — increased force of contraction.
= If over stretched — lose ability to contract effectively.
o Ischaemic heart disease

33yAt42JnkxG5z
=" |HD, CAD, AMI, UAP

= ~=Small anaerobic capability
= Receives blood during diastole (driven by diastolic BP not SBP)
= Receives blood from the outside (epicardiac) must pass through extensive
capillary network to internal mm.
pH

1627124061
Ischaemia usually precipitated by increased myocardial O2 demand eg
exertion.
Imbalance between myocardial O2supply and demand.
Usually due to coronary artery disease (CAD).
+/- ST changes on ECG (STEMI).
Angina pectoris- Chest discomfort caused by impaired blood supply to the
myocardium. 33yAt42JnkxG5z
Stable angina — occurs at same RPP (rate —pressure product, HR x SBP)

Variant angina- Prinzmetal, Vasospasm of CA.
Unstable (UAP)-Atrest.
Stable AP occurring at lower RPP.
33yAt42JnkxG5z
o Acute myocardial infarction (AMI)

Prolonged ischaemia may result in myocardial injury or death.
Caused by;
e Complete occlusion of CA by plaque
e Increased vasomotor tone
e Plaque rupture / embolism
e Increased myocardial demands
Site and severity depends on:
e Artery occluded
e Collateral circulation
e =Previous injury
e Other factors eg SNS
Transmural — throughout wall
Subendocardial — innermost layer of myocardium
Management;
e Medications
e Cardiac rehab
e Risk factor modification
e PTCA/ stent
33yAt42JnkxG5z
e CABG
Angioplasty- wire guided into artery until tip passes through plaque
narrowing. Balloon catheter is moved along wire until it is in the plaque
narrowed segment and is then inflated. Balloon is deflated and removed.
o. Heartfailure
Congestive heart failure, congestive cardiac failure.
Inadequate cardiac performance — unable to meet demands.
Generally classified according to signs and symptoms.
Heart failure when there are S&S attributable to reduced cardiac
performance.
R ventricular failure (RVF);
e Mm pathology
e Volume = tricuspid valve, pulmonary valve
e Pressure
e Pulm valve
pH

1627124061
e Pulm art stenosis
e Increased capillary pressure in the lung
e High pressures in the pulmonary capillary system will eventually
cause RVF- COR PULMONALE.
o Compression of pulm vasculature
o Destruction of pulm vasculature
33yAt42JnkxG5z
o Polycythaemia
o Hypoxic vasoconstriction
e General e.g. fatigue, cerebral (confusion, depression), weight gain
e Systemic oedema (7 JVP, splenomegaly/hepatomegaly, peripheral
oedema, ascites).
=" LVentricular failure (LVF);

e Mm myopathy
e Volume — mitral valve, aortic valve 33yAt42JnkxG5z
e Pressure
e Aortic valve - stenosis
e Aortic stenosis / aortic coarctation
e Increased systemic BP
33yAt42JnkxG5z e General eg fatigue, cerebral (confusion, depression), weight gain.
e Pulmonary oedema- Backlog of blood into the pulmonary system.
o Increase in capillary pressure in the lungs causes fluid to leak out
into the interstitium and then the alveoli.
Cardiogenic and non- cardiogenic causes
0
Non — cardiogenic;
0
Leaky capillaries e.g. ARDS

oOo
Changesin oncotic pressures e.g. J albumin

o Cardiogenic- LVF
¢ > poor ventilation, lung compliance (restrictive), 7’ WOB.
e S&S of pulmonary oedema;
oOo Cyanosis
Hypoxaemia
o00006d~CO0dWU6lUlO
SOB
Frothy thin (pink) sputum
Crackles on auscultation (wheezes)
Orthopnoea
PND
CXR (fluffy, bilateral alveolar pattern, not limited by fissures,
cardiomegaly).
>
> thinkswap
1627124064
33yAt42JnkxG5z

o Differentiating pulmonary oedema from primary respiratory condition
Pulmonary oedema Pneumonia

33yAt42JnkxG5z
History of cardiac disease Historyof flu like symptoms
May or may not have chest pain Pleuritic chest pain
Cough — pink or white frothy Cough — sputum
No fever Fever
Crackles Crackles
CXR CXR
o Heart failure compensation

Dilation of the heart
e Usually in response to a volume load
e Useful initially (Starling) but becomesineffective
Hypertrophy of the mm
e In response to pressure load
e Increase in mm fibre size
e Useful initially
e Self defeating finally — reduced bl supply
33yAt42JnkxG5z
Increased SNS activity

e To increase CO
e Increased HR
e Increased demand for 02
Redistribution of circulating blood volume — constriction of renal vessels
Salt and water retention
e Totry to increase circulating blood volume to maintain CO.
e Further volume load
e Describe the common investigations which can be undertaken to assess the patient
with cardiovascular dysfunction.
o The ejection fraction

A clinical measure of heart function
Obtained during cardiac cath / GHPS
Essentially measuring cardiac contractility
EF =SV/LVEDV
Normal 55% - 65% at rest
Increases with exertion
Poor EF — heart failure (not always)
o Heart rate, SV, CO, stress test.

33yAt42JnkxG5z
>
> thinkswap 1627124064

Understand the general medical managementof patients with cardiovascular
disorders.
o Medications
o Control underlying disease
o Treat heart
= Increase contractility
=" Reduce load/demand
=" Reduce blood volume
Treat major symptoms e.g. resp support eg O2
Cardiac rehabilitation.
Discuss the basic concepts of physiotherapy cardiac rehabilitation.

o Increasing demand
= Not when acute / unstable
= Recent AMI, AP
=" Decompensated HF
o Contraindications / precautions
="
33yAt42JnkxG5z
Head Down tip

=» Suctioning
o Exercise
= Risks vs benefits
o Naylor et al (2004)
=" High incidence of heart disease in those receiving respiratory physiotherapy.
=" Many patients with CV disease had dependentlobe pathology.
=" Physiotherapy intervention may place increased stress on the cardiovascular
system.
= Physio intervention is possibly of concern in patients with heart disease.
= Common to modify postural drainage- evidence for this? Are we denying
necessary treatment?
33yAt42JnkxG5z
> thinkswap
33yAt42JnkxG5z
1627124066

2040 Full Notes

Uploaded by

Copyright:

Available Formats

You might also like

2040 Full Notes

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

2040 Full Notes

Uploaded by

Copyright:

Available Formats

PHTY2040- CARDIOPULMONARY PHYSIOTHERAPY I

LECTURE 1- AN INTRODUCTION TO CP PHYSIOTHERAPY

e Understand the concept of cardiopulmonary dysfunction and where dysfunction

=" Gas exchange 1

=" Gas exchange 2

= Lung defence (ciliary clearance, cough, upper airways)

e Relate CP dysfunction to identifying respiratory problems amenable to

Signs and symptoms- SOB, cough, sputum, chest pain, wheeze

e Identify commonly encountered respiratory problems amenable to physiotherapy

=" Reduced exercise tolerance

e Discuss the impact of CP problemson the patient in termsofactivity limitations

LECTURE 2- CARDIOPULMONARY ASSESSMENT: MEDICAL INFORMATION

e Describe and list possible sources of information in the clinical setting.

o Ward board (patient name,bed #, status, investigations planned).

Progress notes (admission details, reports)

Old notes (particularly useful for chronic conditions)

Other staff (doctors, nurses, allied health).

e Describe the structure, contents and abbreviations of the medical assessment.

o Initial information — name,age etc

=" Summaryof current problem

> thinkswap Find more study resources at https://www.thinkswap.com

GIT (tenderness, guarding, masses).

e Clotting times (APT, APTT)

Arterial blood (arterial blood gases- ABGs)

Lung function (e.g. spirometry)

e Recognise the importanceof differentiating relevant from irrelevant information.

P thinkswap Find more study resources at https://www.thinkswap.com

e Outline the general contents and overall structure of the physiotherapy

o Analysis of assessmentfindings — problems

= How long they have had the disease?

= Compare present condition to “norma

= Relieving and aggravating factors

Living and home situation

Understanding of disease /condition

PPthinkswap Find more study resources at https://www.thinkswap.com

shape, accessory muscle use.

e Discuss the situations in which modifications to the physiotherapy assessment may

LECTURE 6: TREATMENT FOR PULMONARYVENTILATION, GAS EXCHANGE, AND LUNG

o Functional residual capacity (FRC

P thinkswap Find more study resources at https://www.thinkswap.com

= Lung parenchymal disease (E.g. collapse)

=" Thoracic / chest wall disorders

e Describe the consequencesof reducedalveolar ventilation and lung volume on the

respiratory system in terms of:

REDUCED LUNG VOLUME

4 Closure of small lung units and small airways sy

V/Q mismatch LUNG COLLAPSE / ATELECTASIS Reduced alveolar

Find more study resources at https://www.thinkswap.com

REDUCED LUNG VOLUME

Reduced cough effectiveness

PPthinkswap Find more study resources at https://www.thinkswap.com

o Lack of distending forces on lung

o Localised airway obstruction

= Small airway collapse

o Negative airway pressure

o Most patients have degree of atelectasis post-surgery, clinical course varies

e Outline the assessmentofalveolar ventilation and lung volume.

Observation (7. RR, shallow breathing, |. chest expansion).