Unit 6 - Advanced Ventilatory Support, Lung Transplantation, and Pediatric Respiratory Support

Ventilation

movement of air in/out of lungs (not just oxygen delivery)

Noninvasive Ventilation

Positive pressure via mask, no artificial airway

Invasive ventilation

Uses airway adjuncts (ETT, tracheostomy)

Noninvasive and Invasive Ventilation

Positive pressure aids ventilation

• Driving air into alveoli

• Splinting airways open

• Increasing lung volume

• Decreasing work of breathing

Noninvasive and Invasive Ventilation

Indications

• Type I failure = poor oxygenation

• Type II failure = poor CO₂ removal

Noninvasive and Invasive Ventilation

PTs

should note pressure/FiO₂ to gauge severity and risk

PEEP

• pressure at end of exhalation

  • Keeps alveoli open, improves oxygenation

CPAP

• One continuous pressure throughout breathing cycle

• Used for OSA, pulmonary edema, post-op atelectasis

BiPAP

• PAP (inhalation) + EPAP (exhalation = PEEP)

• Adds pressure support to assist ventilation

• Ideal for COPD, hypercapnic respiratory failure

CPAP and BiPAP

PT considerations

• Higher pressures = sicker patient

• Monitor tolerance, ensure mask seal during activity

• CPAP may be maintained during exercise in select cases (e.g. HF)

Mechanical Ventilation

Positive-pressure ventilation

replaces or augments spontaneous breathing

Mechanical Ventilation

Delivers set tidal volume, rate, FiO₂, and PEEP via ETT or tracheostomy

Mechanical Ventilation

Indications

airway protection, hypoxemia (Type I), hypercapnia (Type II), ↓ WOB

Mechanical Ventilation

Goals

improve gas exchange, ↓ work of breathing, stabilize overall status

Mechanical Ventilation

PTs

coordinate with ICU team to assess readiness, monitor stability, and promote mobility

Airway Adjuncts

Oropharyngeal

Oral; for unconscious patients; triggers gag reflex; temporary

Airway Adjuncts

Nasopharyngeal

Nasal; tolerated when semi-conscious; used for suctioning or patency

Airway Adjuncts

Endotracheal tube

Oral/nasal; for mechanical ventilation; prevents speech/eating; high monitoring needs

Airway Adjuncts

Tracheostomy

Surgical; long-term ventilation; allows speech/oral intake; more stable for PT

Airway Adjuncts

PT Role

Identify device, ensure airway safety, coordinate care, plan safe mobilization

Ventilator Modes

determine how much support the ventilator provides and can be interpreted to understanded patient readiness for activity

Ventilator Modes

Assist Control (AC)

• Full support; set volume/pressure for every breath

• No spontaneous effort required

• Often early critical illness; low activity tolerance

Ventilator Modes

Synchronized Intermittent Mandatory Ventilation

• Partial support; set breaths + unassisted spontaneous breaths

• Encourages muscle use; common in weaning

• May tolerate upright activity if stable

Ventilator Modes

Pressure Support Ventilation (PSV)

• All breaths initiated by patient; pressure aids inspiration

• Requires drive and effort; used in weaning

• Monitor for fatigue or distress

Ventilator Modes

Ventilator Screen for PTs

• Check mode, FiO₂, PEEP, rate, tidal volume

• Confirm settings match expected clinical status

• Unexpected changes may signal decompensation

Mobilizing While On Mechanical Ventilation

• Use standard safety criteria to guide decision-making

• Assess FiO₂, SpO₂, RR, mode before mobilization (e.g., FiO₂ < 0.6, RR < 30)

• Confirm hemodynamic and neurological stability (e.g., stable HR/BP, able to follow commands)

• Begin with positioning, progress to sitting, standing, walking as tolerated

• Monitor tubing integrity and secure airways to prevent accidental extubation

• PTs must coordinate with the care team to ensure safe and appropriate progression

Acute Respiratory Distress Syndrome (ARDS)

• Acute lung inflammation → impaired gas exchange & respiratory failure

  • Rapid onset following infection, trauma, or systemic insult

  • Hallmark = severe hypoxemia unresponsive to oxygen therapy

Acute Respiratory Distress Syndrome (ARDS)

Common Causes: Direct

Pneumonia, aspiration, pulmonary contusion, inhalational injury

Acute Respiratory Distress Syndrome (ARDS)

Common Causes: Indirect

Sepsis, trauma, burns, pancreatitis, massive transfusion

Acute Respiratory Distress Syndrome (ARDS)

Diagnosis

• Bilateral opacities on imaging (not explained by heart failure)

• Must rule out cardiac cause of pulmonary edema

Acute Respiratory Distress Syndrome (ARDS)

Clinical Importance

• High ICU mortality, especially with comorbidities

• Early recognition is critical for appropriate intervention

Acute Respiratory Distress Syndrome (ARDS)

Three phases

Exudative → Proliferative → Fibrotic

Acute Respiratory Distress Syndrome (ARDS)

Exudative phase

Alveolar-capillary damage → fluid leak → surfactant loss → alveolar collapse

Acute Respiratory Distress Syndrome (ARDS)

Proliferative phase

Alveolar repair and fluid reabsorption begin; fibroblasts active

Acute Respiratory Distress Syndrome (ARDS)

Fibrotic phase

Scar tissue replaces alveoli → stiff, noncompliant lungs

Acute Respiratory Distress Syndrome (ARDS)

PT implications

• Exudative = passive movement, careful monitoring

• Proliferative = begin active mobilization, breathing retraining

• Fibrotic = focus on rehab, endurance, managing long-term restriction

Acute Respiratory Distress Syndrome (ARDS)

Medical Management and PT considerations —> Goal

Support oxygenation, protect lungs, aid recovery

Acute Respiratory Distress Syndrome (ARDS)

Medical Management and PT considerations —> Proning

• 12–16 hrs/day)

• Improves oxygenation and survival

• PTs assist with safe, pressure-relieving positioning

Acute Respiratory Distress Syndrome (ARDS)

Medical Management and PT considerations —> PT focus

• Early: PROM, positioning, monitoring

• Later: Sitting, transfers, mobility as tolerated

COVID-19 Overview

• a major cause of ARDS since 2020

• Virus enters via ACE2 receptors in lungs and other organs. Triggers cytokine storm → widespread inflammation

COVID-19 Overview

Multi-organ effects

• Lungs → ARDS, hypoxemia

• Heart, kidneys, liver, brain also affected

  

COVID-19 Overview

PT in acute phase

• Positioning, PROM, monitor vitals/O₂

• Caution with oxygen desaturation, fatigue

COVID-19 Overview

PT in subacute phase

• Mobilization, breathing retraining, reconditioning

• Consider multi-system impairments during rehab

Long COVID

Common symptoms impacting function

• Fatigue, dyspnea, brain fog, dizziness, joint/muscle pain

• Post-exertional symptom exacerbation

• Autonomic dysfunction (e.g. POTS), cognitive decline

Long COVID

PT screening priorities

• History of COVID (even mild)

• Monitor vitals: HR, SpO₂, orthostatic response

• Screen for activity intolerance, PEM, and cognitive

• issues

Long COVID

Exercise approach

• Start low, go slow – titrate to symptom tolerance

• Use pacing, frequent breaks, and energy conservation

• Emphasize function, not intensity

Long COVID

Collaborative care

• Refer for cognitive, mental health, or speech support if needed

• Educate on realistic goals and symptom self-monitoring

Lung Transplantation

• Most common for Emphysema and Pulmonary Fibrosis. Other indications include Cystic Fibrosis, Pulmonary Hypertension, Sarcoidosis

• Rigorous evaluation process

  • Pulmonary function testing, 6MWTs, frailty, and psychosocial factors

  • Prioritizes those most likely to benefit

• Rising transplant numbers with need still exceeding supply

Lung Transplantation

Prehabilitation

• Rehab evaluation prior to transplant assesses pulmonary function, functional capacity, and secretion clearance.

• Prehabilitation includes cardiovascular training, resistance exercise, airway clearance, and breathing retraining.

  • Strength training focuses on proximal muscle groups to support function and recovery.

  • Airway clearance training prepares patients for post-op secretion management.

  • Breathing retraining encourages diaphragmatic breathing to reduce accessory muscle use.

• Education on pacing, energy conservation, and oxygen use promotes safe activity participation.

• Typical frequency is 30–40 minutes of combined training, 3–5 times per week, progressed based on tolerance

Lung Transplantation

Postoperative Rehab & Precautions —> Rehab begins within 24 hours in ICU

• Focus: positioning, breathing exercises, airway clearance

• Strict infection control due to immunosuppression

Lung Transplantation

Postoperative Rehab & Precautions —> Early mobilization as tolerated

Goal: reduce ICU-acquired weakness and pulmonary complications

Lung Transplantation

Postoperative Rehab & Precautions —> Airway clearance is essential

Denervated lungs impair cough reflex

Lung Transplantation

Postoperative Rehab & Precautions —> Therapist role includes education & vigilance

• Monitor for signs of infection, rejection, or desaturation

• Prepare patient for discharge and outpatient rehab

Pediatric Respiratory Conditions

• Issues related to prematurity (infants born <37 weeks)

  • Example: Respiratory Distress Syndrome (RDS)

• Bronchopulmonary dysplasia (BPD)

• Meconium aspiration syndrome (MAS)

• Cystic fibrosis (CF)

• Childhood asthma

• Early understanding of developmental origins guides appropriate care strategies

Respiratory System Development

Begins 4th week of gestation

Respiratory System Development

Maturation of lungs

• Pseudoglandular (weeks 5-16)

• Canalicular (weeks 16-26)

• Terminal Saccular (week 26-birth)

• Alveolar (32 weeks- 8 years)

Respiratory System Development

Anatomical considerations

• Rib cage is circular & horizontal, lacking bucket handle orientation

• Narrower airways can become obstructed easily

• 50% fewer type I muscle fibers than adults

• Airways are narrower, more compliant, and fatigue more easily

Respiratory Distress Syndrome

• Caused by surfactant deficiency in premature infants

• Leads to alveolar collapse, low compliance, and V/Q mismatch

• Presents with tachypnea, grunting, nasal flaring, and retractions

• “Ground-glass” appearance with air bronchograms on chest X-ray

• Treated with CPAP, ventilation, and exogenous surfactant

Bronchopulmonary Dysplasia

• Chronic lung disease from prolonged oxygen or ventilation after RDS

• Caused by inflammation, fibrosis, and impaired alveolar development

• Clinical signs: tachypnea, wheezing, oxygen dependence, delayed growth

• Radiograph shows scarring, atelectasis, emphysema, and cystic changes

• Treatment includes gentle ventilation, oxygen, diuretics, steroids, and developmental therapies

Meconium Aspiration Syndrome (MAS)

• Caused by inhalation of meconium-stained amniotic fluid before or during birth

• Leads to airway obstruction, inflammation, surfactant inactivation, and V/Q mismatch

• Clinical signs: respiratory distress, cyanosis, retractions, and patchy infiltrates on X-ray

• Treatment includes suctioning, oxygen/ventilation, surfactant, and inhaled nitric oxide

• May require ECMO in severe cases; PT supports breathing and positioning once stabilized

Treatment Strategies

• Age appropriate and fun (play based)

• In the least restrictive environment

• Focused on developmental progression when appropriate

• Practical for family carryover

• Meaningful to the family

• Settings include: inpatient hospital (acute & rehab), outpatient, early intervention centers, home, school