Cardiorespiratory Physiotherapy

6 core cardiorespiratory problems

1. Respiratory failure (Type 1 and 2)

2. Sputum retention

3. Loss of volume

4. Increased work of breathing

5. Pain

6. Reduced exercise tolerance

What are the 5 Carinal Signs of Respiratory Disease?

1. Dyspnea

2. Cough

3. Sputum

4. Wheeze

5. Chest Pain

Cardinal Sign - Dyspnea

+ and the 4 classes

• increase work of breathing/shortness of breath

• can be related to: Orthopnea (lying down), Paroxysmal nocturnal dyspnoea (SOH when asleep)

• Important to gain info on: Duration, severity, pattern and associated factors

• Classified into 4 classes

  • Class 1: no physical activity limitation

  • Class 2: slight physical activity limitation

  • Class 3: marked physical activity limitation

  • Class 4: unable to perform physical activity

Cardinal Sign - Cough

• Protective reflex

• Caused by: inflammation, irritation, habit, excess secretions

• Check: frequency (day/night), effectiveness (weak/strong/pain), Quality (wet/dry/raspy)

• Complications: fractured ribs, hernias, incontinence, embarrassing

Cardinal Sign - Sputum

• excess tracheobronchial secretions, combination of saliva and mucus result of infection/disease

• cleared by huffing/coughing, improving gas exchange & expiratory flow

• may contain: mucus, cellular debris, microorganisms, blood (hemoptysis), foreign particles

• Checklist: quantity (small/5c coin/cup), quality (consistency/colour/odour)

The ABCDE Approach

Airway- Blocked? Upper airway collapse? Aspiration? Tracheostomy? Ventilated? Do they require O2?

Breathing - Work of breathing? Pattern? Distress? Auscultation? Fatigue/weakness? Accessory muscle use?

Circulation - Colouring? Temp? BP/HR? Blood results? Stability for intervention? Oedema?

Disability - Previous medical history? Limiting factors? Impact on my ability to treat? surgery? Pain?

Environment/Exposure - Wounds/scars? Temperature? Palpation? Medication? Antibiotics/steroids?

Observations of the Head and Neck

• Facial expression

• Colour/pallor

• Use of accessory muscles

• Sculpturing: how much of the muscles can you see

• pursed lip breathing

How to Auscultate?

Breath sounds - Wheeze

• vibration of the walls of a narrowed airway

• pitch determined by diameter and elasticity of the airway

• expiratory wheeze - bronchospasm

• inspiration wheeze - airway obstructions, oedema, mucous

Breath sounds - Crackles

• discontinuous, short, explosive sounds

• fine or course sounds

What colours do Air, Fat, Soft tissues and Bone correlate to in an X-ray?

Air = Black

Fat = Dark grey

Soft tissue = grey

Bone = white

X-ray Exposure

• Should be able to see T4 (not T5) vertebrae on PA

• Over-exposed = appears black

• Under-exposed = appears falsely white

X-ray Reading - Logical Progression - ABCDEFGHIM

Airways - Trachea should be central but deviates slightly to right

Bones - compare bone density

Cardiac silhouette - check heart is normal shape

Diaphragm - right is higher than left, should be smooth

Edges - should be well defined acute angles

Fields - should be equal, compare size

Gas - abdominal gas bubbles

Hilum - left higher than right, compare shape and density

Instrumentation - ETT, tracheostomy tube, catheter, nasogastric tubes, pacemaker

Mediastinum - border should be fuzzy and trachea visible

Pathology - Consolidation

• Air filled paces replaced with fluid, blood or sputum

• E.g. Pneumonia

Pathology - Collapse

• Elevation of hemidiaphragm

• decrease in rib spacing

• displacement of mediastinum, hilum, fissure - volume loss

Pathology - Pleural Effusion

• Accumulation of fluid in pleural cavity

• collects in costophrenic angles

• “Meniscus sign”

• lateral lying x-ray

Pathology - Pneumothorax

• lack of lung marking

• deep sulcus sign

• sharply outlined diaphragm

Pathology - Tension Pneumothorax

• ipsilateral diaphragm depressed and flattened

• mediastinum and heart pushed to other side

Pathology - Haemothorax

• blood in lungs

• air-fluid level

• no meniscus sign → flax line

Pathology - Subcutaneous Emphysema

• dark streaks in soft tissues

• Air appears black (radiolucent) on X-ray

• streaky, bubbly, or reticular (net-like) black areas in the soft tissue

Pathology - Bronchiectasis

• Dilatation caused by congenital deficiency and weakening of the muscular and elastic layers in the bronchial walls

• ring shadows

• increased bronchiole diameter

Pathology - Cystic Fibrosis

• may show hyperinflation

• dilated bronchi

• over time, inflammation can cause scarring, leading to a mosaic pattern

Pathology - Pulmonary Oedema

• “batwing” pattern

• increased cardiac silhouette sign

• pleural effusions present

What is Perfusion?

Total volume of blood reaching the pulmonary capillaries

What is the ventilation-perfusion ratio when standing?

• 3.3 in the apex of the lung and 0.63 in the base

• Ventilation exceeds perfusion in apex, and perfusion exceeds ventilation in base

• The overall value in the average human lung is 0.8 V/Q

In regular upright ventilation, where does more ventilation go? And why?

into the lung base rather than the lung apex

• more alveoli at the larger lung bases

• basal alveoli are less stretched than the apical alveoli

What is the “dependent region” in relation to distensibility?

dependent region: basal region of the lung in relation to gravity

• basal alveoli are more compliant (distensibility), therefore is more ventilated at the basal alveoli

In regular upright ventilation, where does more perfusion go? And why?

into the lung base rather than the lung apex

• more alveoli and pulmonary blood vessels at base

• gravitational effects on pulmonary blood

Both ventilation and perfusion are greater at the lung bases in upright posture, but perfusion increases more steeply than ventilation

what happens if there is a mismatch between alveolar ventilation and blood flow?

• it will be seen in the V/Q ratio

• if the V/Q ratio reduces due to inadequate ventilation, gas exchange within the affected alveoli will be impaired.

• ^ capillary partial pressure (PO2) falls and PCO2 rises

What are some reduced ventilation problems?

• affects oxygen levels as carbon dioxide is more soluble and continues to diffuse despite impairment

• Type 1 Respiratory Impairment

  (PaO2 less than 80mmHg) → Type 1 Respiratory Impairment

  (PaO2 less than 60mmHg) → Type 2 Respiratory Failure

• Pneumonia, Asthma, COPD, Hypoxia

What are some reduced perfusion problems?

• pulmonary embolism → circulation is obstructed

• other areas will receive increased blood supply

• hypoxemia to the lung

What are some contraindications to a head down tilt position?

• cardiac failure

• Unstable HR

• Hypertension

• cerebral oedema (swelling of brain)

• hemoptysis (coughing up blood)

• obesity

• pregnancy

• surgery/head or neck trauma

What is SpO2?

peripheral oxygen saturations measured by pulse oximetry (finger/earlobe/forehead)

What is SaO2?

arterial oxygen saturations measured by ABG

How to document Oxygen Use? “7 steps”

• Document starting device/flow;

• Start O2 and ensure target is achieved quickly;

• Titrate O2 to keep in SpO2 range

• Monitor O2 minimum 4 hourly

• Record SpO2 & delivery device

  • Wean off O2 if clinically stable

• Codes to be written on obs. chart and initialled.

When are ABGs required with Oxygen therapy?

• Critically ill patients with cardiorespiratory or metabolic dysfunction

• In patients with a SpO2<92%

• Deteriorating oxygen saturation requiring increased FiO2

• Patients at risk of hypercapnia

• Breathless patients in whom a reliable oximetry signal cannot be obtained

What is the normal peak inspiratory flow rate (PIFR)

ranges between 20-30 L.min-1

What is FiO2?

Minimum flow rate required to ensure a patient receives an exact concentration of oxygen

What are some Low Flow Oxygen Devices

• Nasal cannula (long-term O2 therapy, hypoxic patients)

• Hudson face mask (short-term use, following surgery)

• Reservoir mark (emergencies, severe hypoxaemia)

What are some examples of High Flow Oxygen Devices?

• High-flow nasal cannula therapy (HFNC) (100% O2 delivery, increased tidal volume, minimal air room entrainment)

• Venturi Mask (increase flow of gas without increasing amount of O2)

Physiotherapy role in Oxygen delivery

• Ensure correct mode of delivery

• Assess the need for oxygen with exercise

• Advise whether oxygen is sufficient

• Can alter prescription in certain situations

Benefits of Humidification

• Improves mucociliary function

• Facilitates secretion removal

• Reduce work of breathing

• Improved patient comfort and compliance

Methods of Humidification

• Systemic Hydration (drinking/IV water)

• Bubble through (cold water)

• Heated water bath (humidifier)

• Pass over humidification

What is the ventilation-perfusion ratio?

ratio of alveolar ventilation (V̇A) to pulmonary blood flow (e.g. V/Q)

In the ventilation-perfusion relationship, where in the lung is there more perfusion and ventilation?

• more perfusion at bases

• more ventilation at the apical regions

Nasal cannula: What is the recommended dosage for oxygen?

No more than 4 L.min-1 O2

Hudson face mask: What is the recommended dosage for oxygen?

Minimum of 5 L.min-1 O2

Reservoir Mark: What is the recommended dosage for oxygen?

Minimum 12 L.min-1 O2

What are the 5 physiological mechanisms responsible for the efficacy of high-flow nasal cannula?

1. Increases function residual capacity (FRC)

2. Washout of waste gases including carbon dioxide (CO2)

3. Decreased respiratory rate

4. Provides Positive end-expiratory pressure (PEEP) ~2-4cmH2O

5. Increased tidal volume (VT)

Administration range for SpO2 in a patient with an acute condition:

Administration range for SpO2 in a patient with COPD:

acute condition: less than 92% and titrated to 92-96%

patient with COPD: less than 88% and titrated to 88-92%

What is a PF Ratio? (PaO₂ /FiO₂)

A measure of how well oxygen is being transferred from the lungs into the blood (assess severity of hypoxemia)

Determined by dividing Blood/Oxygen = (hopefully more than 400)

Normal: >400

What is a “A-A” gradient? + normal range

The difference in partial pressure of oxygen between arterial blood and alveolar gas

Normal: 5-10mmHg

Requirement for normal airway clearance - Mucociliary escalator

• Whipping action of the cilium within the sol layer of the mucus produces a wave motion

• Stroking action speed = 2cm per min

Requirement for normal airway clearance - effective cough and phases

• A voluntary cough is generally characterised by an inspiration of approximately 80-90% total lung capacity

• The contraction of abdominal muscles and expiratory muscles generates a sudden increase in intrathoracic pressure, before the glottis is rapidly opened, and a blast of turbulent air is expelled

• 3 phases → inspiration, compression, expulsion

Peak Cough Flow in Adults

Normal: 720 L.min-1

Minimum required for effective airway clearance: >160 L.min-1

Factors decreasing mucociliary clearance

• medications

• mucosa drying

• High FiO2

• Endotracheal tube

• Pollutants

• Decreased lung volumes

• Dehydration

Reasons for an Ineffective Cough?

• Decreased lung volume

• pain, restriction, weakness

^ Solution: use breath-stacking to increase lung volume

• Decreased expiratory force

• poor elastic recoil, can’t close glottis

^ Solution: assist expiratory phase

7 Examples of Physiotherapy techniques to improve Airway Clearance Therapy (ACT)?

• Gravity-assisted positioning (GAP)

• Airway clearance devices

• Manual techniques (chest wall vibrations, percussion)

• Drainage

• Nebulized inhalation therapy

• Exercise

• Assist cough

Indications and Considerations for Airway Clearance Therapy (ACT)

Indications

• Diseases (COPD, CF etc), post-operation, collapsible airways, productive asthma

Considerations

• consent, infection control, patient comfort

If a patient has bronchoconstriction (wheeze), consider Salbutamol or nebulized mucolytic

OSCE: Active Cycle of Breathing Technique (ACBT)

Components (varies with each patient)

• Breathing Control (gentle breathing, lower chest) ~2mins

• Thoracic expansion exercise (deep breathing, hands on ribs, with or without hold) (x3)

• Forced expiratory technique HUFF (x2) (squeeze not wheeze, “Fogging up a mirror”)

What for?

• secretion clearance, improving ventilation, no equipment required, moist environments (shower)

What is an Equal Pressure Point mechanism?

• describes how, during forced expiration, the point where ‘airway pressure = pleural pressure’ determines where the airway is prone to collapse, limiting expiratory flow.

Ideal positioning for Airway Clearance Therapy (ACT)

• Sitting position with arms supported that promotes an increase in FRC

• (Sitting supported)

OSCE: Positive Expiratory Pressure Devices - PEP mask

• prevents small airway collapse

• The patient performs controlled expiration against the resistance, to maintain respiratory pressures between 10-20cmH20

• Consider size and patients expiratory flow

• 10-12 cycles of 8-10 exhalations= until secretions are cleared

OSCE: 3 Types of Oscillating Devices with PEP

1. Acapella

   • creates oscillation effect on airways with PEP

2. Flutter

   • creates oscillation effect on airways, with a steel ball interrupting the flow of air

   • Position dependent

3. Aerobika

   • dial up resistance, independent of gravity

All treatments consist of 10-12 cycle of 10-12 exhalations

3 Stages of Autogenic Drainage

Stage 1: low volume breaths to mobilize secretions

Stage 2: medium (tidal) beaths to collect mucus

Stage 3: Large volume breaths to enable expectoration

OSCE: Manual Technique - Chest wall Vibrations (CWV)

• increases peak expiratory flow

• helps to shift secretions from lung peripheries

• never perform on a breathless patient

• creates airway oscillation

Manual Technique - Exercise

• performed before ACTs to loosen secretions

• increased BMI and posture, well-being, cardiovascular fitness etc

What is Atelectasis?

• The collapse of a part/all of an alveolus, leading to reduced gas exchange and respiratory problems (Loss of volume).

• Usually from surgery, smoking, obesity, age, impaired cognition etc

Type: Obstructive (bronchial obstruction)

Type: Non-Obstructive (surgery, wound etc)

6 Signs and Symptoms of a Post-Op chest Infection

• SpO2 less than 90% on 2 consecutive days

• Chest x-ray findings

• Temp over 38deg 1-day post-op

• Productive Sputum

• Abnormal lung auscultation

• Raised white cell count

4 Clinical Signs of Atelectasis?

• Reduced PaO2

• Reduced lung compliance

• Reduced FRC

• Non-productive cough

What is Collateral Ventilation?

Thoracic expansion exercises

• Increase collateral ventilation

• Increase lung volume

• Mobilise secretions as air can get behind the sputum.

Importance of Mobilization

• uptake of O2

• reduction in FiO2

• increase in cardiac output and oxygen extraction in tissues

• exercise increases SV and HR therefore increases CO

What is Alveolar Interdependence?

When an alveolus begins to collapse, the surrounding alveoli pull open the collapsing one (using expanding forces and neighboring tension)

• protective mechanism against atelectasis

• Expanding forces exerted between adjacent alveoli & higher lung volume > expanding forces

OSCE: Positive Expiratory Pressure - Pari PEP

• splinting open airways prone to dynamic compression during forced expiration

• Can be used in conjunction with a Nebulizer

• not position dependent

• Maintain 10-20cmH2O

• Backwards pressure to hold airways open

OSCE: Nebulized Inhaled Therapy

• Inhalation of saline solution through Pari PEP to increase water to lungs to thin out sputum for it to be coughed up easier

• Breathe in and out normally

OSCE: Incentive Spirometry

• provide visual feedback via a ball/chip rising to the preset marker via inspiration

• track lung volumes

Movement of the Ribs

Ribs 1-6: _______

Ribs 7-10: _______
Ribs 10-12: ________

Ribs 1-6: “Pump handle” - up and down movement

Ribs 7-10: “Bucket handle” - contraction of diaphragm
Ribs 10-12: “Caliper motion” - outwards and backwards swing

What are the 3 Basic elements of the Respiratory Control System? (C.E.S.)

1. Central Controller (brainstem)

2. Effectors (causes of ventilation)

3. Sensors (chemoreceptors to adjust output (Co2, H+ and O2)

What is the Normal PaCO2, and some problems that can arise?

Normal PaCO2 = 35-45mmHg

• Type 2 Respiratory Failure (PaCO2 more than 50mmHg (hypoxemia) & PaO2 less than 60mmHg (hypercapnia))

What is Ventilation? + normal ranges

The movement of air between the environment and the lungs via inhalation and exhalation

• Normal at rest: 5-8L/min

• Light exercise: 12L/min

• Moderate exercise: 40-60L/min

What is Work of Breathing (WOB)?

The amount of work that the respiratory muscles have to exert during a single respiratory cycle

• Airflow resistance

• Increased elastic load

• Loss of elastic recoil

4 Causes of Respiratory muscle dysfunction?

1. Change is length-tension relationships (hyperinflation)

2. Myopathy (steroid-induced)

3. Neuromuscular disease

4. Connective tissue disorders

What is Dynamic Hyperinflation?

air gets trapped in the lungs during rapid or obstructed breathing, causing lung volumes to gradually increase above their normal resting level.

Objective Findings for Dyspnea (B.R.A.A.C)

• Abnormal breathing pattern

• Increased RR

• Apical breathing (upper chest)

• Accessory muscl use

• Weak cough

How to assess Work of Breathing? (R.F.P.R)

• Patient rates their symptoms

• Impact on functional abilities

• Clarify pattern of breathlessness

• Look for reversible causes

H.I.F.L.O.W. Humidification Benefits

H - Heated & humidified

I - Inspiratory demands

F - Functional residual capacity

L- Lighter = more tolerable

O - Oxygen dilution

W - Washout of dead space (CO2 removal)

6 Physiologic mechanisms for efficacy of High Flow Nasal Cannula

1. Increases FRC

2. Physiological dead space washout of waste gases

3. Decreased respiratory rate

4. Provides positive end-expiratory pressure (PEEP)

5. Increased tidal volume

6. Increased lung recruitment

4 Outcome measures for Dyspnea

M

V

B

15

1. Medical Research Council Dyspnea Scale (MRC Scale)

2. Visual Analogue Scale (VAS)

3. Modified 0-10 Borg Breathlessness scale

4. 15-count breathlessness score

5 Rights of Clinical Reasoning

1. Right Cue

2. Right Patient

3. Right Time

4. Right Action

5. Right Reason

pH level less than 7.35 / PaCO2 more than 50mmHg / HCO3 22-26 (normal) is what _________?

Uncompensated Respiratory Acidosis

pH level less than 7.35 / PaCO2 more than 50mmHg / HCO3 more than 26 is what _________?

Partially Compensated Respiratory Acidosis

pH level between 7.35-7.45 (normal) / PaCO2 more than 50mmHg / HCO3 more than 26 is what _________?

Compensated Respiratory Acidosis

pH level more than 7.45 / PaCO2 between 35-45mmHg (normal) / HCO3 more than 26 is what _________

Uncompensated Respiratory Alkalosis

pH level more than 7.45 / PaCO2 more than 50mmHg / HCO3 more than 26 is what _________

Partially Compensated Respiratory Alkalosis

pH level between 7.35-7.45 (normal) / PaCO2 less than 35mmHg / HCO3 less than 22 is what _________

Compensated Metabolic Alkalosis

OSCE: Positions of Comfort & Ease

1. High side lying

2. Supported side lying (optimal treatment position)

3. Unsupported 45-60deg

4. Supported in 45-60deg

5. Upright sitting supported

1. Slumped over railing, chair or table

• Increase the curvature of diaphragmatic fibres (effectively contract)

• Provide support for the arms/shoulder optimising accessory muscle function

OSCE: Breathlessness Techniques

Pacing

• Breathing may be timed with stepping during walking or stair climbing

• co-ordinate breathing control with activity.

Pursed lip breathing

• Exhaling against pursed lips helps to splint open the airways and improve oxygenation…but it increases the work of expiration.

Blow as you go

• breathe out on effort

Fan therapy

• stimulates the trigeminal nerve reducing perception of breathlessness

Bronchiectasis

What is it: irreversible dilatation and destruction of the bronchial walls, leading to impaired clearance of mucus, recurrent infections, and airway inflammation.

Caused by: post-infection, immunodeficiency, tumors, enlarged lymph nodes

Clinical Features: Productive cough, foul sputum, hemoptysis, dyspnea

Management: ACT, antibiotics, bronchodilators, surgery, vaccines

Cystic Fibrosis

What is it: genetic, autosomal recessive disorder caused by mutations in the CFTR gene (Cystic Fibrosis Transmembrane Conductance Regulator).

Clinical Features: chronic cough, wheeze, finger clubbing, diabetes, malabsorption, steatorrhea (fat in feces)

Management: ACT, antibiotics, lung transplant, diet changes, CFTR modulators

Pneumonia

What is it: acute infection of the lung alveoli, interstitium, and distal airways, causing inflammation and consolidation

Caused by: CAP (community-acquired), HAP (hospital-acquired), immunocompromised

Clinical Features: fever, chills, cough, dyspnea, tachycardia, confusion, consolidation, bronchial breath sounds/crackles

Management: oxygen, IV fluids, antibiotics, steroids