Cardiopulmonary

Practice Patterns
Anatomy & Physiology / Cardio & Pulm Diseases / Vascular Diseases /
Lab Values / ECG’s / Line Management / Transplants / Exercise
Screening & Prescription / Assessment/ Interventions / Pediatrics / ICU
1/20/21: Class ID#1

CARDIOPULMONARY
PRACTICE PATTERNS INTRO.
Dr. Amy J Bayliss, DPT, PT
Why is the Cardiopulmonary System
important?

 Hypertension is a pandemic
 Ischemic heart disease is the leading cause of
mortality and disability in industrialized countries
 Diseases of our civilization primarily involve the
cardiopulmonary systems
 Heart disease, chronic lung disease, hypertension & stroke,
diabetes & metabolic syndrome, cancers
Why is the Cardiopulmonary System
important?
 There are significant cardiopulmonary consequences of
systemic diseases
 Effects on oxygen transport can be direct or in combination with 1o or 2º
cardiopulmonary disease
 Systemic diseases include:
 Musculoskeletal system disorders*
 Connective tissue diseases
 Neuromuscular diseases*
 Kidney disease
 Hepatic disease
 Hematological disease
 Nutritional disorders including eating disorders and obesity
 Cancer*
Cardiopulmonary manifestations of a musculoskeletal
disorder like ankylosing spondylitis

Manifestation Why??
Decreased alveolar ventilation Chest wall rigidity, altered respiratory
mechanics, decreased chest wall excursion.
Impaired mucociliary transport Retained secretions, airflow obstruction,
pulmonary restriction, atelectasis.
Increased work of breathing Inefficient breathing pattern
Increased work of the heart Inefficient breathing pattern, constrictive
pericarditis
Decreased aerobic capacity Is due to secondary effects on muscle,
bones and joints. Worsened with inactivity.
Cardiopulmonary manifestations of a neuromuscular
disease like Parkinson disease

Manifestation Why??
Decreased alveolar ventilation  Chest wall rigidity, weakness of
restrictive lung dysfunction respiratory muscles resulting in altered
respiratory mechanics, decreased chest
wall excursion.
Impaired mucociliary transport  Upper airway obstruction, retained
obstructive lung disease secretions  pneumonia.
Increased work of breathing Inefficient breathing pattern – medication
causes dyskinetic breathing and abnormal
central control of breathing
Decreased aerobic capacity Is due to secondary effects on muscle,
bones and joints. Worsened with inactivity.
Cardiotoxicity associated with cancer treatment

Cancer treatment Types of possible side effects

Chemotherapeutic agents Acute myocarditis  can lead to CHF
Endocardial fibrosis
Ischemia, arrhythmias
Pericarditis
Hypo or hypertension
Biologic agents Hypo or hypertension
Chest pain, arrhythmias
LV dysfunction, CHF
Radiation therapy to chest Pericarditis
Premature CAD, MI or valve disease
Arrhythmias, conduction disturbances
Stem cell transplantation Acute arrhythmias, conduction disturbance.
Pericardial effusion.
A. Review: Position of the heart
 A. Review: Position of lungs
 The lower edge of the
lung varies according to
the amount of inflation.
 In quiet respiration it is
 opposite the sixth cartilage
and rib from the sternum to
the mid-clavicular line
 opposite the eighth in the
mid-axillary line
 the tenth in the scapular
line
 and the eleventh near the
vertebrae
 Pleura is 2 ribs lower
Anatomical lines for respiratory excursion
B. Review: Heart anatomy
B. Review: Heart anatomy
B. Review: Heart anatomy
B. Review: Lung anatomy
B. Review: Lung anatomy
B. Review: Bronchopulmonary segments
C. Review: Movement of the ribs
 Pump handle
 Upper ribs elevate with
sternum thrust forward
 Increases AP diameter
& depth of the thorax
C. Review: Movement of the ribs
 Bucket handle
 Lower ribs swing outward
& elevate
 Increases the lateral or
transverse diameter of the
thorax
D. Review: Muscles of Respiration
 Inspiration 1o  Expiration 1o
 Diaphragm  Relaxation of diaphragm
 External intercostals  Internal intercostals
 Inspiration accessory  Expiration
 Sternocleidomastoid  Rectus abdominis
 Scalenes  External obliques
 Serratus anterior &  Internal obliques
rhomboids  Transverse abdominis
 Pectoralis major & minor
 Upper trapezius
 Erector spinae
E. Review: Cardiac Innervation
A. Review: Ventilation

 Ventilation (or breathing) is the mechanical

movement of gases into and out of the lungs
 Controlof ventilation (CNS)
 Afferent connections to the brainstem

 Mechanics of breathing
 Intrapulmonary and atmospheric pressures
 Intrapleural and transmural pressures
 Physical properties of the lungs
A. Review: Ventilation

 Control of ventilation (CNS)

 Breathing usually occurs automatically and involuntarily
 Neurons in parts of the brainstem regulate automatic
breathing (pons and medulla oblongata)
 Breathing requiring a conscious change in pattern
involves the motor cortex of the frontal lobe
 Impulses sent from here bypass the brainstem and are sent
directly down the corticospinal tracts
A. Review: Ventilation

 Afferent connections to the brainstem

 Hypothalmicand limbic influence
 Chemoreceptors (peripheral and central)
 Innormal ventilation is driven mostly by CO2 levels in
arteries detected by peripheral receptors
 This is altered in chronic pulmonary disease

 Lung receptors (irritant receptors, stretch receptors and

J receptors)
 Joint and muscle receptors
A. Review: Ventilation – Mechanics of breathing

 Intrapulmonary and
atmospheric pressures
 A difference in pressure
between the
atmosphere & lungs
facilitates flow of air
into the lungs
 Intrapleural and
transmural pressures
 These pressures keep
the lung near the chest
wall
A. Review: Ventilation – physical properties of lungs

 Compliance
 Allows lung tissue to stretch during inspiration
 Elasticity
 The elastic recoil of the lung allows passive expiration
to occur
 Surface tension
 The surface tension at the air-liquid interface on the
alveoli allows the lung to get smaller during expiration
 Surfactant is the surface-agent in lungs

 Resistance to airflow
Lung Compliance

 Compliance is the measure of how easy it is to inflate

something.
 If it is easy to inflate something, then compliance is high.
 Prime example is emphysema
 Due to loss of elastic tissue in the lungs
 These patients have over-inflated lungs and cannot move the air out
 If it is hard to inflate something, then compliance is low
 Stiffer lungs are harder to expand
 Aging lungs
 Pulmonary fibrosis (scarring on lungs)
 COVID patients
 Neonates
 Reduced surfactant makes the lungs have lower compliance, so it is harder
for the babies to move air into their lungs
B. Review: Respiration
 Respiration refers to the process of gas exchange in
the lungs, it requires:
 Diffusion

 Perfusion

 Ventilation and perfusion matching

 Effective transport of oxygen and carbon dioxide

 Acid-base balance
B. Review: Respiration -Diffusion
 For effective gas exchange to occur
between the alveoli and pulmonary
capillaries, differences in partial
pressures of oxygen and carbon
dioxide must exist creating a
pressure gradient
 This gradient allows gases to diffuse
from high areas of concentration to
areas of low concertation
 This process can be significantly
affected in disorders that damage
alveolar walls
B. Review: Respiration -Perfusion
 Blood flow to the lungs available for gas exchange
 It is a low pressure-low resistance pathway
 Partial pressure of oxygen affects perfusion
 Pulmonary arterioles constrict when alveolar partial
pressure of oxygen are low and dilate when partial
pressure of oxygen increases
 This reduces blood flow to poorly ventilated areas

 Alterations in pH of blood affects vasomotor tone

of the pulmonary vasculature also
B. Review: Respiration -V/Q ratio
 The ventilation/perfusion ratio (or V/Q ratio) is a
measurement used to assess the efficiency and
adequacy of matching
 It is defined as: the ratio of the amount of gas to
the amount of blood reaching the alveoli
 Positions play a vital role
 Inupright position, perfusion and ventilation matching is
greatest to the base of the lungs
 With position change the gravity-dependent areas will
have optimal matching
B. Review: Respiration -V/Q ratio
B. Review: Respiration –transport of oxygen
and carbon dioxide
 Majority of oxygen (98%) is transported by
hemoglobin
 Oxyhemoglobin dissociation curve describes the
relationship between the amount of O2 bound to
hemoglobin
 Shiftto right = decreased oxygen affinity and greater
dissociation of oxygen and hemoglobin
 CO2 is carried in the blood dissolved in plasma,
bound to a protein component of hemoglobin or as
bicarbonate ion
Oxyhemoglobin dissociation curve
B. Review: Respiration – acid-base
balance
 An analysis of arterial blood gases will provide:
 pH

 PaCO2

 PaO2

 HCO3-

 From these values we can ascertain the presence of

alkalosis, acidosis and which system is involved
(respiratory or metabolic)
C. Review: Cardiac cycle
 The period from the
beginning of one heartbeat
to the next is the cardiac
cycle
 The cardiac cycle is further
divided in to two periods
systole and diastole
 Involves both electrical and
mechanical events
C. Review: Cardiac cycle
D. Review: Cardiac Output
 Cardiac output = heart rate x stroke volume
 The heart rate is regulated by the autonomic
nervous system which influences the firing of the SA
node, receptors in the myocardial walls & coronary
artery flow
 Stroke volume is affected by preload, contractility
and afterload
G. Review: Cardiac Output

 Preload is the ventricular volume at the end of diastole.

 An increased preload leads to an increased stroke volume
(up to a certain point)
 Preload is a reflection of the blood returning to the heart
aka venous return
 Venous return is influenced by changes in position, intra-
thoracic pressure, blood volume and the balance of
constriction and dilatation (tone) in the venous system

Relationship between preload and stroke volume  Starling law

 G. Review: Cardiac Output
 Normal (top curve), as preload increases,
cardiac performance also increases.
However at a certain point, performance
plateaus, then declines.

 In heart failure (HF) due to systolic

dysfunction (bottom curve), the overall
curve shifts downward, reflecting
reduced cardiac performance at a given
preload, and as preload increases,
cardiac performance increases less.

 With treatment (middle curve),

performance is improved, although not
normalized
D. Review: Cardiac Output

 Afterload is the reflection of the pressure against which the

heart has to contract to pump blood into the aorta (ejection of
blood during ventricular systole)
 Determined by the
 extensibility of aorta
 Vascular (peripheral) resistance
 patency of aortic valve
 viscosity of blood
 Increased with systemic hypertension or aortic valve stenosis
 Reduced with vasodilators, calcium channel blockers, beta
blockers, ACE agents
D. Review: Cardiac Output

 Ejection fraction is the best indicator of cardiac function

 It represents the percentage of blood ejected by the ventricles
relative to the volume of blood received by the ventricles prior
to contraction
 Normal ejection fraction is 60-70%
CARDIAC CONDITIONS
Dr. Amy J Bayliss, DPT, PT

P524: 2/8/21
Abbreviations used
• AHA = American Heart • TC = total cholesterol
Association • HDL = high density
• CAD = coronary artery lipoprotein
disease (our text • LDL = low density lipoprotein
interchanges with CHD = • RPE = rate of perceived
coronary heart disease) exertion
• CV = cardiovascular • JVD = jugular venous
• CVD = cardiovascular distention
disease • PND = paroxysmal nocturnal
• MI = myocardial infarction dyspnea
• HTN = hypertension • SAN = SA node
• HF = heart failure • PAD = peripheral arterial
• SOB = shortness of breath disease
• QOL = quality of life
Why are we concerned about
Cardiac Disease?
• Current estimate is that at least 83 million Americans have
one or more forms of CV disease

• Therefore many patients you treat will have CV disease

• Must understand for safety/effective care

• Many risk factors are modifiable

• PT’s have many opportunities to educate
• We are the experts in physical fitness
Cardiac Risk Factors
CANNOT modify CAN modify

• Age • Smoking
• Biological sex • Physical inactivity
• Family History • Obesity
• Previous MI • Suboptimal diet
• Race/Ethnicity • Hypertension
• Elevated serum
cholesterol level
• Stress
• Syndrome X/Diabetes
Cardiac risk factors
• Emerging risk factors
• Type A personality
• Hostility
• Non-trusting
• Humorless
• Depression
• C-reactive protein (marker for inflammation, lowered by statins)
• Homocysteine (high levels of amino acids damage endothelium,
can be decreased with good diet choices – diet high in vegetables
and fruits)
Cardiac Disease
• Coronary Artery • Other Cardiac
Disease Pathology
• Hypertension • Valve disease
• Atherosclerosis • Aneurysm
• Angina Pectoris • Infective endocarditis
• Myocardial infarction • Myocarditis
• Pericarditis
• Heart Muscle • Rheumatic Heart
Dysfunction Disease
• Heart failure • Sudden cardiac death
• Cardiomyopathy
Hypertension (HTN)
• Persistent elevation of BP > 130-139 or >80-89 (Stage 1 HTN)
• Primary HTN
• Risk factors include age, ethnicity, glucose intolerance, smoking,
stress, excess sodium or alcohol intake
• Secondary HTN
• Labile HTN
• BP is sometimes elevated, sometimes normal
• White coat HTN
• Elevated BP in the clinic but not in normal life (accounts for 25% of HTN)
• Masked HTN
• Normal clinic BP, elevated in normal life so goes untreated
• Malignant HTN
• Markedly elevated BP
Hypertension (HTN)
• PT Implications:
• Pathophysiology of HTN results in organ damage
• Clinical monitoring is vital
• Clinical manifestations include:
• Exertional dyspnea &/or chest discomfort, fatigue, impaired exercise
tolerance, & tachycardia
• Side effects of medications and any exercise interactions must be
well understood by a PT
• Particularly watch for hypotension with
• Change of position, post-exercise, long term standing, warm
environments
• We must encourage compliance with anti-hypertensive treatments
in our patients
Hypertension (HTN)
• Guidelines for exercise:
• Cardiovascular exercise testing
• If resting BP >180mmHg systolic , > 120mmHg diastolic - obtain
physician clearance before testing
• Discontinue exercise test if > 240mmHg systolic, >110 mmHg diastolic
• Cardiovascular exercise training
• If resting BP is in the severe range of >180 systolic and/or 120mmHg
diastolic, physician clearance is needed prior to prescribing an exercise
program
• Endurance training at moderate intensity
• Resistance exercise
• No Valsalva aka breath hold
• Low weights, high reps with a long rest time between sets
Coronary Artery Disease (CAD)
• Disease of the arteries of the heart leading to:
• Narrowing or blockage of the coronary arteries
• Arteries cannot meet metabolic demands
• Produces ischemia and necrosis of the myocardium due to lack of
nutrients & oxygen to the myocardium
Angina pectoris
• Transient process
• Occurs when the coronary arteries are unable to supply
adequate oxygen
• 3 common types
• Stable
• Unstable
• Variant
Stable Angina
• Sometimes referred to as chronic, stable angina
• Occurs during physical effort but may be related to stress
• Individuals can describe triggers and the intensity
required to bring on angina therefore it is stable
• The pattern is generally predictable
Stable Angina
• Symptoms • PT Implication
• Temporary pain • Be aware of precipitating
(gripping, viselike) factors
• Sudden onset • Is their medication
• Pain that may radiate present
(neck, jaw, back, • Monitor vitals
shoulder, arm)
• SOB, belching, burning
indigestion
• Usually lasts 5-15 mins
• Usually relieved with rest
or nitroglycerin (nitrate)
Angina – Symptom referral
• Cardiac symptoms can
refer to any of the areas
shaded
Stable Angina
• Is angina different in patients who are biological sex
female (CGF,TGM or non-binary)?
• Yes, symptoms can present quite differently.
• Unusual chest pain (quality or location), stomach or abdominal pain
• Left chest pain with no sternal pain sensation similar to breathing cold
air
• Continuous mid-thoracic or inter-scapular pain
• Continuous neck or shoulder pain
• Aching in right bicep
• Pain relieved by antacid; pain unrelieved by rest or nitroglycerin
• Nausea and vomiting, flu-like manifestation without chest pain
• Unexplained intense anxiety, weakness or fatigue
• Breathlessness, dizziness
Variant Angina
• Also called Prinzmetal’s or atypical angina
• Occurs at rest, usually on waking at the same hour
• Due to vasospasm
• Exertion or emotional stress does not influence the
development of angina
• Often relieved by nitrates
• May be treated long term with calcium channel blockers
• Arrhythmias common
Unstable Angina
• Can occur at rest or with physical exertion or emotional
stress
• There are 3 principal presentations
• Resting angina or angina > 20 minutes
• New onset angina (within the last month)
• Crescendo angina (more frequent, longer and more severe)
• Less responsive to nitrates
• Indicator of progression of the CAD & increased risk of MI

Unstable angina  physiologic difference, absence of the need for an increase

in myocardial oxygen demand to provoke symptoms.
Unstable Angina
• PT Implication
• Monitor vitals
• Contact MD (EKG most likely needed)
• May require immediate hospitalization if symptoms do not resolve
with rest in 20 minutes or worsen with rest
• Can progress to a MI quickly
Acute coronary syndrome
• Chest discomfort continuing for greater than 20 minutes
due to insufficient blood supply to the myocardium
• Can be due to unstable angina or an acute myocardial infarction
• The only way to distinguish is with an EKG
• After an EKG your patient will be given 1 of the 3 following
diagnoses:
• Unstable angina
• ST-segment elevation myocardial infarction (STEMI)
• Non-STEMI
• Does the diagnosis matter to PT? YES
Acute coronary syndrome
• A STEMI causes a transmural injury (full or near full
thickness injury)
• Pathological Q waves & ST segment elevation are seen on EKG

• A non-STEMI causes subendocardial or nontransmural

injury (affects the subendocardial region only)
• No pathological Q waves, may see ST segment depression or T
wave changes

• The location and the time it takes for arterial reperfusion

also matters!!
Acute coronary syndrome
Myocardial Infarction – Actual event
• Symptoms • PT Implication during
• Sudden, severe, • 911
constant pain &/or • CPR
pressure • Notify MD
• Radiation of symptoms
• Document
• SOB
• Profuse perspiration
Remember: if arterial
• Unexplained fatigue perfusion to the myocardium
• Nausea, light occurs in 20 minutes of the
MI, necrosis can be prevented
headedness
• Denial
CPR
Review for board exam!!
Know for patient safety!
Myocardial Infarction – after event
• Can be uncomplicated (=small infarction)
• Minimal change in cardiac performance
• Or complicated, at risk for any or all of the following:
• Arrythmias
• Persistent systolic hypotension
• Pulmonary edema
• Cardiogenic shock
• Persistent angina or extension of infarction
• Complications in other systems (pulmonary, renal, thrombosis)
Heart Failure
• An inability of the heart to maintain proper cardiac output
of 4 lpm at rest
• Diagnosed by reduced ejection fraction, <40%
• Most common etiology is chronic hypertension or CAD
• Remember if CO is affected, it can be due to effects on;
• Preload, Afterload, or Contractility

http://www.merck.com/mmpe/sec07/ch074/ch074a.html
Heart Failure
• Heart unable to maintain an adequate cardiac output
• Characterized by:
• Abnormal retention of fluid
• Congestion of the pulmonary and/or systemic circulation
• Can be named for;
• acute vs chronic
• compensated vs decompensated
• the side of the heart that is failing This is the important
one to know
• Stage I-IV
• Systolic vs diastolic
Heart Failure: Characteristic signs & symptoms
• Dyspnea • Hepatomegaly
• Tachypnea • Jugular venous
• Paroxysmal nocturnal distension
dyspnea • Crackles (rales)
• Orthopnea (=dyspnea • S3 heart sound
when lying down) (pathological)
• Edema – pulmonary or • Exertional hypotension
peripheral • Decreased exercise
• Cyanotic extremities tolerance
• Weight gain [> 3lbs a day] • Increased resting heart
rate
Specific symptoms: depends on type of HF
Heart failure: Medical tests
• Radiologic findings
• Enlarged heart with signs of pulmonary edema
• Laboratory findings
• Elevated BNP,  protein in urine, elevated BUN & creatinine,
potassium and sodium abnormalities, PaO2 and PaCO2 levels may
move towards respiratory acidosis
• Echocardiography
• Determines ejection fraction, ventricular dimensions, ventricular
volume, wall motion, and chamber geometry
Comparison of Left and Right Sided HF
LEFT: Symptoms RIGHT: Symptoms

• Pulmonary congestion • Systemic congestion

• Pulmonary edema • Enlarged liver
• Ascites
• Dyspnea, orthopnea
• JVD
• PND
• Dependent pitting edema
• Cough
• Fatigue
• Bronchospasm
• Oliguria, nocturia
• Hypotension
• Cyanosis
• Fatigue • Pleural effusion (R>L)
• Oliguria • Anorexia and chronic GI
• Cyanosis blood loss
• Tachycardia • Unexplained weight gain
Complications of Heart Failure
• Decreased exercise tolerance
• Cardiac dysrhythmias
• Chronic atrial fibrillation
• Ventricular assistive device (VAD) placement
• Candidate for heart transplant
• Sudden death
PT Implications for Heart Failure
• Must be reassessed each visit for:
• Signs & symptoms of decompensation (weight gain, leg swelling,
are both clear signs)
• Monitor vitals, typically you will see elevated HR’s and low
BP at rest
• Listen to heart and lung sounds
• Monitor for signs of exercise intolerance
• Treatment modifications are typically needed
• For example, 1-2 minute frequent rests
• Monitor for side effects of medications
• Use quality of life and functional outcome measures
Cardiomyopathy
• General term reflecting disease of the myocardium
• Impairs the ability for the heart to contract and relax
• Non-reversible disease process
• May lead to heart failure
• Only treatment option is heart transplant
• Primary and secondary causes, typically idiopathic
• 3 types from a functional standpoint:
• Dilated
• Hypertrophic
• Restrictive
Cardiomyopathy
• Symptoms • PT Implication
• Dependent on type • Same implications as HF
• Symptoms same as patients
heart failure • Many secondary causes
• Jugular venous of cardiomyopathy make
distension our typical PT caseload
• Obesity
• Fatigue, weakness,
• Diabetes
possible chest pain
• Muscular dystrophy
• Sudden death
• Cancer
• Exercise intolerance • Drug/alcohol use
Valvular Heart Disease
• Heart valve incompetence is either;
• congenital or acquired (through infection)
• can be any one of the four valves
• some defects will require surgery
• Symptoms are;
• Exertional dyspnea, excessive fatigue, palpitations, fluid retention,
& orthopnea
• Potentially hemodynamically unstable so vitals must be monitored

Exercise implications in later lectures.

Aneurysm
• Weakening of the vessel wall
• Produces a sac-like area
• Aorta common site
• Surgical repair prior to rupture has a good prognosis
• High mortality rates with aortic aneurysm rupture
Aneurysm
• Symptoms
• Often asymptomatic
• Intermittent or constant pain can be present (depends on location)
• In aortic aneurysms:
• Low back pain is common (abdominal aortic aneurysm)
• Leg pain/claudication pain +/- leg numbness
• Excessive fatigue especially with walking
• Pulsing mass in abdominal area
• May hear bruits over swollen area in abdomen
• Poor distal pulses
Aneurysm
• PT Implications (if aware one is present but not at surgical
size or non-surgical candidate)
• Monitor vitals
• If any symptoms call 911
• Avoid valsalva maneuver/breath holding with exercise
• No sustained overhead work
• No heavy lifting, may have restriction from MD
• Notify MD of any changes in resting or exercising BP, must be in
AHA recommended ranges
Aneurysm dissection/rupture
• Clinical manifestations
• Sudden, excruciating pain
• Hypotension
• Tachycardia
• Pallor
• Diaphoresis
• Shock

 Call 911 immediately

Myocarditis
• Uncommon condition • Symptoms
of inflammation of • Mild, low level chest pain
the myocardium • Soreness in the
• Usually due to epigastric area
infection • Fatigue
• Palpitations
• Left untreated
progresses to • PT Implication
cardiomyopathy with • Refer to MD
heart failure
Pericarditis
• Inflammation of the pericardium (outer membrane of
the heart)
• Can be acute or chronic
• Etiology often unknown
• Some causes are infection, MI, post cardiac surgery,
radiation therapy
• Left untreated it can be fatal
• PT Implication
• Contraindication for PT treatment until medical treatment has been
stated and cleared by MD
 Pericarditis
• Symptoms
• Pericardial friction rub
• Pleuretic chest pain
• Diffuse ST segment
elevation
• Enlarged heart on X-ray
• Retrosternal chest pain
• Cough & hoarseness
• Fever, fatigue, and
weakness
• Joint pain
Differential diagnosis for chest pain
Types Descriptors
Stable angina Tightness, pressure that develops with exertional activity.
Unstable angina More severe and prolonged than classic angina,
accelerating in frequency and severity.
Variant angina Occurs at rest (typically early morning).
Pericarditis Pain at rest, responds to anti-inflammatories, EKG and
radiography findings.
Musculoskeletal Mechanical pattern with aggravating and relieving factors,
chest wall pain can locate painful area with palpation.
Pleuritic pain Often sharp, changes with breathing.
Bronchospasm Exertionally related or induced by irritants and associated
with difficulty breathing.
Vascular - PE Sudden onset, severe unrelenting pain.
Gastrointestinal Usually related to food intake or position after eating.
Rheumatic Heart Disease
• Rheumatic fever can occur from streptococcal group A =
strep throat
• Results in damage to the heart secondary to inflammation
from rheumatic fever
• Autoimmune disease
• Can affect all CT of the heart, joints, CNS, heart valves
• Low mortality rate
• Reoccurrences influence level of disability
Rheumatic Heart Disease
• Symptoms • PT Implication
• Carditis with chest pain • Co-morbidity
• Acute onset of • Vital signs
polyarthritis • Differential diagnosis
• Chorea
• Arthralgias and
weakness
• Fever
• Palpitations
Sudden Cardiac Death in Athletes
• Why?
• Hypertrophic cardiomyopathy (HCM)
• Coronary artery abnormalities
• Coronary myocarditis and CAD
• Congenital heart disease
• Medication induced
• HCM is the most common and due to the hypertrophy of
the septum can cause an obstruction to blood flow
• These patients often present with a heart murmur and an abnormal
EKG
Cardiac Medication Review
• Diuretic agents • Some examples:
• Increase sodium and • Hydrochlorothiazide*
water excretion to (Esidrix, Oretic,
decrease plasma volume Hydrodiuril)
- manages HTN & HF • Chlorthalidone*
•  preload so improved (Thalitone, Hygroton)
ventricular length- • Furosemide# (Lasix)
tension relationship • Spironolactone^
(Aldactone)
• Types: Thiazide*, Loop#, • Amiloride^ (Midamor)
Potassium sparing^
Cardiac Medication Review
• Beta- adrenergic • Some examples:
blocking agents (Beta- • Bisoprolol (Zebeta)
blockers) • Atenolol (Tenormin)
• Decrease the heart’s • Metoprolol (Lopressor,
oxygen demand Toprol)
through decreasing • Propranolol (Inderal)
heart rate and
contractility, BP
• Treat angina,
arrhythmias, and HTN
• Cant use HR, must use
RPE
Cardiac Medication Review
• Alpha-adrenergic • Some examples:
blocking agents • Prazosin (Minipress)
• Block post-synaptic • Terazosin (Hytrin)
alpha 1-adrenergic • Doxazosin (Cardura)
receptors which dilates
arterioles & veins
• Decreases BP
Cardiac Medication Review
• Angiotensin-converting • Some examples:
enzyme inhibitor • Captopril (Capoten)
(ACE) agents • Enalapril (Vasotec)
• Decrease in afterload • Lisinopril (Prinivil, Zestril)
due to less arterial • Fosinopril (Monopril)
vasoconstriction
• Benazepril (Lotensin)
• Decreases intravascular
• Ramipril (Altace)
volume which  preload
• Prescribed for patients in
HF and with HTN
Cardiac Medication Review
• Angiotensin II receptor • Some examples:
blockers • Losartan (Cozaar)
• Used when patients • Valsartan (Diovan)
cannot tolerate ACE • Irbesartan (Avapro)
inhibitors
• Blocks receptors to
angiotensin II
• So angiotensin II cannot
exert vasoconstrictive
effects on the body
Cardiac Medication Review
• Calcium channel • Some examples:
blocker agents • Amlodipine (Norvasc)
• Decreases the heart’s • Nifedipine (Procardia,
oxygen demand by Adalat)
reducing the flow of • Verapamil (Calan)
calcium
• Diltiazem (Cardizem)
• Decreases vasospasm
and facilitates
vasodilatation
contributing to improved
oxygenated blood flow
Cardiac Medication Review
• Nitrates • Some examples:
• Decrease ischemia • Nitroglycerin (Nitrostat)
through smooth muscle • Isosorbide dinitrate (Isordil)
relaxation
• Dilate coronary arteries to
improve collateral flow to
ischemic regions of the
heart treat stable and
variant angina
• As a venodilator this 
venous return ( preload)
• As a arteriodilator, this 
afterload
Cardiac Medication Review
• Anti-arrhythmic agents • Some examples:
• Complex – there are 4 • Lidocaine (Xylocaine)
classes of drugs • Amiodarone (Cordarone)
• The goal is alter • Bretylium tosylate
conductivity in order to (Bretylol)
correct ectopic stimuli or • Procainamide
other electrical (Procanbid)
abnormality
• Digitalis (digoxin)
• Crazy effects on EKG
• Primary prescribed
Cardiac Catheterization
• Complications:
• dysrhythmias, hemorrhage, MI, arterial spasm, vascular dissection,
perforation, emergent CABG
• After catheterization, patient is on bedrest briefly until the
manual compression or a vascular closure device such as
a vasoseal is used to achieve hemostasis
• PT Implications:
• Check activity orders before mobilizing patient, it can be as little as
1-2 hours or as long as 4-6 hours if the femoral artery is
accessed
• If the radial artery is the access point there maybe no weight
bearing through the wrist for 24-72 hours
Tilt Table Testing
• Patient placed in horizontal position and tilted upwards
toward vertical (60o), while vitals are monitored
• Monitor BP, HR, ECG (if available), and symptoms
• Indications: syncope, orthostatic hypotension, diagnosis
of POTS (postural orthostatic tachycardia syndrome)
• PT implication: can use for treatment of patients’ after
prolonged bedrest
Holter Monitor
• Continuous ECG recording to detect cardiac
dysrhythmias, correlate rhythm and symptoms during
activities
• Can be done as inpatient or outpatient
• Indications: syncope, dizziness, SOB, palpitations,
pacemaker function, high risk for sudden cardiac death
• Patient records activities in activity log
• PT implication: Record activity during patient treatment &
monitor vitals
Echocardiography (a.k.a. ultrasound)
• Most widely used non-invasive cardiac imaging technique
(gold standard for diagnosis of HF)
• Utilizes sound waves to provide an image of the
myocardial structure
• Can be performed at rest and/or after exercise
• Doppler Echo
• through chest wall (trans-thoracic)
• uses a microphone to provide information on blood velocity
Echocardiography
• Evaluates
• size of ventricles
• valve function
• wall motion
• estimation of ejection fraction
• Indications are numerous – pericardial effusion, cardiac
tamponade, cardiomyopathy, valve problems, congenital
heart disease
• Limitations: obesity (uses TEE instead), chest wall
abnormalities (uses TEE instead), does not image the
coronary arteries
Transesophageal Echo (TEE) &
Intracardiac Echo (ICE)

• TEE - Catheter is
passed into the
esophagus
• Used for patients with
pulmonary disease,
obesity, chest wall
defects, aortic tears
• ICE - Access
through femoral
artery or vein
• Major diagnostic tool
for pediatrics
Pharmacological Stress Tests
• Dobutamine Echocardiography
• If traditional exercise test contraindicated
• Intravenous dobutamine is administered
• Then the heart can be evaluated under stress
Chest Radiograph

• Standard, non-invasive method of chest imaging

• Indications:
• Assess heart size (≤1/2 of thoracic cavity)
• Diagnose cardiomegaly, heart failure, pericardial effusion
• Provides a baseline
• Verifies lines/lead placement
Electrophysiologic (EP) Study
• Used for the diagnosis of heart rhythm disorders
• Electrode catheter inserted into femoral vein to the right
atrium to record electrical activity in heart
• Continuous ECG monitoring, electrical signals sent
through catheter to record electrical potentials, induce
dysrhythmia
• Complications: bleeding, blood clots, perforation of the
myocardium
• PT Implication: Check results! Recovery is same as from
cardiac catherization
Magnetic Resonance Imaging
• 3D view
• Evaluate cardiac function,
contractility, myocardial
perfusion
• Evaluate LV mass, blood
flow velocities, coronary
artery anatomy
• Differentiates between
myocardial injury and
infarction
Radioactive Nuclide Perfusion Imaging
• Am example is Thallium Perfusion imaging
• A patient is scanned using a gamma camera following and injection
of Thallium, which is a vasodilator
• This enhances blood flow with hypo-perfused areas appearing
white due to diminished thallium activity
• Evaluates myocardial perfusion of the heart
To recap:
• The most basic symptoms that should make you think of a
cardiac pathology are:
• Chest pain
• SOB
• Cardiac arrhythmia (palpitation)
• Fainting
• Claudication
• Cyanosis of lips and nail beds
• Fatigue
• Edema
CARDIAC DISEASE LAB SHEET

1. Why should a patient not smoke 4 hours before their Physical Therapy session? Nicotine is a vasoconstrictor which will
adversely affect the muscles and heart’s ability to perform rehab.

2. You are treating a patient who suffered a MI 5 days ago, the first day you see them you perform a full medical chart
review. You review the EKG and find abnormal Q waves and an elevated ST segment, does this tell you anything about the
diagnosis? Acute coronary syndrome (STEMI)

What other information would be useful to know to help determine prognosis?

The location and the time it takes for arterial reperfusion. If arterial perfusion to the myocardium occurs in 20 minutes of
the MI, necrosis can be prevented.

3. What differences in symptoms do women experience with angina compared to men?

• Unusual chest pain (quality or location), stomach or abdominal pain
a. Left chest pain with no sternal pain sensation similar to breathing cold air
• Continuous mid-thoracic or inter-scapular pain
• Continuous neck or shoulder pain
• Aching in right bicep
• Pain relieved by antacid; pain unrelieved by rest or nitroglycerin
• Nausea and vomiting, flu-like manifestation without chest pain
• Unexplained intense anxiety, weakness or fatigue
• Breathlessness, dizziness

P524, 2021 1
 4. What is the gold standard medical test for the diagnosis of coronary artery disease? What are the PT implications?
Cardiac catherization
PT implication: check activity orders, could be 1-6 hours post insertion in femoral artery and 24-72 hours if radial

5. Complete the table:

Left sided heart failure Right sided heart failure
Systemic or pulmonary? Pulmonary Systemic
Symptoms/signs Pulmonary edema Enlarged liver
Dyspnea, orthopnea Ascites
PND JVD
Cough Dependent pitting edema
Bronchospasm Fatigue
Hypotension Oliguria, nocturia
Fatigue Cyanosis
Oliguria Pleural effusion (R>L)
Cyanosis Anorexia and chronic GI blood loss
Tachycardia Unexplained weight gain

Response to exercise S3 sound, crackles, SOB Hypotension, SOB

Etiology Chronic HTN Mitral stenosis
CAD PD
Valvular disease Valvular disease
Cardiomyopathy Infective endocarditis
CHD Pulmonary HTN
Infective endocarditis L sided HF

P524, 2021 2
6. You have a patient exercising on a treadmill in your outpatient clinic. You observe them rubbing his jaw. When you ask
him what he is doing, he says that his jaw hurts. You should then ask?
Do you have pain in your neck, shoulder, or arm? Any SoB, burning or indigestion in your chest?

What are your thoughts about the differential diagnosis of this jaw pain? Which 2 systems could be involved? How could
you determine what is causing the jaw pain?

Either musculoskeletal or cardiopulmonary

To find the source of the jaw pain, you could ask about the other symptoms above and do further test and measures such
as palpation, vitals, and a deeper look at the PMH.

7. What risk factors for CV disease does the following patient have?
Mary, is 65 years old and has been married for 35 years. Her husband is currently on hospice because he has lung cancer.
She reports she is feeling stressed and sometimes has a glass of wine to calm her down. You measure her blood pressure
at 142/82, she is 5ft 2 inches and 220 lbs (BMI of 40.2). She reports she knows she should lose weight because both her
parents were heavy and had heart attacks before they were 70 years old. Right now she reports being too busy caring for
her husband to care for herself.

Age, family history, physical inactivity, obesity, HTN, stress

8. You have a new patient to see on CCU, his name is Bill. His medications include a beta-blocker, digitalis, a diuretic, an ACE
inhibitor, and aspirin.
From this list of medications what is your initial impression of the cardiac disease process he may have?
a) Unstable angina
b) Myocardial infarction
c) Heart failure
d) Pericarditis

P524, 2021 3
 9. What would you expect to see on Bill’s chest X-ray?
e) Pulmonary edema, the cardiac silhouette half the size of the width of the chest cavity
f) Pulmonary edema, the cardiac silhouette over half the size of the width of the chest cavity
g) Normal chest X-ray, he has a heart problem not a lung problem
h) Cardiomegaly

10. What would you expect to find clinically when you examined this patient?
 Extremity edema if R sided HF  Non-productive cough
 Elevated HR  Side effects from
polypharmacy
 Depressed BP  Frequent rest breaks
 Reduced exercise tolerance  Orthopnea
 Abnormal heart and lung sounds  SOB
(S3) (crackles)

11. Complete the table on differentiating chest pain.

Characteristics Stable Angina (Predictable) Musculoskeletal Pericarditis

Location Sternum Outside chest wall Retrosternum
Radiation Neck, jaw, back, shoulder, arm None Neck, trapezius, joint
Quality Gripping, viselike, burning, SOB, Sharp, intermittent Sharp (pleuritic), cough, hoarseness,
belching, indigestion, tightness fatigue, weakness
Alleviating factors Rest, nitroglycerin, antacid (female) Rest, PT NSAID’s, shallow breathing, Tripod
position breathing
Aggravating factors Stress, physical activity Direction dependent, palpation Rest, supination

P524, 2021 4
 Duration Sudden onset, temporary (5-15 Pt. dependent Acute (hours) or chronic, fatal if
minutes) untreated

12. Mrs. Howe is a 74-year-old woman with known CAD. She complained of flu-like symptoms, feeling tired, SOB on minimal
exertion, and a dry cough especially at night. Since yesterday, her SOB has worsened to an extent that prevents her doing
her ADL’s at home. There are a number of medical conditions that could cause these symptoms, how would you
differentiate between pneumonia and acute heart failure?

PMH CAD  HF
SOB on exertion = dyspnea  HF
Decreased exercise tolerance  HF
Decompensation signs and symptoms  HF

* Decompensation would signify heart cannot maintain cardiac output = sudden weight gain, increased SOB, more lower extremity or abdominal edema,
more pronounced cough, increasing fatigue, light headed or dizzy.

13. Which condition has vascular lesions associated with it?

i) Infective endocarditis
j) Heart failure
k) Myocardial infarction
l) Pericarditis

14. Which of the following statements are true when describing preload? (circle all that are true)
a) Preload is the end-diastolic muscle fiber length of the ventricles before systolic ejection.
b) An increase in ventricular volume increases the force of the myocardial contraction and stroke volume.
c) Preload of the left side of the heart is dependent on venous return, blood volume and left atrial contraction.
d) Ventricular preload is increased by an increased heart rate.

P524, 2021 5
15. Which of the following statements are true when describing afterload? (circle all that are true)
a) Afterload is the resistance to the ejection of blood during ventricular systole.
b) An increase in afterload causes an increase in stroke volume.
c) Afterload is determined by the distensibility of the aorta, the vascular resistance, the patency of the aortic valve
and the viscosity of the blood.
d) Afterload can be thought of as the "load" that the heart must eject blood against.

16. What are some adverse effects of diuretics? Dehydration, orthostatic hypotension, electrolyte imbalance (Na, K, Ca),
hyperglycemia, metabolic alkalosis, LDL increase

17. What do calcium channel blockers achieve at a physiological level? How does this impact your therapeutic interventions?

Vacillates vasodilation for increased BF while also decreasing the heart’s demand for oxygen (Reduced Ca flow). More
blood flow and less O2 demand means the heart can work longer and harder during Tx.

18. Which cardiac medications reduce preload? Diuretics, ACE inhibitors, Nitrates, beta blockers

19. Which cardiac diagnostic test has the least side effects and is least invasive?
a) Chest X-ray
b) Echocardiogram (ultrasound)
c) MRI scan
d) Electrophysiological study

P524, 2021 6
20. If a patient is shoveling snow in cold weather and it brings on their angina pectoris, how would you explain this using your
knowledge of pathophysiology?

Occurs when the coronary arteries are unable to supply adequate oxygen due to vasoconstriction and physical exertion

21. What questions would you include on a medical history form to screen for cardiac disease?

1. Do you experience chest pain at rest or during physical activity?

2. Due you experience shortness of breath at rest or during activity?
3. Do you ever feel palpitations in your chest?
4. Do you ever feel like your about to faint after physical activity?
5. Do you experience challenges in walking or pain, discomfort, numbness, or tiredness in the legs that occurs during
walking or standing and is relieved by rest? (claudication)
6. Do your finger tips/nailbeds or lips ever turn blue/purple? (cyanosis)
7. Do you notice any swelling in your hands or feet?

8. What are the clinical considerations for cardiac medications in general for PT’s to remember?

Patients will have lower HR’s, BPs, GI disturbances, dehydration, possible orthostatic hypotension

9. What are the PT implications when working with a patient with a known abdominal aneurysm?

PT Implications: avoid Valsalva maneuver, no overhead lifting, no heavy lifting

P524, 2021 7
Great Grandpa Ball (John “Jack”) Native American Name: Friendly Eagle

Age: 83

Gender: Male

Race: Native American

Medications: Digoxin, Lisinopril, Lasix, Flomax, Toprol XL, Potassium supplement, Allopurinol, Zanax

Medical History: Myocardial infarctions at age 68 and 75, developed congestive heart failure at 76.

Work History: Jack joined the Navy shortly after finishing high school. He met his wife when he was 18
years old, on the same day he had signed up for the Army Air Corp. They dated for 4 weeks and
married the day before he left on his first tour. His wife had their first daughter, Mildred, 9 months
later. Their 2 daughter, Ruth, was born the year he returned from war. After returning from war, Jack got a job for the railroads
nd

managing the trains and track maintenance, repair, and upkeep in his town.

Living Environment: Jack lived with his wife in a small, one story, 2 bedroom home. There were 4 steps up to the door. They had a
medium sized yard that Jack mowed every weekend in the summers. Now Jack is in an ECF since he needs skilled nursing attention
due to his worsening heart condition.

Social History: Jack loved to play poker with his buddies at least once a week and go to the local casino. He would often lose money
when playing at the casino. When he was not playing cards, Jack enjoyed rocking on his front porch, sipping a bourbon and water,
and smoking a cigar. Jack was known by many as a wonderful story teller with a contagious laugh. Every Sunday, he liked to take his
wife for a car ride in the country.

Lifestyle: Jack smoked a cigar daily, drank one alcoholic drink daily, and was sedentary for most of his adult life. He enjoyed fried
and salty foods. Jack is moderately overweight.

P524, 2021 8
Cardiac drug reminder:

Digoxin (heart contractility) – it will hopefully improve exercise tolerance. However the main negative side effect of digitalis is
toxicity, where a patient can present with cardiac arrhythmias, GI symptoms as well as neurological symptoms.

Lisinopril (ACE inhibitor) – it should reduce afterload & preload. In rare cases renal symptoms may result as well as hyperkalemia. In
general ACE inhibitors have minimal side effects.

Lasix (diuretic) – Lasix is a loop diuretic and as a result has the side effects of fluid and electrolyte imbalance, hypotension, anorexia,
vertigo, hearing loss and weakness.
Potassium supplement – for counteracting the effects of the loop diuretic. Side effects can include diarrhea, stomach irritation, and
nausea. At higher doses, muscle weakness, slowed heart rate, and abnormal heart rhythm may occur.

Toprol XL (beta-blocker) – it should lower resting heart rate. Side effects can include asthma, nodal dysfunction in the heart,
diabetes mellitus and depression.

What were Jack’s risk factors for cardiac disease that he could have modified? Diet, smoking habit, physical activity frequency

What other medical co-morbidities are you concerned could be present now and in the future for Jack?

CHF could lead to need for heart transplant, VAD placement, atrial fibrillation development, and sudden death

P524, 2021 9
William “Bill” Emerson
Age: 39

Gender: Male

Race: Caucasian

Work History: Bill went to college at THE Ohio State University followed by IU
law school. He met his wife while at school and they married shortly after
they finished the program. He currently owns his own private practice
where he works as many as 60 hours a week when he does not have his
children.

Living Environment: Currently, Bill lives with his girlfriend/secretary in a 2nd

story condo. There is not an elevator to the 2nd story. His children live with
him for 2 weeks each month. He drives a sports car that is fairly low to the
ground. His office is on the ground floor of the office building.

Social History: Bill and his wife divorced about a year ago because he was
having an affair with his secretary. When he is free, he enjoys playing golf
and tennis, playing cards with colleagues, and watching football. He might
exercise twice a month currently with work, socializing and childcare
schedules.

P524, 2021 10
What are Bill’s risk factors for cardiovascular disease? Workaholic, sedentary lifestyle

What other information would you ask him about his cardiovascular health?

Does he smoke?
How long does he play golf and /or tennis?
Has he ever received imaging on his heart?
Does he take any medications for his heart or lungs?
Does his feet every swell during long periods of sitting? (60+ hrs a week)
Does he ever have SOB or chest pain when playing golf or tennis?
Does he ever have SOB while at rest?

What advice could you give Bill to decrease his stress?

Work less, such as hiring another lawyer, which will give him more time to:

exercise
play w/ kids
hang out w/ colleagues

Why is stress a risk factor for CAD? Explain at a pathophysiological level.

Stress contributes to the sclerotic component of CAD and is related to an increase in catecholamines and platelet secreted
proteins.

P524, 2021 11
Pulmonary Disease
Dr. Amy J Bayliss

P524; 2/3/21
Pathophysiological overview of
lung disease
• As lung disease progresses in severity, the pathophysiology
progresses to involve the:
• Heart
• Arterial & venous systems
• Resulting in a plethora of systemic symptoms
• Right ventricular failure/cor pulmonale
• Increased systemic venous pressure
• LE edema
• Liver ascites
• Jugular venous distension
• Decreased cardiac output to arterial system
 Obstructive Disease vs
Restrictive Dysfunction
• Two large categories of
lung disease
• Obstructive lung
disease
• Restrictive lung
dysfunction

• Some patients may

have both
components, but for
simplicity each group
will be described
separately
Obstructive Lung Disease
• Characterized by an:
• obstruction to airflow
• Ultimately affects mechanical function & gas exchange
• Characteristic physical symptoms:
• Chronic cough
• Mucus expectoration
• Wheezing
• Dyspnea on exertion
• Decreased expiratory flow rates
• Sputum sits in lungs infection
Obstructive Lung Disease
EARLY ADULT
• Cystic Fibrosis • Chronic bronchitis
• Asthma • Emphysema
• Bronchiectasis
What is COPD?
• Chronic Obstructive Pulmonary Disease
• Includes;
• Chronic bronchitis
• Emphysema
• Asthma
• Bronchiectasis
Chronic Bronchitis
• Characterized by; • Impairments;
• Increased mucous • Hypertrophy of
production from the mucous secreting
bronchioles glands
• Structural changes to • Ciliary action impaired
bronchi • Insufficient
• Chronic swelling & oxygenation of the
inflammation of alveoli
bronchi & bronchioles
Chronic Bronchitis
• Clinical Diagnosis • Clinical Signs
• Productive cough • Thick sputum
present for 3 months • Increased use of
during 2 consecutive accessory muscles
years • Persistent cough
• Pulmonary function • Increased PAP
tests
• Wheeze
• X-ray
• Dyspnea
• Cyanosis
• V/Q abnormalities
Emphysema
• Characterized by; • Impairments;
• Abnormal & • Alveoli over-inflated
permanent • Loss of elastic recoil
enlargement of • Collapse of airways
terminal airways
• Airflow obstruction
• Destruction of alveolar
walls • Expiration is difficult
• Increased lung
compliance
• Large residual volume
Emphysema
• Clinical Diagnosis • Clinical Signs
• History • Orthopnea
• Pulmonary function • Scant sputum
tests production
• X-ray (bullae present) • Increased use of
• Distant breath sounds accessory muscles
• Chronic cough
• Dyspnea
•  chest AP diameter
• Right sided heart
failure
Chronic Bronchitis &
Emphysema – PT Implications
• PT evaluation should include:
• Assessment of airway clearance
• Chest wall & shoulder mobility
• Respiratory muscle strength
• Physiologic responses to exercise
Chronic Bronchitis &
Emphysema – PT Implications
• PT interventions should take into consideration:
• Endurance training is very beneficial for patients with COPD
• Resistance exercise is also recommended
• Help patient ID triggers for dyspnea
• Teach patient bronchial hygiene techniques (airway clearance)
• Therapeutic exercise to improve chest wall and shoulder mobility
• Relaxation techniques
• Progressive muscle relaxation, diaphragmatic breathing
• Energy conservation
• Adequate hydration & nutrition
Chronic Bronchitis &
Emphysema – PT Implications
• PT interventions should take into consideration:
• Physiological monitoring is indicated
• Use of bronchodilators before PT treatments
• Never exercise patients on less oxygen than they are using at rest
• Be able to recognize signs and symptoms of hypoxemia
• Side effects of medication
• Increased resting & exercise HR’s with bronchodilators
• Bronchodilator toxicity can cause arrhythmias
• Corticosteroids provoke catabolism
• Osteoporosis
Chronic Bronchitis &
Emphysema – PT Implications
• What is your role in administering oxygen when prescribed by
a physician?
• Medical oxygen is defined as a prescription drug
• If a set flow rate is in the orders, any deviations from prescribed
dosage requires an updated order from the physician
• Alternatively work with physician to prescribe a specific oxygen
saturation then you can adjust flow during activity
Chronic Bronchitis &
Emphysema – PT Implications
• Typical oxygen delivery levels for these patients are typically
low (1-3 liters per minute)
• Why is it so low, isn’t more better??
• Respiratory homeostasis: in healthy individuals, a rise in carbon
dioxide causes an increase in the drive to breathe.
• However, in some patients with chronic obstructive pulmonary
disease, this response has been blunted, leaving low
oxygen levels as the main stimulus of respiration (hypoxic drive).
So if you place oxygen high then you will reduce the drive to
breath!
Asthma
• Obstructive lung disease
• Reversible
• Chronic inflammatory disease of the large airways
• Increased responsiveness of the trachea and bronchi to stimuli
• inflammationoverproduction of mucousairway narrowing
• Acute attacks can be mild or life threatening
Asthma
• Factors precipitating an attack
• Allergens (extrinsic asthma)
• Pollen, animals, feathers, molds
• Non-allergic (intrinsic asthma)
• Respiratory infections
• Inhaled irritants
• Weather
• Medications
• Emotions
ASTHMA: Clinical presentation
• Inc. RR (dyspnea) • Lung function test
• Wheezing abnormalities
• Prolonged expiration • During an attack;
time • low PaO2
• Increased use of • high PaCO2
accessory muscles • pH < 7.3

• Non-productive
cough
Asthma – PT Treatment
• Breathing exercises (relaxation)
• Correction of breathing technique
• Cardiovascular exercise programming
• Implications
• Understand urgency of Status Asthmaticus
• https://www.youtube.com/watch?v=EK8nzKzdnIM
• Education
• Awareness of triggers
• Use inhaler 15-30 minutes prior to PT
Bronchiectasis
• Progressive obstructive lung disease
• Abnormal dilation of medium sized bronchi & bronchioles
• Irreversible
• Associated with:
• chronic infections
• aspiration
• Cystic fibrosis
• immune system impairment
• Gastroesophageal reflux & aspiration
Bronchiectasis
• Signs & symptoms are;
• Consistent productive cough
• Sputum is copious, foul smelling
• Hemoptysis
• Weight loss
• Fatigue
• Anemia
• Adventitious lung sounds - crackles & wheezes
• Loud breath sounds
• Right sided heart failure
Bronchiectasis – PT treatment
• Airway clearance
• Thoracic cage mobility
• Breathing exercises
• Controlled breathing exercises
• Inspiratory muscle strength training
• Cardiovascular exercise programming
• Strength training for core and proximal muscles
• Energy conservation training
• Nutritional advice
Cystic Fibrosis (CF)
• Multisystem disorder
involving the
exocrine glands
• The pancreas,
intestines and lungs
are the most
commonly affected
organs systems
Pathophysiology of CF (lungs)
• Increased viscosity of mucus gland secretions
• Bacterial infections occur frequently
• Lung disease starts in small airways, progresses to larger
airways
• Repeated infection >> impaired pulmonary function
• V/Q abnormalities
• Later:
• pulmonary HTN
• Leads to respiratory failure and transplant requirement
• cor pulmonale
• right ventricular failure
• hypercapnia
• respiratory failure
Review of pathophysiology:
pulmonary hypertension
• Pulmonary hypertension is the narrowing of the pulmonary
arterioles within the lung.
• The narrowing of the arterioles creates resistance and an
increased work load for the heart. The heart becomes
enlarged from pumping blood against the resistance.
Review of pathophysiology:
Cor pulmonale
• Pulmonary hypertension present
• Change in structure & function of the right ventricle
• Leads to right sided heart failure
• Symptoms in the progressive disease are chronic cough, chest
pain, distal swelling bilaterally, shortness of breath (SOB),
fatigue & weakness
• Acute cor pulmonale may occur  medical emergency
because it can be due to a pulmonary embolus
Review of pathophysiology
hypoxemia signs & symptoms
Pa02 (mmHg) Signs & Symptoms
80-100 Normal
60-80 Moderate tachypnea & dyspnea
50-60 Malaise, nausea
Possible onset of respiratory distress
Poor judgment, motor incoordination, slowed reaction
times
35-50 Respiratory distress & arrhythmias
Marked confusion, agitation
25-35 Marked respiratory distress
Lethargy, loss of consciousness
Lactic acidosis
<25 Hypoventilation, apnea
Bradycardia, myocardial depression, shock
Cardiac arrest
Cystic Fibrosis (CF)
• Pulmonary symptoms/signs:
• Cough
• Increased RR
• Tenacious sputum
• Chronic lung infections
• Crackles/wheezes
• Sinusitis
• Decreased expiratory flow rates
Cystic Fibrosis (CF)
• Other symptoms/signs:
• Pancreatic enzyme deficiency
• Liver and GI obstruction
• Low weight
• Reproductive deficiency/urinary incontinence
• Due to persistent cough causing stress incontinence
• Digital clubbing
• Osteoporosis/osteopenia
• Glucose intolerance CF related diabetes
• excessive fatigue, weight loss or difficulty maintaining weight and
unexplained worsening of pulmonary function
CYSTIC Fibrosis: Medical
Diagnosis
• Genetic testing
• Sweat test
• increased chloride concentration in the sweat (>60mEq/L)
• Chest X-ray:
• hyperinflation, peribronchial thickening, atelectasis; upper lobes
usually more involved
• Sputum culture:
• recurrent infections
• Staphlococcus & Pseudomonas common
CYSTIC Fibrosis: PT Treatment
• Airway clearance
• Pulmonary rehab
• Thoracic mobility
• Cardiovascular exercise programming
• Strengthening – core & respiratory muscles
• Pelvic floor exercises
CYSTIC Fibrosis: PT Treatment
• PT Implications
• Early treatment of infections is imperative
• Airway clearance has been found to be beneficial
• May have G-tube in place for nutrition
• May have IV access: Home IVs, PICC line, indwelling catheter
• PICC line common to introduce antibiotics to fight infections
• Multidisciplinary team approach required
• Referral to organizations & specific clinics
What are the signs & symptoms of a
Pulmonary Infection?
• Increased cough
• Increased sputum production
• Fever
• Increased respiratory rate
• Increased white blood cell count
• Decreases in pulmonary function tests (PFT’s)
• Decrease in appetite and activity level
• Findings on auscultation or radiograph
• On auscultation findings would be
• Crackles
• Wheezing
Restrictive Lung Dysfunction
• Not a disease, but dysfunction caused by many other diseases
or conditions
• Abnormal reduction in pulmonary ventilation due to:
• Decreased lung compliance
• Decreased chest wall compliance
• Decreased lung volumes
• Increased work of breathing
Restrictive Lung Dysfunction

Pulmonary causes

Cardiovascular causes

Neuromuscular causes

Musculoskeletal causes

Other causes
Restrictive Lung Dysfunction:
pulmonary causes
• Primary restrictive lung disease
• Characterized by the stiffening of the lung parenchyma ( lung
compliance)
• Interstitial pulmonary fibrosis
• Highest group receiving lung transplant
• Pulmonary alveolar proteinosis
• Sarcoidosis
• Pneumoconiosis
• Scleroderma
Restrictive Lung Dysfunction:
Interstitial Pulmonary Fibrosis
• Common histological response to a wide variety of insults
• Insult or injury leads to:
• Diffuse inflammatory process in terminal bronchioles
• Thickened alveolar walls
• Fibrosis and scarring
• Irreversible damage
Restrictive Lung Dysfunction:
cardiovascular causes
• A mechanically inefficient heart disrupts blood flow and
oxygenation
• Right heart failure = peripheral edema
• Left heart failure = pulmonary edema
• Systemic hypertension
• Pleural effusions
Restrictive Lung Dysfunction:
neuromuscular causes
• General manifestations
• Impaired mucociliary transport
• Impaired alveolar ventilation
• Increased work of breathing
• Decreased aerobic capacity
• Seen with multiple conditions
• Multiple sclerosis
• Cerebral palsy
• Stroke
• Parkinson syndrome
Restrictive Lung Dysfunction:
musculoskeletal causes
• General manifestations
• Impaired mucociliary transport
• Decreased alveolar ventilation
• Increased work of breathing
• Increased work of the heart
• Decreased aerobic capacity
• Seen with multiple conditions
• Rheumatoid arthritis
• Ankylosing spondylitis
Restrictive Lung Dysfunction
• Clinical signs
• Increases RR (tachypnea)
• Hypoxemia
• Decreased breath sounds
• Decreased lung volumes/capacities
• Decreased diffusion capacity
• Decreased lung compliance
• Pulmonary hypertension
• Muscle wasting
• Weight loss
• Persistent non-productive cough
Restrictive Lung Dysfunction:
General PT Considerations
• Consider medications and potential effects i.e.
bronchodilators, antibiotics
• Progressive mobility/activity
• Breathing exercises to increase volume, strengthen diaphragm
• Coughing assistance, airway clearance
• Strengthen abdoninals
• Thoracic mobility exercises
• A limiting factor at some point in the disease process
• Pulmonary hypertension  Cor pulmonale
Restrictive Lung Dysfunction:
Specific Condition  ARDS
• Acute respiratory distress syndrome (ARDS)
• Caused by acute lung injury (multiple causes)
• Severe hypoxemia
• Increased permeability of the alveolar capillary membrane
• Non-cardiogenic pulmonary edema
• < 50% survive
• Some get full recovery, others end up with restrictive lung
disease
Restrictive Lung Dysfunction:
Specific Condition  Pneumonia
• Pneumonia
• Inflammatory process of the lung parenchyma
• Results in infection in the lower respiratory tract
• Typically leads to consolidation of some or all of the alveoli as
they fill with cellular exudate & cell debris (consolidation)
• Many conditions have increased risk for pneumonia
• It can be due to bacterial, viral, mycoplasms or fungi
• Patients present with:
• Pleuritic chest pain, cough, dyspnea, fever, bronchial breath sounds,
hypoxemia, consolidation on X-ray
Restrictive Lung Dysfunction:
Specific Condition  Pleural effusion
• Pleural effusion
• Excessive fluid accumulates in the pleural space
• Fluid can be transudative (watery) or exudative (protein rich)
• Effusions develop if there is underlying disease of the lung or
problems with the pleura
• They can also develop if there is heart or abdominal disease
• If the fluid is grossly purulent it is called an empyema
• Patients present with:
• Pleuritic chest pain, possible fever, absent breath sounds over the
effusion, dyspnea
Unique Respiratory conditions
• Pneumothorax
• Subcutaneous emphysema
• Atelectasis
• Tuberculosis
• Respiratory failure
Pneumothorax
• Is a lung collapse;
• occurs when air leaks
into the area between
the lungs and chest wall
(a.k.a. pleural space)
• on X-ray there are no
vascular or pulmonary
markings
• can be traumatic or
spontaneous
• Can progress to a
tension pneumothorax
Subcutaneous emphysema
• Inadvertent
introduction of air into
tissues under the skin
covering the chest wall
or neck
• This can happen due to
stabbing, gun shot
wounds, other
penetrations, or blunt
trauma
• Typically after a
pneumothorax
Atelectasis
• Atelectasis is the loss of lung volume
• The absence of air in part or all of the lung
• An air sac collapse
• Often seen post-operatively
• On X-ray, generally this is accompanied by increased density
and possibly elevation of the hemidiaphragm, or mediastinal
displacement
Tuberculosis
• Bacterial infection
• Transmitted by airborne fashion
• Lungs primary site
• Lesions seen in lungs on X-ray
• Symptoms are fatigue, weight loss, night sweats, low grade
fever, productive cough, hemoptysis, SOB
• As a PT – wear a fit test mask! (N95 mask)
Acute Respiratory failure
• Pathological process interfering with gas exchange;
• Hypoxemic respiratory failure
• PaO2 ≤ 50 mmHg
• Hypercapnic respiratory failure
• PaCO2 > 50 mmHg
Hypoxemic Respiratory Failure
• Most often caused by respiratory disease
• Decreased oxygen intake e.g. COPD, high altitude
• Impaired diffusion e.g. pneumonia
• Hypoventilation e.g. drug overdose
• May occur with hypercapnic respiratory failure
• Patient will present with tachypnea, cyanosis, headache,
confusion, seizures
Hypercapnic Respiratory
Failure
• Caused by ventilatory insufficiency and decreased minute
ventilation
• CNS disorders e.g. drug overdose
• Neuromuscular disorders e.g. SCI
• Chest wall abnormality e.g. trauma
• Severe obstructive lung disease e.g. COPD
• Increased physiologic dead space
• Adequate ventilation, poor perfusion with lack of CO2 removal
Bronchopulmonary Dysplasia
• Chronic lung disease in infants
• Diagnosed when need for O2 and
respiratory distress persists for > 1
month
• Seen in premature births, after
meconium aspiration, prolonged
surgery, or neonatal pneumonia
• A small number die in the first year of
life
• Pathophysiology is typically a
combination of obstructive &
restrictive disease
Bronchopulmonary Dysplasia
• Physical Therapy Implications
• If you choose to work with pediatrics!
• Some kids require trachs until they are 1-2 years old
• Recurrent wheezing and pulmonary insufficiency persists, up to
10 years
• Some cases may progress to right heart failure
• May predispose an individual to COPD as an adult
Bronchopulmonary Dysplasia

Normal children’s X-ray Bronchopulmonary dysplasia

Breathing patterns
https://www.youtube.com/watch?v=2ERlxc3kqHs
Breathing pattern Description Associated with…
Agonal Slow, shallow inspirations Often seen during cardiac
(3-4 per min) followed by arrest.
long irregular pauses Sign of cerebral ischemia or
hypoxia.
Biot’s Breaths are a rapid shallow Stroke, meningitis
gasp with regular depth
and apneic periods

Cheyne Stokes Cyclic waxing and waning Often brainstem damage,

of depth of respiration increased ICP
followed by a period of
apnea
Kussmaul breathing Deep and labored Severe metabolic acidosis,
breathing pattern - particularly diabetic
increased rate and depth ketoacidosis (DKA) but also
to eliminate excess CO2 kidney failure
Sputum
Sputum Type Description Associated with PT Implication
Rusty Rust colored Pneumococcal Refer to MD if not
(due to being pneumonia being treated.
blood stained) Acute infection is
an exercise
contraindication.
Serous Clear, watery or Pulmonary If new or
frothy. Pink edema, heart worsening notify
failure. MD. Check vital
Sometimes lung signs.
cancer.
Mucoid Clear, white or In asthma, Refer to MD if
grey. chronic bronchitis symptoms worsen
and acute viral or patient cannot
infections. clear sputum.
Sputum
Sputum Type Description Associated with PT Implication
Mucopurulent Yellow, green or Pulmonary Patient needs
brown infection, antibiotics, refer
bronchiectasis to MD if not
already being
treated.
Hemoptysis Blood present in Pulmonary or Always notify
sputum. Mild to bronchial nurse and MD.
massive. hemorrhage due Document the
to coughing amount.
(rupture of a small
vessel), Tb,
infection, cancer,
pulmonary infarct
(embolus).
Medical Diagnosis of Lung
Disease
• Clinical exam (Class ID #11)
• Lung function tests (Class ID #15)
• X-ray

• Multiple other medical tests, refer to NEJM clinical videos or

the National Lung and Blood Institute:
• Thoracentesis is used diagnostically to establish the cause of a
pleural effusion. It can also be performed to drain large effusions
that lead to respiratory compromise.
• Bronchoscopy is used to investigate the bronchi and bronchioles
X-rays
How do I read an X-ray?
1. Identify details of the film
i. Patient’s name, age, date
ii. Patient’s position, view of film
iii. Orient film properly on the screen
iv. Lines, leads
How do I read an X-ray?
2. Assess quality of film
i. Exposure
• Normal = IV spaces thru trachea
ii. Centering & symmetry of thorax
• Clavicles and SC joints
iii. Inspiratory volume or effort
• Normal- anterior end of the 6th rib should bisect
the diaphragm
How do I read an X-ray?
3. Assess specific features related to
patient’s condition
i. Bony skeleton
ii. Soft tissues
• Heart, diaphragm, trachea, breast shadows,
subcutaneous tissue
iii. Lung fields and boundaries
• Silhouette sign, fluid vs air
A
B
C
D
E
F
G
H
Pharmacological Interventions
Medication PT implication/patient response
Steroids Cause weight gain, increased HR, increased BP with
exercise, may increase blood glucose levels, hi dose
or long term may decrease bone density and
proximal muscle weakness osteoporosis
Abrupt discontinuation leads to adrenal
insufficiency crisis.
Bronchodilators Cause increased HR, increased BP. Non-selective
beta agonists can cause arrhythmias.
Anti-histamines Commonly cause drowsiness. May cause altered HR
and BP abnormalities.
Mucolytics May elicit bronchospasm and GI symptoms.
Encourage patient to hydrate.
Pharmacological Interventions
Medication PT implication/patient response
Leukotriene Monitor for GI complaints and hepatotoxicity
modifiers (yellowing of skin is a sign).
Mast cell In Xolair monitor for signs of infection.
stabilizers
Cough drops May interact with steroids, and cause increased
blood glucose.
Take home points
• Knowledge of pathophysiology is the key to understanding
how to assess and treat
• Know the rules of interpreting X-rays and learn the most
common and those affecting safe practice
• Review your pulmonary medications
• PT implications for pulmonary conditions
 Dr. Amy J Bayliss, DPT

P524: Class ID#15: 3/15/2021

What is the Purpose of PFT’s?
 To determine the mechanical & functional status of
the lungs:
 How much air volume can be moved in and out of the
lungs
 How fast the air in the lungs can be moved in and out
 How stiff are the lungs and chest wall - a question about
compliance
 The diffusion characteristics of the membrane through
which the gas moves (determined by special tests)
 How the lungs respond to physical activity & chest physical
therapy procedures
What is the clinical significance
of PFT’s?
 Screening for early disease in adults smokers prior to clinical
symptoms
 Screening for the presence of obstructive and restrictive
diseases
 Evaluating the patient prior to surgery
 Evaluating the patient's condition for weaning from a
ventilator
 Documenting the progression of pulmonary disease -
restrictive or obstructive
 Documenting the effectiveness of therapeutic intervention
What are Pulmonary Function
tests?
 Tests to measure a patient’s
 Lung volumes
 Lung capacities (= 2 or more lung volumes)
 Flow rates
 Gas exchange
Lung Volumes
 Tidal volume (TV)
 The volume of air inhaled or exhaled during a single
breath in resting state
 Inspiratory reserve volume (IRV)
 The maximum amount of air that can be inspired
following a normal inspiration
Lung Volumes
 Expiratory reserve volume (ERV)
 The maximum amount of air that can be exhaled
following a normal exhalation
 Decreased in obstructive diseases
 Residual volume (RV)
 The volume of air remaining in the lungs at the end of
maximal expiration that cannot be forcibly expelled
Lung Capacities
 Inspiratory capacity (IC)
 The largest volume of air that can be inspired in one
breath from the resting expiratory level (IC =TV + IRV)
 Functional residual capacity (FRC)
 The volume of air remaining in the lungs at the end of a
normal expiration
 (FRC =ERV + RV)
 A high FRC is bad if it’s the RV that is increased
Lung Capacities
 Vital capacity (VC)
 The maximum amount of air that can be expired slowly
and completely following a maximal inspiration
 (VC =TV + IRV + ERV)
 Total lung capacity (TLC)
 The volume of air contained in the lung at the end of
maximal inspiration
 (TLC = TV + IRV + ERV + RV)
 A high TLC is bad if it’s the RV that is increased
Flow Rates
 Forced vital capacity (FVC)
 Volume of air that can be expired forcefully & rapidly
after a max inspiration
 Forced expiratory volume in 1 second (FEV1)
 Volume of air expired over 1 second
 FEV1/FVC
 The percent of FVC that can be expired over 1 second
Flow Rates
 Forced expiratory flow 25-75% (FEF25-75%)
 The average flow of air during the middle 50% of a FEV
maneuver
 Peak expiratory flow rate (PEFR)
 The maximum flow rate attainable at any time during an
FEV
Flow Rates
 Maximum voluntary ventilation (MVV)
 Also called maximum breathing capacity
 The largest volume of air that can be breathed per
minute by maximal voluntary effort (an indicator of
diaphragm strength)
 Flow-volume loop
 Graphic analysis of max forced expiratory flow volume
followed by a max inspiratory flow volume
PFT Equipment for Flow Rates
 A.k.a. spirometry test
 A person breathes into mouthpiece that is connected to
an instrument called a spirometer.
 The spirometer records the amount and the rate of air
that is breathed in and out over a specified time.
Contraindications to Use of Spirometry
 Acute disorders affecting test performance
 (e.g., vomiting, nausea, vertigo)
 Hemoptysis of unknown origin
 FVC maneuver may aggravate underlying condition
 Pneumothorax
 Recent abdominal or thoracic surgery
 Recent eye surgery
 increases in intraocular pressure during spirometry
 Recent myocardial infarction or unstable angina
 COVID 19
 Thoracic aneurysms
 risk of rupture because of increased thoracic pressure
Gas exchange
 Diffusing capacity of carbon monoxide (DLCO)
 Assesses the gas exchange area
 The diffusion capacity is measured when a person
breathes carbon monoxide for a very short time, often
one breath.
 The concentration of carbon monoxide in exhaled air
is then measured.
 The difference in the amount of carbon monoxide
inhaled and the amount exhaled allows estimation of
how rapidly gas can travel from the lungs into the
blood.
What is normal for Volumes/Capacities?
 Tables of normal values adjusted for
 Age, gender, & height
 Sometimes also adjusted for ethnicity
 Most equipment has programs with normal values, so
the results have the comparison
 What is considered normal is not universally accepted
 Generally >80% of predicted values
Abnormal Lung Volumes/Capacities
Normal Flow Rates
 Normal flow rate
outcomes
 > 80 % of predicted
normal values
Abnormal Flow Rates
 FEV1 & FVC are unique measures
 It is looked at as a whole number and should be
> 80% of predicted value
 FEV1/FVC should be 75% or greater
 Used for categorizing COPD if ratio is <75%
How do I interpret PFT’s in regards to Flow
Rates?
 You are really looking for 1 of 3 interpretations:
 Normal, Restrictive or Obstructive
 There are 4 steps to follow.
1. Look at the forced vital capacity (FVC)
2. Look at the forced expiratory volume in one second
(FEV1)
3. Normal FEV1/FVC ratio? Move on; Abnormal ratio
Disease
4. Abnormal ratio determine Obstructive or restrictive
How do I interpret PFT’s in regards to Flow
Rates?
 Step 4.
 If Step 4 indicates that there is disease then you need to
go to the % FEV1/FVC.
 If the % FEV1/FVC is 85% or higher, then the patient has a
restricted lung dysfunction.
 (FEV1 is high, FVC is low in restricted disease)

 If the % FEV1/FVC is 75% or lower, then the patient likely has

an obstructed lung disease.
 (FEV1 is low, because the obstruction affects the ability to
force air out quickly)
 Case # 1. (post bronchodilator)

Predicted Measured %
Values Values Predicted
FVC 6.00 liters 4.00 liters 67 %
FEV1 5.00 liters 2.00 liters 40 %
FEV1/FVC 83 % 50 %

 Obstructive
 Case # 2.

Predicted Measured %
Values Values Predicted
FVC 5.68 liters 4.43 liters 78 %
FEV1 4.90 liters 4.43 liters 72 %
FEV1/FVC 84 % 100 %

 Restrictive
 Case # 3.

Predicted Measured %
Values Values Predicted
FVC 5.04 liters 5.98 liters 119 %
FEV1 4.11 liters 5.28 liters 111 %
FEV1/FVC 82 % 88 %

 Normal
Comparison of spirograms
 Normal (NL)
 FEV1 = 3.0L
 FVC = 4.0L
 FEV1/FVC = 75%
 Restrictive (R)
 FEV1 = 2.5L
 FVC = 3.0L
 FEV1/FVC = 83%
 Obstructive (O)
 FEV1 = 1.0L
 FVC = 3.8L
 FEV1/FVC = 26%
Flow-Volume Loops
 Graph of the rate of airflow
as a function of lung
volume during a complete
respiratory cycle
 Consists of a forced
inspiration followed by a
forced expiration
Flow-Volume Loops
 In obstructive diseases,
there is a scooped out
appearance on exp.
 It reflects the
pronounced expiratory
flow limitation due to an
obstruction in the
airways (intrapulmonary
airway obstruction)
Flow-Volume Loops
 In restrictive diseases,
the patient has smaller
lung volumes
 The flow is abnormally
high during expiration
because of increased
recoil (low lung
compliance)
Diffuse capacity of carbon monoxide
 Diffusing capacity
 The better the diffusing capacity, the more carbon
monoxide will be absorbed from a single, 10 second
inhalation.
 DLCO – often expressed as a percentage of the alveolar
volume (adjusted for TLC)
 > 80% is considered normal
 < 80 % is considered abnormal
 Often seen in restrictive diseases that affect lung compliance,
or with pulmonary infarcts due to emboli
Breathing mechanics
 Breathing and posture are multisystem events
 Breathing and posture are integrally linked
 Muscles of ventilation include more than we typically
think about (diaphragm, intercostals, accessory
muscles)
 The diaphragm is not just a respiratory muscle
 Internal organs play an important role in respiration
“Soda-pop Can” model of postural support
 What makes a thin aluminum soda-pop can strong?
 Aluminum shell is weak and easily crushed if top is open
 When the can is closed it becomes “strong”
 A closed system gives strength because of internal
pressure
Pressure support for our trunk
 Primarily supported by muscle tone
 Primary muscles generate, maintain & regulate
pressure in the abdominal and thoracic cavity
 Intrinsic laryngeal muscles
 Intercostals
 Diaphragm
 Abdominals
 Paraspinals
 Pelvic floor muscles
Pressure support for our trunk
 A breach in the pressure support will result in loss of
trunk muscles to regulate pressure in both chambers
 Tracheostomies
 They lose the pressure support at the top end of the can – at
the level of the vocal cords
 Then the abdominal contents push up and they cannot
generate pressure in the abdomen
 Decreased ventilatory capacity
 Also leads to constipation
 Intercostal weakness/paralysis
 Abdominal weakness/paralysis
 Pelvic floor dysfunction
Role of the internal organs
 Need abdominal cavity pressure to:
 Expand the lungs via negative thoracic pressure
 Mobilize fluid based systems such as GI tract, lymphatic
drainage and arterial/venous circulation
 Inhalation pressure creates a peristaltic like action to
intestines
 Diaphragm is integral since it divides the chambers
Diaphragm’s multi-role
 Has 3 openings for aorta, esophagus, and inferior vena
cava
 Aorta passes through fibrous portion so diaphragm will
not affect during inhalation/exhalation
 Esophagus passes through muscular portion and
diaphragm helps prevent reflux
 Vena cava passes through the tendon therefore not
constricted during inhalation, pressure differences in
cavities create a straw effect (aids venous return)
The Diaphragm: Is it just a respiratory muscle?
 NO!!
 Multiple simultaneous roles
 Respiratory muscle
 Postural control muscle with TrA
 GI muscle: anti reflux and lower GI motility muscle
 Venous return muscle
 Inferior vena cava
Accessory support for breathing & posture
 Paraspinals
 Stabilizes thorax posteriorly to allow normal anterior
chest wall motion
 Pectoral muscles
 Can provide anterior & lateral chest expansion
 Can assist with expiration when trunk moves into
flexion
 Serratus anterior
 Provides posterior expansion of rib cage when upper
extremities are fixated
Accessory support for breathing & posture
 Scalenes, SCM, trapezius
 Provides superior & anterior expansion of the upper
chest, assists with inhalation
 Vocal folds (“gate keeper”)
 Protects from aspiration
 Maintains pressure
 Pelvic floor
 Maintains pressure
 Integumentary
 Need adequate mobility of the skin
The Significance of Breathing Patterns

Breathing pattern Description Associated with

Agonal Shallow, slow (3-4 per minute), Cerebral ischemia, due to
irregular inspirations followed by extreme hypoxia or even
irregular pauses. anoxia. Often seen during
cardiac arrest. (must give
rescue breaths) Serious
medical sign precedes death.
Apnea Absence of ventilation. Lack of Airway obstruction,
airflow to the lungs for > 15 cardiopulmonary arrest,
seconds. alterations in respiratory
center, narcotic overdose.
Biot’s Breaths are a rapid shallow gasp Elevated intracranial pressure
with regular depth and apneic and meningitis.
periods
Bradypnea Respiratory rate < 12 breaths per Use of sedatives, alcohol,
minute. Regular rhythm. neurologic or metabolic
disorders, excessive fatigue.
Cheyne Stokes Cyclic waxing and waning of depth Associated with critically ill
respirations of respiration followed by a period patients - elevated intracranial
of apnea pressure, often brainstem
damage, narcotic overdose.
Hyperpnea Increased depth of respiration. Activity, pulmonary
infections, heart failure.
Hyperventilation Increased rate & depth of respiration Anxiety, nervousness,
resulting in decreased PCO2 respiratory alkalosis (result).
Metabolic acidosis
(compensate)
In ketoacidosis referred to as
Kussmaul’s respirations.
Hypoventilation Decreased rate and depth of Sedation or drowsiness,
respiration resulting in increased neurologic depression of
PCO2 respiratory centers,
overmedication, respiratory
acidosis (result). Metabolic
alkalosis (compensate).
Orthopnea Dyspnea that occurs in a flat supine Chronic lung disease, heart
position. Relief occurs with more failure.
upright sitting and standing.
Paradoxical respirations Inward abdominal or chest wall Diaphragm paralysis,
movement with inspiration and respiratory muscle fatigue,
outward movement with expiration. chest wall trauma.
Sighing respirations The presence of a sigh > 2-3 times Angina, anxiety, dyspnea.
per minute. In anxiety it may be called
psychogenic dyspnea.
Tachypnea RR > 20 breaths per minute Acute respiratory distress,
fever, pain, emotions.
 Case Study 1 – Cystic Fibrosis (CF)
*Will have a CF case on the final exam

Referral

A 26-year-old female with CF is referred to physical therapy with a severe respiratory infection.
Melanie is 26 years old and recently moved into an apartment with her boyfriend and works 30
hours per week in a hair salon. Prior to the infection the patient was living at home and was able to
manage the disease with occasional assistance from family members. The physical therapy referral
is for chest physical therapy.

Subjective Examination
Melanie reports she has been gradually becoming more fatigued over the last week. She complains
of dyspnea at rest, increased sputum production that is often difficult to clear because it is more
tenacious. She also has sore abdominal muscles from the increased coughing.
She uses the active cycle of breathing in the 12 postural drainage positions, 1-2 times daily to clear
her airways. Her boyfriend and parents have been assisting with manual percussion.
She has a history of previous rib fractures with excessive coughing, her X-rays are currently
negative for fractures but do show a large area of consolidation in the right lower lobe.
Her medications are albuterol, biaxin and prednisone.

TASKS

What is the clinical presentation of cystic fibrosis at birth?

The most consistent symptom is the finding of high concentrations of sodium and chloride in
the sweat. Parents will notice a salty taste when kissing their child. Other symptoms depend
on the systems that are affected by the disease and the course of progression. These systems
include pulmonary, gastrointestinal, digestive (liver, intestinal, pancreatic), genitourinary,
and musculoskeletal impairments. Early symptoms may include a persistent cough, salty
skin, sputum production, wheezing, poor weight gain, and recurrent infections. A
quantitative pilocarpine iontophoresis sweat test is the sole diagnostic tool in determining the
presence of CF.

List the objective examination techniques you would perform in this patient. Auscultation,
percussion, palpation, observation. Breath sounds, lung sounds, and voice sounds would also
be assessed. 6MWT, vital signs, MMT

What would you expect to see if pulmonary function tests were performed? Increased RV,
decreased VC and ERV. TLC and FRC increased due to increase in RV. The predicted
FEV1 and FVC will be below 80%, as well as the FEV1/FVC ratio.

P524: 2021
 Case Study 2 – Chest Trauma

History/Chart Notes
This 67-year-old man has a history of alcohol abuse. Yesterday he was tripped by his dog and fell
on the headboard of his bed and sustained trauma to the left side of his chest. On arrival to the
emergency room, he was found to have multiple rib fractures on the left and a pneumothorax. A
chest tube was inserted with good results. He is on disability, secondary to old musculoskeletal
injuries sustained in a MVA in 1969. He is a smoker and although he denies heavy smoking, he
has marked nicotine stains on his fingers.
Since admission, he has required regular analgesics because of left sided chest pain. On
examination, he was mildly drowsy but oriented in all spheres. He was in moderate distress and
experienced marked discomfort with movement or taking a deep breath. Examination of his thorax
revealed subcutaneous emphysema on the left side of the chest with mild bruising on the lateral
aspect of the left side of the chest.

Referral
Chest PT.

TASKS

Describe the physical findings in the history of this patient related to respiratory compromise.
Trauma that led to pneumothorax, Hx of smoking, no movement due to pain decreased
respiration, emphysema.

List the precautions and considerations when assessing the mobility of a patient with a chest tube.
Precautions with chest tube: don’t tip the collection system, keep collection system below level
of insertion, consider pain meds prior to PT, and don’t kink lines

What are the breath sounds and the adventitious sounds that you expect to hear when auscultating
this patient?

With untreated pneumothorax and untreated left emphysema

Breath sounds: Decreased on left

Adventitious sounds: none or crackles/wheezes

P524: 2021
Which direction will a tracheal shift occur with an untreated vs. treated pneumothorax? If
untreated, it will shift to the right since the pneumothorax was on the left. If treated, there
will be no shift since there is no compensation.

List the objective measures you would want to perform on this patient. Auscultation, percussion,
palpation, observation. Breath sounds, lung sounds, and voice sounds would also be assessed.

For a more general assessment, I would look at ROM as tolerate, MMT, bed mobility,
sit<>stand, sitting and standing balance.

Case Study 3 – Chronic Heart Failure – Post MI

History/Chart Notes

Mrs Honey is a 74-year-old woman with known CAD. She complained of flu-like symptoms,
feeling tired, SOB with minimal exertion, and a dry cough especially at night for more than a
week. Since yesterday, her SOB has increased to the extent that she can no longer manage at
home.
Medical diagnosis: CHF, R/O pneumonia.
PMH: Large anterior MI 2 years ago. She quit smoking 10 years ago. Frequent hospital admissions
for pulmonary edema. Left ventricular ejection fraction was 25% 6 months ago. Mrs Honey also
has diabetes and uses insulin, 50 units in the morning and 40 units in the evening.
Social and functional history: Lives alone in a ground floor apartment. Manages to look after self
but needs help with house cleaning. She seldom goes out and can only walk 2 city blocks.
On examination: Mrs.Honey was sitting upright on the stretcher. Her BP on admission to the ER
was 121/90. Heart rate was 118. Her RR was in the mid 30’s. She required 50% oxygen to
maintain oxygen saturation above 92%. Jugular veins were distended and ankle edema was
marked. The extremities were cold and clammy. Inspiratory crackles were heard from the mid to
lower lung zones.
Investigations: Initial blood work revealed normal WBC and creatinine. Admitting EKG showed
left atrial enlargement and old anterior infarct unchanged from last report.
ABG’s were:
pH 7.38, PaCO2 40 mmHg, PaO2 64 mmHg, HCO3- 23 mmol/L
Medical management: Mrs.Honey was given IV Lasix and morphine. Nitroglycerin was given
sublingually. Foley catheter was inserted. High flow oxygen was used to maintain oxygenation.
Patient was transferred to the CCU.

P524: 2021
TASKS

What are the differentiating features between pneumonia and acute heart failure?
Pneumonia is an infection, common clinical signs that distinguish it from heart failure are:
1. Increased temperature.
2. Cough usually productive of purulent sputum.
3. Common physical findings of the involved area may include inspiratory crackles,
bronchial breath sounds, dullness on percussion, or bronchophony.
4. Positive sputum culture.
5. Lab findings such as increased WBC count.
6. Localized chest x-ray findings.

From the clinical information given, what was her preadmission cardiac function level? Very
poor Hx or MI, pulmonary edema, diabetes and EF of 25% (normal is 60-70%)

Is there a primary acid-base disturbance? Is there hypoxemia? No pH disturbances, everything

there is in the normal ranges. Hypoexmia is present (64mmHg) since normal PaO2 is 80-95
mmHg

Physical therapy management

Test exercise tolerance with a 6 minute walk test, monitor O2, EKG, HR & BP. Explain the
benefits of exercise, in laypersons terms. Prescribe a program including daily cardiorespiratory and
stretching. Cardio should build to 20 minute sessions daily. RPE 10-16/20. THR 40-70% of HRR.
Warm-up and cool down are essential. Strength training may be included, no sustained overhead, 2
sets of 10 reps 2-3 days/weekly. The goal is to get up to activities requiring 5 MET’s.

Long term goals

1. Patient able to complete 6MWT with supplemental oxygen, saturations >90% and cover a
distance of greater than 1000ft.
2. Patient able to complete ADL’s with the exception of vacuuming independently.
3. Patient able to be independent with cardiovascular exercise, flexibility and strengthening
regimen.

P524: 2021
 Physical Signs Observed in Various Cardiopulmonary Disorders Condition

Condition Breath sounds Adventitious Voice sounds Inspection Tactile Percussion

sounds (trachea, breathing pattern?) fremitus
Normal individual Normal None Muffled, distant, indistinct. Trachea midline, symmetric chest Normal Normal
expansion.
Asthma, acute , bronchial, Inspiratory plus   use of accessory muscles,  Normal –
moderately severe prolonged expiratory tachypnea hyperresonant
attack expiration wheezes sound.
Atelectasis  or none Dry crackles +/-  or none Trachea deviated to affected side, if  Dull sound, over
large.  chest wall excursion on affected area.
affected side.
Bronchitis Normal, possible Crackles, wheezes  or none bilaterally Possible  motion, occasional use  bilaterally Hyperresonant
prolonged of accessory muscles bilaterally.
expiration
Bronchiectasis Normal, unless Wet crackles Normal or increased if lots  expansion on affected side,  fremitus over Normal
current infection – of mucus or a current tachypnea, clubbing of digits. large/mid sized
then bronchial. infection – then whispered airways (due to
pectoriloquy, damage to
bronchophony, egophony . vessels)
COPD  , prolonged Crackles or  or none bilaterally Barrel shaped chest, moves as a  bilaterally Hyperresonant
expiration wheezes likely but unit,  use of accessory muscles bilaterally.
may be none
Consolidation Bronchial Crackles Whispered pectoriloquy,  motion on affected side  Dull sound over
bronchophony, egophony. area of
consolidation.
Pulmonary Fibrosis  Crackles   motion over affected area/s  or none (due Dull sound (due
to reduced lung to scarring of lung
volumes) tissue)
Heart failure Normal Dependent Normal Normal chest expansion, tachypnea Normal Normal
crackles
Pleural effusion  or none over Possible pleural  over the effusion.  motion on affected side,  RR,  or none. Dull sound over
(moderate to large) effusion. Bronchial rub  above the fluid. trachea deviated to the opposite effusion.
above the fluid side.
(due to
compression of
lung tissue).
Pneumothorax (>15%)  or none None  or none  motion on affected side  or none Hyperresonant.

2021 Know normal & consolidation for final! 1

Dr. Amy Bayliss, DPT, PT

P524: 3/22/21
 Arterial disorders  Venous disorders
 Atherosclerosis  Varicose veins
 Peripheral arterial disease  DVT & Thrombophlebitis
 Aneurysm  Chronic venous
 Arterial thrombosis insufficiency
 Arterial emboli
 Systemic vasculitis  Other associated
 Raynaud’s disease disorders
 Complex regional pain  Pulmonary embolus
syndrome  Lymphedema
 Compartment Syndrome
 Is defined as
 Atherosclerotic
occlusive disease
 Atheromatous plaque
obstruction of the large
or medium sized arteries
supplying the
extremities (typically
lower)
 Blood flow to the tissues
is affected and can lead
to complete obstruction
 Severity of PAD can be classified
 Grade 0 = asymptomatic
P524 territory!!
 Grade 1 = intermittent claudication
 Grade 2 = ischemic rest pain
 Grade 3 = minor or major tissue loss from the foot
 Clinical signs and symptoms;
 Peripheral pulses that are reduced or absent
 Presence of bruits on auscultation of major arteries
 Coolness and pallor of skin, especially with elevation
 Presence of ulcerations, atrophic nails, and hair loss
 Increased BP
 Subjective reports of calf or LE pain induced by
walking, relieved by rest (intermittent claudication)
 Subjective reports of continuous burning in toes
exacerbated at night and worse with elevation
(ischemic rest pain)
 Medication
 Antihypertensive therapy
 Lipid lowering treatment with statins
 Antithrombotic therapy
 Cilostazol for symptom relief
 Prostaglandins to decrease vascular resistance,
relieve pain & promote healing of ulcers
 Surgical procedures for revascularization
 Angioplasty
 Endarterectomy
 Bypass graft
 Most patients with PAD also have coronary
artery disease or cerebrovascular disease
 Must examine thoroughly
 Monitor vital signs
▪ BP may also rise quicker during exercise
 Oxygen supply is often not adequate for
exercising muscles  claudication
 A subjective scale should be used to assess
claudication pain (0-4)
 Exercise training is beneficial
 Train the muscle to rely less on oxygen
 New studies on use of e-stim
 Must be aware of consequences of complete
obstruction (5 P’s)
 Pain, pulselessness, pallor, parathesias, paralysis
 Localized dilatation or outpouching of
the vessel wall
 Most common in abdominal aorta or
iliac arteries, followed by popliteal,
carotid and femoral arteries
 Defined as a 50% increase in normal
diameter
 Aneurysms will rupture if the
intraluminal pressure exceeds the
tensile strength of the arterial wall
 Individuals with Marfan’s syndrome
often have aneurysms
 Most common signs & symptoms of an AAA
 Pulsating tumor or mass in abdominal area
 Bruit heard over swollen area in abdomen
 Abdominal, back or flank pain
 Leg pain/claudication pain
 Numbness in lower extremities
 Excessive fatigue, especially with walking
 Poor distal pulses, especially dorsalis pedis
 Pale skin (pallor)
 Hypotensive
 Tachycardic
 Prior to surgery or patient not a surgical
candidate
 Monitor vital signs
 There may be a systolic limit set (140)
 No valsalva maneuver
 No upper extremity lifting or sustained activity
 Surgical resection
and graft
replacement
 Endovascular repair
 Incision – location, inspect, splinting
 Pulmonary – breathing, coughing
 Grafts across hip joint, may need to clarify
the amount of hip flexion allowed
 Grafts in LE’s, the patient may have weight
bearing restrictions
 Systolic BP limits?
 Don’t forget neuro status check and MMT
 Must monitor vitals
 General term referring to inflammation of the
arteries and veins that progresses to necrosis,
leading to narrowing of vessels
 Precise etiology is unknown
 Autoimmune mechanism is suspected
 Secondary complications are numerous
 May be a factor in differential diagnosis
 Polyarteritis Nodosa
 Disseminated disease affecting mid-sized arteries
 Hepatitis B may be a trigger
 Aneurysm formation with destruction of the
medial layer
 Affects kidney, heart, liver & GI tract
 Treated with corticosteroids and cytotoxic
therapies
 Wegener’s Granulomatosis (WG)
 Uncommon disease that affects about 1 in 30,000
 There is no known cause of WG; but it is not
contagious, and there is no evidence it is hereditary.
 It is systemic, primarily affects lungs and upper
respiratory tract
 For reasons not clear, blood vessels in those areas
may become inflamed and clusters of certain cells
(granulomas) may occur
 Pulmonary signs mimic pneumonia
 Treated with corticosteroids and cytotoxic therapies
 Thromboangiitis Obliterans (Buerger’s
disease)
 Directly related to heavy smoking
 Thrombotic occlusions in arteries in the distal
upper and lower extremities
 Intermittent claudication is common
 Giant cell arteritis
 Affects large arteries and destroys the intima
 Temporal arteritis often seen
▪ Persistent HA
▪ Transient visual disturbances
▪ Jaw and tongue pain
 Who cares?
 These conditions are a differential diagnosis for
musculoskeletal and/or pulmonary conditions
 Left untreated, 1 year mortality rate is as high as
90%
 A.k.a. CRPS or reflex sympathetic dystrophy
 Constant, extreme pain
 Occurs after the healing phase of a minor or
major trauma, fracture, surgery
 Result from a disturbance in the functioning
of the sympathetic nervous system
 So what does this have to do with the
vascular system?
  in sympathetic activity causes release of
norepinephrine in the periphery
 Subsequent vasoconstriction of blood vessels
 Produces pain and other noxious symptoms
 Stage I (acute stage)
 Pain, edema, thermal changes, discoloration, stiffness
and dryness of skin.
 Stage II (dystrophic stage)
 Worsening pain, edema, trophic skin changes, bone
loss, osteoporosis, subchondral bone erosion.
 Stage III (atrophic stage)
 Pain spreads, hardened edema,
decreased limb temperature,
atrophic changes in fingertips & toes,
muscle wasting and joint contractures.
Stage I
Stage III
 Interesting, complex phenomenon often
referred to PT
 So what do we do? We cannot fix the
sympathetic NS!
 PT is the cornerstone and first line treatment
for CRPS
 Restore ROM, flexibility, strength
 Encourage weight bearing and normal gait
 Sensory desensitization
 Myofascial release and massage
 Aquatic therapy
 Modalities - TENS
 Be too aggressive fires up autonomic
system
 Use ice there’s already vasoconstriction
 Includes
 Nerve blocks
 Implantable pain treatment devices
 Drug infusions
 Sympathectomy
 Life threatening disorder
 This disorder consists of deep vein
thrombosis (DVT) and pulmonary embolism
(PE), 2 interrelated conditions caused by
venous blood clots
 Several secondary conditions can occur
 Post-thrombotic syndrome
 Chronic thromboembolic pulmonary hypertension

Clinical practice guidelines posted

 Results from venous stasis and
hypercoagulability
 Thrombosis of a vein leads to inflammation
of the vessel wall = thrombophlebitis
 Thrombophlebitis eventually scars the vein
wall and destruction of the valves
 What is the biggest health risk from a DVT?
 Pulmonary emoblus
 Immobility, venous stasis
 Prolonged bed rest (>3 days) or air travel
 Neurologic disorders
 Limb immobilization or paresis
 Trauma, venous damage
 Varicose veins
 Fracture of hip, pelvis or leg
 Major orthopedic surgery
 Local trauma
 IV injections, central lines
 Certain medications & chemotherapy
 Hypercoagulability
 Thrombophilic disorders
 Malignancy
 Other
 Previous history of DVT
 Age > 60 yr
 Obesity
 Acute medical disorders
 Oral contraceptives or hormone replacement therapy
 Signs and symptoms
 Pain and swelling distal to the site of thrombus
 Redness & warmth in the area of thrombus
 Dilated veins
 Low grade fever
 Dull ache or tightness in the region of the DVT
Clinical variable Score
Active cancer 1
Paralysis, or recent immobilization of lower extremity 1
Recently bedridden for 3 days or more, or major surgery in last 12 1
wks
Localized tenderness along deep venous system 1
Entire leg swelling 1
Calf swelling at least 3cm larger (10 cm below tibial tuberosity) 1
Pitting edema confined to symptomatic leg 1
Collateral superficial veins 1
Previously documented DVT 1
Alternative diagnosis at least as likely as DVT -2
 Homan’s sign (present in < 30% of cases)
 Not precise, use the Well’s model
 Vascular diagnostic tests such as a venous
scan or an ultrasound is required to confirm
 Anti-coagulants: Heparin, Warfarin
 Thrombolytic therapy
 Surgical thrombectomy
 Catheter-directed thrombolysis
 Inferior vena cava filter placement
 Used for those that are pregnant where an NSAID
or anticoagulant is contraindicated
 14 key action statements
1. PT’s should advocate for a culture of mobility
and physical activity unless medical
contraindications for mobility exist.
2. PT’s should screen for risk of VTE during the
initial patient interview and physical
examination.
3. PT’s should provide preventative measures for
patients who are identified at high risk for LE
DVT.
 14 key action statements
4. PT’s should recommend mechanical
compression (e.g. IPC, GCS) when individuals
are at high risk for a DVT.
5. PT’s should identify the likelihood of LE DVT
when signs and symptoms are present.
6. PT’s should communicate the likelihood of LE
DVT and recommend further medical testing.
 14 key action statements
7. When a patient has a recently diagnosed LE
DVT, PT’s should verify the patient is taking an
anticoagulant, what type and when it was
initiated.
8. Mobilize patients who are at a therapeutic level
of anticoagulation.
9. Recommend mechanical compression (e.g. IPC,
GCS) for patients with LE DVT.
 14 key action statements
10. Mobilize patients after surgical procedures (IVC
filter or catheter-thrombolysis) once
dynamically stable.
11. Consult with the medical team if patient is not
anticoagulated and without an IVC filter/surgery.
12. Screen for fall risk.
 14 key action statements
13. Recommend mechanical compression when
signs and symptoms of post-thrombotic
syndrome is present.
14. Implement management strategies to prevent
future VTE.
 A clinical decision needs to be made based on
the patient’s:
 co-morbidities
 type of anticoagulant therapy
▪ different timelines to reach fully coagulated state
▪ Lovenox: drug of choice for DVT
▪ Can start Tx right after Lovenox given
 presence of a IVC filter
 other procedures performed
 Mechanical blockage of a pulmonary artery or
capillary
 Severity depends on clot size
 Results in acute ventilation/perfusion
mismatch  tissue hypoxia
 It can ultimately lead to respiratory failure
and death if large or untreated
 Signs and symptoms, sudden onset of;
 Shortness of breath
 Chest pain
 Hemoptysis (coughing up blood)
 Rapid HR
 Prevention of DVT
 Thrombolytic therapy
 Placement of inferior
vena cava filter (in
patients who have
recurrence)
 Catheter-
thrombolysis

Inferior vena cava filter

 Do not treat if you suspect a PE
 The type of medication will alter the time
frame that therapy is on hold
 Mobilization and PT follow the same guidelines as
DVT management
 Result from venous outflow obstruction or
valvular dysfunction
 Often seen within 5 years post a DVT
 Hallmark signs
 Chronic swollen limbs
 Thickened, coarse, brownish skin discoloration in
distal LE
 Venous stasis ulceration
 PT Implications
 Leg elevation 2-4 x daily for 10-15 mins.
 Compression hose (knee high) 30-40 mmHg
 Skin hygiene
 No crossing of legs for prolonged periods
 Exercise to aid venous pumping
▪ Ankle pumps, quad set, glute set, TA contraction
 Edema
 Abnormal accumulation of fluid in the tissues

 Lymphedema
 Abnormal accumulation of protein rich fluid in
the tissues due to a low volume (mechanical)
insufficiency of the lymph system
 It occurs if the lymphatic system is damaged,
or underdeveloped in some way.

 Divided into 2 broad categories:

 Primary (idiopathic)
 Secondary (acquired)
 Unknown
 Hereditary
 Developmental abnormality
 Aplasia (absent)
 Hypoplasia (less)
 Hyperplasia (grossly dilated/enlarged)
 Filariasis  Crush injury
 Cancer  Burns
 Surgery  Morbid obesity
 Radiation treatment  Paralysis
 Chemotherapy  HIV/AIDS
 Severe infection  Liposuction
 Chronic venous  Severe
insufficiency laceration/degloving
 Stage 0: at risk – no signs yet
 Latent stage or sub-clinical stage
 At risk of developing lymphedema
▪ In this stage the transport capacity of the lymphatic system is
reduced, but the remaining lymph vessels are sufficient to
manage the flow of lymph, and swelling is not visibly present.
 Examples include individuals who underwent surgeries for
malignancies, such as breast cancer, cancer affecting the
genitourinary and gynecologic systems, cancers in the head and
neck region, melanoma or soft tissue malignancies.
 Stage I:
 Accumulation of protein
rich, pitting edema
 Reversible with elevation
 Area affected may be
the normal size in the
a.m.
 Increases with activity,
heat & humidity
 Stage II
 Accumulation of protein
rich, non-pitting edema
with connective scar tissue
 Irreversible, no change w/
elevation
 Does not resolve overnight
 Clinical fibrosis
 Skin changes may start
 Stage III
 Called lymphostatic
elephantiasis
 Accumulation of protein
rich edema with
significant increase in
connective scar tissue
 Irreversible
 Severe non-pitting
fibrotic edema
 Atrophic changes
 Stemmer sign
 Patient is supine
 Pick up a skinfold over the
dorsum of the second toe
 Negative – a skinfold can be
pinched (Stage 0 & 1)
 Positive – a skinfold cannot
be pinched (Stage 2 & 3)
 Measure girth
 One example of grading
▪ Mild < 3 cm difference between limbs
▪ Moderate 3-5 cm difference
▪ Severe > 5 cm difference
 Measure pitting edema
 There are some scales but controversial
 Generally apply pressure for 15-30 seconds
 Count how long it takes for the indentation to
recover (tissue normalization)
 Lymphedema or?
 Deep venous thrombosis
 Congestive heart failure
 Chronic venous insufficiency
 Infection
 Recurrence of cancer
 Comprehensive lymphedema treatment
includes:
 Manual lymph drainage
▪ Clear proximal to distal with superficial pressure
 Compression bandaging
 Exercise guidelines
 Compression garments
 Education & home program
 Compression pumps +/-
 PT Implications
 Prevention and early detection role of PT’s
 Patient education is vital
 Lifelong management is required for those at risk
 Position statements on exercise, travel, &
prevention are readily available
01/27/21: Class ID#3

ACUTE CARE TOPICS 2:

LAB VALUES
Dr. Amy Bayliss DPT, PT
 Sodium Electrolyte Levels
 Normal
 Sodium: 134-142 mEq/L
 Abnormal
 Hyponatremia (< 130 mEq/L)
 Causes - diuretics, burns/wounds, GI loss, hypotonic IV use, cirrhosis
 Symptoms – headache, lethargy, nausea, decreased reflexes, orthostatic
hypotension, seizure, coma
 PT implication – monitor vitals secondary to orthostatic hypotension

 Hypernatremia – trending upward

 Causes – water deficit, diabetes insipidus, CHF, administration of sodium, renal
insufficiency, Cushing’s syndrome
 Symptoms – irritability, agitation, seizure, hypotension, tachycardia
 PT implication - monitor vitals & cardiac rhythm before/during/after PT &
seizure precautions for patients with past medical history of seizures
 Potassium Electrolyte Levels
 Normal
 Potassium: 3.7-5.1 mEq/L
 Abnormal
 Hypokalemia (<3.7 mEq/L)
 Causes –diarrhea, vomiting, diuretics, Cushing syndrome, malnutrition, restrictive
diet, alcohol abuse
 Symptoms - fatigue, muscle weakness, decreased reflexes, paresthesia, leg
cramps, ventricular fibrillation, cardiac arrest, hypotension
 PT implication - monitor vital signs & cardiac rhythm b4/during/after PT

 Hyperkalemia (>5.1 mEq/L)

 Causes - renal failure, metabolic acidosis, Diabetic ketoacidosis, Addison’s disease,
excessive potassium supplements
 Symptoms - muscle weakness, bradycardia, heart block, Vfib, cardiac arrest
 PT implication - monitor cardiac rhythm before/during/after PT (>5 mEq/L patient
is at risk for cardiac issues)
 Arterial blood gas interpretation: Normal

 pH  7.35-7.45

 PaO2  80-95 mmHg

 PaCO2  35-45 mmHg

 Partial pressures of
bicarbonate, HCO3  22-28 mEq/L

Hypo or hyper values mean NO PT emergency

(can only do breathing techniques)
Acid/Base Interpretation
1. Determine the pH value
 <7.35 = acidosis and >7.45 = alkalosis
 Normal range is 7.35-7.45
2. Examine the PaCO2
 First as an indicator of ventilatory status (so is it a respiratory problem?):
 35-45mmHg = adequate ventilation
 < 30mmHg = alveolar hyperventilation
 >50mmHg = alveolar hypoventilation, ventilatory failure
3. Determine the relationship between the pH and PaCO2 values, if the normal inverse
relationship exists it is respiratory
 PaCO2 > 45mmHg & pH<7.40 = acute respiratory acidosis
 PaCO2 < 35mmHg & pH>7.40 = acute respiratory alkalosis
4. Check the relationship between pH & HCO3-
 HCO3- < 22mEq/L & pH<7.40 = metabolic acidosis
 HCO3- > 28mEq/L & pH>7.40 = metabolic alkalosis
2. Abnormal Acid/Base Balance: Acute

TYPE pH PaCO2 HCO3 Causes

Respiratory   WNL Alveolar hyperventilation

alkalosis

Respiratory   WNL Alveolar hypoventilation

acidosis

Metabolic  WNL  Bicarbonate ingestion,

alkalosis vomiting (K loss),
diuretics, steroids, adrenal
disease
Metabolic  WNL  Diabetic, lactic or uremic
acidosis acidosis, prolonged
diarrhea (HCO3 loss)
 PT Implications: Acid and Base
 Respiratory acidosis – patient typically SOB with poor
breathing mechanics (inadequately ventilated) causes
alveolar hypoventilation
 Pursed lip breathing
 Decrease use of accessory muscles
 Avoid putting hands on pt. traps, shoulders
 Respiratory alkalosis – typically hyperventilating
 Rebreathing into a paper bag
 Focus on inspiratory hold for 3-5 seconds and slow
exhalation
Detecting a myocardial infarction

 There are variations of enzyme concentrations over

time for detecting an acute MI
 These are markers for myocardial damage

Enzyme Rise Peak Normalization

CK 12 hours 36-72 hours 3-5 days
(Creatinine kinase)
CK-MB 3-6 hours 18-24 hours 2-3 days
(Creatinine kinase
myocardial band)
Troponin I 3 hours 14-18 hours 5-7 days
Grading the severity of heart failure

 B-type natriuretic peptide (BNP) is a protein

produced in the left ventricle to help regulate blood
volume
 It can be used to diagnose and grade severity of
heart failure
Test Reference Interpretation
BNP <100 pg/mL Indicates no heart failure
100-300 pg/mL Class I – cardiac disease but no limitation in ADL’s
>300 pg/mL Class II – mild symptoms likely with mild limitations in ADL’s
>600 pg/mL Class III - marked limitation in activity due to symptoms,
walking 20-100m only
>900 pg/mL Class IV – severe limitations, symptoms at rest
Lipid profile

Lipid panel Desired level

 LDL (low-density  < 100mg/dl

lipoprotein cholesterol)
 HDL (high-density  Males > 40 mg/dl
lipoprotein cholesterol) Females > 50 mg/dl
 Triglycerides  < 150 mg/dl

 Cholesterol  < 200 mg/dl

Increased LDL & decreased HDL are associated with

increased risk of CAD
Thrombosis risk
 D-dimer is a small protein fragment present in blood
after a blood clot is degraded by fibrinolysis
 Themain type of blood clot we come across as PT’s is a
deep vein thrombosis (DVT)
 Often done prior to an ultrasound to see if the
ultrasound is indicated
 Platelet Count

Normal Platelet Count

140,000 – 400,000/mm3 OR 140-400 k/uL

 >450,000/mm3  Venous thromboembolism (DVT) risk is high

 >20,000/mm3  Therapeutic exercise & bike with or without
(variable in sources) resistance.
 10, 000-20,000/mm3  Therapeutic exercise with no resistance.
(variable in sources)

 <10,000/mm3  No therapeutic exercise/hold PT,

particularly if a fever is also present.
 Prothrombin time/INR

Normal
11-13 PT seconds, INR 0.8-1.2
 Prothrombin time (PT)
 Is the time it takes for your blood to clot
 >70 seconds signifies spontaneous bleeding
 INR = International normalized ratio
 PT compared to a normal ratio (13 secs x 1.2= 15.6 secs to clot anything higher is a concern)
 Low INR = coagulation  clots  emboli or thrombus
 High INR = poor coagulation  bleeding++
 Stroke prophylaxis - 2.0-2.5
 Patients with atrial fibrillation, PE or DVT - 2.0-3.0
 Patients with prosthetic heart valves – 2.5-3.5
 Patients with lupus anticoagulant – 3.0-3.5
 Ranges above 3.6, patients will have a high risk of bleeding No exercise (13 x 3.6= 46.8 secs to
clot)
 Hematocrit(Hct)/Hemoglobin(Hgb)

Normal Hematocrit
Females 37-47%, Males 42-51%
Normal Hemoglobin
Females 12-16 g/dL, Males 14-17 g/dL
 High critical can lead to blood clotting and clogging of capillaries
 Hgb >20 g/dl, Hct >60%

 Hgb 10 g/dL & Hct ~30%  Mod to max resistance exercises and ambulation are
permitted.
 Hgb 8-10g/dL & Hct 25-30% Light exercise permitted (1-2lb weights, light
aerobics). ADL’s with assistance.
 Hgb <8 g/dL & Hct <25% No aerobic or progressive exercise. ADL’s with
assistance, isometrics and light AROM.
 Low critical can lead to heart failure and death
 Hgb <5-7 g/dl, Hct <15-20%
White blood cell (WBC) count

Normal WBC’s
5,000-10,000 cells/mm3 OR 5.0-10.0 109/L

 <5,000 with fever  no exercise permitted

 4,000 with NO fever ok to exercise
 2,500 w/ fever or no fever dangerous to be out
in community with
Thyroid function
 TSH, T4 and T3 levels are tested
 Increased T3 and/or T4 levels = hyperthyroidism
 Monitor heart rate and blood pressure as well as EKG for
arrhythmias during exercise
 Tachycardia

 Decreased T3 and/or T4 levels with increased TSH =

hypothyroidism
 Monitor heart rate – bradycardia is common
Glycated hemoglobin A1c
 Glycated hemoglobin A1c (HgbA1c)
 Elevated levels are indicative of diabetes mellitus and
this lab value is used as a measure to monitor control
 Pre-diabetes
mellitus 5.7-6.4%
 >6.5% indicates poor glucose control
 Blood glucose levels

Normal Values
70-99 mg/dL
 Exercise guidelines for patients with diabetes:
 Absolute contraindication
 Hypoglycemia= < 70 mg/dL
 PT Implication: administer carbs/ glucose rich foods
 Hyperglycemia= > 300mg/dL or ketones are present
 PT Implication: diabetic coma is a possibility so emergency help
 Relative contraindication
 70-100 mg/dL
 Pre-diabetes = 100-125 mg/dL
 Hyperglycemia= >126mg/dL
 250-300 mg/dL with no evidence of ketoacidosis
 if no ketones and blood glucose is stable or falling, and the patient feels OK,
you can proceed with 10-15 minutes of exercise and recheck BG.
Renal Balance
 Creatinine: Renal Efficiency
 Elevated– renal impairment, recent muscle injury
 Decreased – age, low muscle mass, liver disease

 BUN: Renal Function

 Elevated – renal disease, dehydration, high protein
diet, GI bleed, fever
 Decreased – malnutrition, severe liver damage, fluid
volume excess
 Heart Rate
 Measured in beats per minute (bpm)
 Increase: pain, anxiety, medications, fever, caffeine, activity
 Decrease: medications, exercise intolerance, physically fit
 It can be measured for 15 or 30 seconds and multiplied accordingly (15 x 4
or 30 x 2).
 If the HR is irregular measure for 60 seconds

 HR increases linearly as workload increases

 Stop exercise if HR decreases with increased workload: ominous sign,
poor prognosis
 Factors affecting HR: age, fitness, sex, body size, cardiac disease.
 If HR is blunted (B-Blocker meds, heart transplant), use additional measures
to determine work-rate such as RPE (rate of perceived exertion)
Heart Rate: Abnormalities
 Pulse abnormalities may be palpated
 Pulsusalterans – regular rhythm, alternates with strong
vs. weak pulse waves
 Left ventricular failure
 Bigeminal pulses – every other pulse is weak and early
 Premature ventricular contraction’s (PVC’s)
 Pulsus
paradoxus – reduction in strength of pulse with
abnormal decline in BP during inspiration
 COPD, pericarditis, pulmonary emboli, cardogenic shock
Blood Pressure
 Systolic over diastolic measured in mmHg
 Difference between the 2 pressures is the pulse pressure
 >50mmHg at rest is considered high
 100mmHg with exercise is normal
 <25mmHg at rest indicates a low stroke volume
 The mean arterial pressure (MAP) = 1/3 pulse pressure + diastolic BP
 Need a MAP of 60 to perfuse organs
 Normal is between 70-110 mmHg
 feet flat, back supported, arm support at heart level, no talking
 Increase in BP
 pain, anxiety, age, obesity, activity, Valsalva maneuver, vascular disease, crossing legs, stress,
medications, hereditary factors, eating, smoking, caffeine
 Decrease in BP
 medications, orthostatic hypotension, low blood volume, weight loss

 Contraindications if arm has:

 Lines, AV shunt or fistula, edema, mastectomy, injury, paretic side, recent surgery
BP: PT Implications
 Systolic BP increases in direct proportion to workload
 SBP increases 10± 2mmHg per MET  in workload
 Peak is 160-200mmHg, SBP may plateau at peak ex.

 Diastolic BP should stay within +/- 10 mm Hg of the

starting point as workload increases
 Pulse pressure (SBP-DBP) generally increases in
direct proportion to workload
 Orthostatic hypotension
 Drop of 20mmHg in SBP or 10mmHg in DBP within 2-5
mins. of quiet standing
BP: Application
 Incorrect cuff size changes  The "ideal" cuff should have
BP reading a
 Too small, false higher  bladder length that is
reading 80% of the arm
 Too large, false low circumference
reading  width that is at least 40%
of arm circumference
 a length-to-width ratio of
2:1
 Lower edge should be
centered 2 finger widths
above bend of elbow
BP: Measurement

 Measuring systolic & diastolic pressure

 Best practice is 2 measures, 1 minute apart
 Round measure to nearest 2mmHg
 With 2 measures average the two unless they differ by 5mmHg (then do
a third measure)
 Treatment Guidelines for Adults with BP
Abnormalities
Systolic BP Diastolic BP
Hypotension <90 60

Optimal <120 <80

Prehypertension 120-129 <80

HTN 1 130-139 80-89

HTN 2 >140 Or >90

HTN 3 >180 >120

Respiratory Rate

 Breaths inspired or  Count the respiratory rate while

expired per minute pretending to take the patient's
 Increase in RR pulse, pt. should not be aware
 pain, anxiety,  More reliable to count over a full
medications, fever, minute
activity, pulmonary  Note the rate, pattern and comfort
disease of respiration
 Decrease in RR  RR increases immediately with
 sleeping, increased workload and decreases
medications, immediately during recovery
anesthesia
 Oxygen Sat. & Partial Pressure
 Normal range  Clinical application
 >98-100% in our text  88-90% is a yellow light

 >95% generally  < 90% O2

considered as normal supplementation needed

 Usually 2 liters is safe
 NO PT

 SaO2: percent saturation of

PaO2 # SaO2 oxygen bound to hemoglobin
(Remember the oxygen dissociation curve) in the arterial blood is termed
At 90% saturation, SaO2
the partial pressure of oxygen
is 60 mmHg.  PaO2: partial pressure of
oxygen dissolved in the
arterial blood
 Vital Signs Across the Lifespan –Accepted
Normal Values

AGE HR AVERAGE RR TEMP.

BP oF

Adult 60 - 90 <120/80 12 – 20 96.8 – 99.5

Older Adult 60 - 90 <120/80 12 – 20 96.5 – 97.5

 Cardiopulmonary Practice Patterns P524
LAB SHEET – ACUTE TOPICS 2

1) What do you think will happen to the pulse pressure with

atherosclerosis/aging? Why?

Increase, less extensibility from atherosclerosis or compliance from aging

of blood vessels means more pressure builds up in the walls of arteries.

2) What is a mean arterial pressure? Work it out for the following

BP’s, 120/90 and 160/70.

MAP is 1/3 PP + DBP

Ex 1. (1/3) (30) + 90= 100 mmHg high at rest
Ex 2. (1/3) (90) + 70= 100 mmHg high at rest

3) What is the normal response of the HR to exercise?

An increase, usually about 10 bpm

4) What is an abnormal response of the HR to exercise?

A very rapid rise with increased workload, a very flat rate of rise
(bradycardic response), and a decrease in palpated HR.

5) What is an abnormal response of the diastolic blood pressure is

response to exercise?

DBP increases or decreases 10+ mmHg compared to starting point

6) Do these lab values indicate respiratory or metabolic acidosis,

respiratory or metabolic alkalosis?

Lab Values (pH/PaCO2/HCO3) Condition

7.55, 40mmHg, 29 mEq/L Metabolic alkalosis

7.3, 40mmHg, 18 mEq/L Metabolic acidosis
7.3, 47mmHg, 24 mEq/L Acute respiratory acidosis
7.5, 32mmHg, 24 mEq/L Acute respiratory alkalosis
7.50, 48mmHg, 30 mEq/L Metabolic alkalosis w/ resp comp
7.3, 50mmHg, 29 mEq/L Acute respiratory acidosis w/ renal
compensation

P524: 2021 Page 1

 7) Consider the following SaO2 and PaO2 numbers.

SaO2 (%) PaO2 (mmHg) Approx. measurement

80 50
90 60
95-98 75-100

What is the normal PaO2 in arterial blood?

Normal PaO2 is >80 mmHg.

What relevance does the comparison of abnormal numbers for PaO2

and SaO2 have for patient care?

As O2 saturation decreases, there is a significant decline in the oxygen

carrying capacity of hemoglobin which if not corrected, PaO2 will continue to
decline and the patient is likely to go into respiratory failure.

The lower the O2 saturation the lower the partial pressure of oxygen
dissolved in arterial blood.

8) Which lab values constitute a medical emergency? Yes/No

Lab value Yes/No

pH = 7.19 Yes  highly acidic
PaCO2 = 36 mmHg No  within normal range
PaO2 = 39 mmHg Yes severely low (SaO2 likely ~70%)
Glucose = 350 mg/dL Yes  high sugars with ketones
with ketones present
Platelets = 50,000/mm3 No  within normal range
Hb = 10 g/dL No within normal range
INR > 6 Yes  anything greater than 3.6 is bad
HCO3 = 9 mEq/L Yes  severely low

P524: 2021 Page 2

 9) A physical therapist reviews the results of a complete blood
count taken on a 65-year-old male recently admitted to the
hospital. Which of the following lab values may be considered a
precaution for exercise?
a. hematocrit: 46 %--> normal is 42-51%
b. hemoglobin: 8 g/dL light TherX only
c. platelet count: 250,000 mm3 normal is 140,000-400,000
d. blood glucose: 120 mg/dL pre-HTN but not a concern

10) A physical therapist working on an oncology unit reviews the

medical chart of a patient prior to initiating an exercise program.
The patient’s cell counts are as follows; hematocrit 24%,
platelet count 70,000 mm3, hemoglobin levels 7 g/dL, INR 1.4.
Which of the following activity choices is MOST appropriate?
a. no exercise allowed
b. light AROM is allowed the Hb & Hct are the limiting factor
c. gait and ADL’s only
d. resistive exercise is allowed

11) How many blood pressure readings are recommended each time
you measure blood pressure?
a. One
b. At least two
c. As many as there is time for
d. The same number as taken at the last patient visit

12) Which of the following patient postures can cause an error of a

higher blood pressure reading?
a. Patient seated on the exam table feet dangling
b. Arm at heart level
c. Forearm supported with palm up
d. Patient’s back against chair with feet flat on the floor

13) A physical therapist using a mercury column instrument observes

a systolic blood pressure reading of 133. Which is the correct
recording to document in the patient’s chart?
a. 130
b. 132
c. 133
d. 134 always round up to the even number

P524: 2021 Page 3

 14) When selecting the correct cuff size, the bladder should be wide
enough to encircle at least what percent of the upper arm?
a. 30%
b. 40%--> bladder width
c. 50%
d. 80%--> bladder length

15) What is the correct time to wait between two consecutive blood
pressure readings on the same individual?
a. Not more than 30 seconds
b. At least 1 minute
c. More than 5 minutes
d. No specific time between readings in required

16) A patient presents to you in your outpatient clinic for work

conditioning (which includes heavy lifting, cardio exercise,
strength training over a duration of 2-3 hours),
they have no history of cardiac problems and currently take no
BP medication. Their BP is measured as 146/89.

How would you categorize their BP?

Stage 2 HTN if at least one BP is in the next category, then you place
the pt. in that category.

What should you do in regards to their BP? Circle all that are
correct.
a. Wait one minute and recheck BP on the same arm
b. Recheck their BP on the other arm
c. Hold treatment that day
d. Notify the physician.
Since the BP is untreated, need to address that first

17) A patient has potassium levels of 5.7 mEq/L. What are the PT
implications of hyperkalemia?

Muscle weakness, bradycardia, heart block, ventricular fibrillation, cardiac

arrest

Are any of the PT implications life-threatening?

Yes, dysrhythmia could be lead to a fibrillation, than sudden cardiac

death.

P524: 2021 Page 4

 18) A patient has hyponatremia: < 130 mEq/L.
What serum electrolyte is responsible for this condition?

Sodium

Can you perform exercises and gait training with this patient?

Yes, monitor for orthostatic hypotension

19) A PT monitors blood pressure using the brachial artery. What

effect would you expect to see in the BP value if the PT used a
cuff that was too narrow for the patient’s arm?
a. systolic values will be higher and diastolic values will be
lower
b. systolic values will be lower and diastolic values will be
higher
c. systolic and diastolic values will be higher
d. systolic and diastolic values will be lower if cuff too big

20) A physical therapist is preparing to initiate an exercise program

for a patient with diabetes. Which objective measure should you
monitor MOST closely to avoid complications from exercise?
a. oxygen saturation
b. blood pressure
c. heart rate
d. glucose levels

21) What would increase a person’s heart rate?

Caffeine, exercise, fever, anxiety, pain

22) With hypernatremia, what symptoms would you expect your

patient to have?

Irritability, orthostatic hypotension, tachycardia, seizures

23) What are possible causes of hyperkalemia?

RF, metabolic acidosis, diabetic ketoacidosis, potassium supplements,

Addison’s disease

P524: 2021 Page 5

 24) What do the BUN and creatinine levels indicate?

Kidney function/filtration

25) What platelet count would require you to hold PT and do no

activity with your patient?

<10,000 mm^3

26) In a patient with no cardiac symptoms should you measure the

HR for; (circle all correct answers)
a. 15 seconds
b. 30 seconds
c. 60 seconds not necessary for asymptomatic

27) How much BP change do you expect to see in a patient who has
orthostatic hypotension, when they move from supine to quiet
standing after 2-5 minutes?

Supine<>standing should have a relative drop of 20 mmHg drop in

systolic or 10 mmHg drop in diastolic BP

28) If a patient develops orthostatic hypotension in the sitting

position. What exercises would enhance venous return and
thereby increase blood pressure?

Ankle pumps, LAQ, hip marches, diaphragmatic beathing

29) If a patient has a pH of 7.30, PaCO2 of 52mmHg and a HCO3- of

30mEq/L, what mechanism is occurring with your patient?
a. Respiratory acidosis with renal compensation
b. Respiratory alkalosis with renal compensation
c. Metabolic acidosis with respiratory compensation
d. Metabolic alkalosis with respiratory compensation

The trick with this is finding two values that should go together. Low pH
and high PaCO2 is indicative of respiratory acidosis. The pt. also has high
bicarbonate, which means there is renal compensation.

P524: 2021 Page 6

 30) A patient with type I diabetes has a blood glucose level of
310mg/dL and a fruity odor to their breath. What is the BEST
action for the PT to take?
a. Give the patient some glucose rich food.
b. Have patient take double their usual dose of insulin.
c. Notify physician and call an ambulance.
d. Continue with the therapy session but monitor blood glucose
levels every 30 minutes.

P524: 2021 Page 7

EKG’s / ECG’s
Dr. Amy Bayliss, DPT, PT

P524: 02/10/21
Because….
 Recognize warning signs
 Recognize contraindications
 Many of our interventions influence the
cardiac system
 Assist with decisions about a patient’s
readiness for & response to physical
activity
 Assist with decisions regarding delegation
of care to a PTA
Uses of an EKG
 Determine whether the heart is performing
normally or suffering from abnormalities;
 May indicate acute or previous damage to heart muscle
or ischemia of heart muscle
 Can be used for detecting electrolyte disturbances
 Allows the detection of conduction abnormalities
 As a screening tool for ischemic heart disease during an
exercise tolerance test
 Can provide information on the physical condition of the
heart
 Can suggest non-cardiac disease, like medication
overdose
Electrical Conduction System
 Sinoatrial (SA) node
 Atrioventricular (AV) node
 The bundle of His
 The left bundle branch (LBB), x2
 The right bundle branch
 Purkinje network of fibers
 Ventricular myocardium
Normal Conduction System
Basics of an EKG
 Records electrical flow of current through
the myocardium with surface electrodes
Basics of an EKG
 P wave = atrial depolarization
 PR interval is the time from onset of atrial
depolarization to onset of ventricular
depolarization
 QRS complex = ventricular depolarization
 S-T wave = ventricular repolarization
 QT interval is the duration of ventricular
depolarization and recovery

 U wave = "after depolarization's" in the ventricles

12 lead EKG (10 electrodes)
 Why all the leads?
 This gives 12 views of the heart from different
directions.
 Used to assess
 Heart rate
 Heart rhythm
 Hypertrophy
 Infarction
 Present in the chart of all cardiac patients
 12 lead 
placement of
10 electrodes
EKG views of the heart
Sample 12 lead EKG
Steps for Interpreting an EKG
1. Determine the rate?
 P-P interval = atrial rate
 R-R interval = ventricular rate
 Determine the heart rate using the R-R by 1 of 3
methods.
 Typically we just measure R-R interval to get the
heart rate but if the atrial and ventricular rate are
different then the next 7 steps help us work out what
is wrong!
Determination of Heart rate
Determination of Heart Rate
 Count off method
 Find a R wave on a heavy line, then count off
300, 150, 100, 75, 60, 50, 43, 37, 33, 30 for
each large box you land on until the next R
wave
Determination of Heart Rate
 Mathematical method
 300 / # of bold large boxes between two R
waves

300/7.5 = rate is 40
Determination of Heart Rate
 Six second method
 Count off 30 bold large boxes = 6 seconds
 Then count number of R waves in 6 seconds
and multiply by 10

6 X 10 = rate is 60
Steps for Interpreting an EKG
2. Determine the rhythm
 Is the rhythm regular or irregular?
 To determine if the atrial rate is regular or irregular,
measure the distance between two consecutive P-P
intervals. Then compare this with other P-P intervals.
 Determine if the ventricular rate is regular or
irregular, measure the distance between two
consecutive R-R intervals. Then compare this with
other R-R intervals.
Steps for Interpreting an EKG
3. Evaluate P waves?
 Are the P waves all identical & smooth?
 Are P waves upright (positive) in Lead II?
 Is there only one P wave before each QRS
complex or is there more?

 If yes, this indicates the sinus node pacemaker

is in command = normal atrial activity.
Steps for Interpreting an EKG
4. What is the PR interval?
 A consistent P-R interval of 0.12 to 0.20
seconds indicates normal conduction
 A P-R interval > 0.2 seconds indicates a
conduction delay or block
Steps for Interpreting an EKG
5. Evaluate the QRS complex
 Do the QRS complexes occur uniformly and
look the same throughout the strip
 The QRS normally measures 0.06 to 0.10
seconds in duration.
 If the QRS measures 0.06 second or less it is
considered narrow and is presumed to be
supraventricular in origin.
 If the QRS complex is greater than 0.12 second or
more it is considered wide, and presumed to be
ventricular in origin until proven otherwise.
Steps for Interpreting an EKG
6. Evaluate T wave
 Are T waves present, smooth and rounded?
 Is the deflection the same as the QRS
complex?

7. Assess ST segment
 Is it level with the baseline
 Elevated, depressed or sloped is significant
Normal Sinus Rhythm
 Each P wave is followed by
a QRS
 P wave rate 60-100 bpm
with < 10% variation
 P wave height < 2.5mm
 P wave width < 0.11s
 PR interval 0.12 to 0.20
seconds (3-5 small squares)
 QRS complex 0.06-0.10
seconds (2.5 small squares)
 ST segment, no elevation
or depression
Sinus Rhythms (=SA node in control)

 Normal Sinus Rhythm

 Sinus Bradycardia
 Sinus Tachycardia
 Sinus Arrhythmia/Dysrhythmia
 Sinus Pause/ Blocks
Normal Sinus Rhythm

0.06 to 0.10
Sinus Bradycardia
Sinus Bradycardia (<60 bpm)
 Can be seen in  Abnormal causes;
healthy individuals;  Vomiting, gagging
 Athletic, fit  Tracheal suctioning
 During rest or sleep  Myocardial ischemia or
when parasympathetic infarction
NS is dominant  Severe body anoxia
 Increased ICP
 Certain medications
 B-blockers
 Ca-channel blockers
 Digitalis
Sinus Bradycardia – PT Implication
 None if patient is non-symptomatic
 If symptomatic, record rate, stop PT and
contact the physician
 Symptoms may include syncope, dizziness,
angina, diaphoresis
a.k.a cardiac output drops
 If rate drops into the low 40’s
 IP’s, stop PT, contact nurse and physician
 OP’s, stop PT, call physician and will likely
need to transport by ambulance to emergency
room
Sinus Tachycardia
Sinus Tachycardia (>100 bpm)
 Compensatory  Abnormal causes:
mechanism of the  Heart failure
body to increase CO in  Shock
stressful conditions:  Hyperthyroidism
 Exercise  Hypoxia
 Fear  Anemia
 Fever  Certain drugs
 Pain
Sinus Tachycardia – PT Implication
 Typically benign
 Associated with conditions that increase SA node
activity, many are harmless
 Record HR, cause may be clear, such as pain so
continue with PT, may avoid CV exercise and
heavy lifting
 If other symptoms are present or new onset, call
MD
 Patient may require treatment with beta-blockers
Sinus Pause/Arrest/Block
 The rhythm is irregular
due to the pause
 Occurs when the SA node
fails to initiate an impulse
usually for one cycle
 Sinus pause = occasional pause
 Sinus arrest = long pause 0.06
to
 Sinus block = dropped beat 0.10

 The Rate, P waves, PR

intervals, and QRS
width are the same as
other sinus rhythms
Sinus Pause/Arrest/ Block
 Possible causes include;
 Increase in parasympathetic nervous system
 Sick sinus syndrome (organic disease of the SA
node)
 If SA node pathology progresses, pt. will need
pacemaker
 Infection
 Rheumatic disease
 Severe ischemia
 Infarction to the SA node
 Digitalis toxicity
Sick sinus syndrome (SSS)
 Common among older people
 SSS is an improper firing of electrical impulses
caused by disease or scarring in the sinus or SA
node
 SSS normally causes the heart rate to slow, but
sometimes it alternates between abnormally slow
and fast
 A progressive condition, with episodes increasing
in frequency and duration, SSS can be caused
by:
 Degeneration of the heart's electrical system; or
 Diseases of the atrial muscle.
 Sinus Pause/Arrest/Block
PT Implication
 Significance 
 no cardiac output during the pause
 syncope and dizziness may occur
 May require a pacemaker
 Hold PT until pt. gets pacemaker
 Sick sinus syndrome can be dangerous if left
untreated
 Notify nurse/doctor of frequency of occurrence
 If new onset, hold on PT until cleared by the MD
Arrhythmias
 = abnormal heart rhythm
 It is a term used synonymously with
dysrhythmia
 Your text breaks it up into
 Atrial
 Junctional
 Ventricular
General symptoms of Arrhythmias
 Cardiovascular
 Heart racing/palpitations
 Pain in chest or left side of the upper body
 General
 Dizziness
 Fatigue on light exertion
 Respiratory
 Air hunger
Atrial Arrhythmias
 Premature Atrial Contractions (PACs) Better

 Atrial Tachycardia
 Atrial Flutter
 Atrial Fibrillation Worse

All have abnormal P waves

Premature Atrial Contractions:
PT Implications
 Typically benign if infrequent
 Apparent in patients’ with COPD
 Patient reports they feel as if their heart
skipped a beat, palpitation
 Can proceed with treatment with close
monitoring
 Frequent PAC’s may lead to SVT or Atrial
fibrillation, or atrial flutter
Atrial Tachycardia

100-200 0.06 to
bpm 0.10

Sudden bursts of very rapid atrial or nodal tachycardia.

Atrial Tachycardia
 Atrial tachycardia= 3 or more PAC’s
 Impulses arise from the atrial pacemaker
beside the SA node
 May be due to
 Digitalis toxicity
 Coronary artery disease
 Rheumatic heart disease
 COPD, cor pulmonale, pulmonary HTN
 Stress, tobacco, coffee, alcohol
 It can affect cardiac output if prolonged
Atrial Tachycardia – PT Implications
 ANS maneuvers such as Valsalva and coughing
may stop it
 Patient reports their heart is racing
 Symptoms include dizziness, lightheadedness,
syncope, angina and hypotension
 Stop therapy if this occurs, report to MD and gain
clearance before proceeding (particularly if patient has
symptoms)
 Must be controlled before continuing with PT
 If rate is extremely rapid, decreased cardiac
output can result
Atrial Flutter

0.06 to
0.10

Very rapid atrial tachycardia

Atrial Flutter - Causes
 Organic heart disease
 Myocardial infarction
 Valve disease
 Rheumatic heart disease
 s/p cardiac surgery
 Idiopathic
Atrial Flutter – PT Implication
 Relatively non-life threatening if HR < 100
bpm
 If HR >100 at rest then medical treatment
is required, stop PT and contact MD (since
patient may be hemodynamically
unstable)
 Signs and symptoms of decreased cardiac
output aka hemodynamically unstable
Signs Symptoms
 Diaphoresis (sweating)  Light headed or dizzy
 Paleness  Fatigue
 Anxiety  Angina or chest
 Increased RR discomfort
 Irregular pulse  Shortness of breath

 Abnormal BP  Feeling anxious

 Vomiting  Nausea

 Fainting to  Confusion
unconsciousness  Denial
Atrial Fibrillation

0.06 to 0.10

Erratic quivering of the atrial muscle, no P waves.

Atrial Fibrillation
 Defined as erratic quivering or twitching of
the atrial muscle:
 Causes same as for atrial flutter
 Risk of emboli production
Atrial Fibrillation – PT Implication
 HR > 100bpm will decrease effective cardiac
output
 Consult with nurse/MD before proceeding with PT
 If new onset of AF, risk of embolic stroke so hold
treatment
 If chronic and not in congestive heart failure,
would treat with caution
 Potential of emboli, so patients will be on blood
thinners (typically coumadin or aspirin)
Ventricular Arrhythmias
 Premature Ventricular Contractions
(PVCs)
 Ventricular Tachycardia
 Ventricular Fibrillation
 Asystole

All have NO P waves

Premature Ventricular Contractions
Premature Ventricular Contractions
 Rate is usually normal between 60-100
bpm
 An early beat occurs
 Early beat is wide and bizarre
 QRS of early beat is > 0.11 secs
 P wave absent
 ST segment often slopes in the opposite
direction
 May be followed by compensatory pause
Premature Ventricular Contractions
PT Implication
 Cardiac output and functioning may decrease
 Some are benign, can be a result of stress,
caffeine, alcohol or overexertion
 Some are due to CAD, digitalis toxicity, MI,
acid-base imbalances, electrolyte imbalance
 If > 6-9 per minute, stop & rest, monitor
(orange light)
 If > 10 per minute, stop, hold PT, until
patient cleared to proceed (red light)
 Can progress to ventricular tachycardia
Ventricular Tachycardia

A run of three or more PVC’s ,

usually at a rate of 100-250 beats/min
Ventricular Tachycardia
 Due to rapid discharge of ectopic ventricular
foci, rate usually >100bpm
 No P waves observed, superimposed on QRS
complexes
 Causes:
 Acute MI, CAD, hypertensive heart disease
 Digitalis or quinidine toxicity
 Occasionally seen in athletes during exercise
 Indicates marked ventricular irritability
 Can progress to ventricular fibrillation
Ventricular Tachycardia
 How will the patient look?
 Patient can be symptomatic, asymptomatic,
unconsciousness or pulse less.
 What do I do?
 Stop activity, look at patient & EKG
 Usually a medical emergency
 Likely to need to call a full code
Ventricular Tachycardia:
Torsades de Pointes
 Unique configuration of ventricular tachycardia,
“twisting of the points”
 Patient often is extremely light-headed, near
syncope
 Patient needs immediate medical attention, likely
to need a full code
Ventricular Fibrillation

Erratic quivering of ventricular muscle

Ventricular Fibrillation
 Rapid, irregular twitch-like contractions of the
ventricles
 Followed by immediate loss of consciousness
and loss of circulation (i.e. cardiac arrest)
 MEDICAL EMERGENCY
 CALL A CODE, CPR, AED AND SHOCK

 New orders will be required to resume PT in

the future should the patient survive
Ventricular Asystole “Cardiac Arrest”
Ventricular Asystole
 Cardiac arrest has occurred, patient has
most likely expired
 Rarely as a PT will you come across this,
in a hospital alarms would sound
 If you are the first to see this, call a CODE

 Exceptions to calling a code?

Heart Blocks
 FirstDegree A-V Block
 Second Degree A-V Block Type I
 Second Degree A–V Block Type II
 Third Degree Heart Block
First Degree Heart Block
P wave

Prolongation of conduction thru AV node, PR interval 

First Degree Heart Block
 Prolonged PR interval greater than 0.20 sec
 HR may be < 60/min
 Seen in elderly, CHF, acute MI
 Can also be caused by digitalis toxicity

 PT Implication
 No treatment restrictions, but be cautious of
possible underlying heart disease
 And monitor for progression to higher block
Third Degree Block

All the impulses are blocked at the AV node so that no

impulses from the SA or atria reach the ventricles.
Third Degree Block
 The AV Node blocks all conduction from the SA
Node.
 Complete AV block, no atrial impulses pass
through the atrioventricular node and the
ventricles generate their own rhythm
 There is no association between atrial and
ventricle activity = AV dissociation
 Causes:
 Digitalis toxicity
 MI or ischemia
 Diseases affecting the AV node
Third Degree Block – PT Implication
 Very unstable rhythm
 NO THERAPY
 Medical emergency in many cases
 They need a pacemaker
Effects of Digitalis
What will the EKG of a patient on
digitalis look like?
 It can have any of the following
 Lengthened PR interval
 Shortened QT interval
 ST segment depression
 Multiple ectopic beats
 Ventricular / atrial premature beats
 Atrial tachycardia with variable AV block
 Ventricular tachycardia
 Or ventricular fibrillation
ST segment depression
What conditions have an elevated ST
segment?
 Transmural infarction aka STEMI
 Left bundle branch block
 Acute pericarditis
 May be normal in the athletic heart
What conditions have an depressed ST
segment?
 Myocardial ischemia
 Digitalis effect
 Ventricular hypertrophy
 Non-STEMI
 Pulmonary embolus
 Left bundle branch block
Dr. Amy Bayliss DPT, PT

02/01/21: Class ID#4

 Review medical record
 Note any precautions (including isolation)
 Practice standard precautions
 Discuss your plan with primary nurse
 Check you have the right patient on entering
the room
 Survey the patient and room
 Gently trace each line, ensure no tension on
lines before moving your patient
 Get help if needed
 Don’t free a line you cannot see it
 Ask the nurse if any can be disconnected to
make mobilization easier
 Consider portable suction/telemetry/oxygen
units
 Do not silence any alarms unless you are
familiar with the patient/equipment and have
discussed with nursing
 On completion of treatment
 ensure any alarms are turned back on
 equipment is back in place, plugged in….
 Notify the nurse of any changes in the
patient’s status
 Document thoroughly
1. Peripheral Intravenous (IV) line
2. Midline & Peripherally inserted central catheter
(PICC)
3. Arterial line
4. Central line
5. Pulmonary Artery Catheter – Swann-Ganz
6. Dialysis
7. Chest drainage tubes
8. Urinary catheters
9. Feeding tubes
10. Patient-controlled analgesia
11. Other tubes/drains/lines
http://content.nejm.org
 Provide IV solutions at a given rate and
volume
 Cannot be used to draw blood
 Alarms for low battery, dose end, line
occlusion & air in the line
 Risks – cellulitis, hematoma, thrombosis, air
embolus, sepsis
 PT Implications:
 Unplug and place on a portable pole for
mobilization
 Watch occlusion (kink) of line particularly when
over a joint
 Tape in place with a safety loop or re-tape as
needed (to avoid kinking)
 Avoid using a BP cuff on the involved extremity
 Get nursing assist when it is alarming
 Observe for signs of infiltrated IV or phlebitis
 Used for certain meds, antibiotics, & total
parenteral nutrition
 Midline, may be in place for 4-6 weeks
(advanced to the axillary vein)
 PICC may be for long term use
(advanced to the superior vena cava)
 Risks – thrombosis, hematoma close to
airways, hemothorax, pneumothorax,
dysrhythmias
PICC=peripherally inserted central catheter
 PT Implications
 No BP in the upper arm
 No axillary crutches
 No heavy resistance
exercise or lifting
 No aquatic therapy
 For the PICC wait to
mobilize until after an X-
ray has been taken to
confirm proper
placement PICC line
 Is a hemodynamic line
 In radial, brachial or
femoral artery
 Requires calibration for
accuracy
 Allows for continuous
monitoring of BP &
frequent blood draws
 Calibrated at 4th costal
space (phlebostatic axis)
 PT Implications
 If you dislodge an A-line, blood loss++
 If you move the patient it will not be calibrated,
recalibrate (the transducer can be taped to the
patient’s gown during mobilization)
 Radial line
 may need a splint to keep the wrist neutral, no wrist ROM
 Femoral line
 no hip flexion > 60-80 degrees
 After femoral A-line removal, strict bed rest for 60-90
minutes
 Two main reasons for use to highlight:
 Can be surgically placed for long term central
venous access > 6 months
 Called a port
 For chemotherapy, total parenteral nutrition
 Can be used for hemodynamic monitoring in
unstable patients
 Measures blood pressure through monitoring central
venous pressure (CVP)
 Quick medication, blood or fluid delivery
 Allows frequent blood draws
 Venous line into the
subclavian, basilic, jugular
or femoral vein
 Advanced to the right
atrium
 Measures volume status
(fluid balance) and
function of the right side of
the heart
 By measuring CVP = central
venous pressure
 Normal reading 0-8 mmHg
with a transducer don’t
memorize
 PT Implications (general):
 Do not take blood pressure on an extremity with
this type of line (basilic vein entry site)
 Do not perform manual techniques over the
insertion area
 Limit joint motion
 shoulder IR/ER , hip or cervical motion depending on the
site of the line
 PT Implications (specific – hemodynamic)
 If above norms, patient may be too unstable for
treatment check with nursing and/or MD
 Short line (typically < 6 feet in length) connects to
a monitor and needs to be calibrated like an
arterial line
 Most invasive line  Measures:
 Balloon tipped line  Right atrial & pulmonary
 Placed through a artery pressures
sheath into the internal  Venous O2 saturation
jugular or subclavian  Cardiac output
vein  vena cava  Pulmonary vascular
right atrium  right resistance
ventricle  pulmonary  Pacing
artery  Pulmonary artery wedge
pressures
Pulmonary Artery Catheter = Swan-Ganz catheter
 Allows for better management of heart
failure & cardiogenic shock
 Continuous monitoring of 2 right atrial
pressures through balloon inflation
▪ Pulmonary artery wedge pressure (PAWP)
▪ Pulmonary artery pressure (PAP)
 PT Implications:
 Used in critically ill patients with significant hemodynamic
compromise
 Patient maybe on bed rest or could be walking with assist
 Avoid head and neck or extremity movements that could
disrupt the line at the insertion site
 High pressures maybe a contraindication to exercise*
 TYPES
 Hemodialysis: blood cleaned externally
 Peritoneal dialysis: blood cleaned internally
 Continuous
(Veno-venous hemodialysis)
 ACCESS
 External access,
venous port
(subclavian, femoral
or jugular)
 Internal access (in
arm via AV fistula)*
Abnormal fistula
 Peritoneal access
(low back or
abdomen)
 Arteriovenous fistula
Venous port (temporary access) (permanent access)
 PT Implications:
 Don’t disrupt dialysis site
 No BP on extremity with dialysis access
 May need to take the BP in the lower extremity
 Palpable turbulence is normal in the AV fistula, and
it may have a raised rope-like appearance
 Exercise is encouraged either during or outside of
dialysis treatment sessions
 Watch for gait belt placement in peritoneal dialysis
 Can be either intrapleural
or mediastinal (excess
fluid after cardiac
surgery) drainage tubes
 May or may not be
attached to a sealed
drainage system and/or
suction
 Used to evacuate air
and/or fluid
 How do they work?
 Three compartment model
 Drainage collection chamber
 Water seal chamber with a one-way valve that
prevents air or fluid from re-entering the drainage
chamber
 Suction chamber
 PT Implications:
 Mobility is encouraged
 Don’t tip the collection systems, it can compromise the
seal, Don’t kink tubes
 Keep collection unit below the level of tube insertion
 They are painful, consider pain meds prior to therapy
 Note changes in quantity or quality of exudates before,
during and after position changes and intervention
 If it was to fall out or get pulled out accidentally
▪ Seal off the insertion site immediately by pressing a
gloved hand over it call a nurse!
 Foley catheter  Suprapubic tube
 Placed through the  Surgically implanted
urethra catheter
 Inserted directly into the
 PT Implication bladder through the
suprapubic area
 Hang bag below the
bladder
 Support line  PT Implication
 Bring it with the  Same as Foley catheter
patient!
 Percutaneous
Endoscopic Gastrostomy
(PEG)
 Placed in the stomach
 Gastrostomy (G tube)
 Placed in the stomach
 Jejunostomy tube (J
tube)
 Placed in the jejunum
 Nasoenteric feeding tube
 PT Implications
 Wait to mobilize after X-ray confirmation tube is
in the correct place
 Keep HOB > 30 degrees while feeding is running
 Feeding can generally be stopped for PT
 Better to stop the feeding 20-30 minutes prior to
activity
 Put gait belt near armpits instead of around waist
 PT Implications
 Watch gait belt
placement
 Some facilities require
feeding tubes be flushed
with water when placed
on-hold for > 15 minutes
to minimize risk of
clogging
 Can be via an IV, epidural, regional or
intranasal

 PT Implications:
 Medications are typically opioids so consider side
effects
 Know the insertion site and protect during
mobilization
 May need to teach splinting over painful site during
forceful maneuvers like coughing
 Nasogastric tube
 Keeps stomach empty after surgery, rests the
bowels
 Often connected to suction

 PT Implications:
 Usually they can be off suction for PT (check with
nurse)
 When disconnected open end should be capped
 Monitor for nausea and/or abdominal distension
if/when disconnected
 Hemovac drain or Jackson Pratt
 May be seen post-abdominal or joint surgery
 Could be connected to suction

 PT Implications:
 Place in a pocket, clip to gown  do not let them
hang down
 Usually they can be off suction for PT (check with
nurse)
 Watch gait belt
 Colon tube and colon bag

 PT Implications:
 Limit shear forces or pulling on it
 Consider patient’s self-image, be respectful
 Refer to support groups
 Many hospitals have dedicated nurse educators for
ostomy care
 Rectal pouch/tube
 Tube inserted into rectum to collect/contain
bowel drainage

 PT Implications:
 Very easily dislodged particularly during bed mobility
 Keep collection bag below site of insertion
 Upright sitting maybe too painful
 Neurological lines for intracranial pressure
monitoring:
a) Epidural sensor
 Fiber-optic flow sensor placed in the epidural space to
monitor intracranial pressure (ICP)
 Transducer does not need to be adjusted
b) Intraventricular catheter
 Catheter threaded into a lateral ventricle of the brain
 Allows drainage of CSF and monitors ICP
 Transducer must be repositioned
 Neurological lines, PT Implications:
a) Epidural sensor
 Can break easily, no tensile forces

b) Intraventricular catheter
 Usually HOB at 20-30 degrees
 Neck flexion should be avoided
 ICP range should generally be 0-10mmHg for adults
 Avoid activities that increase BP, like Valsalva

Check with MD/nursing prior to proceeding with PT.

 Lumbar drain
 Drainage of CSF from the subarachnoid space in
the lumbar spine
 PT Implications
 Changes in patient position, level of collection or
intrathecal pressure impacts rate of drainage
 Usually on bed rest
 Typically should avoid coughing
1. Oxygen cylinders
2. Oxygen delivery devices
3. Bed alarms
4. SCD (sequential compression device)
 Should stay upright
 Should never be left standing alone, they should be
in a carrying or storage device
 Should be left in the off position when not in use
and purge the regulator
 Flammable
 Some pt’s will smoke while on oxygen
 Emergency cylinders should be checked weekly
a) Nasal cannula
b) Oxymizer LOW FLOW

c) Simple face masks

d) High flow nasal cannulas
e) Non-Rebreather mask
f) Venturi mask HIGH FLOW

g) BiPAP vs. CPAP

h) Tracheostomy collar
a) Nasal cannula
 Used for low flow and home O2 use
 Humidified or non-humidified
 Flow on regulator, flow rates generally 1-6 Lpm
1 Lpm=24% 4 Lpm=36%
2 Lpm=28% 5 Lpm=40%
3 Lpm=32% 6 Lpm=44%
 Document: NC at 3 lpm
b) Oxymizer
 It is a reservoir cannula
 Allows less flow with the same oxygen delivered,
which conserves a patient’s use of oxygen
 Facilitates conservation through the use of a
reservoir that stores oxygen during exhalation for
delivery during inhalation
 Used at local hospitals up to 15L/min to give more
O2 than a nasal cannula can
c) Simple face masks
 Can deliver 35%-55% oxygen at flow rates of 5
to 10 L/min
 As with nasal cannula if a precise FiO2 is
required this should not be used
d) High flow nasal cannula
 A high flow humidifier is required when used at
> 5L/min
 Used in neonates to geriatrics
 Flows are typically delivered at 15-40 L/min for
adults
 FiO2 can be up to 100%
 Reduces the work of breathing
 Optiflow & Vapotherm are brands used at local
hospitals
https://www.fphcare.com/us/hospital/adult-respiratory/optiflow/mechanisms-of-action/
e) Non-Rebreather Mask
 Simple face mask
with an attached
oxygen reservoir
 Provides 60-80%
FiO2
 Oxygen regulator
should be set at 10-15
Lpm to keep the bag
half full with each
breath
 The mask requires a
good seal to work
properly
f) Venturi mask rebreather
 High flow oxygen delivery
 Simple face mask with a variety of different
color diluter jets (24,28,31,35,40 and 50%) or a
wall unit
 The wall unit allows humidification and
adjustable FiO2
 Document as percentage FiO2 via Venturi mask
Venturi mask
g) BiPAP g) CPAP
 Bi-level airway pressure  Continuous positive
 On insp. & exp. airway pressure
 Lower during expiration  Through face or nasal
 Tight fitting nasal mask mask
 Used for respiratory  Used for obstructive sleep
failure, post-surgical, apnea & weaning from a
respiratory treatments, ventilator
apnea & NM disorders
CPAP & BiPAP masks
h) Tracheostomy tube
 An artificial airway inserted into the trachea via
an anterior cervical incision
 Most have cuffs to prevent aspiration
 Allows easy access for suctioning secretions
 Delivers oxygen & humidification
 Portable set-up similar to Venturi mask
 Used to wean from ventilation sometimes
Tracheostomy tube & collars
 Remember to turn them off when mobilizing
 Turn them back on when you leave the
patient

What would you do if you forgot to turn it back

on and then the patient fell getting out of bed
and fractured their hip?
 What is the most
important thing to do?
 Turn them back on!
 Contraindicated if
active DVT
1. Mechanical Ventilators
2. Monitors
 PT’s do not manage ventilator settings or the
ventilator
 PT’s assist with:
 Ventilator weaning
 Suctioning (in some settings)
 Mobility
 Minimizing the effects of immobilization
 “Effects of Physical Training on Functional
Status in Patients with Prolonged Mechanical
Ventilation”
 RCT
 6 weeks of physical training improves;
▪ Limb strength
▪ Ventilator free time
▪ Functional outcomes

Chiang et al, Physical Therapy. 2006;86(9): 1271-1281.

 Mode of Ventilation decided by MD and RT,
these factors are considered;
 Trigger
 Flow rate
 Frequency
 Spontaneous breath
 Mode of Ventilation (most assist to least)
 Controlled mechanical ventilation
▪ Delivers a preset breath
▪ Without regard for a patient’s spontaneous breathing
 Assist control ventilation
▪ The patient has some spontaneous breathing
▪ Delivers a preset breath when the patient triggers the
ventilator
▪ If patient’s effort is less than required the machine will
deliver a preset minute ventilation
 Mode of Ventilation (most assist to least)
 Intermittent mandatory ventilation
▪ RR> 10 but effort still weak
▪ Allows the patient to breath spontaneously between
“mandatory” ventilator breaths
▪ There is a synchronized mode available also
▪ Used in initial weaning form a ventilator
 Mode of Ventilation (most assist to least)
 Continuous positive airway pressure (CPAP)
▪ Spontaneous weaning mode of ventilation
▪ Maintains positive pressure continuously in the airways
▪ Pressure support is added to augment patient’s tidal
volume
 Pressure supported ventilation
▪ Augments the inspiratory phase of a patient’s
spontaneous efforts
▪ This will reduce the patient’s work of breathing
 PEEP (positive end expiratory pressure)
▪ There are three purposes to using PEEP:
▪ 1) To keep alveoli open for longer to maximize gas
exchange and decrease atelectasis, while minimizing
overdistension.
▪ 2) Decreases the work of breathing.
▪ 3) To assist cardiac performance, during heart failure, by
increasing mean intrathoracic pressure.
 Ventilator Alarms!?
Always look at the patient first
 Low pressure alarm
▪ check for detached tube or air leaks
 Apnea alarm
 High respiratory rate
 High pressure alarm
▪ check for coughing, water in the tubes, blocked/kinked
tube, or a mucus plug
 PT Implications:
 May need to do airway clearance/suction*
 Progress strengthening/mobility on the ventilator
(EBM supports)
 Watch tubing with rolling
 If water in tubes then empty, because it could go
back into the lungs
 Get assist from nursing or RT as needed
 Typically display all vital signs being
measured
 HR, Oxygen saturation, BP, ICP, PAP, EKG
 PT Implications:
 Record initial readings prior to PT
 Monitor during
 Record readings after PT
 Get nursing assist if alarms sound
 Thoracic Organ Transplantation

Dr. Amy Bayliss, DPT, PT

Class ID#19: 03/31/21

PT Role Pre-Transplantation Specifics
of PT evaluation
 Observation  Strength
 Edema  Bed mobility
 Vital signs  Transfers
 Breathing/ventilation  Gait
 Huff/cough  ADL’s
 Pain  Exercise tolerance
 Posture  6 minute walk test
 Range of motion  Sit-to-stand test
 Step test
 Submax treadmill or cycle
test
Preoperative rehabilitation
 Strength program is individualized but comprehensive
 Example below
 1 set of 8-12 reps using pulleys or theraband
 Latissimus pull downs
 Rhomboids
 Shoulder extension/rotation/ flexion
 Pectoral exercise
 Triceps
 Quadriceps
 Hip extensors
 Hip abductors
Transplant Donation
 Cadaveric donors (heart & lungs)
 Living donor (lung, kidney & liver)
 Often family
Heart Transplantation
1) Orthotopic
 Most common
 Replaces the recipient heart with a donor heart
 Donor heart in normal anatomical position
 Denervated, extrinsic nerve supply severed during
procurement
 Either biatrial or bicaval technique
 Biatrial (old school) – quicker, 2 SA nodes
 2 P waves on EKG
 Bicaval (new school) – most common now, some studies are
pointing to better outcomes
Heart Transplantation
 Orthotopic
 PT implications
 Median sternotomy (sternal precautions)
 Chest tubes, arterial line, Swann-Ganz catheter
 Epicardial pacing wires
 Easy to dislodge
 2 P waves since 2 SA nodes if biatrial surgical technique
 This can change to one P wave after one month
Heart Transplantation
1) Orthotopic
 Activity implications
 Resting HR is higher, 90-110 bpm*
 HR & SV respond more slowly to exercise
 Extended warm-up and cool down required
 HR will increase due to circulating catecholamines
 Peak HR lower (typically ~70-80% of normal)
 Therefore use RPE for exercise, <10/20 on modified Borg
scale
 Monitor EKG and BP
 Orthostatic hypotension is common
Heart Transplantation
2) Heterotopic
 “piggy-back”
 Disease heart is left intact
 Donor heart is placed on the right side of the thorax
 Anastomosis of the 2 hearts occurs
 The purpose is for the donor heart to assist
 Used in instances when there is a mismatch in donor and
recipient heart size or the recipient has mod-severe
pulmonary HTN
 Donor heart denervated
Heart Transplantation
2) Heterotopic
 PT Implications
 Median sternotomy (sternal precautions)
 Chest tubes, arterial line, Swann-Ganz catheter
 Epicardial pacing wires
 2 separate PQRST complexes
Heart Transplantation
2) Heterotopic
 Activity implications
 Donor heart response is the same as the Orthotopic heart
transplant patient
 Except you also have the native heart present
 Always make activity tolerance decisions by donor heart
response
 Monitor both on EKG
 May experience angina pain from native heart
Changes in cardiovascular status after
heart transplant
 Differences in exercise response
 Resting HR 90-110 bpm
 HR response to activity: delayed response & lower (70-80% of
normal or 150 bpm max)
 Since heart is denervated, HR increases due to circulating
catecholamines in the plasma
 Peak VO2 is lower
 Resting BP higher than normal
 Exercising BP: peak systolic is reduced, diastolic BP more likely
to have abnormal increases or decreases
Heart Transplantation Post-op Course
 Protective isolation room (you wear a face mask)
 Mediastinal drainage is promoted with head of bed
elevated 30 degrees, turned every 1-2 hours
 PT can begin when hemodynamically stable (POD #2-3)
 Must monitor vital signs before, during, after activity
 In hospital 1-2 weeks
Heart Transplantation Post-op Course
 Level 1
 Breathing exercises
 Exercises in supine or seated with emphasis on proximal muscles,
high reps 15-20x
 Shoulder flexion, adduction, horizontal abduction*
 Trunk rotation
 Hip/knee flexion (seated marching)
 Bridging or hip extension
 Knee extension
 Ankle pumps
 Gait: standing pre-gait activities (mini-squats, weight shifting, single
leg stance)
 Up in a chair 30-60 minutes
Heart Transplantation Post-op Course
 Level 2
 Exercises in standing with emphasis on proximal muscles, high
reps 15-20x
 Shoulder exercises*
 Lunges
 Marching in place
 Mini-squats, weight shifting, single leg stance
 Toe raises
 Up in a chair ad lib
 Gait: ambulate in room ad lib, ambulate in hall as tolerated
Heart Transplantation Post-op Course
 Level 3
 Exercises in standing with emphasis on proximal muscles, high
reps 15-20x
 Head and neck stretches
 Shoulder exercises: progress to wrist weights
 Toe raises (progress to single leg)
 Dynamic balance exercises
 Include 2-3 minute warm up and cool down
 Gait: progress ambulation to 10-15 mins continuously
 Stair stepping
Heart Transplantation Post-op Course
 Level 4
 Exercises per level 3
 Dynamic balance exercises
 Include 2-3 minute warm up and cool down
 Gait: progress ambulation to ~20 mins continuously
 Stationary cycle: progress to 10-20 minutes at mild resistance
Heart Transplantation Post-op Course
 Suggested guidelines for exercise
 Resting HR < 120 bpm
 No significant arrhythmias or angina
 Exercise HR not more than 40 beats above rest
 Systolic BP < 190, Diastolic BP < 110 at rest
 Systolic BP should no increase > 40 mmHg or decrease > 10
mmHg with exercise
 No diastolic drop or increase > 15mmHg during exercise
 Aim for RPE of 3-4 (light) on the 0-10 scale during inpatient
stay
Heart Transplant: Exercise
 Effects of exercise training
 Little or no change in resting HR
 A small increase in peak HR (6-10 bpm)
 No change in resting SV or CO
 VO2 max is between 50-70% of age/gender matched controls
 Improved FEV1
Heart Transplant : Exercise Testing
 Can use a treadmill or cycle, stages of 3 minutes with work
rates increased by 2 MET’s per stage is recommended
 Step protocol or 6 minute walk test are also effective
 Because of delayed and blunted response in HR, what should
you do?
 RPE, BP and EKG (EKG is less sensitive to ischemia due to
denervation)

 In some patients within 1-4 years post-transplant, they can regain

sympathetic innervation, so HR could be used
Heart Transplant : Exercise Prescription
 Aerobic
 Walking/cycling/swimming
 RPE <5/10 on modified Borg Scale (so RPE 3-4)
 Daily exercise
 30 min in a day (can be accumulated in a day)
 Warm-up and cool down should be emphasized
Heart Transplant : Exercise Prescription
 Strength
 All major muscle groups, particularly proximal muscles
 Low-moderate intensity (50% of 1RM at most)
 1-2 sets of 10-15 reps
 2-4 days/week
 Avoid isometrics
 Increases systolic BP, and its already high due to medications (HTN) and
nature of transplant
Heart Transplant: Exercise Prescription
 Flexibility
 Start in upper body 6-12 weeks after surgery due to sternotomy
precautions
 UE and LE’s
 At minimum 2-3 days per week
Lung Transplantation
 Single lung transplantation
 Never done in CF or bronchiectasis
 Standard posterolateral thoracotomy
 Atrial anastomosis
 Pulmonary artery anastomosis
 Bronchial anastomosis
Lung Transplantation
 Double lung transplantation
 Lungs transplanted sequentially
 Incision is a bilateral anterior thoracotomy in 4th/5th intercostal
space or a transverse thoracosternotomy
 Typically for patients with CF or bronchiectasis
Lung Transplantation
 Living donor lobar transplantation
 Transplantation of lobes
 Need two donors, right lower lobe from one person and left
lower lobe from another person
 Primarily performed in patients with CF
 Additionally may be used for bronchopulmonary dysplasia,
pulmonary fibrosis, primary pulmonary HTN
Lung Transplantation
 Single lung transplantation
 Complications specific to single lung transplantation
 V/Q mismatch
 Mechanics is never normal due to disease and residual impairments in
non-transplanted lung
 PT Implications
 Intensive respiratory PT required
 Thoracotomy precautions
 Patient should lie on non-operative side to reduce postsurgical edema,
assist with drainage, promote inflation of new lung
 Respiratory isolation
Lung Transplantation
 Double lung transplantation
 PT Implications
 Intensive respiratory PT required
 Incisional precautions
 Patient should avoid supine lying to minimize secretion retention
 Respiratory isolation
Change in pulmonary status after lung
transplant
 VO2 max – between 40-60% of age/gender matched controls
 Anaerobic threshold reduced compared to normal
 RR mildly elevated at rest
 Disruption of the vagal and autonomic nerves, coughing
reflexes typically blunted
 Restrictive physiology is present with a decrease in TLC
Lung Transplantation
 PT interventions
 Postural drainage
 Airway suctioning
 Vibration/gentle percussion
 Diaphragmatic breathing
 Coughing exercises
 Use of incentive spirometer
 Acapella device
 Must monitor O2 sats.
Lung Transplantation Post-op Course
 Respiratory isolation room (you wear a face mask in their
room, the patient wears one outside of their room)
 PT can begin when hemodynamically stable (POD #2-3)
 Generally ventilated for 2-3 days
 Must monitor vital signs (including O2 sats) before, during,
after activity
 Supplemental O2 should be used to keep O2 sats above 90%
 In hospital 1-2 weeks
Lung Transplantation Post-op Course
 Day 1 of PT
 Breathing ex., airway clearance, supine-sit, up in chair,
marching at bedside
 Day 2 of PT
 Begin progressive, monitored ambulation. Add thoracic
mobility exercises. Continue with pulmonary PT.
 D/C goals for PT
 Independent ambulation 600-700ft or 20-30 minutes,
independent up/down a flight of stairs and with HEP
 Wean off O2
 HEP for upper extremity & thoracic stretches
Lung Transplant: Exercise
 Differences in exercise response
 Bronchial hyperresponsive
 Abnormal mucociliary clearance, impaired cough with
wheezing often present
 Altered respiratory pattern (disproportionate  in tidal
volume)
Lung Transplant: Exercise
 Effects of exercise training
 Improved minute ventilation
 Respiratory pattern may improve
 Improved VO2 from baseline but still reduced (60%) compared
to age/gender matched controls
 RR with exertion decreases, less dyspnea

 Keep O2 saturations > 90%

 Dyspnea likely to be limiting factor
 Patient should wear a mask when around people
Lung Transplantation: Exercise Testing
 6 minute walk, cycle or treadmill submaximal tests are
recommended
 Testing used to prescribe exercise at an appropriate level
after transplantation
 Functional tests may also be effective
 Systemic hypertension can be an adverse effect of
immunosuppressive medications, monitor BP closely
 Always monitor O2 sats & have supplemental O2 available
Lung Transplantation: Exercise Prescription
 Aerobic
 Walking, swimming, cycling
 Upper cycle ergometer may even be used for endurance
 THR 60-80% of peak HR
 RPE <5/10 on modified Borg scale
 1-2 sessions per day
 3-7 days per week
 20-30 minute sessions
 Duration is more important than intensity
Lung Transplantation: Exercise Prescription
 Strength
 Low resistance, high reps
 Emphasis on proximal muscles
 3 days per week
 Flexibility
 Daily
 May consider Tai chi
To clarify & simplify for all transplant
patients:
1) Warm-up and cool down at 1/10
2) Exercise at RPE of 3-4/10
Heart Lung Transplantation
 Heart and lungs of the donor are removed en bloc and placed
in the recipients chest
 The anastomosis to join the donor organs is at the trachea,
right atrium and aorta
 Rejection of the heart and lungs can occur independently
 Bacterial pneumonia is one of the most common causes of
death after a heart-lung-transplant
Complications for transplants
 Rejection
 Hyperacute
 Ischemia & necrosis
 Within 48 hours after transplant
 Caused by ABO incompatibility & cytotoxic antibodies
 Patient will have general malaise & high fever
 Non-reversible
 Only treatment is removal of organ and immediate
retransplantation to survive
Complications for transplants
 Rejection
 Acute
 Treatable and reversible
 Occurs within the first year
 Most patients have some degree of acute rejection due to foreign
antigens from the graft
 Treated with change in immunosuppressive drugs
 First signs may be seen as soon as 4-10 days
Complications for transplants
 Rejection
 Acute (general signs and symptoms)
 Sudden weight gain (6lbs in 3 days)
 Peripheral edema
 Fever, chills, sweating, malaise
 Dyspnea
 Decreased urine output, increased BUN and serum creatine
 Electrolyte imbalances
 Increased BP
 Swelling and tenderness at graft site
Complications for transplants
 Rejection
 Chronic
 After first year
 Deterioration of the graft is gradual and progressive
 Immunosuppressive drugs do not stop this type of rejection
 Increasing immunosuppresive drugs may slow the process
Complications for transplants
 Rejection
 Chronic
 In heart transplant patients
 Coronary allograft vasculopathy
 Accelerated atherosclerosis &/or myocardial fibrosis
 Increasing blockage of coronary arteries
 MI is consequence
 What would you see as a PT?
 Arrythmias, dyspnea, dizziness, resting BP higher, BP response to exercise
altered
Complications for transplants
 Rejection
 Chronic
 In lung transplant patients
 Bronchiolitis obliterans bronchial walls get thick and lumen gets
narrow obstructive disease
 Progressive dyspnea
 Increasing airflow obstruction
 FEV1 affected
 What would you see as a PT?
 RR , SOB on exertion, COPD symptoms
Medications
 Classifications (theses are all considered immunosuppressive
medications)
 Glucocorticoids e.g. Prednisone
 Side effects of prednisone: fluid retention, muscle atrophy and
decreased leg strength, increased risk for fracture
 Antiproliferative agents e.g. Azaithioprine (Imuran)
 Antibodies e.g. Orthoclone
 Calcineurin inhibitors e.g. Cyclosporin, Prograf
 Other drugs maybe prescribed for side effects e.g. antacids,
mycostatin lozenges.
 Continual advancements
Medications
 Immunosuppressive agents
 Inhibit or prevent activity of the immune system
 Prevent the rejection of the transplanted organ
 Non-selective, the immune system loses the ability to fight
normal infections and spread of malignant cells
 Side effects are common
 Cyclosporine causes an increase in resting and submaximal BP
 Prednisone causes proximal muscle weakness and osteoporosis
Medications
 PT Implications of Immunosuppressive medications
 Side effects include:
 Tremor
 Leukopenia, Thrombocytopenia
 Arthralgia, Muscle wasting, Muscle cramping
 Osteoporosis
 Toxic to kidneys and liver
 Edema
 Insomnia
 Paresthesia
Long term complications of organ
transplant?
 Accelerated atherosclerosis, hypertension &
hyperlipemia
 Infections
 Cancers
 Osteoporosis
 Steroid myopathy with muscle weakness
 Glucose intolerance (Type 2 diabetes)
 Nephrotoxicity (Renal dysfunction)
 Delayed wound healing
 Gastrointestinal complications
 Post-surgical Intervention for
Cardiovascular & Thoracic
Procedures

Dr. Amy Bayliss, DPT, PT

Class ID #14: 3/1/21

Surgical approaches
• Posterolateral thoracotomy
• Lateral thoracotomy
• Anterolateral thoracotomy
• Median sternotomy
• Thoracoabdominal incisions
 Posterolateral thoracotomy
• Arm positioned in ~ 90o flexion
• Starts midway between T4 and
scapula
• Curves around inferior angle of
scapula to 5th/6th intercostal
space
• Finishes at anterior axillary line
• Lower trap, serratus ant., & lat
dorsi divided in an effort to avoid
the long thoracic nerve
• Risk of intercostal nerve damage
Used for lung resection procedures.
 Lateral thoracotomy
• Several variations
• Begins near the nipple line
• Extends towards the scapula
• L.dorsi muscle is retracted
(not incised)
• S.anterior &/or intercostals
are incised

Used for lung resection procedures.

Anterolateral thoracotomy
• Upper arm typically extended but may be flexed or
horizontally adducted
• 4th – 5th intercostal space at mid-axillary line to sternum
• Pectoralis major is incised
• Fibers of serratus anterior are separated
• In females sometimes breast reflected superiorly

Used infrequently.
Can be used for cardiac procedures,
pulmonary resections,
or esophageal procedures.
Median Sternotomy
• Patient supine
• Midline inferior to
suprasternal notch
• Extends to below xiphoid
• Sternum divided along its
midline
• Sternum closed with steel
sutures

Cardiac procedures
 Thoracoabdominal incision
• Arm position – full
shoulder flexion
• 8th/9th IC space at
posterior axillary line to
the mid-abdomen
• Transect latissimus
dorsi, s.anterior,
external oblique, rectus
abdominis

Procedures on the diaphragm, esophagus,

biliary tract, liver, spleen, adrenal glands, kidneys.
Minimally invasive approaches
• Video assisted thoracotomy (incisions are ~ 5cm)
• Used for lung cancer, pleural problems, pneumothorax
• Recovery is much quicker so becoming more widely used
PT Implications
• Shoulder pain is the primary complaint from patients
• Several causes
• Chest tube placement can irritate the pleural cavity and cause
shoulder pain
• Prolonged positioning during surgery
• Intercostal nerve damage (most common in posterolateral
incisions)
• Poor posture post-operatively can cause sub-acromial
impingement. Long term this can predispose a patient to
adhesive capsulitis.
• Additional nerve damage – long thoracic nerve
• Scapular winging
Cardiac Procedures
• Cardiac catherization
• Angiogram
Revascularization
• Percutaneous transluminal coronary angioplasty (PTCA) procedures
• Stent implantation

• Coronary artery bypass graft (CABG)

• Valve replacement
• Pacemaker insertion
• Ventricular Assist Device (VAD)
• Pediatric cardiac surgery*
Cardiac Catherization
• A physician inserts a thin plastic tube into an artery or vein in
the arm or leg.
• From there it can be advanced into the chambers of the heart
or into the coronary arteries.
• This test can measure:
• blood pressure within the heart
• how much oxygen is in the blood
• information about the pumping ability of the heart muscle
• evaluate congenital defects
Angiogram
• Angiogram is when the catheter advanced during a
catherization is used to inject dye into the arteries
• Pictures can be gained of the flow in the coronary arteries
PTCA
(Percutaneous transluminal coronary angioplasty)
• A balloon tipped catheter is inserted generally via the femoral
artery
• The balloon is then inflated, compressing the plaque and
dilating (widening) the narrowed coronary artery
• Directional coronary artherectomy (DCA) may be performed
prior to the balloon inflation
Stent Placement
• Stents’ are often placed after the artery is widened (PTCA)
• Act as a scaffold to stop the artery re-narrowing
• Stent looks like a tiny coil of wire
• Typically coated with medication
• The medication is a cell antiproliferative drug
What are the risks during the
procedures?
Cardiac catherization angiogram PTCA stent placement

• Bleeding
• Restenosis
• Blood clots
• Which is why we use a Antiproliferative drug
• Artery damage
• Arrhythmias
• Heart attack
• Ongoing disease
PT Implications:
Cardiac catherization angiogram PTCA stent placement

• Safety
• New orders needed after procedure
• Know signs & symptoms of the risks
• Activity level
• Check activity orders before mobilizing patient, it can be as little
as 1-2 hours (radial) or as long as 6-8 hours (femoral)
• If radial artery is used then you can mobilize patients more
quickly following the procedure
• Post procedural rehab
• Incorporate results of procedure into plan of care
Coronary Artery Bypass Graft
(CABG)
• Median sternotomy
• Performed for revascularization
when > 3 vessels are involved
• Vascular grafts are harvested
from:
• saphenous veins
• left internal mammary artery
• Placed on cardiac bypass during
the procedure (“on-pump”
procedure)
• Sometimes patients can have a
smaller incision and an “off-
pump” procedure
CABG: PT Implications
• Pain
• Lines and tubes
• Chest tubes
• A-line, IV line
• Catheters
• Sternal precautions
• Potential loss of joint motion
• shoulder
• Pulmonary complications
• Superficial incisional infection
• Blood loss
• Brachial plexus injury
• Other complications: stroke, atrial fibrillation, myocardial injury
• Exercise prescription
CABG
• What are sternal precautions?
• Functional restrictions given to patients to facilitate sternal
healing after a median sternotomy
• Restrictions may include shoulder range of motion, lifting,
reaching, dressing, exercise & driving
• Highly variable depending on physician and facility
• Most current research has developed an algorithm based on
individual risk factors
• 2-4 weeks of precautions
Sternal precautions
• Example of a high risk patient
• 85 year old female patient who is a smoker, type II diabetes,
osteoporosis, COPD with large breasts (gravity on sternum)

• Example of a moderate risk patient

• 60 year old patient who had emergency surgery and a longer than
usual intensive care stay, with a BMI of 30

• Example of a low risk patient

• 21 year old who had a single valve replacement, healthy BMI and
no co-morbidities affecting healing
Sternal precautions
• Most current research has developed an algorithm based on
individual risk factors
• High risk patients
• Conservative activity guidelines for 2-4 weeks
• Moderate activity guidelines for 2 weeks
• Progressive activity guidelines for 2 weeks
• Medium risk patients
• Conservative activity guidelines for 2 weeks
• Moderate activity guidelines for 2 weeks
• Progressive activity guidelines for 2 weeks
• Low risk patients
• Moderate activity guidelines for 2 weeks
• Progressive activity guidelines for 2 weeks
Sternal precautions
• Conservative activity guidelines (2-4 weeks)
• No lifting, pushing, pulling > 10lbs
• No shoulder abduction/flexion > 90o when UE is weighted
• Shoulder AROM in painfree range
• No scapular retraction past neutral
• Avoid active trunk flexion & rotation with supine to sit
• No UE use with sit to stand
• Apply sternal counter pressure (splinting) (heart pillow) with
coughing and & Valsalva
• No driving
• No manual muscle testing of UE
Heart Valve Replacement
• Replacement not repair
• 95% of all valve replacements are performed for mitral or
aortic valves (because the left side of the heart withstands higher
pressures)
• The mitral valve is positioned between the left atrium & left
ventricle
• The aortic valve separates the left ventricle from the aorta
• 3 types of valve replacement
• Mechanical valve
• Tissue valve (xenograft)
• Allografts or homografts
• Better outcome for women who want to get pregnant, no need for
anticoagulants
Heart Valve Replacement
• PT Implication
• Very similar to post CABG if a sternal incision is used
• Advances in surgery have resulted in many patients having
minimally invasive procedures so PT implications are similar to
post PTCA
• Differences
• You may here the mechanical valve clicking
• Anti-coagulants, INR ranges 2.0 to 3.0
• Antibiotics required prior to dental procedures for all patients
with artificial valves
Pacemakers
• Different types – 3 basic types;
• Single-chamber pacemakers
• One wire (or pacing lead) is placed, it may be either in the atrium or
ventricle
• Dual-chamber pacemakers
• Two wires, one paces the atrium, one paces the ventricle
• Rate responsive pacemakers
• Sensors are present that automatically adjust HR based on to someone’s
physical activity

What conditions need them?

Sick sinus syndrome

Tachycardia
Heart Blocks
Pacemakers
• These items do not • Microwave ovens
affect a pacemaker: • TV transmitters
• CB radios • TV remote controls
• Electric drills • X-ray machines
• Electric blankets • Airport security
• Electric shavers detectors*
• Ham radios • Theft detectors*
• Heating pads • Cellphones*
• Don’t use on left ear
• Metal detectors
Pacemakers
• Here is a list of devices that will affect pacemakers. Your
pacemaker may not work properly if you come into contact
with these devices.
• Power-generating equipment
• Welding equipment (arc welding)
• Certain pieces of equipment used by dentists
• Magnetic resonance imaging (MRI) machines
• Radiation machines for treating cancer
• Heavy equipment or motors that have powerful magnets
• Some TENS/E-stim units
• Diathermy (shortwave & microwave)
Pacemakers – PT Implication
• Post-surgical placement
• Restrict upper extremity AROM below shoulder height (90) for 2
weeks, then to R1 at surgical site for 6 weeks
• No lifting > 10lbs for 2-3 weeks
• Most normal activities can be resumed at 6 weeks
• Swimming, golf, repeated overhead motion can be resumed at 3
months
• No contact sports ever
• Contact with others: football, rugby, hockey, basketball
• Contact with ground: skiing, dirtbiking, cycling

Monitor BP, RPE, symptoms

Implantable Cardioverter
Defibrillator (ICD)
• Implantable cardioverter
defibrillator (ICD) is used to
correct life-threatening
arrhythmias:
• Ventricular tachycardia
• Ventricular fibrillation
• Sudden cardiac death caused by
arrhythmias
ICD: PT Implications
• Restrict upper extremity AROM below shoulder height (90) for 2
weeks, then to R1 at surgical site for 6 weeks
• No lifting > 10lbs for 2-3 weeks
• Most normal activities can be resumed at 6 weeks
• Swimming, golf, repeated overhead motion can be resumed at 3
months
• No contact sports ever
• Contact with others: football, rugby, hockey, basketball
• Contact with ground: skiing, dirtbiking, cycling
• Patients with ICD’s or pacemakers should always carry a card
• Additionally it is best to avoid airport security devices & store
security devices (magnetic fields/signals sent)
Intra-aortic Balloon pump
• Uses inflation & deflation of a balloon in the aorta
• Inflation at beginning of diastole boosts intra-aortic pressure,
restoring arterial pressure & improving perfusion
• Deflation during left ventricular systole decreases afterload and
assists left ventricle to eject a larger stroke volume
• Inserted in femoral artery, limited hip flexion
• Used for short term treatment of cardiogenic shock
Ventricular Assistive Device
(VAD)
• It is a mechanical device that is used to take over the pumping
function for one or both of the heart’s failing ventricles.
• Used for
• Bridge to recovery
• Bridge to transplant
• Destination therapy
• Post-cardiotomy support
Ventricular Assistive Device
(VAD)
• VADs are designed to support the
• Right heart alone (right ventricular assist device, or RVAD)
• Both ventricles (biventricular assist device, or BiVAD)
• Or more commonly the left ventricle (left ventricular support
device, or LVAD) is the primary point of support
• Can be permanent or temporary
• All devices have the following components;
• Pump
• Binder/drive line
• System controller
• Batteries
• Power base unit & display module
LVAD (Heart Mate & Heart Mate II)

www.thoratec.com
BiVAD
• Used to give the heart a rest
often after a MI or cardiac
surgery
• Short term device
• Reversible heart failure

www.abiomed.com
VAD: PT Implications
• Major risk factors
• Infection
• Bleeding
• Blood clots
• Right ventricular failure (in LVAD patients)

• Pre-VAD placement
• Exercise prescription
• Bed mobility & transfers– independence with these activities is
required to be candidate
• Post-VAD placement
• Equipment
• Contraindications to PT
• Precautions in this patient group
• Exercise prescription
VAD: PT Implications
• Post-VAD placement
• Equipment
• Pump – how does it work, what do I do in an emergency?
• Binder/drive line – is the binder on, fitting correctly? Infection
risk.
• System controller – alarms?
• Power base unit – cables connected right?
• Batteries – how long is the life?
• Display module – how does it work?
• Yellow and red caution lights on all units
• What is the source of back-up power?
VAD: PT Implications
• Post-VAD placement
• Contraindications for PT
• Patient must have a new post-op PT order and be stable
• Refer to previous contraindications for exercise
• During exercise – drop in pump flow since it may indicate pump
failure
• Symptomatic – dyspnea, high RPE, dizziness, nausea, O2 sats. low
• We should know the yellow advisories and red heart hazards**
VAD: PT Implications
• Post-VAD placement
• General precautions
• Components cannot get wet
• No swimming, jumping or contact sports
• Individuals should not become pregnant
• Don’t directly touch TV or computer screens because of the
excessive static
• Do not lie prone
• Can’t do chest compressions in an emergency*
• The VAD coordinator or implanting physician must be
contacted
• Hand pumping is most likely required
VAD: PT Implications
• Post-VAD placement
• Exercise test
• 6 minute walk test
• Exercise prescription
• Breathing techniques
• Warm-up/cool down
• Cardiorespiratory fitness
• Resistance training
• Functional exercise
• Edema management
• Body mechanics
Lobectomy/Pneumonectomy
PT Implications
• Lobectomy (removal of a lobe)
• Pneumonectomy (removal of an entire lung)

• Most common reason for both procedures are lung cancer

• Positioning
• Tracheal shift towards the lobectomy/pneumonectomy
• If you lie on the side the trachea is shifted to – it will increase the
shift often
• Decreased perfusion,  V/Q mismatch
• Thoracic expansion
• Airway clearance
• Surgical approach
• Chest tubes
• Lung function
Bullectomy/Lung volume
reduction surgery
• Type of surgeries performed in patients with emphysema
• If bullae are greater then 1cm in diameter and occupy >33% of
the hemi-thorax
• Incision is thoracotomy or median sternotomy
• The goal of surgery is to improve expansion and recruitment
of functional lung tissue
• As well as restore the dome shape of the diaphragm
 Surgical Approach PT Implications

Surgical Approach PT Implication

Posterolateral thoracotomy Muscles incised – Lower trap,
serratus anterior, & latissimus
dorsi

Risk of: intercostal nerve damage

& shoulder adhesive capsulitis,
shoulder pain, long thoracic nerve
damage

Lateral thoracotomy Muscles incised – Serratus

anterior &/or intercostals

Risk of: shoulder adhesive

capsulitis, shoulder pain, long
thoracic nerve damage

Anterolateral thoracotomy Muscles incised – Serratus

anterior & pec major

Risk of: shoulder adhesive

capsulitis, shoulder pain, long
thoracic nerve damage

Median Sternotomy Muscles incised – none

Sternum divided along midline

Thoracoabdominal incision Muscles incised – latissimus dorsi,

serratus anterior, external
obliques, rectus abdominis.

Risk of: shoulder adhesive

capsulitis, postural dysfunction,
reduced lumbar and thoracic
ROM, shoulder pain, long thoracic
nerve damage
Monitoring Clinical Responses
to Exercise & Exercise Testing

Dr. Amy J Bayliss DPT, PT

P524: 2/15/21
Cardiovascular Disease Effects
 Primary effect is decreased CO with exercise
 Decreased SV leads to decreased CO
 Affected by preload, contractility, afterload

 Decreased VO2 Max

 Inadequate delivery of O2 to exercising muscles
 Decreased A-VO2 difference
 Decreased extraction of O2 from skeletal muscles
 Limited by decreased redistribution of blood to muscles
 Lower anaerobic threshold
 Endurance is limited

Review
Cardiovascular Disease Effects:
Clinical Picture
 Patient reports dyspnea, fatigue, and increased rate of
perceived exertion (RPE)
 Increased HR for lower workload
 Inability of HR to increase with progressive increase in
workload - blunted response
 Blunted, flat SBP or decreased SBP
 ECG: ST segment depression with exercise
 Onset of 3rd heart sound (S3)

Review
Pulmonary Disease Effects
 Ventilation limitations (dyspnea)
 Decreased minute ventilation
 Impeded expiration
 Limited inspiratory capacity

 Deconditioning
 Cardiovascular
 Peripheral muscle

 Impaired left ventricular function due to hypoxemia

 Reduced pulmonary blood flow, V/Q mismatch
 Impairment of gas exchange
 Chronic hypoxemia can also cause erythrocytosis (increased
blood viscosity)
Review
Pulmonary Disease Effects:
Clinical Picture
 Most common symptom is dyspnea
 Decreased pulmonary reserve
 Decreased vital capacity
 Hypoxemia
 Earlier fatigue
 Perception of increased work of breathing (WOB)

Review
Why monitor clinical responses to
exercise?
 For safety in acute & chronically ill patients
 For diagnosis or to plan treatment
 Collecting baseline data
 Basis for exercise prescription
 To motivate by setting realistic goals
 Provide information about an individual’s level of aerobic
fitness relative to norms
 Assessment of the system during stress to determine safe
level of activity (prevention)
 To track progress
What should you include when
monitoring clinical responses?
 Most useful parameters for PT’s are;
 Patient history
 Heart rate
 ECG monitoring
 Blood pressure
 Respiratory rate
 Rate of perceived exertion
 Oxygen saturation
 Abnormal symptoms & signs
Patient history
 Review of medical records & patient/family interview
 Known coronary risk factors
 Factors associated with risk of pulmonary disease
 For example smoking history
 Other diseases/disorders associated with CVP complications
 Information from physician’s notes
 Diagnostic test findings
 Signs & symptoms suggestive of CVP dysfunction
 Potential contraindications to exercise testing
 Absolute Contraindications to Exercise
Testing/Activity
 Unstable angina or change  Acute pulmonary embolus or
in resting EKG suggesting DVT
ischemia  Acute myocarditis or
 Uncontrolled arrhythmia pericarditis
causing HD compromise (3rd  Acute systemic infection
degree heart block) accompanied by fever >
100oF
 Uncontrolled symptomatic
 Suspected or known
HF dissecting aneurysm
 Uncontrolled asthma  ICP > 20mmHg
 Uncontrolled symptomatic  Review lab values too!
HTN

Consensus from our text and ACSM

 Relative Contraindications to Exercise
Testing/Activity

 Aortic stenosis or left main  Hypertension (severe at rest

coronary artery stenosis but not symptomatic)
 Tachy or brady dysrhythmia  Systolic > 165mmHg
 Known aneurysm  Diastolic >110mmHg
 NM or MS disorder exacerbated  Hypotension
by exercise  Systolic BP < 80mmHg
 Orthostatic hypotension
 Uncontrolled metabolic disease
(diabetes)  Resting HR > 120bpm
 2nd degree heart block  Resting RR > 45
 Unstable asthma  Oxygen saturation < 90%
 Cognitive impairment on room air
 Check lab values too
Consensus from our text and ACSM
Clinical Monitoring: Heart Rate
 Normal exercise response
 Increase of 10 + 2bpm per MET increase in workload for
untrained individuals
 HR response maybe blunted in fit individuals, because of
training effect increasing stroke volume
 A leveling off of HR rise with an increase in workload signals
the approach of VO2max
Clinical Monitoring: Heart Rate
 Abnormal HR exercise responses
 Tachycardia: HR rises more rapidly than expected
 Severely deconditioned or CVD with limited ability to increase SV
 May also be seen in anemic patients
 Bradycardiac: blunted exercise response with increasing
workload
 <8bpm/MET, usually seen in patients on B-blockers
 Chronotropic incompetence: a true bradycardiac response with
a peak exercise HR > 20bpm below age-predicted HRmax
 In patients not on B-blockers, usually due to severe CAD

Heart rate recovery can also be abnormal. A normal response would be

within 2 minutes, the HR should decrease by a minimum of 22 bpm.
Clinical Monitoring: ECG
 Normal exercise response
 Heart should remain in sinus rhythm
 Develop progressive tachycardia in proportion to workload

 Abnormal exercise response

 ST segment depression or elevation
 Exercise-induced arrhythmias
 Heart blocks
Clinical Monitoring: BP
 Normal BP response to exercise
 SBP increases 10 + 2mmHg per MET increase in workload
 SBP peaks at 160-200mmHg then may plateau
 DBP remains within + 10mmHg of starting point
 If performing an endurance activity (workload stays the same)
of > 3-5 minutes, BP should reach a steady state
Clinical Monitoring: BP
 Abnormal BP responses to exercise
 Hypertensive response
 > 10mmHg increase in DBP with activity
 >12mmHg per MET increase of SBP
 SBP >250mmHg, DBP >115mmHg

 Blunted response
 Some increase in SBP but <8mmHg per MET increase in workload
 May occur in individuals on anti-hypertensive medications
Clinical Monitoring: BP
 Abnormal BP responses to exercise
 Hypotensive response
 SBP fails to rise (>10mmHg) or falls with increasing workload
 DBP drops >10mmHg
 Low maximal BP
 A maximal value of <140mmHg suggests a poor prognosis
What about the abnormal BP response
after exercise?
 With a passive (such as seated) recovery
 systolic blood pressure may drop abruptly due to the pooling of
blood in the peripheral areas of the body,
 and there may also be a drop in diastolic blood pressure, during
the recovery phase of exercise due to the vasodilation.
  vagal response
 Light-headed, nausea, fainting
What about the abnormal BP response
after exercise?
 The drop in blood pressure after exercising should not
happen if:
 someone cools down appropriately
 exercises within their limits
 and is well hydrated
 Note, it can also be a sign of heart disease
 Hypertrophic cardiomyopathy which can lead to sudden cardiac
death
 Valve or coronary artery disease
 Referral to MD may be required
Clinical Monitoring: Respiration
 Normal respiratory responses to exercise
 Tidal volume and respiratory rate both increase proportionally
to workload to increase the minute ventilation
 Tidal volume will level off at its maximum (60% of vital
capacity)

 Abnormal respiratory response to exercise

 If it is the limiting factor during exercise
 Exaggerated respiratory response at low levels of exercise
Clinical Monitoring: RPE
 Normal RPE during exercise
 An RPE of 13-14/20 (5/10) represents 70% of VO2max during
a treadmill or cycle exercise test
 An RPE of 11-12/20 (2-3/10) corresponds to the lactate
threshold for both trained and untrained individuals

 Since this is a subjective scale and provides an estimate of

exercise intensity
 Ratings can be influenced (appear abnormal) due to:
 Psychological factors, mood states, environmental conditions,
exercise modes, age
Clinical Monitoring: Oxygen saturation
 Normal response to exercise
 >90%, with no more than a 5% change from the starting value

 Abnormal response to exercise

 <90% in patients without lung disease
 <85% in patients with a chronic lung condition
Clinical Monitoring: Abnormal Signs
& Symptoms
 Angina  Lower extremity
 Dyspnea claudication
 Excessive fatigue or  Nausea, vomiting
weakness  Mental confusion
 Lightheadedness or  Onset of pulmonary
dizziness crackles
 Near syncope or syncope  Onset of third heart sound
 Pallor or cyanosis
 Facial distress
The Angina Scale
 0-4 scale
 1 = mild, barely noticeable
 2 = moderate, bothersome
 3 = severe, very uncomfortable
 4 = excruciating, most severe pain ever experienced
Absolute Indications For Stopping An Exercise
Test or Activity

 ECG: Sustained ventricular tachycardia, new onset of 2nd or 3rd

degree heart block, ST segment elevation > 1.0 mm, rapid AF
 Decrease in SBP > 20 mm Hg with increased workload or more
than a 10mmHg change in DBP
 Moderately severe angina (2 on a 1-4 scale)
 Increasing nervous system symptoms: ataxia, dizziness, syncope,
confusion
 Sign of poor perfusion: pallor, cyanosis, O2 sats <88% in normal
and <85% in lung disease patients
 Technical difficulties monitoring ECG or BP
 Subject’s request to stop
 Relative Indications For Stopping An Exercise
Test or Activity

 Drop in SBP between 10-15mm Hg with increased workload

 Hypertensive response: SBP > 200mmHg and/or DBP >
110mmHg
 ECG changes – 6 -9 PVC’s in a minute, atrial flutter
 Fatigue, SOB, &/or wheezing
 Chest pain: onset of angina (1/4)
 Leg cramps or claudication pain
 Nausea or vomiting
Evaluation process for exercise
testing/activity
 Informed consent
 Patient history
 Identification & risk stratification
 Physical examination (gathering of baseline clinical
monitoring data)
 Test choice/activity decision?
Risk Stratification
 Determine with an exercise screening questionnaire for risk
 Risk stratifications
 ACSM
[http://physiology.md.chula.ac.th/Fitness%20Calculators/Ris
kClass.html]
 PAR-Q
 AACVPR
 AHA
 YMCA online survey

6 cardiac events per 10,000 exercise tests (per ACSM)

Risk Stratification
 Low risk
 No physician supervision required for testing

 Moderate risk
 No physician supervision for sub maximal testing
 Physician recommended for maximal testing

 High risk
 Physician supervision recommended for all exercise testing
Cardiorespiratory Fitness
Test/Activity choice?
 Maximal testing
 Submaximal testing
 Predictive testing
 Performance or field testing
 Non-exercise test

Why do you choose one over the other?

Cardiorespiratory Fitness
Maximal Testing
 Maximal Oxygen Uptake
 VO2 max = CO x a-VO2 difference
 “Gold-standard” for measuring cardiorespiratory fitness;
usually expressed relative to body wt (ml/kg/min)
 Direct measurement – collect/analyze expired gases
(research & athletes)
 Indirect measurement – physiologic responses to maximal
effort in a graded test protocol
Cardiorespiratory Fitness
Submaximal Testing (Predictive)
 A cardiorespiratory fitness test designed so that the intensity
does not exceed 70% HRR (85% of age-predicted max HR)
 Set protocol & end-point
 Indirect measurement of VO2
 Estimated or predicted VO2max + 10-20%
Cardiorespiratory Fitness
Submaximal Testing (Predictive)
 Provides an estimation of the VO2max based on several
assumptions
 Steady state HR obtained for each exercise work rate
 Linear relationship between HR, RR, and workload
 Max HR for a given age is uniform
 VO2 at a given work rate is the same for everyone
 Subject is not on medications that alter heart rate
Cardiorespiratory Fitness Submaximal
Testing (Performance/Field)
 Subset of submaximal exercise tests
 Utilize activities that are everyday functional
 No set end point in regards to stages & vital signs in protocol
 Percentile value tables for age and gender are typically
available
 Include:
 2 minute step test
 6 minute walk test
 Run tests
 Shuttle tests (pyramid designs are newer)
Cardiorespiratory Fitness
Submaximal Testing (Non-exercise)
 Based on research findings in exercise physiology
 Indicating maximal oxygen uptake is;
 negatively related to age & body composition
 positively related to exercise habits
 Based on these variables there are multiple regression
equations
 There are 2 that are well researched
 University of Houston Non-Exercise Test (VO2)
 Jurca et al (CV Fitness – MET level)
 Exercise Test Selection
Goal: Produce a significant level of exercise
stress without physiologic or biomechanical
strain
Factors to consider
 Acutely ill vs subacute or chronic pathology
 Primary and secondary pathologies and their effects
 Age, weight, cognitive status, mobility, assistive devices, work/school/home
environment, client’s goals
 Population for which test was developed
 Degree of reliability, validity, sensitivity
 High risk client may require MD specialist, specialized setting, emergency
services available
Standardization
 To increase reliability of results
 Calibrate equipment
 Practice session, rest, then test**
 Verbal encouragement should be standardized
 Standardize measurements: stable baseline, during test, and
recovery
 HR, BP, RPE
Where does our acutely ill patient fit?
 Are we exercising or performing therapeutic activity?
 Activity (aka Mobilization )
 Goals are to:
 Optimize oxygen transport
 Provide a gravitational and exercise stimulus
 Therapeutic & prescriptive application of low intensity exercise in clients
with a CP pathology who are usually acutely ill
 Exercise
 Prescription of activity to manage patients with subacute and chronic CP
pathology
Is your patient ready for
mobilization?
 Parameters indicating a lack of readiness for PT interventions
 Pulmonary measures
 SaO2: <90% or experiences a 10% oxygen desaturation below resting
 Respiratory rate: > 30 breaths/min
 PEEP: >10cm H2O
 FiO2: >60%
 Cardiovascular measures
 New onset of angina-type chest pain
 New ventricular arrhythmia developed
 Systolic BP: <90 or >180 mmHg
 Diastolic BP: >120 mmHg
 Resting heart rate: <50 or >140bpm

Nordon-Craft et al. PTJ. 2012;92:1494-1506.

Is your patient ready for
mobilization?
 Parameters indicating a lack of readiness for PT interventions
 Laboratory values
 Hematocrit <25%
ADL’s with assistance, isometrics and light AROM
 Hemoglobin <8 g/dL
 Platelets <10,000/mm3 No exercise particularly if fever present
 Anticoagulation INR>3.6 No exercise
 Metabolic measures
 Glucose levels in non-diabetic patients <70 or >200 mg/dL
 Glucose levels in diabetic patients
o >300mg with ketones (absolute)
o >300mg with no evidence of ketoacidosis (relative)
 Cognition
 Can patient follow one step instructions
Mobilization choices
 One flight of stairs (5 MET’s)
 Ambulation (2mph in hallway = 4 MET’s)
 ADL’s (3 MET’s)
 Standing (2 MET’s)
 Dangling legs on side of bed (< 2 MET’s)
 Turning in bed (< 2 MET’s)
 Bed exercises (< 2 MET’s)
Remember assistive
devices & safety.
Mobilization – Exercise Test choice
 Six minute walk test is the gold standard
 Accuracy of the procedure dictates the reliability
 The basics
 Flat corridor, 20m in length
 Standard patient instructions
 Resting vitals
 Alter vitals gathered depending on primary pathology
 Final BP & distance
 Compare to norms in the literature (there are norms for different
medical conditions)
Exercise testing in Subacute or
Chronic Patients
 For the next few slides we will consider the;
 Mode
 Test interpretation
 What to ensure before your client leaves
 Pathology influences on exercise testing
Exercise Testing Modes: Treadmill
 Allows max or submax testing
 Functional activity so familiar to most people
 Can get artifact with HR, BP monitoring
 Predicted VO2max 4-8% higher than cycling

Modified Naughton treadmill protocol

Time 0 3 6 9 12 15 18 21
(min)
Speed 2 2 2 2 2 3 3 3
(mph)
Grade 3.5 7 10.5 14 17.5 12.5 15 17.5
MET 3 4 5 6 7 8 9 10
Exercise Testing Modes:
Cycle Ergometry
 Max or submax
 Use for those with a limited
ability to ambulate, poor
balance
 More ease and stability with
HR, BP monitoring
 Less familiar, increased
localized muscle fatigue
 Predicted VO2 max 4-8%
lower than treadmill
Exercise Testing Modes:
Upper Extremity Ergometry
 Max or submax
 Work increments of 10 Watts /2-3 minutes, 60 rpm
 Seated with handle adjusted to shoulder height
 BP more difficult to measure - either with one UE dropped
or immediately after test
 Uses smaller muscles increasing RR more rapidly
 Useful for LE impairment, SCI, amputee
 Peak HR is 10-15 bpm lower than bicycle ergometer
 VO2 max is 20-30% lower than treadmill testing
Exercise Testing Modes:
Step Test
 Submaximal performance
 Small space, portable
 Test people simultaneously
 Increased local muscle fatigue
 More unfamiliar
Exercise Testing Modes:
6 minute walk test
 Submaximal performance
 Small space & limited equipment required
 Test people simultaneously
 Safe test
 However limited utility to older patients and those with a
pathology
Test Interpretation
 Information you gather during the test is used to calculate
VO2 max via:
 Nomograms
 Metabolic equations
 Tables of normative values (age/gender)
 Measurements inform us about exercise response
 Compare to norms by age, sex, medical condition
 Compare to threshold marker of disease
 Repeat tests for comparison - note trends for improvement
or decline of individual
Test Interpretation
 Results of a submaximal test can’t be directly equated to a
maximal test

 “The submaximal test results are ______. The same value

for a maximal test would place this individual at _____
percentile for age and sex per ACSM norms.”

All values should return to within 10% of baseline

prior to subject leaving the therapy room/clinic.
Exercise Testing:
Cardiovascular Disease
 Used to investigate:
 Myocardial ischemia most common indication
 Functional assessment post MI
 Pre-operative evaluation
 Ability to return to work
 Sequential tests to follow disease progression
 Evaluation of disability
Exercise Testing :
Cardiovascular Disease
 Increased use of ECG monitoring
 End points: angina, dyspnea
 Knowledge of pacemaker type
 Required before participation in Cardiac Rehab Program
 HR/BP responses in cardiac transplant patients are not
reliable - denervated heart (to be discussed more in the
transplant lecture)
Exercise testing options for:
Post-cardiac surgery/MI/Angina/Silent Ischemia
 Must have ECG & close hemodynamic monitoring in
 Contraindications and indications to stop the test must be
closely observed
 Low-level submaximal exercise testing (generally ≤ 6 METs)
 6 MWT
 Standardized cycle or treadmill tests
Modified Sheffield-Bruce submaximal protocol
Stage Speed (mph) Grade (%) Time (min)
1 1.7 0 3
2 1.7 5 3
3 1.7 10 3
4 2.5 12 3
Exercise testing:
Atrial Fibrillation
 Maximal test is typically used
 Standardized treadmill tests are often used
 Heart rate is not a reliable measure in this patient
 RPE used to determine end point of the test
Exercise testing:
Valvular Heart Disease
 Aortic stenosis is a relative contraindication
 You must listen to heart sounds
 Exercise testing if not contraindicated, will indicate how the
valve disease is affecting someone functionally
 Low level submaximal testing only
Exercise testing:
Congestive Heart Failure
 Valuable to characterize the severity of CHF
 Symptoms often observed under 5 MET’s so lower level patient
 Exertional hypotension is common
 6 minute walk test is very effective in place of a graded
treadmill test
Summary: Exercise Testing
Cardiovascular Disease
 Risk stratification must be done
 Monitor HR, BP, RPE, and possible symptoms
 angina, dyspnea
 Inpatients at greater risk due to proximity of event, consider
submaximal performance tests first
 Additional monitoring for increased risk: ECG
Exercise Testing:
Pulmonary Disease
 Used for evaluation of:
 Exercise-induced bronchospasm (EIB)
 Pre-operative evaluation
 Determine need for supplemental O2
 Sequential tests to follow disease progression
 Evaluation of disability
 Dyspnea most likely reason for termination
 Arm ergometry not the best choice for mode of
testing: many patients with COPD c/o more dyspnea with
UE vs LE exercise
 Increased use of pulse oximetry
Exercise Testing:
COPD & Restrictive Dysfunction
 Consider cycle, treadmill or 6 minute walk test
 Cycle is the easiest to control work rate & measure oxygen
saturation
 Typical protocol is 3 min of unloaded pedaling, followed by
ramp increase in work rate of 5, 10, 15, or 20 W
 May need supplemental oxygen to maintain above 85% (we
administer oxygen once it drops below 90%)
Exercise Testing:
Asthma
 In a person with well controlled asthma, exercise testing has
no restrictions
 Unstable asthma – relative contraindication
 Uncontrolled asthma – absolute contraindication
 For exercise induced asthma (EIA)
 Intensity to 75% of predicted max HR
 Duration 8 min at that intensity
 Measurement of airflow obstruction 6-8 min after cessation of
exercise
 How do you measure airflow obstruction?
 Peak Flow
 Peak flow meter
 Measures amount of air
that can be expelled from
the lungs
 Peak flow rates will drop if
airways are narrowing due
to asthma
 Inexpensive ($25-40)
 Quick
 Device is small & portable
Exercise Testing:
Cystic Fibrosis
 6 minute walk test is appropriate in adults or a standardized
submaximal cycle or treadmill test
 May need to use oxygen during the test if hypoxemia is
present at rest or during early stages of the test
 In children, it is recommended protocols should be
individualized or use protocols specific to children
 New research is pointing to 6MWT, 12MWT or a run test in
children with CF
 Rather than standardized exercise tests on treadmills/bikes

Radtke et al. Pediatric Transplantation. 2011;15:294-99.

Summary: Exercise testing in
Pulmonary Disease
 Monitor HR, RR, RPE, O2 sats, and possible symptoms
 dyspnea
 Limitation is likely to be dyspnea
 How far can O2 sats drop before exercise should be
terminated?
Percentage of maximal heart rate (MHR)
 Method of monitoring exercise intensity
 Can be determined by a maximal functional capacity
test or by the age-predicted maximal heart rate
formula (220 – age)

Formula:
Target heart rate (THR) = 220 – age x desired intensity %

Self study
Heart-rate Reserve (HRR)
 The result of subtracting resting heart rate (RHR)
from maximal heart rate (MHR)
 Represents the working range between resting and
maximal heart rate within which all activity occurs

Formula: HRR = (220 – age) – RHR

Self study
 Karvonen formula
 The mathematical formula that uses HRR to determine target
heart rate (THR)
 A common mistake is forgetting to add back in the RHR

Formula: HRR x desired intensity % + RHR

Self study
Metabolic equivalent (MET)
 A simplified system for classifying physical activities
where 1 MET = resting O2 consumption
 Resting O2 consumption equals approximately 3.5
mL/kg/min

Formula: 1 MET = 3.5 mL/kg/min

Self study
 Rating of perceived exertion (RPE)

 Developed by Gunnar Borg,

this scale provides a standard
means for subjective self-
evaluation of exercise intensity
level
Original scale: 6–20

 Revised (modified) scale: 0–10

Self study
P524: Class ID#10
02/22/21

Exercise Prescription

Dr. Amy Bayliss DPT, PT

Benefits of Routine Exercise
 Decrease myocardial  Decrease serum
oxygen cost triglycerides
 Decrease resting HR and  Decrease risk of heart
BP disease
 Increase maximal oxygen  Decrease body fat
uptake  Improve glucose tolerance
 Decrease minute  Increase HDL cholesterol
ventilation
 Decrease in
depression/anxiety
Benefits of Routine Exercise
 Decreased platelet  Improves sleep
aggregability  Decreased impotence
 Weight management  Improves ability to
 Offsets other risk factors concentrate
(smoking)
 Improves self esteem
 Manages stress
Principles of Training
 Overload Principle:
 Stress the system to strengthen it
 Increase intensity, frequency, and/or duration
 Repeated exposure to stress causes adaptation
 Specificity Principle: (does NOT work for low lvl pt’s)
 Training in one mode doesn’t necessarily carry over to other
modes
 Train for endurance and/or strength
 Cross training has wider application to everyday activities and
sports
Principles of Training
 Individual Differences Principle
 Everyone advances at a different pace
 Exercise prescription is not “one size fits all”
 Reversibility Principle
 Benefits will not be sustained if activity is not continued
 Benefits will be apparent in 6 weeks, but effects can diminish in
2 weeks and disappear in 2-8 months
 No 2 days off in a row for low level patients
 Use it or lose it!
Components of Cardiovascular Exercise
Prescription: Mode
 Aerobic: Increase VO2 max
 Large muscle groups, rhythmic, continuous
 Walking, running, cycling, swimming, dancing, cardio-machines,
cross-country skiing, jump rope
 Cross-training reduces chance of overuse injury, uses greater
number of muscle groups
 Consider level of skill
 Consider goals of exercise program
Components of a Cardiovascular Exercise
Prescription: Duration
 Duration
 Length of exercise session
 Interplay with other components
 Continuous or intermittent
 If intermittent each session should be at minimum 10 minutes
 The goal is 30-60 minutes of activity accumulated throughout
the day
 Inpatient or low fitness level
 Start with intermittent and progress to continuous
 Start with 2 short sessions and progress to 1 long session
 Intervals within a session maybe as short as 2-5 minutes
Components of a Cardiovascular Exercise
Prescription: Frequency
 Frequency
 How often exercise is performed
 Interplay with other components
 Patients who are deconditioned should do shorter sessions,
but more often
 6-7 times per week if low-mod intensity
 3-5 workouts per week if sufficient intensity
 No more than 2 days off in a row
Components of a Cardiovascular Exercise
Prescription: Intensity
 Intensity
 Measurement of effort
 Interplay with other components
 Lower intensity & longer duration (fewer injuries) vs. higher intensity
& shorter duration
 ACSM: 55-90% of Max HR or 40-85% of HR reserve (fits wide
variety of individuals)
 40% HRR if inpatients/sedentary
 85% HRR if very conditioned
 60-80% HRR for most people
 Can measure with METS, target HR, RPE, “Talk test”
Intensity: HR Target (Karvonen Formula)
[(HRmax – HRrest) x 60% to 80%] + HRrest = Target HR Range

 220 – age = Max HR for age

 Max HR – resting HR = HR reserve
 HR reserve x 60% to 80% depending on fitness level (as
low as 40-50% for inpatient/low fitness)
 Add back in resting HR
 [(220 – 36 yrs.) – 66 bpm] x 60% + 66 bpm = 137.0 bpm
 [(220 – 36 yrs.) – 66 bpm] x 80% + 66 bpm = 160.0 bpm
 Target HR Range = 137 to 160 bpm
Intensity: Rating of Perceived Exertion (RPE)
 Uses
 Adjunct to HR (shown to correlate, but not always direct
relationship)
 When difficulty palpating/counting pulse
 When HR response blunted: Beta blocker, heart
transplantation (sympathetic and parasympathetic nerve supply
is disrupted)
 For most people use “somewhat hard to hard” 12 to 16
(6-20 scale) or 3 to 6 (0-10 scale)
 May need to use lower intensity level based on symptoms
or fitness level
RPE Scales
RPE Scales - clinical application
Intensity: Talk Test

Level 1 No problem; easy to talk.

Can whistle or sing.

Level 2 Able to talk a little; can’t whistle or sing.

This is where you should be with moderate
activity.
Level 3 Too short of breath to talk.
You need to slow down or take a break.
Vigorous activity.
What are pathophysiological reasons
for your choice of exercise!!

Inflammation
Mechanical deformation
Nutrition
Blood flow
Cardiovascular variables
Weight loss
Muscle length
What are pathophysiological reasons for
your choice of exercise!!
 Pendular exercise for the   blood flow & nutrition,
shoulder in SAI  inflammation & pain
 Repeated lumbar  Centralize disc thru
extension in HNP mechanical loading
 10 minutes of walking,  Decrease stress, decrease
twice daily resting HR and BP….
Adherence to Exercise Program
 Most difficult part of any exercise prescription
 Start with where the patient/client is, not where you want
them to be; move one stage at a time
 Where are they in the stages of change?
 What activities are they interested in?
 How can activity be incorporated into their day?
 What motivates them?
 Set up reward system
 Follow up and encouragement
 Educate about the benefits for them
Duncan et al. (RCT)
 Sedentary adults
 Exercise prescription needed to improve cardiovascular
disease risk factors?
 5 groups
 Exercise counseling conditions (4 groups)
 Physician advice group (1 group)
 Outcomes
 Cardiorespiratory fitness
 Cholesterol
Duncan et al. (RCT)
 Exercise counseling groups were;
 Mod intensity-low frequency
 Mod intensity-high frequency
 Hard intensity-low frequency
 Hard intensity-high frequency
 Constant - the exercise was 30 minutes of walking.

Moderate = 45-55% HRR

Hard = 65-75% HRR
Low = 3-4 days/wk
High = 5-7 days/wk
Duncan et al. (RCT)
 They found;
 To improve CV fitness, you need moderate intensity 5-7 d/wk,
or hard intensity 3-4 d/wk
 To effect HDL cholesterol levels, you need hard intensity and
high frequency
 Physician advice group made no gains
 So patients need structure with exercise
Phases of Exercise
 Warm Up
 Especially important in morning, elderly, heart transplant patients
 Intensity and length of warm up depends on fitness level
 Exercise Session
 Cool Down
 Best time for stretching because muscles are warm
 Active vs. passive
 Warm up and Cool down  reduces strain on the heart
Exercise Prescription Parameters for Aerobic
Benefits in Healthy People
 Mode (Type)
 Rhythmic activity involving large muscle groups
 Intensity
 70-80% of HRR
 Duration (Time)
 20-40 minutes
 Frequency
 3-5 times a week
Exercise Programming in Cardiovascular or
Pulmonary Patients
 Cardiac or Pulmonary Rehab (to be discussed in another
lecture)
 Programming without formal exercise stress testing for
cardiac patients
 A starting point for programming with cardiac and
pulmonary disease
 Programming for specific disease processes with case
scenario practice
Exercise Prescription for cardiac patients
without an entry exercise test
 Warm-up, 5-10 mins
 Muscular fitness = resistance exercise, 10-20 mins, 2
days/week
 Cardiorespiratory fitness
 Frequency: 1-2 bouts per day, 5 days per week
 Duration: 30-45 minutes total
 Intensity: RPE 11-13, RHR +20 bpm
 Cool down, 5-10 mins (includes stretching)
Basic Aerobic Exercise Prescription for
Patients with Cardiac Disease
 Intensity
 40-80% of HRR*
 RPE 12-16 (on 0-20 scale) or 3-6 (0-10 scale)
 Duration
 20-40 minutes continuous
 Three 10-minute sessions per day
 Frequency
 < 2-3 METs short sessions several times daily
 3-5 METs once daily
 5-8 METs, 3 to 5 times weekly
Basic Aerobic Exercise Prescription for
Patients with Pulmonary Disease
 Intensity
 40-70% of HRR*
 RPE 11-13 (on 0-20 scale) or 2-4 (0-10 scale)
 Lower than cardiac disease to prevent pulmonary HTN
 Duration
 20-30 minutes continuous
 Or three 10-minute sessions per day
 Frequency
 Preferably 5 days per week
 Progress parameters more slowly, at 6-8 weeks
Exercise Prescription in Specific Disease
Processes
 Cardiac disease  Pulmonary disease
 Angina  Asthma
 Myocardial infarction  COPD
 Coronary artery bypass  Restrictive Lung
graft Dysfunction
 Valvular heart disease
 Congestive heart failure  Pulmonary Artery
 Hypertension Hypertension
 Atrial fibrillation
Exercise prescription: Angina
 Intensity must be below the patient’s ischemic threshold
 Target heart rate of 10-15 bpm lower than the heart rate
where ischemia/angina is present
 Progression must be gradual with ongoing communication
with patient about episodes of angina
 Repeat formal exercise tests with an EKG are
recommended to adjust maximum exercise heart rate
Exercise prescription: Myocardial Infarction
 No exercise training for one week post an uncomplicated
MI
 Formal exercise test is recommended in all cases
 Intensity is started on the low end
 40-60% of HRR or 11-13 RPE
 Duration 20 minutes, 3-5 days a week
 Progression, 40 minutes 3-5 days per week, 60-70% of
HRR
 Cannot push up to 80% since you have damaged myocardium
that will not heal
Exercise prescription: CABG
 No exercise training for two weeks post an
uncomplicated surgery
 Formal exercise test is recommended in all cases
 Intensity is started on the low end
 40-60% of HRR or 11-13 RPE
 Duration may be 20 minutes 3-5 days a week
 Progression, 40 minutes 3-5 days per week, 60-80% of
HRR
 Now the heart is fixed (flow repaired), so we can push the
heart harder compared to an MI
Exercise prescription: Valve disease
 Formal exercise test is recommended in all cases
 Intensity typically remains at the low end unless they have
surgery and a valve replacement
 50-60% of HRR (or VO2max) and 11-13 RPE
 Duration 20 minutes, 3-5 days a week
 Progression is very slow, time rather than
intensity
 Time increased to 45-60 minutes rather than HR or RPE
Exercise prescription: HF
 Exercise testing is recommended (6MWT is used
frequently)
 Intensity has a large range depending on how
deconditioned someone is
 40-70% of HRR and 11-16 RPE
 Cant stress a heart too much, avoid 80%
 Duration recommendation is daily
 Progression is as tolerated by the patient
 Better outcomes occur if a patient can perform
activities in 6-10 MET range
Case Study: Hypertension
 A 58-year-old male was interested in starting an exercise
program. He had no health complaints but did have
hypertension and hyperlipidemia. He is also overweight.
He had been sedentary for years, did not smoke, and had
a family history of premature atherosclerosis.
 His medications are: Atenolol, Simvastatin.
 Atenolol is a beta-blocker.
 Simvastatin is a statin used for lowering cholesterol (LDL
levels)
Case Study: Hypertension
 S: “I think I should start an exercise program”
 O: Vitals: Height: 6’0”, Weight: 210lb BMI: 29.4 kg/m2
 HR: 58 beats/min BP: 144/92 mmHg
 Normal heart sounds.
 Graded exercise test (Bruce protocol)
 Terminated at 6 minutes because of leg fatigue.
 Peak RPE: 18/20
 Peak HR: 136 beats/min Peak BP: 186/90 mmHg
 ECG: no significant ST changes, occasional PVC’s
 A: Impaired aerobic capacity associated with deconditioning.
Case Study: Hypertension
 P: Develop an appropriate and safe exercise plan to
improve cardiovascular fitness.
 Considerations:
 Patient is on a beta-blocker
 The time interval between taking his atenolol and exercise training could
alter CV response to exercise, therefore testing/re-testing and exercise
sessions should be attempted at the same time of day
Case Study: Hypertension
Mode Frequency Duration Intensity Progression

Aerobic 3-5 days/wk X2 10 minute RPE 11-13 Build to 5-7

sessions 50-70% HRR days/wk
Since pt. is on
20-40 minutes beta blocker,
total per day cant take HR

Warm up Before & after 10 minutes RPE < 10/20 Maintain

Cool down
Case Study: Atrial fibrillation
 A 54-year-old male had a 10-year history of intermittent
AF before it became chronic AF. He had a history of post-
traumatic stress disorder, depression, and lumbar
laminectomy. He also had a 30 pack-year history of
smoking, but has stopped smoking.
 Medications: Warfarin, Metoprolol
 He is on warfarin to minimize the risk of emboli
 Metoprolol is a beta blocker
Case Study: Atrial fibrillation
 S: “I want to be able to play with my grandchildren”
 O: Vitals: Height: 6’0”, Weight: 177lb, BMI: 24.8 kg/m2
 HR: 86 beats/min, irregular BP: 135/96 mmHg
 INR: 1.88
 ECG: AF with ventricular response of 86 bpm
 Graded exercise test (Naughton protocol)
 Peak exercise: 5.5 METs (68% of predicted) Peak RPE: 18/20
 Termination from leg fatigue.
 Peak HR: 155 bpm
 Peak BP: 186/94 mmHg
 No ECG changes or symptoms of cardiac ischemia
 A: Impaired aerobic capacity associated with deconditioning
Case Study: Atrial fibrillation
 P: Develop an appropriate and safe exercise plan to
improve cardiovascular fitness.
 Considerations:
 Patient is on a beta-blocker
 The time interval between taking his atenolol and exercise training could
alter CV response to exercise, therefore testing/re-testing and exercise
sessions should be attempted at the same time of day
 Patient has chronic AF so using HR is not a valid measure for exercise
testing or prescription
 We must calculate intensity using MET’s or we can use RPE
Case Study: Atrial fibrillation
Mode Frequency Duration Intensity Progression

Aerobic x4 wk 20 minute RPE 11-14  Increase

bout duration to
5 METS 40%-70% 40 minute
HRR bout
 RPE 12-15

Warm up Before & after 10-15 min RPE < 10/20 Maintain
Cool down
Intensity using METs and VO2max
 MET Method
 1 MET = 3.5 ml/kg/min
 VO2max = 35 ml/kg/min = 10 METS at peak exercise
 50% of 10 METS = 5 METS
 75% of 10 METS = 7.5 METS
 Find activities that correspond to these values
Is resistance exercise safe in patients
with HTN/CAD?
 YES and NO??
 There are some reports of aneurysm rupture &
subarachnoid hemorrhage rupture during resistance ex.
 Studies have found resistance exercise increases systolic
BP considerable more in hypertensives compared to
normotensives
 This difference is greater when individuals are exercised to the
point of exhaustion even at lower-intensity (40% 1RM)
 Safest prescription is:
 Low intensity (40-60%1RM)
 Low reps (6-12 reps)
 Long rest periods between sets (90-180 seconds)
De Souza Nery et al. Clinics. 2010
Exercise prescription: Asthma
 In individuals with exercise induced asthma an exercise
test has likely been performed to determine diagnosis
 Exercise recommendations in stable asthma are very
similar to healthy adults
 Intensity
 60-80% of HRR
 Duration
 20-45 minutes
 Frequency
 3-5 times a week
Exercise prescription: COPD &
Restrictive dysfunction
 Starting point is at the lowest for intensity
 Intensity
 40% of HRR, RPE 11/20
 Duration
 30 minutes
 Frequency
 3-5 times a week
 Progression at approximately 6-8 weeks, RPE 13/20, HRR
moving to 60%-70%
 Likely limited by SOB
Case Study: Pulmonary hypertension
 Pulmonary hypertension
 Pulmonary hypertension is the narrowing of the pulmonary
arterioles within the lung.
 The narrowing of the arterioles creates resistance and an
increased work load for the heart. The heart becomes enlarged
from pumping blood against the resistance.
 Exercise with pulmonary hypertension historically
 Typically patients have exercise restrictions placed on them
 Depending on the stage of disease, even light exercise may be
discouraged from physicians
 Isometrics and weight training are strongly discouraged
Case Study: Pulmonary hypertension
 Exercise with pulmonary hypertension now
 Studies are showing improvement in:
 Quality of life
 Function
 6 MWD
 Exercise capacity
 Peak oxygen consumption
 Oxygen saturation
 It is safe, the primary adverse event has been syncope (~4% of
patients)
 HRR was 60-80%

Grunig et al. Eur Respir J. 2012;40:84-92.

Case Study: Pulmonary hypertension
 Read through this real patient exercise test and try and
make your own conclusions
 After making your own conclusions come and get a copy
of the discussion of her test
 Come up with a CV exercise plan
 Mode
 Frequency
 Duration
 Intensity
 Progression
Case Study: Pulmonary hypertension
Mode Frequency Duration Intensity Progression

Aerobic - 6 days/wk 45 min 70-75% HRR Speed of

Walking walking

Warm up Before & after 10-15 min RPE < 10/20 Maintain
Cool down
Take Home Points
 You should be able to state the benefits of CV exercise.
 You should be able to prescribe CV exercise for a;
 A healthy adult
 Cardiac patient without an entry exercise test
 Basic aerobic prescription for cardiac & pulmonary patients
 In a given case scenario formulate a CV exercise prescription
that is safe and effective
Cardiopulmonary Assessment

Heart auscultation
• Patient position
 supine or sitting for all areas
 left side lying for listening for the mitral area
• Equipment:
 cardiac quality stethoscope
o to listen to lower frequency sounds (S3 & S4) hold the
stethoscope with light pressure, higher frequencies (S1 & S2)
firmer pressure.
 regular stethoscope with a diaphragm and bell
o the diaphragm detects higher pitched sounds and the bell
accentuates lower frequency sounds including gallops (S3 & S4)
• Procedure
 Listen at all 4 locations on each other (avoid listening over clothing)
 Then listen to the pre-recorded sounds in Canvas
Aortic = 2nd intercostals space, close to the right side of the
sternum.
Pulmonic = 2nd intercostals space to the left side of the
sternum
Tricuspid = lower left sternal border at 4th/5th intercostals
space (large breasts can get in the way)
Mitral/apex = 5th left intercostals space, medial to mid
clavicular line

(Acronym = All patients take meds)

Table 1: Normal heart sounds (lub dub)
Heart sound Auscultation site Cause
S1 (lub) Mitral or tricuspid Closure of mitral & tricuspid valves.
(firm pressure) Contraction of ventricles.
S2 (dub) Aortic or pulmonary Closure of aortic & pulmonary valves.
(firm pressure) End of ventricular systole & start of ventricular
diastole.
Table 2: Abnormal heart sounds (gallops)
Heart sound Auscultation site Cause
S3 (lub dub dub) Mitral In children and young people it is considered a normal
(light pressure or Bell side physiologic third heart sound.
Follows S2. for cardio stethoscope) In older, inactive patients > 40 years old, it is a sign of
ventricular dysfunction, tachycardia or mitral
regurgitation. Seen commonly in CHF.
Comes on at the end of PT Tx, sign that heart is
struggling
S4 (la lub dub) Mitral for left S4 Left sided S4  severe hypertension, aortic stenosis,
Tricuspid for right S4 cardiomyopathies, and left ventricular myocardial
Before S1. infarctions.

P524; 2021 Page 1

 (light pressure or Bell side Right sided S4  pulmonary stenosis, pulmonary
for cardio stethoscope) hypertension, or right myocardial infarction.
*Murmurs and friction rubs may be heard but they are outside of the scope of our practice.
S3 in young active individuals is considered normal. Perform a CV screen w/ subjective
questioning, vital signs. Refer if symptomatic.

Lung Auscultation
• Patient position
 Sitting
• Procedure
 Expose area, drape as needed
 Instruct patient how to breathe deeply through an open mouth
 Listen for one full breath in each location
 Auscultate over entire lung space systematically, right to left, front to
back (do not do all right and then all left, do alternations)
 Then listen the pre-recordings in Canvas from our simulator for normal
and abnormal sounds listed below
• Safety: check sitting balance is adequate, be vigilant for hyperventilation

Table 3: Normal Breath Sounds Resonant sound that is loud and low pitch
Breath sound Duration Pitch/Intensity Location Abnormal finding
Expanded upon in
Table 4.
Bronchial (orange) Inspiration<expiration High pitched, Manubrium Abnormal if heard
(may be referred Pause between loud, tubular. (or over over lung fields, sign
to as tracheal inspiration & Louder on trachea) of consolidation in
since they are very expiration. expiration. lungs.
similar)
Bronchovesicular Inspiration=expiration Moderate pitch, Bronchi. Abnormal if heard
(blue) No pause. medium Posteriorly over lung fields, sign
intensity. between of consolidation in
scapulae. lungs.
Anteriorly,
ICS #1 & #2.

P524; 2021 Page 2

 Vesicular Inspiration>expiration Low pitch, soft, Peripheral If absent or
(red) No break between rustling lung fields decreased in the
inspiration and peripheral lung fields.
expiration.
*ICS = intercostal space

Table 4: Abnormal breath sounds

Abnormal breath Pitch/Intensity Location Cause PT Implication
sounds Duration
Bronchial Higher pitched, Peripheral lung Consolidation or Airway clearance
(aka tubular louder on tissue. secretions. techniques for
breath sounds) expiration. Pneumonia (rusty secretions.
colored sputum)
Pleural fluid.
Decreased Normal vesicular Peripheral lung Hyperinflation Breathing exercises.
sounds are tissue. (COPD)or
further reduced. hypoinflation
(atelectasis, pain,
pleural effusion).
Absent No sounds are Anywhere in Pneumothorax. Airway clearance,
audible. lung fields. Larger pleural breathing exercises.
effusion. Severe If new onset or
hyperinflation. patient distressed,
Obesity. notify MD, may need
ED.
Consolidation: present of exudate in alveolar space, present instead of air.
Table 5: Additional lung sounds
Adventitious/ Duration Pitch/Intensity Location PT Implication
Extrapulmonary Insp/exp
Breath sounds
Stridor Continuous Extremely high Upper airway Heard with croup,
Inspiration & pitched obstruction epiglottitis, or after
expiration. extubation. Can be
(louder on sign of something
inspiration) lodged in the
bronchus, or epiglottis
interference.
Wheeze Continuous 1. High pitched Airway If on inspiration &
Expiration 2. Low pitched obstruction, expiration,
commonly, but (aka rhonchi) typically obstruction is greater.
may be bronchi. Bronchodilator
inspiration too. required.
If worsening, medical
assist required
possible asthma
attack.

P524; 2021 Page 3

Crackles Discontinuous Wet or coarse Lung fields Wet – pulmonary
(A.k.a. Rales) Inspiration Dry or fine edema or secretions.
mostly. (sounds like Dry – atelectasis.
bubbles
bursting)
Pleural rub Discontinuous Grating, creaking Lower lateral Pleural inflammation,
Expiration or sound. chest walls. notify MD if new.
inspiration.
Voice sounds/transmission tests (test done on posterior aka back of pt.)
• These tests are only used in special situations. All these tests become abnormal
when the lungs have a consolidative pathology. Tested on boards, not done
clinically, replaced by chest x rays
 Tactile Fremitus
o Palpate using the ulnar side of the hand generally.
o Ask the patient to say "ninety-nine" several times in a normal
voice.
o You should feel the vibrations transmitted through the airways to
the lung and to your hands in normal circumstances.
o Increased tactile fremitus (vibration) suggests consolidation
(compare left and right) of the underlying lung tissues.

Sequence of tactile fremitus examination

 Bronchophony (increased vocal transmission)

o Ask the patient to say "ninety-nine" several times in a normal
voice.
o Auscultate several symmetrical areas over each lung.
o The sounds you hear should be muffled and indistinct.
o Louder, clearer sounds are called bronchophony, due to
consolidative pathology.

 Whispered Pectoriloquy
o Ask the patient to whisper "ninety-nine" several times.
o Auscultate several symmetrical areas over each lung.
o You should hear only faint sounds or nothing at all.
o If you hear the sounds clearly this is referred to as whispered
pectoriloquy.

P524; 2021 Page 4

  Egophony
o Ask the patient to say "ee" continuously.
o Auscultate several symmetrical areas over each lung.
o You should hear a muffled "ee" sound.
o If you hear an "ay" sound this is referred to as "E -> A" or
egophony

Palpation
• Tracheal shift assessment
 Have the patient sitting & flex the neck to relax the SCM
 Then determine if there is an equal distance between the trachea
and sternoclavicular joints
 Contents of the thorax can shift to the side of decreased pressure
 Left tracheal shift due to
o left pneumonectomy
o left lobectomy
o left sided atelectasis
o untreated right tension pneumothorax
o right pleural effusion
o right sided tumor
*Signs will be opposite in Right tracheal shift
• Chest wall pain or discomfort
 Further investigate observed abnormalities, palpate areas of tenderness
& muscle tone
• Respiratory excursion
 Determine if your patient is a diaphragmatic breather or utilizing
intercostals and accessory muscles.
 Normal thoracic expansion in adults varies with age & sex (typically
between 3-5 cm).
o If you are using a measuring tape then measure at the
axillary(upper chest) level and xyphoid process(lower chest) level
at the point of maximum inspiration and maximum expiration.
 Or symmetry can be assessed via palpation
o Palpate upper, middle, and lower lobe motion

• Evaluation of circulation
 Carotid pulse

P524; 2021 Page 5

 o Palpate by sliding the second and third finger of either hand along
the side of the trachea at the level of the thyroid cartilage
(i.e.Adams apple). - do not push on both sides simultaneously as
this may compromise cerebral blood flow.
o The carotid pulsation is palpable just lateral to the groove formed
by the trachea and the surrounding soft tissue, the pulsations
should be easily palpable.
o Diminution may be caused by atherosclerosis, aortic stenosis, or
severely impaired ventricular performance.
Percussion of the Chest
• A percussion examination is used to detect changes in lung density and
diaphragmatic excursion
• It produces sounds that can be heard
• Percussion will set tissues in motion only about 5-7cm into the chest.

Table 6: Percussion
Sound Description Example location
Resonance Loud, low pitch, longer Normal lung
duration.
Dullness “thud” Low amplitude, medium Normal sound over the liver. In the lung it indicates
pitch, short duration. atelectasis, consolidation or a pleural effusion.
Hyperresonant Very low pitch, Heard over tissue with decreased density, lungs with
or tympanic prolonged duration. emphysema.

• Patient position
 Patient in supine for percussion on the front of the chest
 Patient in sitting for percussion of the back
• Procedure
 Firmly rest the first joint of the middle finger of one hand on the patient's
chest, but don't let the rest of the hand touch the chest.
 With the tip of the middle finger of the flexed hand, strike the first joint
of the middle finger of the hand that is on the patient's chest, have the
motion come from the wrist. (or use a reflex hammer)
 Withdraw the striking finger immediately to avoid damping the vibration.
 Strike once or twice, and then move your hands symmetrically to another
part of the chest.
 You can also evaluate diaphragmatic excursion between normal
inspiration and deep inspiration) – 3-5cm is normal

P524; 2021 Page 6

P524; 2021 Page 7
Physical Therapy Intervention for Pulmonary Conditions

1. Positioning for respiratory success

Upright and moving Best

Erect sitting
Forward lean sitting
Erect long sitting
Side lying/semi-prone
Worst
Supine

Position How is ventilation affected? Therapeutic

improvements
SUPINE Decreased functional residual volume Improve upper chest expansion
(FRV). by removing pillows under the
Pulmonary secretions collect in head.
dependent lung fields. External rotation of shoulders
Increased airway resistance. and scapular retraction.
Towel roll placed under thoracic
spine.
SITTING Increased FRV (compared to lying) Pelvic alignment is important to
Diameter of main airways slightly optimize ventilation:
increases. - anterior pelvic tilt enhances
Maximum expiratory pressure achieved. - can keep anterior tilt by placing
Upper lungs – larger initial volume, but a rolled up towel under ischial
smaller volume change with respiration. tuberosities or behind lumbar
Lower lungs – smaller initial volume, spine for greater lordosis
larger volume changes with inspiration. - vertical towel roll placed down
spine also

SIDE LYING FRV and work of breathing between Reduce pillow under head to
sitting and supine volumes. improve upper chest expansion.
Gas exchange is the best in the lower A quarter turn to prone is
lung. beneficial for decreasing
dependent atelectasis due to
supine positioning.
Take home: no pillow behind head & rolled up towel behind spine
2. Positioning for relief of dyspnea

Patients with severe COPD have flattened

diaphragms and stiff barrel-shaped chests.
Dyspnea is common with exertion.
Positions like the one in the picture serve to fix the
distal attachments of the pectoralis major
muscles so they work in “reverse” action to lift
the upper chest and increase ventilation.
Additionally this position increases intra-
abdominal pressure pushing the diaphragm up and improving its position.
* watch for overuse of accessory muscles in this position

P524, 2021 Page 1

 3. Breathing exercises

a) Ventilation and movement strategies

• Inspiration is associated naturally with;
 Trunk extension
 Shoulder flexion, abduction & external rotation
 Upward eye gaze (untucks the chin)

• Expiration is associated naturally with;

 Trunk flexion
 Shoulder extension, adduction & internal rotation
 Downward eye gaze

Good for Parkinsons’s patients

b) Diaphragmatic breathing
• Definition: During inhalation, the diaphragm (the primary muscle involved in
breathing) contracts downward, allowing the ribs to move outward, increasing
lung capacity. During exhalation, the diaphragm relaxes upward, allowing the
ribs to close in, expelling the air from the lungs. This natural way of “belly”
breathing is associated with rest and relaxation.
Good for those with asthma, post lung transplant, pulmonary fibrosis
• Instructions:
 Take a moment and allow yourself to sit comfortably in an upright
position.
 Gently place your right hand over your abdomen (near your belly
button) and your left hand over your chest (near your heart).
 Keeping your hands in place, breathe in and out naturally through your
nose (while keeping your mouth closed). Notice the movement of your
hands. Your right hand (over your abdomen) should be moving OUT
as you breathe in and moving IN as you breathe out. Your left hand
(over your chest) should remain relatively STILL throughout.
Remember:
Breathe IN Belly OUT
Breathe OUT Belly IN
• Techniques for a therapist to facilitate
 Provide tactile stimulus
 Instruct patient to initiate with a “sniff”
 Use a quick stretch on abdomen or a scooping technique just before
inspiration

What type of patients often do not benefit from diaphragmatic

breathing? Emphysema, COPD

P524, 2021 Page 2

 c) Pursed-lip breathing
• The goal is to slow the rate of expiration, increase
volume of expired air and limit hyperinflation
o Emphysema, COPD
• Instructions:
 Inhale slowly through nose
 On exhalation let the air escape gently through
pursed lips, avoid pushing with abs
 Imagine you want to make a flame flicker on a candle but don’t blow it
out
 Stop exhaling when you feel your abs contract

d) Segmental breathing exercises

• The goal is to get localized lung expansion.
• Instructions:
 Therapist places hands over the area that needs increased expansion
 Tell the patient to take a slow deep breath and “breathe into my hands”
 Hold maximal inspiration for 2-3 seconds then exhale (the 2-3 second
hold is called an “inspiratory hold technique”)
• You can apply a quick stretch with this technique just before inspiration
• For HEP patient can use their own hands or add resistance with a towel, belt,
theraband
 Good for reducing atelectasis, pneumonia

e) Stacked breathing exercise

• The goal is to improve cough effectiveness and can reduce atelectasis
• It is a series of deep breaths that build on top of the previous breath without
expiration until a maximal volume tolerated by the patient is reached
• Each inspiration is accompanied by an inspiratory hold
• Often used in neurological patients (ALS)
• Contraindicated for those with dyspnea

f) Inspiratory Muscle training

i) Incentive spirometry
• The goal of the device is to facilitate a deeper
inspiration and prevent atelectasis
• The patient goal for the mL of inspiration is
determined by tables for sex/age/height
• Instructions
 Patient exhales completely
 Then place mouthpiece in the mouth, forming
a tight seal with the lips
 Then perform a slow deep diaphragmatic
breath in order to raise the piston
 Sustain inspiration as long as possible
 Repeat 10 times every hour
P524, 2021 Page 3
 ii) Diaphragm-strengthening exercises
• Fair diaphragm strength
 Weights or manual resistance over the
epigastric area with patient in supine
 Progress to Trendelenberg (head lower than
feet) position with weight over epigastric area
 Goal is to perform for 15 minutes
• Poor diaphragm strength
 Strengthen as above in supine with head raised
 Consider an abdominal corset.
o Helps push up a flat diaphragm
Good for those with pulmonary fibrosis
Contraindicated for HF, HTN, SCI with phrenic nerve involvement

iii) Inspiratory muscle training devices

• Generally facilitated by a device

Threshold IMT provides consistent and specific pressure

for inspiratory muscle strength and endurance training,
regardless of how quickly or slowly patients breathe.

When patients inhale through Threshold IMT, a spring-

loaded valve provides a resistance to inspiration.

Generally performed for 15-30 minute sessions.

3-5/wk
For HF patients

P524, 2021 Page 4

 4. Thoracic mobilization

a) Thoracic mobility exercises

• Total body motions
 Sitting in a chair, the patient exhales while bending forward to touch
the floor. Then the patient extends up while taking a deep inspiration
and lifts arms up and out into a “V” above the head
• Shoulder and trunk mobility exercise examples
 Wall push-ups timed with breathing
 Corner stretch
 Scapular retractions

b) Thoracic mobilization techniques

• Positioning on a vertical rolled towel to open up the anterior chest wall
• Segmental breathing
• Manual chest wall stretching
• Soft tissue mobilization
• Rib and thoracic spine mobilizations
• Trunk rotation

P524, 2021 Page 5

 5. Airway clearance techniques
Defined as techniques that facilitate clearance of secretions from the airways.
The decision on which technique to use will depend on multiple factors –
pathophysiology, symptoms, contraindications, medical stability, co-
morbidities. Considerations: a) infection control and b) equipment (tissues,
sputum cup, suction equipment, pillows, rolls, blankets).

a) Postural drainage (PD)

• Uses body position to drain secretions from each lung segment.
• There are 12 standard positions that can be modified if patient has precautions
or relative contraindications.

Precautions and Relative contraindications for Postural Drainage

(most are related to the Trendelenburg positions i.e. head down)
Relative contraindications Precautions

Increased ICP (intra cranial pressure) Active hemoptysis.

Hemodynamically unstable Pulmonary edema with heart failure.
Recent esophageal surgery Large pleural effusions.
Recent spinal injury or fusion Morbid obesity with large pannus
Recent head trauma Massive ascites
Diaphragmatic hernia
Recent eye surgery

• Perform lung auscultation prior to postural drainage

• Postural drainage is performed with breathing exercises, +/-
percussion/vibration, the active cycle of breathing, cough, and/or suction.
• DOSAGE:
 Each position should be maintained for 5-10 minutes if patient is
performing breathing exercises only
 Or each position should be maintained for 2-5 minutes if paired with
percussion/vibration or the active cycle of breathing.
• The number of positions tolerated or required will be variable, could be 2-3 or
all 12child with cystic fibrosis.
• Total treatment should not exceed 30-40 minutes per session.

P524, 2021 Page 6

Standard patient positions for postural drainage

Upper lobe: anterior upper segments (sometimes

called anterior apical)
Patient sits and leans back on pillows against
pillows or a table, at a 40 degree angle.
Apply percussion or vibration over the clavicular
region above breast tissue.

Upper lobe: posterior apical segment

Patient is in long sitting with a pillow under knees
and leaning forward in the trunk ~ 20 degree angle.
Apply percussion or vibration between clavicle and
top of the scapula (over upper trap).

Upper lobe: anterior segments (middle)

Patient lies flat on their back with knees on a pillow.
Apply percussion or vibration on the superior aspect
of the upper chest (between the clavicle and breast
tissue).

Upper lobe: left posterior segment

Patient leans forward on pillows or a table at a 30
degree angle then rolls left shoulder 45 degrees back
with pillows placed for comfort.
Apply percussion or vibration over the upper back
on the left.

Upper lobe: right posterior segment

With the bed flat the patient lies on the left side then
rolls the right shoulder 45 degrees forward with
pillows placed for comfort.
Apply percussion or vibration over the upper back
on the right.

P524, 2021 Page 7

 Left lingular lobe
The patient lies on the right side with the head 12 inches
lower than the hips, the patient rolls the left shoulder back
45 degrees onto a pillow.
Apply percussion or vibration over the left nipple area and
just below (or just below for females).

Right middle lobe

The patient lies on the left side with the head 12 inches
lower than the hips; the patient rolls the right shoulder back
45 degrees onto a pillow.
Apply percussion or vibration over the right nipple area and
below (or just below for females).

Lower lobe: superior segments

With the bed flat the patient lies prone with pillows placed
under abdomen and legs for comfort.
Apply percussion or vibration over the mid back just
below the scapula.

Lower lobe: anterior segments

With the bed lifted 18 inches at the foot, the patient
lies supine with pillows for comfort.
Apply percussion or vibration over the lower ribs on
each side.

P524, 2021 Page 8

 Lower lobe: posterior segments
The patient lies in prone with the bed lifted 18
inches at foot, place pillows for comfort.
Apply percussion or vibration over the lower ribs on
each side.

Lower lobe: right lateral segment

The patient lies on their left side with the bed lifted
18 inches at the foot, place pillows for comfort.
Apply percussion or vibration over the lower ribs on
the right side.

Lower lobe: left lateral segment

The patient lies on their right side with the bed lifted
18 inches at the foot, place pillows for comfort.
Apply percussion or vibration over the lower ribs on
the left side.

P524, 2021 Page 9

 b) Percussion

• Can be performed manually or with a device

• Manually performed by a rhythmical clapping with cupped hands over the
affected lung segment in the postural drainage positions.
• Air is trapped between each cupped hands and the patient’s chest. A hollow
thumping sound should be produced. Slapping sounds indicates poor
technique.
• Percussion should be performed over a layer of thin clothing
• It is not the force but the cupping that is effective
• Performed on inspiration and expiration for 2-5 minutes per segment

c) Vibration
• Vibration utilized over affected segments in the postural drainage positions.
• The clinician’s palmar surface of the hands are in full contact with the
patient’s chest wall.
• At the end of a deep inspiration, the clinician exerts pressure on the patient’s
chest wall and gently oscillates it through the end of expiration.

Precautions and Relative contraindications for Percussion & Vibration

Relative contraindications Precautions

Hemoptysis Uncontrolled bronchospasm

Untreated tension pneumothorax Osteoporosis
Low platelet count < 20, 000mm3 Rib fractures
Unstable hemodynamic status Metastatic cancer to the ribs
Open wounds, burns in thoracic area Tumor obstruction of airway
Pulmonary embolism Anxiety
Subcutaneous emphysema Coagulopathy
Recent skin grafts or flaps on the thorax Convulsive or seizure disorder
Recent pacemaker placement

P524, 2021 Page 10

 d) Active cycle of breathing
• Typical cycle is shown below.
• Breathing control = diaphragmatic breathing at a typical tidal volume for 5-10
seconds. Alternatively you can use pursed-lip breathing for COPD patients.
• Deep breaths = lateral costal breathing that can be accompanied with
percussions or vibration.
• This can be incorporated into postural drainage positions as well
• Forced expiration technique = a huff. (video)Patient instruction: “a huff is
similar to fogging a pair of eyeglasses, except you force the air out with more
force. You need to force the air out of your lungs through an open o-shaped
mouth, you should feel your chest and abdominal muscles contract as you do
it”

Will not work for children, those with cognitive impairments

Can combine with vibration
e) Suctioning
Used for patients with a tracheostomy or endotracheal tube. Steps for a suctioning
procedure;
 Administer supplemental oxygen, to increase arterial oxygenation.
 Monitor oxygen sats with a monitor, goal is to maintain above 90%.
 Suction at pressures of 100-150 mmHg generally.
 Don sterile gloves, remove the catheter from packaging with care to not
contaminate.
 Remove the patient from the ventilator/oxygen source.
 Hyperinflate 5-10 breaths with a manual resuscitator bag and 100% O2.
 Insert the correct sized catheter, you will meet resistance at the level of the
carina or mainstem bronchi, withdraw slightly, apply suction by placing finger
over the catheter vent.
 Then continue applying suction, as you withdraw the catheter slowly while
rotating it to optimize exposure to all sides of the airways.
 Hyperinflate, reoxygenate before repeating if airway still has secretions.
Sometimes sterile saline is introduced into the airway to moisten/dilute thick
secretions prior to suctioning.

P524, 2021 Page 11

 • Contraindications; hypersensitivity or a vasovagal response to suctioning,
recent trauma to the pharynx, thrombocytopenia, or epiglottitis.

6. Cough techniques and assists

• For patients with reduced cough effectiveness and the ability to follow
instructions;
 Teach the patient correct timing of an effective cough (adequate
inspiration, glottal closure, build-up of intrathoracic & intraabdominal
pressure, glottal opening & expulsion)
 Position the patient to allow for trunk extension (inspiration) and
flexion (expiration)
 Maximize the inspiratory phase (verbal cues, positioning, active arm
movements)
 Improve the inspiratory hold (verbal cues and positioning)
 Maximize intrathoracic and intraabdominal pressures with muscle
contractions or trunk movement
• For patients post-surgery;
 Teach splinting with the cough
 May start with small coughs then medium and then a large cough
• For neurological patients: SCI
 Costophrenic assist
https://www.youtube.com/watch?v=qgVHfWS0t7E
 Abdominal thrust or Heimlich-type assist
https://www.youtube.com/watch?v=g8Xwrl1JZm8
 Use ventilation (stacked breathing) and movement strategies (trunk
flexion & extension)

7. Respiratory equipment/devices

a) The Acapella™ Device (or flutter mucous clearance device)

These small, handheld devices provide positive expiratory pressure
(PEP.) The positive pressure prevents the small airways from
collapsing which stops secretions getting trapped so they can
moved out as well as improving collateral ventilation. By exhaling
through the device creates oscillations, or "flutter" in pressures in the
airway. The oscillations helps to loosen the mucus.
http://www.smiths-medical.com/catalog/bronchial-
hygiene/acapella/acapella.html

P524, 2021 Page 12

 b) Vest systems
These are vests that provide high frequency chest wall
oscillations, they are designed as airway clearance systems and
replace traditional postural drainage that is combined with
vibration/percussion. Some vests are battery operated so patients
can wear them and continue on with life. www.thevest.com

8. Energy conservation techniques

Technique Examples
Establish a routine  Avoid multiple trips up and down stairs, plan your day to do
all the activities on one level then go to the next level

Pace yourself  Allow ample time to complete each task

 Work to music with a slower beat

Sit whenever possible  Place a chair or stool in the shower

 Sit to dress

Eliminate unnecessary tasks  Let dishes air dry

 Delegate tasks to others when necessary

Avoid strenuous arm activities  Pace yourself with arm activities

 Overhead sustained overhead tasks

Keep cool  Perform outdoor activities at the cooler part of the day

Avoid lifting  Transport items in a wheeled cart if possible

 Divide groceries and laundry into small, easily handled parcels

Organize your work areas  Keep items most often used within easy reach

Avoid isometric contractions  Avoid pushing, pulling, or lifting heavy items

 Avoid breath holding during activities

Use assistive devices  Use a shower chair

 Consider a wheeled walker with a seat

Avoid sustained positions  Change your posture frequently

 Take short breaks frequently to ease the stress on your body

P524, 2021 Page 13

Vascular Assessment &
Intervention

DR. AMY BAYLISS, DPT, PT

Class ID#16: 4/03/19

 Symptoms and Signs

Symptoms Signs

 Leg pain  Limb girth 

 Leg swelling  Pulse abnormalities
 Weakness/fatigue  Skin discoloration
 Skin abnormalities in
temperature/sensation
 Positive special tests
 Sores on feet/legs

These are general, see lab sheet for specifics!

 Pulse

 Femoral Artery
 Popliteal Artery
 Posterior Tibial Artery
 Dorsalis Pedis Artery

Pulse Grades

0 = Absent or non-palpable
1+ = Diminished (barely felt)
2+ = Normal
3+ = Bounding
 Lymph node palpation, what is normal?

 Lymph node is palpable and

 Moves freely

 Non-tender

 < 1 cm

 Soft to firm and not hard, rubbery, dense or matted down

 Tests

 Vascular tests
 ABI

 Capillary refill

 Segmental pressure measurements

 Elevation pallor

 Dependent rubor

 Venous filling time

 ABI

 Ratio of ankle systolic pressure over brachial

systolic pressure
 Patient supine
 Obtain brachial systolic pressure on both arms
 Identify the pulse at the posterior tibial artery or dorsalis
pedis with a Doppler ultrasound. Next inflate the
sphygmomanometer around the patient’s distal calf. Obtain
the ankle systolic pressure.
 Calculate the ABI

Use highest pressure in arm and ankle for calculations.

Calculating ABI
 Interpreting the ABI

 >1.3 Incompressible artery, vessel calcification

 1.0-1.2 Normal
 0.8-1.0 Minimal peripheral arterial disease (PAD)(stage 0)
 0.5-0.8 Moderate PAD, intermittent claudication (stage 1)
 <0.5 Severe PAD, rest pain (stage 2)
 <0.2 Tissue death will occur (stage 3) gangrene

Reference: Integumentary text by Hamm

 Capillary refill time

Normal refill is <3 seconds in hands and <5 seconds in

toes
 Segmental Pressure Measurements

A difference of 30 mmHg between limb segments (ankle-leg-thigh)

indicates significant obstruction.
A difference of 20 mmHg between symmetric limb segments (ankle to
ankle, leg to leg, thigh to thigh) is also abnormal.
 Elevation pallor

 To assess arterial perfusion

 Limb is elevated 60 degrees and color changes are observed
over 60 seconds of the plantar aspect of the foot (soles)
 A gray or pale (pallor) discoloration will result from arterial
insufficiency or occlusion
 Grading of pallor
 0=no pallor in 60 seconds
 1=pallor in 60 seconds
 2=pallor in 30-60 seconds
 3=pallor in less than 30 seconds
 4=pallor with limb flat

Pallor in 45-60 secs = mild arterial insufficiency (1/4)

Pallor in 30-45 secs = moderate arterial insufficiency (2/4)
Pallor in <25 secs = severe arterial insufficiency(3/4)
 Dependent Rubor

Normal circulation – foot will become a healthy pink color in 15 seconds.

Arterial insufficiency – it may take up to 30 seconds and result in a dark
red (rubor) appearance.
 Venous Filling Time

* Pallor at 30 seconds in the elevated pallor test indicates arterial insufficiency and a
venous filling time of at least 20 secs
 Exercise testing and Peripheral Arterial Disease

 The primary objectives of exercise testing a client

with PAD are to;
 Obtain reliable measures of claudication pain times
 Obtain reliable ABI’s following exercise
 Assess whether CAD is present
 Exercise testing and Peripheral Arterial Disease

 Procedures for testing;

 Patient supine for 15 mins, measure ABI

 Treadmill test, 1-2 MET’s per stage preferred

 Protocol of constant speed of 2 mph and an increase in grade

of 2% every 2 mins, starting at 0% grade
 Record claudication pain, HR & BP during the last minute of
each 2 minute stage
 Claudication pain will likely be stopping point for test

 Recovery period in supine, record ABI’s and time to reach 0/4

on claudication scale
Exercise Prescription and Peripheral Artery Disease

 Precautions
 Need medical clearance

 Must perform graded exercise test prior to prescription

 Ensure no concurrent morbidities

 Don’t exercise outside in cold weather

 Peripheral neuropathies may also be present, check footwear

 Educate on symptoms to be alert for

Exercise Prescription and Peripheral Artery Disease

 The goal is to improve claudication pain symptoms

and reduce CV risk
 General recommendations
 Interval walking or stair climbing
 Intensity to 3/4 on claudication scale
 Full recovery of claudication pain between intervals
 Dosage – 20 mins total*, 40-70% of HRR, 3 x week
 Progress to 40 minute sessions over 4-6 months
Intermittent Claudication Pain Scale
 Exercise and Aneurysms

 Effects of exercise training

 Not well studied because of the complications with increased
HR and BP
 Exercise training is a relative contraindication in patients with
aneurysmal disease

 So why are we talking about it?

 Patients need to be functional

 Not everyone is a surgical candidate

 We need to be able to advise on safe options

 Exercise testing and Aneurysms

 No maximal testing
 Never do maximal strength testing either

 Submaximal stress tests can be performed

 6 minute walk test is recommended

 HR and BP may have upper limits set by MD

 Generally HR no higher than 100 bpm

 Exercise prescription and Aneurysms

 Precautions
 No contact sports

 Patients typically on beta-blockers, so may need to use RPE

 Emphasize no over-exertion to your patient

 No valsalva with walking or ADL’s

 Educate on emergent need to get to the ER if they have signs of

dissecting aneurysm
 Exercise prescription and Aneurysms

 General recommendations
 Walking or swimming

 HR < 100 bpm

 RPE < 11/20

 Dosage – 30 minutes, 3-4 x weekly

 Emphasize duration over intensity

 What are other PT interventions for vascular
disorders?

 Exercise is the primary intervention for arterial

disorders
 Soft tissue/massage techniques may be useful for
short term symptom relief in some arterial and
venous disorders
 Compression therapy may be indicated for venous
disorders
 E-stim is a newer intervention choice
 Soft tissue/massage techniques

 Isolated not reimbursable

 Often you may teach a patient or family member how
to perform at home
 The techniques are
 Petrissage
Medium to deep pressure
 Effleurage

 May help with Raynaud’s disease and patients with

varicose veins in particular
 Do not massage directly over the varicose vein
 Effleurage

 Smooth, gliding stroke

used at the beginning
 Move from distal to
proximal for improving
venous flow
 Ending stroke at
known locations of
lymph nodes
Basic sliding effleurage
 Petrissage techniques

 Lift, wring or squeeze

tissues in a kneading
motion
 Or roll tissues under or
between hands
 “milk” the muscle of
metabolites, increase
venous return, improve
circulation
 Random intervention

 Desensitization regimen for complex regional pain

syndrome
 Sometimes called pain exposure therapy
 Change components like pressure, temperature, length of
exposure to a new condition
 The thought is to desensitize the nerves by exposing the limb
to normal sensory stimulus in a controlled manner
 Program example is in our lab handout
 Done every 2 hours daily
 Intermittent pneumatic compression pump

 Can be used for

 Chronic venous insufficiency

 Stasis ulcerations

 Mild to moderate edema from venous insufficiency

 Lymphedema
 Intermittent pneumatic compression pump

 Dependent on reason for use:

 General guidelines:
 Pressure lower than diastolic pressure

 Higher pressures produced discomfort and a tourniquet type

effect
 Need multiple chambered compression pump

 Treatment duration is ~ 1 hour per session (1-4 times daily)

 Inflation/deflation times vary for certain conditions

 Intermittent pneumatic compression pump

 Contraindications
 Deep vein thrombosis*

 Congestive heart failure

 Inflammatory phlebitis

 Pulmonary embolus

 Infections in the limb

 Untreated cellulitis

 Lymphangiosarcoma
Intermittent pneumatic compression pump

 For edema from venous disorders

 Pressure
 40 mmHg
 Short inflation/deflation times
 inflation 15 secs/ deflation 10 secs
 Dosage
 45-60 minute sessions 1-2 x daily

J Tissue Viability. 2003 Jul;13(3):98-100

 Intermittent pneumatic compression pump

 For lymphedema
 Multi-chamber pump
 Some units are programmable others are pre-set
 Pressure
 40-50 mmHg
 Some protocols keep distal chambers always inflated to stop
backflow of fluid
 Inflation/deflation time
 5-45 seconds inflation/5 second deflation
 Dosage
 60 minute sessions 1-2 x daily
Newest technology for lymphedema: Flexitouch

 32 chambers
 Inflation is every 1-3
seconds
 Decongests trunk first
then limb
 Also applies a quick
stretch to the patient’s
skin to mimic massage
 Compression stockings

 Indicated for patients with

 Venous disorders
 Post DVT
 Varicose veins
 Aching, painful legs
 Skin changes from venous disorder – pigmentation, thickening of skin
 During pregnancy with varicose veins
 Obese patients with mild to moderate edema
 Healed ulcers
 Post – surgery
 Lymphedema
 Air travel
 Compression stockings

 Have different compression ranges

 15-20 mmHg (generally post surgery or air travel)

 20-30 mmHg (mild venous disorders, achy legs)

 30-40 mmHg (venous disorders with moderate symptoms)

 40-50 mmHg (venous disorders with severe symptoms)

 Have different lengths

 Calf length

 Thigh high

 Pantyhose
 E-stim for Intermittent Claudication

 Two recent studies support using low frequency

TENS to the calf muscles
 Significant increase in max walking distance and less pain
experienced
Low rate TENS
• Frequency 2-10Hz
• Pulse width 200-3oous
• Intensity – strong
tingling up to twitch
contraction
• Treatment time 20-30
mins
• 3-7 days per week
 Treatment for Lymphedema

 Comprehensive lymphedema treatment includes:

 Manual lymph drainage (proximal to distal)

 Compression bandaging

 Exercise guidelines

 Compression garments

 Education & home program

 Pneumatic compression pumps +/-

 EBM on Treatment

 Review articles of RCT’s have made

recommendations for clinical practice:
 Combined physical therapy is effective for lymphedema
management
 This is the use of a combination of techniques (skin care,
manual lymph drainage, exercises, compression garments or
compression bandaging)
 Intermittent compression pumps have also been proven to be
effective

Devoogdt et al. European Journal of Obstetrics & Gynecology

and Reproductive Biology. 2010. 149; 3-9.
 Exercise Guidelines for Clients with Lymphedema
(or at risk)

 Key points
 Medically cleared

 Utilize compression garments during exercise (except in the

water)
 Progress more slowly, avoid strain & overuse

 Exercise should be low intensity

 Keep hydrated

 Exercise outside at the coolest times of day

 Risk Reduction: Skin care

 Keep extremity clean and dry

 Apply moisturizer daily
 Do not cut cuticles during nail care
 Protect skin with sunscreen and insect repellant
 Use care with razors
 Avoid skin punctures – injections/blood draws
 Wear gloves for activities that may cause skin injury
 Use good first aid measures for scratches/cuts
 Contact MD if signs of infection are noted
 Risk Reduction: Activity/Lifestyle

 Gradually build up intensity & duration of exercise

 Take frequent rest breaks
 Monitor extremity before and after activity for
changes
 Maintain optimal body weight
 Avoid heavy lifting with at risk limb
 Avoid prolonged standing, sitting or crossing legs in
those at risk for LE lymphedema
 Risk Reduction: Avoid limb constriction

 Avoid having BP taken on the side of the at risk

extremity
 Wear loose fitting clothes and jewelry
 In LE lymphedema, footwear and hosiery fit should
be considered
 Risk Reduction: Compression garments

 Should we well fitted aka no wrinkles or binding

 Support at risk limb with a garment during
strenuous activity
 Consider wearing a garment for air travel
 Risk Reduction: Extremes of temperature

 Avoid exposure to extreme cold

 Avoid prolonged exposure to heat
 This is greater than 15 minutes particularly hot tubs & saunas
 Conclusion

 What has been the common theme in Cardiovascular

& Pulmonary Disorders, in regards to intervention?
Exercise

 What should you routinely assess in this group of

patients?
Vital signs
Clinical Signs and Symptoms of Vascular Disease

Symptoms of Vascular Disease Signs of Vascular Disease

• Peripheral Artery Disease • Peripheral Artery Disease
o Leg pain with exercise o Elevation pallor (pallor within 30
o Leg swelling secs)
o Weakness or tiredness in the legs o Positive Allen’s test
o Sores on feet or legs that won't o Bruits
heal o Pulse abnormalities
o Dependent rubor (+30 secs w/ red
flooding)
o Segmental pressure abnormalities
o Claudication on exercise testing
o Hair loss
o Ulcers apparent
o Tight, shiny skin
o Thickened toenails
o Cool to touch
o Decreased sensation to light touch

• Carotid Artery Disease • Carotid Artery Disease

o Temporary loss of vision in one o 5 D’s, 2 N’s, 1 T
eye, or blurred or double vision o Confusion
o Confusion o Poor balance and coordination
o Loss of balance or coordination o Altered sensation and/or
o Numbness or weakness on one asymmetrical strength in limbs
side of the body
o Slurred speech or difficulty
speaking
o Change in ability to use arms and
legs
o History of stroke

• Abdominal Aortic Aneurysm • Abdominal Aortic Aneurysm

o Often no symptoms o Pulsing mass in abdomen
o Dizziness
o Sudden onset of abdominal or
back pain

• Venous disease • Venous disease

o Leg swelling o Leg swelling
o Sores on lower legs that do not o Wounds on lower legs that do not
heal heal
o Leg pain o Varicose veins
o Complaints of prominent veins o Dependent cyanosis
o Warm to touch

P524: 2021 Lab Sheet Page 1

 o Skin may be brownish in color

Symptoms of Vascular Disease Signs of Vascular Disease

• Lymphedema • Lymphedema
o Full sensation in the limb o Localized, soft swelling (edema)
o Skin feeling tight of the skin and subcutaneous
o Decreased flexibility across joints tissue
o Limb swelling o Subcutaneous tissue changes
o Difficulty fitting into clothes in (fibrotic)
one area o Skin changes which occur over
o Watch, ring, bracelet tightness time including hyperkeratosis
(skin thickening) and
papillomatosis (rough skin)
o Stemmers sign - skin between
Or they maybe symptom free! 2nd and 3rd toes or fingers
cannot be lifted up in Stage 2 & 3
• Reduced joint flexibility as the
physical weight and size of joint
increase resulting in reduced dexterity
in daily activities, such as driving and
washing.
• Increased skin turgor (an abnormality
in the skin's ability to change shape
and return to normal; change in
elasticity of the skin)

P524: 2021 Lab Sheet Page 2

Vascular Assessment

Orders
History (physician) If an inpatient.
Reports
Admission Note Format

History (subjective information)

• Identify patient
• History of present illness
• Medical and surgical history (particularly diabetes mellitus, HTN, syncope or
vertigo, non-healing ulcers)
• Risk factors for diseases
• Allergies
• Family health history
• Personal and social history (including exercise and dietary habits, tobacco and/or
alcohol use)
• Current medications and level of compliance
• Presence of intermittent claudication, peripheral edema
• Any current precautions

Observation
• Skin color
• Hair distribution
• Venous pattern
• Edema
• Atrophy
• Presence of cellulitis
• Presence of petechiae
• Skin condition/lesions
• Digital clubbing
• Gait abnormalities

Vital signs
• RR
• HR
• BP
• O2 sat level

Palpation
• Pain, tenderness, edema
• Temperature
• Strength and rate of peripheral pulses
• Lymph nodes

P524: 2021 Lab Sheet Page 3

Auscultation
• Presence of bruits in any pulses or over abdomen

Vascular tests (special tests)

• ABI
• Capillary refill time
• Segmental pressure measurements
• Dependent rubor
• Venous filling time
• Homan’s sign
• Elevation pallor (also known as Buerger’s test)
• Allen’s Test

Exercise testing
• Controlled method to quantify claudication
• Screen for cardiorespiratory disease

Other tests
• Girth measurements
 Start at a bony landmark
 Circumference in cm’s to the nearest millimeter
• Neurological – sensation, reflexes
• Muscle strength/length
• Balance/proprioception/gait (use of standardized measures)

P524: 2021 Lab Sheet Page 4

Summary of Special Vascular Tests

Test Indication Description Normal results and values

Pulse All patients to Distal – temporal, 0 = Absent or non-palpable
measure HR. carotid, brachial, 1+ = Diminished (barely felt)
Distal pulses in any ulnar, radial, 2+ = Normal
patient you suspect femoral, popliteal, 3+ = Bounding
PVD. posterior tibial,
dorsalis pedis.
ABI To test for arterial Ankle systolic/ >1.3 Incompressible artery, vessel
disease. brachial systolic calcification
1.0-1.2 Normal
0.8-1.0 Minimal PAD (stage 0)
0.5-0.8 Moderate PAD, intermittent
claudication (stage 1)
<0.5 Severe PAD, rest pain (stage 2)
<0.2 Tissue death will occur, gangrene
(stage 3)
Capillary refill Assess arterial blood Compress skin or < 3 seconds (blanching should resolve)
flow at skin surface. nail bed and release.
Segmental pressure Assess for arterial Take BP just above < 20mmHg between segments, normal
measurements in disease. ankle, below knee > 30 mmHg between limb segments
and above knee. suspect arterial occlusion
LE’s >20mmHg between L/R segments is
abnormal
Dependent rubor Assess for arterial Elevate legs 60 Normal circulation – foot will become a
insufficiency. degrees for 60 healthy pink color in 15 seconds.
seconds then have Arterial insufficiency – it may take up to
patient place 30 seconds and result in a dark red
dependent. (rubor) appearance.

Venous filling time Assess for venous or Elevate feet until Normal 5-15 seconds.
arterial insufficiency. veins on the dorsum Venous insufficiency < 5 seconds.
of the foot are Arterial insufficiency > 20 seconds.
drained of blood,
then lower legs to a
dependent position.
Elevation pallor To assess for arterial Elevate leg 60 Grade pallor on 0-4 scale. No pallor is
perfusion. degrees and observe considered normal.
color changes over 0 = no pallor, normal
60 seconds. 1= pallor in 60 seconds
2 = pallor in 30-60 seconds
3 = pallor in < 30 seconds
4 = pallor with limb flat
Allen’s test To assess for patency Occlude both Paleness should resolve quickly when
of radial and ulnar arteries and have artery is released.
arteries. patient clench their
fist. Then release
one artery and have
the patient open
their hand.

P524: 2021 Lab Sheet Page 5

 Test Indication Description Normal results and values
Stoop test Intermittent claudication A patient is asked to If flexion relieves symptoms the
walk briskly to elicit claudication pain is likely a
claudication pain, neurogenic origin.
once pain is elicited
they are asked to flex
forward and
determine effect on
pain.
Bicycle test Intermittent claudication A patient is asked to Claudication pain elicited is likely
pedal on a bicycle to due to vascular claudication since the
elicit claudication spine is flexed in sitting.
pain. Once pain is If the pain is unchanged with
elicited the patient is increased flexion and erect sitting
asked to flex spine this further confirms that spinal
forward in sitting and position has no effect on symptoms
then sit erect, and the pain is due to vascular
reporting any change claudication.
in symptoms.
Treadmill test Intermittent claudication Two trials are Time to first symptoms, total
conducted; one the ambulatory time and objective
patient is leaning measures such as ABI can be used to
forward holding onto differentiate neurogenic vs vascular
the handrails and the claudication.
second walking erect. In vascular claudication the time to
first symptoms should be unchanged
in either trial.

Characteristics of Vascular Claudication Neurogenic claudication

Discomfort (True Intermittent from (Pseudo-claudication from
Peripheral arterial central spinal stenosis)
disease)

Activity-induced? Walking? Yes Yes (extension)

Location of pain? Unilateral buttock, hip, Back pain or bilateral leg

thigh, calf and foot pain

Nature of symptoms/pain? Cramping Cramping

Tightness Tightness
Tiredness Tiredness
Burning pain (ischemic) Burning pain (ischemic)
Position relief? Stopping activity Slouched, sitting (flexion)

P524: 2021 Lab Sheet Page 6

Interventions to consider

1. Compression pump for venous disorders

o Pressure - 40 mmHg
o Short inflation/deflation times: inflation 15 secs/ deflation 10 secs
o Dosage: 45-60 minute sessions 1-2 x daily

Clinical reminders
 Measure BP before and after
 Measure limb girth in a structured way before and after (start at a boney
landmark and measure circumferentially every 5-10 cm up the leg as far as
swelling is present)
 Elevate legs during treatment
 Treatment should be painfree

Contraindications
 Heart failure or pulmonary edema
 Recent DVT
 Thrombophlebitis
 Pulmonary embolism
 Obstructed lymphatic or venous return
 Arterial insufficiency/ulcers
 Acute skin infection
 Hypoproteinemia (protein < 2gm/dL)
 Acute trauma or fracture
 Arterial revascularization

2. Massage for venous disease

o Combination of effleurage and petrissage to “milk metabolites” and improve
venous flow
o Dosage: 10 minutes per lower leg

Clinical reminders
 You will need to teach the patient or a caregiver how to perform this, it is a
patient education component of a treatment plan

Contraindication
 In any area of the body with:
o blood clots, fractures, open or healing wounds, skin infections, areas of
recent surgery, phlebitis, acute inflammation
 Acute febrile conditions
 Severe varicose veins
 Severe atherosclerosis
 Unstable CV conditions
 Edema secondary to CHF or kidney failure
 Potential for uncontrolled bleeding (for example: hemophilia or lab values indicating
prolonged clotting time)

P524: 2021 Lab Sheet Page 7

3. Electrical stimulation (low rate TENS) for arterial disease
o Frequency 2-10Hz
o Pulse width 200-300us
o Intensity – strong tingling up to twitch contraction
o Treatment time 20-30 mins

Clinical reminders
 On our clinical units this is a biphasic symmetrical waveform
 Treatment will focus on an area of decreased flow, the studies to date have placed
electrodes on the calf muscles

Contraindications
 Demand pacemaker or unstable arrhythmias
 Seizure disorders or epilepsy
 Trans cerebrally or transthoracically
 In the presence of active bleeding or infection
 Superficial metal implants
 When movement is contraindicated
 Electrode(s) over the following areas:
• over/near abdomen or low back in pregnancy
• venous or arterial thrombosis or thrombophlebitis
• pharyngeal or laryngeal muscles
• carotid sinus
• eyes
• urinary bladder stimulator
Precautions
 Cardiac disease (hypotension, hypertension, excessive edema)
 Impaired sensation
 Impaired mentation
 Malignant tumors
 Irritated skin/open wound
 Excessive adipose tissue

P524: 2021 Lab Sheet Page 8

4. Desensitization exercises for complex regional pain disorder

Perform these exercises every 2 hours for 10 minutes. Progress to the next exercise once
the exercises you are performing become painfree and comfortable.

1. Using firm pressure, rub the following textures along your hypersensitive area:
 Flannel
 Cotton
 Polyester
 Nylon
 Fleece
 Wool

2. With these same textures use a lighter pressure.

3. Place your hand/foot in separate containers of the following items:

 Rice
 Bird seed
 Sand
 Dry kidney beans
 Ice chips

4. With a small hand-held massager along the sensitive area.

5. With a small dowel rod or a pencil eraser, tap along the sensitive area.

6. Contrast baths to reintroduce temperature differences, start with temperatures

close to each other then make more extreme to progress.

This is a guide. You can use other fabrics, or items in containers. You can switch the
order of activities.
You may even find firmer pressure is less provocative than light pressure to start.

P524: 2021 Lab Sheet Page 9

Pediatric Cardiovascular & Pulmonary
Physical Therapy

Brooke Selman, DPT & Attie Vogler, MPT

Detecting Heart Defects
• Most babies can survive
gestation with a defect due
to blood circulatory system
• In utero:
– fetal echocardiogram
• Post partum:
– Cyanosis, tachypnea,
apnea, difficulty
feeding, irritability,
intercostal retractions,
stridor, dry diapers
 Congenital Heart Defects

Acyanotic Cyanotic
• Normal oxygen saturation • Decreased oxygen saturation
• Pink – Arterial saturation 15-30%
below normal
• Blood shunts left to right so
oxygenated blood goes to both lungs • Blue (lips, fingers)
and body • Blood shunts right to left so
• Examples: deoxygenated blood goes to the
– ASD & VSD: pulmonary hypertension body
• Pulmonary artery banding can • Examples
prevent pulm HTN
– Tetralogy of fallot, transposition
– PDA: due to hypoxia or prostaglandin of great arteries, hypoplastic left
release heart syndrome
– coarctation of aorta, pulmonary
stenosis, aortic stenosis: narrowing
*Diaphoresis is a clear indicator of heart problem
Atrial Septal Defect
• Left-to-right shunting
across the atria
– Blood in the left atrium
flows into the right
atrium during both
systole & diastole
– If large- creates volume
overload on the right
side of the heart which
increases pulmonary
blood flow/pulmonary
hypertension
Atrial Septal Defect
• Majority are asymptomatic because small enough
that not enough blood shunted to make the heart
& lungs work harder
• Detected by hearing a heart murmur (stethoscope)
• If the patient has pulmonary dysfunction an ASD
can exacerbate the problem
• Small ASDs are monitored – may close on their
own
• Large ones require repair (most via cardiac
catheterization but some open heart)
Atrial Septal Defect
• Restrictions
– If unrepaired,
sports/physical activity
may need to be
restricted due to
pulmonary hypertension
(followed by
cardiologist)
– No restrictions if have a
successful surgical
repair (good outcomes)
– Cardio follow up, likely
echo’s
Ventricular Septal Defect (VSD)
• Most common
• Distinct heart murmur
• Opening between right
and left ventricle
• Left to right shunting
• If large - Causes
pulmonary
hypertension
Ventricular Septal Defect
• Small VSD
– Most are asymptomatic, may close on their own
– Can be found by hearing a murmur
• Moderate VSD
– May cause growth and developmental delay, decreased
exercise tolerance, CHF
• Large VSD
– Require surgical intervention
– Diaphoresis, decreased feeding tolerance, failure to
thrive
Ventricular Septal Defect
• Surgery
– If larger, usually repair before 2 years old, often earlier
– Open heart repair – if patch is necessary
•Fibrin patch or pericardium becomes covered with
new tissue and becomes a permanent part of the
body
– Cath lab – can sew or place closure device
– If there is more than one VSD or too ill, then a temporary
surgical procedure might have to be performed until a
permanent repair can be completed in order to protect
pulmonary arteries/lungs
Pulmonary Hypertension
• High blood pressure in pulmonary arteries
• Considered to be progressive-pulmonary
arteries shrink & increase workload of right side
of heart to get blood through to lungs
• Can lead to right heart hypertrophy and
eventually failure
• Signs/symptoms – fatigue, SOB with activity,
dizziness, fainting, swelling &/or discoloration
in lower legs/ankles, chest pain, blue lips
Pulmonary Hypertension
• Treatment – depends on cause/category
– Eliminate cause of vessel damage
– O2 support to relax blood vessels in lungs
– Meds to relax and promote growth of blood
vessels in the lungs
– Anticoagulants
– Diuretics
– Meds to decrease how hard the heart is working
– Surgical Procedure to help decrease flow to
lungs (PA Band) – palliative, not cure
Pulmonary Artery Banding (PAB)
• A band is placed around pulmonary
artery to reduce excessive blood flow to
the lungs
• Palliative procedure
• Buy kids time until they are bigger and
healthy enough to undergo more
invasive procedures
• Prevention of pulmonary hypertension
which can lead to heart failure
• Minimally invasive and the hardest part
is for surgeon to decide how tight to
make band. (Trusler’s formula)
 Complete Atrioventricular Canal
(CAVC) or AV Canal Defects
• Abnormalities between
both atriums and
ventricles. 2 types:
– Complete
– Partial
• Complete- Mitral and
tricuspid valve are
combined (blood mixes
& increased workload
on heart & lungs)
• Trisomy 21
CAVC
• Surgery-CAVC is usually
repaired in 1st 2-3
months
– Patch septal defect
– Divides valves into
two
– Good outcomes

A partial AVSD usually only

requires patching the ASD &
repair/replace the mitral valve.
Patent Ductus Arteriosus
• Ductus arteriosus is a normal fetal artery that
connects the pulmonary artery to the descending
aorta allowing the fetus blood to bypass the lungs
since not needed to oxygenate the blood
• It is supposed to close after birth but will stay open
or dilate in response to hypoxia or prostaglandin
release
• In certain cyanotic heart defects a PDA is critical to
survival
• High incidence in premature infants
Patent Ductus Arteriosus
Patent Ductus Arteriosus
• Small PDAs are usually asymptomatic & spontaneously
close
• Moderate to large PDA symptoms: increased RR, poor
growth, poor feeding ability, increased HR, SOB, poor
endurance
• Moderate to large PDAs will usually require assistance
to close
– medicine: indomethacin
– Catheterization procedure or surgical closure
• Long term restrictions – none if repair is successful or
closes on own
Coarctation of Aorta
• Narrowing or closing of a section
of aorta resulting in decreased
blood flow to lower body
• If severe can cause L ventricle
hypertrophy & heart failure, high
blood pressure, damage to
organs of lower body
• Repair
– Cardiac cath- balloon
angioplasty, possible stent
– Surgery
• End to end anastomosis
• Enlarge with a graft
Pulmonary Stenosis
• Occurs due to the valve between the right ventricle & the
main pulmonary artery not able to open enough (either 2
sections stuck together or too thick) or a narrowing below or
above the valve
• Symptoms: cyanosis, heart murmur, failure to thrive, activity
intolerance
• Repair
– Cardiac cath – balloon valvuloplasty
– Surgery – replace the valve
Aortic Stenosis
• Occurs when the valve between the left ventricle & the
aorta doesn’t open enough (not all 3 sections formed or
become too thick) causing the left ventricle to work harder
to pump blood to body
• Symptoms: fatigue, murmur, chest pain, arrhythmias
• Repair
– Cardiac cath – balloon valvuloplasty
– Surgery – valve replacement
• Ross Procedure-aortic valve is replaced by patient’s
pulmonary valve, the pulmonary valve is replaced by a
donor pulmonary valve.
• Donor or mechanical valve
Tetralogy of Fallot
• A heart defect with 4
problems:
– Large VSD
– R ventricle outflow
obstruction/pulmonary
stenosis
– Overriding aorta (aorta
is shifted over both
ventricles)
– Hypertrophy of the R
ventricle
Tetralogy of Fallot
• Symptoms
– Blue nailbeds, lips, skin (cyanosis)
– Can have Tet Spells- become bluer, fussy/upset and
then unresponsive
– Murmur
– Dyspnea
– Syncope
– Clubbing of fingertips (older)
• More commonly in kids with genetic syndromes (Down
syndrome, DiGeorge syndrome, etc)
Tetralogy of Fallot
• Surgical intervention:
– Sometimes temporary
surgery- place a shunt
between a main artery
or the aorta to the
pulmonary artery
(closed after complete
repair)
– Complete surgical
repair with closure of
the VSD & opening of
the R ventricle outflow
tract
Transposition of Great Arteries
• The aorta arises from the R
ventricle and the
pulmonary artery arises
from the L ventricle
– Unoxygenated blood
enters the R atrium to R
ventricle to aorta to
body
– Oxygenated blood
enters L atrium to L
ventricle to pulmonary
arterty to lungs
Transposition of Great Arteries
• So to survive you must have an ASD, VSD, or
PDA to allow the oxygenated & unoxygenated
blood to mix.
• Treatment at birth
– Immediately given prostaglandins to help keep
the PDA open or else to cath lab for balloon
atrial septostomy to create a hole in the atrial
septum to allow the blood to mix
– Surgical repair often within a few days
Transposition of Great Arteries
• Arterial Switch
– Switches the aorta and
the pulmonary artery
placement
– Coronary arteries are
reattached to the new
aorta placement
• Long term restrictions-
at risk for arrythmias, valve
leakage or coronary artery
problems
Hypoplastic Left Heart Syndrome
(HLHS)
• Rare (1%) of CHD but
most common cause of
death in neonates in
1st month of life
• Without surgery, death
is certain
• Will be hospitalized
and require O2 support
and IV medication until
repair
Hypoplastic Left Heart Syndrome
• If HLHS is unknown, within days of life symptoms of ashen
or difficulty breathing will occur (as the ductus closes)
• Ideally they want to keep the ductus arteriosus open (done
with IV meds) until surgery can be performed.
• Requires a series of procedures known as “staged
reconstruction”
1. Norwood
2. Glenn
3. Fontan
HLHS – Norwood (Stage 1)
• Purpose is to control
blood flow to prevent
damage to the heart
and lungs, and to
perfuse lungs and
oxygenate blood to
keep child alive until
the second procedure
HLHS - Glenn
• Also known as “hemi-
fontan”
• Occurs from 6-12 months
of age
• SVC attached to the
pulmonary artery
• After this surgery
deoxygenated blood from
upper body will go to the
lung, bypassing the heart
HLHS - Fontan
• Usually occurs 1.5-3
yrs of age
• IVC disconnected from
heart and attached to
right pulmonary artery
• After this surgery all
deoxygenated blood
will go to lungs and
bypass the heart
Extracorporeal Membrane
Oxygenation (ECMO)
• Heart-lung bypass machine that provides life saving
assistance to both heart and lungs
• The ECMO system has an RN assigned to it at all times to
monitor blood gases and circuits (different RN for the
patient)
• Two types of ECMO
– V-V venovenous
•Assisting for lungs
– V-A venoarterial
•Assisting for lungs & heart
ECMO – Pediatric population
• Used for patients with… • PT implications… limited
– Meconium aspiration – Patients usually on
– Respiratory distress paralytics at least
syndrome initially
– Persistent pulmonary – We are mobilizing more
HTN in peds than before
– Bridge to transplant – Positioning
– Pneumonia – Splints
– Congenital heart – ROM
conditions – **talk with RN before
– Congenital touching patient!!
diaphragmatic hernia
Ventricular Assistive Devices
(VAD)
• LVAD-left ventricular
assistive device most
common (also RVAD &
BIVAD)
• Used for patients with
heart failure to assist
with increasing cardiac
output
• Bridge to transplant
• Bridge to recovery
• Destination therapy
VAD
• Pediatric VAD – Berlin
Heart
• Cannot discharge to home
with this type of VAD
• These are ‘busy’ kids
• PT implications
– Sternotomy
– Deconditioning
– Strengthening
– Know VAD numbers and
vitals both at rest &
with activity
Berlin- VAD
Post-Surgical Management
• Pulmonary
– Various levels of O2 support: jet/oscillator,
standard ventilator, SiPap, CPAP, high flow &
standard NC
– Incentive spirometer, blowing bubbles,
pinwheels
• Pain – medications, mobility, facilitate
improved breathing pattern
Post-Surgical Management
• Encourage early mobilization as able
– Educate family on sternotomy precautions
•Not to pick up children under the arms for 4-6
weeks until sternum healed
•Limit prone activity for ~4 weeks
•Limit UE WBing & passive overhead shoulder
flexion for ~4 weeks
– Most kids started out sick and deconditioned
– Always monitor vitals – note trends in vitals with
activity & repositioning
Post-Surgical Management
• Range of motion
– If on a ventilator, children will often get tight in
neck on side of ventilator
• **Always communicate with your nurses and
doctors**
Respiratory Distress Syndrome
(RDS)
• RDS is one of the most common problems in
premature infants (especially less than 28
weeks)
• Severity of symptoms is related to the size,
gestational age, presence of infection
• Caused by a lack of surfactant (a liquid that
coats the inside of the lungs which helps the
lungs fill and the air sacs to stay open)
Respiratory Distress Syndrome
(RDS)
• Symptoms: cyanosis, grunting, nasal flaring,
chest retractions, rapid breathing
• Treatment
– Artificial surfactant (via ETT)
– Different levels of supplemental O2 support
(ventilator, CPAP, high flow, standard NC)
– Medications (diuretics, steroids, sedation)
Bronchopulmonary Dysplasia (BPD)
• A chronic obstructive lung disease associated
with inflammation and scarring in the lungs
• Is often a complication of RDS due to high
levels of O2 support. Pressure from the
ventilator can cause damage, inflammation to
the airways
• Can often be a result of infections in the lungs
Bronchopulmonary Dysplagia (BPD)
• Symptoms: rapid shallow breathing, cyanosis,
chest retractions, coughing, wheezing
• Treatments
– Supplemental O2
– Medications (diuretics, bronchodilators)
– Airway clearance techniques
• Outcomes: Often improve over time as the child
grows and gas exchange surface area increases.
However, likely to go home on supplemental O2 &
high risk for infections
Therapy Implications for RDS &
BPD
• Cluster care – work around feeding times so as
not to interrupt sleep
• Always communicate with RN who can let you
know changes not yet in notes
• Maintain integrity of O2 support while giving
patients opportunity to experience age
appropriate activities & positions
• Adjust activities to what the patient can tolerate
Respiratory syncytial virus (RSV)
• Very common virus that • Signs/Symptoms
both adults and children • Mild
can get
– Cough, sore throat,
– Most kids will have had it congestion, low grade
by age of 2 fever
• Can be dangerous in • Severe
premature infants, kids – High fever, chest
under 6 months old, and retractions, rapid
kids with compromised respiratory rate, difficulty
immune systems breathing, cyanosis, nasal
flaring
• Most of time presents
like a common cold
RSV
• Most common cause of bronchiolitis/pneumonia
• In serious cases, hospitalization is required
– Supplemental oxygen needed
• High flow nasal cannula, nasal cannula, bipap, ventilator
– ICU
– ECMO
– Death
• Prevention
– Hand washing!
– Protective isolation garb
– Shots (Synagis)-not a vaccine but lessens severity
– Latent viral spreading (can be weeks)
Cystic Fibrosis (CF)
• Genetically recessive disorder
• 1,800 different mutations have been found on the CF gene
• Both parents must be CF carriers
• Must inherit 2 mutations to be diagnosed with CF
• CFTR (cystic fibrosis transmembrane regulator) protein
dysfunction
• Abnormal sodium and chloride transport across the cell membrane
• CFTR gene controls the salt channels in:
 Skin Intestines
 Airway • Reproductive Tract
 Pancreas
CF
• Disease characterized by
• Thick and sticky mucus in the lungs & pancreas
• A chronic, dry cough
• Lung infections, such as pneumonia or bronchitis
• Wheezing or SOB
• Poor growth/weight gain despite eating well
• Frequent greasy, bulky stools or difficulty in bowel movements
• Predicted median age of survival for a person with CF
is 46 years old.
• Monitored in clinic by pulmonary function testing (PFT)
– FEV- forced expiratory volume
CF

Measured Test Normal Mild Moderate Severe

FVC More than 80% 60 - 80% 40 - 60% Less than 40%
FEV1 More than 80% 60 - 80% 35 - 60% Less than 35%
FEF25-75 More than 65% 50 - 65% 30 - 50% Less than 30%
CF
Common PT dysfunctions
• Rounded shoulders
• Thoracic Kyphosis
• Posterior Pelvic Tilt/Slouched sitting posture
• Scapular Winging
• Forward head posture
• Tight Hamstrings
CF
• Evaluation/Observation
– chest mobility
•Measure with tape measure 3 landmarks (axilla,
xyphoid, abdomen), posture, trunk/UE ROM
– endurance
•3 min step test, 6 min walk test, phonation
– normal breathing
•upper abdomen, lateral costal expansion, gentle rise
in upper chest
– abnormal breathing
•Shallow, belly, accessory, paradoxical, retractions
CF
• Treatment
– Endurance
•Bike, treadmill, basketball, soccer
•Crab walking, bear crawling, frog jumps
•Intervals!
– Stretching
•pecs, hamstrings, trunk, trap, neck
•Tummy time for infants
– Mobilization
•Ribs, thoracic spine
•PNF
– Education
Acute Care Topics 1
Dr. Amy Bayliss

1/25/21: Class ID#2

Acute care/Hospital setting
• Unique
• Patients faced with physical, psychological and emotional
consequences of hospitalization
• Set protocols & standards of practice
• High tech
PT Role in Acute Care
• Prevention • Educator
• Intervention • Leader in EBM
• Triage
• Consultant
• Collaborator
• Advocate
• Decision Maker
PT Intervention in Acute care
results in:
• Earlier discharge
• Improved outcomes
• Had a significantly higher return to an independent functional status
• Shorter periods of delirium
• More ventilator free days
• Reduced costs
• Increased patient satisfaction
• Reduce secondary complications
• Reduce adverse effects of immobilization
• Intensive care unit-acquired weakness**
At a Physiological level we can also
justify why PT is important!
• Physiological consequences of immobilization /bed rest:
• Numerous
• Multisystem
• Deleterious effects start at 24-48 hours
• Muscle atrophy is seen as early as 7 days into bed rest

J Physiol. 2007; 583(30):1079–1091.

What are the negative effects of
immobilization?
• Musculoskeletal • CNS
•  muscle mass & • Behavioral &
strength emotional disturbance
•  muscle length • Altered sensation
•  endurance • Intellectual deficits
• Potential for joint • Slowed reaction time
contractures
• Disuse osteoporosis
•  risk of ulcers
What are the negative effects of
immobilization?
• Cardiovascular
•  HR •  venous compliance
•  max. SV & CO •  Vo2max
• Orthostatic •  total blood volume
hypotension & plasma volume
•  risk of
thromboembolic
complications
• V/Q mismatch
What are the negative effects of
immobilization?
• Pulmonary
•  oxygen uptake • Less effective airway
•  lung volumes & clearance
capacities
• V/Q mismatch
• Oxygen extraction at
the peripheral level is
reduced
What are the negative effects of
immobilization?
• Genitourinary • Gastrointestinal
•  mineral excretion • appetite & fluid
• difficulty voiding intake
• post-void residuals •  bowel motility
• overflow incontinence •  gastric secretion
•  glomerular
filtration rate
What are the negative effects of
immobilization?
• Endocrine • Neurologic
• altered temperature • sensory & sleep
and sweating deprivation
responses • balance &
• altered circadian coordination
rhythm •  visual acuity
• altered regulation of • risk of compression
hormones neuropathy
• impaired glucose
intolerance
Unique conditions seen in the
ICU patient
• Acute delirium/psychosis
• Cluster of serious psychological symptoms
• Can occur within hours of admission to ICU
• It is reversible
• Many precipitating factors
• Environment
• Infection
• Hypoxia
• Medications
• Sleep deprivation
Unique conditions seen in the
ICU patient
• ICU-acquired weakness
• Develops in patients admitted to ICU
• Occurs due to a variety of reasons, sepsis & acute respiratory
distress are the most common
• May develop after 4-7 days of mechanical ventilation
• Often used as a global term, some specific conditions fall under
this term
• Critical illness myopathy
• Critical illness polyneuropathy
• Still being researched but there are 3 factors that seem to have a
significant influence:
• Tight glycemic control ( with intensive insulin therapy)
• Minimizing corticosteroids and neuromuscular blocking agents
• Early mobility 

Nordon-Craft et al. PTJ. 2012;92:1494-1506.

Unique conditions seen in the
ICU patient
• Critical illness myopathy
• Profound weakness particularly in proximal muscles
• Acute onset of diffuse quadriparesis
• Respiratory muscle weakness and decreased deep tendon
reflexes
• Sensation is intact
• Usually detected when a patient cannot be weaned from a
ventilator
• Brought on by high-dose corticosteroid's
• May be diagnosed with an EMG and muscle biopsy

Nordon-Craft et al. PTJ. 2012;92:1494-1506.

Unique conditions seen in the
ICU patient
• Critical illness polyneuropathy
• Acute onset of widespread symmetrical weakness
• Most commonly seen in patients with multisystem organ failure
• Distal extremity wasting
• Sensory loss with impaired pain sensation, temperature and
vibratory sense
• Loss of reflexes, decreased action potential’s on EMG (sensory
and motor)
• Specific pathophysiology is unknown
• No proven treatment

Nordon-Craft et al. PTJ. 2012;92:1494-1506.

The other condition we are
trying to prevent is PICS
• PICS = post-intensive care syndrome
• Is defined as health problems that remain after critical illness
• A patient presents with physical impairments (directly related to
the ICU-acquired weakness), cognitive dysfunction; and mental
health problems after returning home
• Many patients have these health problems persist and prevent
them returning to work and PLOF
• This group of patients has grown since the COVID-pandemic
Medical record review
• Orders • Nursing PN’s
• Medical history • Ancillary staff PN’s
• Imaging reports • OT
• Lab reports • SLP
• Case Managers
• Surgical reports • Nutrition/Dieticians
• Admission note (MD) • RT’s
• Physician PN’s
• Allergies –Latex?
• Isolation?
• Precautions?
• Restraints?
• Resuscitation status
Basic Guidelines for Safety
• Follow standard precautions for infection control
• Know the emergency codes & procedures during emergency
codes
• Knowledge of policies for chemical, waste or sharps exposure
• Know how to contact other hospital departments
• Understand the medical equipment
• Know precautions with lines, tubes, lab values, vitals, &
monitors*
• Dispose of items according to policy
• Remove damaged/broken equipment from use, label as such
and contact the appropriate department
Basic Guidelines for Safety:
when entering a patient room
• Introduce yourself and your purpose
• Confirm the patient’s name before PT by interview and the ID
bracelet
• If no ID bracelet, contact the nurse
• Reorient the patient if needed
• Prepare the room (equipment, de-clutter, bed height, chair
location)
• Turn off bed alarm if present
Basic Guidelines for Safety:
when leaving a patient room
• Leave the call bell accessible
• Leave glasses, hearing aids, fluids accessible
• Leave the height of the bed at lowest level
• Lock wheels on the bed or chair
• Leave bed rails up for all patients
• Reactivate the bed alarm if in use
• Remove clutter
PT Equipment
• Is all PT equipment able to be used with all patients?
• You must consider:
• Patient’s weight/height
• Standard Walker: Weight limit 300 lbs
• Bariatric Walkers: 300+, 500-1000 lbs
• Axillary Crutches: Weight limit 300 lbs
• Bariatric Axillary Crutches: 300+, 550 lbs
• Canes (wooden, straight, quad): Weight limit 250 lbs.
• Bariatric cane: 250+, 500 lbs.
• Standard Manual Wheelchairs: 250 lbs.
• Bariatric Wheelchairs: 350-700 lbs.
• Hi-Lo Table: Weight limit 400 lbs
• Bariatric tables: Up to 1000 lbs if you have a non-hydraulic table, 625 lbs. with
hydraulics
• Co-morbidities
• Weight-bearing status: FFFB, NWB, TTWB, WB
• Infection control status
Infection Control Issues
• Standard
• Airborne
• Droplet
• Contact
• Enhanced Contact &
Respiratory
• COVID: droplets so small
that they are airborne
Infection Control Issues
• Standard Precautions
• Perform hand hygiene
• Use personal protective equipment whenever there is an
expectation of possible exposure to infectious material
• Follow respiratory hygiene/cough principles
• Ensure appropriate patient placement
• Properly handle and properly clean and disinfect patient care
equipment and instruments/devices
• Clean and disinfect the environment appropriately
• Handle laundry and textiles carefully
• Follow safe injection practices including proper handling of
needles and other sharps
https://www.cdc.gov/infectioncontrol/basics/standard-
precautions.html
Infection Control Issues
• Airborne Precautions
• Source control: put a mask on the patient.
• Ensure appropriate patient placement in an airborne infection isolation room
(AIIR)
• Restrict susceptible healthcare personnel from entering the room of patients
known or suspected to have measles, chickenpox, disseminated zoster, or
smallpox if other immune healthcare personnel are available.
• Use personal protective equipment (PPE) appropriately, including a fit-tested
NIOSH-approved N95 or higher level respirator for healthcare personnel.
• Limit transport and movement of patients outside of the room to medically-
necessary purposes. If transport or movement outside an AIIR is necessary,
instruct patients to wear a surgical mask, if possible, and observe Respiratory
Hygiene/Cough Etiquette.
• Immunize susceptible persons as soon as possible following unprotected
contact with vaccine-preventable infections (e.g., measles, varicella or smallpox).
• Diseases in this category are:
• TB, Measles, Varicella (including disseminated herpes zoster aka shingles),
Smallpox
Infection Control Issues
• Droplet Precautions
• Source control: put a mask on the patient.
• Ensure appropriate patient placement in a single room if
possible.
• Use personal protective equipment (PPE) appropriately. Don
mask and goggles upon entry into the patient room or patient
space.
• Limit transport and movement of patients outside of the room
to medically-necessary purposes. If transport or movement
outside of the room is necessary, instruct patient to wear a mask
and follow Respiratory Hygiene/Cough Etiquette.

• Diseases in this category are:

• Meningitis, mumps, pertussis (whooping cough), influenza,
respiratory MRSA
Infection Control Issues
• Contact Precautions
• Ensure appropriate patient placement in a single patient space or room if
available in acute care hospitals.
• Use personal protective equipment (PPE) appropriately, including gloves and
gown. Wear a gown and gloves for all interactions that may involve contact
with the patient or the patient’s environment.
• Limit transport and movement of patients outside of the room to medically-
necessary purposes. When transport or movement is necessary, cover or
contain the infected or colonized areas of the patient’s body.
• Use disposable or dedicated patient-care equipment (e.g., blood pressure
cuffs). If common use of equipment for multiple patients is unavoidable,
clean and disinfect such equipment before use on another patient.
• Prioritize cleaning and disinfection of the rooms of patients on contact
precautions ensuring rooms are frequently cleaned and disinfected (e.g., at
least daily or prior to use by another patient if outpatient setting) focusing on
frequently-touched surfaces and equipment in the immediate vicinity of the
patient.

• Diseases in this category are:

• Conjunctivitis, herpes simplex, scabies, VRE, MRSA in wounds, C.diff
Infection Control Issues
• Enhanced Contact & Respiratory Precautions
• Wear gloves, gown, N95 mask preferred, hair cover, face shield or
goggles
• Doors closed
• Double hand wash
• Limit patient leaving the room
• Treating & leaving equipment in the room is the only option

• Can you think of diseases in this category?

• SARS, pandemic of influenza, COVID-19
Infection Control Issues for
PT Equipment
• After a patient on isolation is discharged or isolation is
removed
• Clean equipment with an anti-microbial product thoroughly
(EPA registered disinfectant)
• For enhanced contact & respiratory, double clean
Unique Infection Control Issues
• How long do bacteria & viruses live outside of the body?
• Varies from a few seconds to weeks
• HIV is a few seconds
• E.coli up to 24 hours
• Spores of staph aureus can survive for weeks
• Coronavirus – up to 3 days (3 hours in aerosols)
Unique Infection Control Issues
What if you are pregnant?
These infections can pass to the fetus during pregnancy, or cause more
severe illness to a pregnant woman:
• Chicken pox (varicella • Herpes
zoster virus) • Influenza
• Coccidioidomycosis (Valley • Listeria
Fever) • Malaria
• Cytomegalovirus (CMV) • Measles
• Ebola virus • Parvovirus B19 (Fifth
• Hepatitis B virus (HBV) disease)
• Hepatitis C virus (HCV) • Rubella (German measles)
• Hepatitis E virus (HEV) • Toxoplasmosis
• Human Immunodeficiency • Zika Virus
Virus (HIV)
Unique Infection Control Issues
• Bed bugs!!!
• If you discover bed bugs during a patient visit
• Remain calm
• Record the infestation in your notes
• Remove any protective clothing you were wearing and place in a
sealed plastic bag
• Inspect yourself in a mirror to perform a self-inspection. Check
clothing (back of pants, tread of your shoes, shoe laces, socks,
cuffs, collar)
• If you find an insect. Don’t freak out. Use a “wet wipe” to capture
the insect (for later ID).
• Wipe down the surrounding area, paying attention to seams and
other hiding places for bugs.
Unique Infection Control Issues
• Bed bug actions continued
• Then notify your supervisor
• Return to your home
• Remove all clothing before entering your home if possible
• Immediately place clothes in a plastic bag and seal
• Get into the shower
• After showering, place sealed clothing and wash on a hot cycle
• Place shoes in a hot dryer for 30 minutes
• Dry your clothes on high heat
Is your patient ready for
mobilization?
• Parameters to review to determine readiness for PT
• Pulmonary measures to review
• SaO2
• Respiratory rate
• PEEP
• FiO2
• Cardiovascular measures to review
• Presence of chest pain or arrhythmia
• BP
• Resting heart rate
• Mean arterial pressure

Nordon-Craft et al. PTJ. 2012;92:1494-1506.

Is your patient ready for
mobilization?
• Parameters indicating a lack of readiness for PT interventions
• Laboratory values to review
• Hematocrit
• Hemoglobin
• Platelets (+/- elevated temp?)
• INR
• Metabolic measures to review
• Glucose levels
• Cognition status review

Nordon-Craft et al. PTJ. 2012;92:1494-1506.

Is your patient ready for
mobilization?
• Physical Function ICU Test are 4 functional tasks performed in
this order:
• TEST 1: Sit to stand from a standardized chair
• OBJECTIVE MEASURE: assistance recorded as 0-3 people
• TEST 2: Marching on the spot as long as possible
• OBJECTIVE MEASURE: time (seconds), steps and cadence (steps/min)
• TEST 3: Bilateral shoulder flexion (full range of motion) as long as
possible. Patients begin with hands on thighs, measurement
ceased when shoulder flexion was < 90° or >2 s elapsed between
movements.
• OBJECTIVE MEASURE: time, reps, and cadence(reps/min)
• TEST 4: MMT for knee extension and shoulder flexion
• OBJECTIVE MEASURE: 0/5 scale

Skinner et al. Critical Care and Resuscitation. 2009. 11(2):110-115.

Another useful functional measure
for the acute care setting
• AM-PAC “6 clicks”
• This is a validated measure based on the activity limitation
domain of the ICF model
• It is capable of helping PT’s make clinical decisions about a
patient’s need for more than one PT visit in an acute care setting
• A basic mobility scaled score of <44% will need additional PT visits
• Improves efficiency in acute care setting and appropriate referrals
• Also has an occupational therapy version – inpatient daily activity
short form

Jette et al. Physical Therapy. 2014. 94(3):379-391.

Practice Quiz question
• Which of the following is the MOST appropriate (& minimum
required) personal protective equipment that should be worn
when you are performing transfer training who is on isolation
with droplet precautions?
A. N95 mask, hair cover, gown, face shield, gloves. enhanced
B. Gloves and gown contact
C. Goggles and mask
D. Goggles, gloves and gown
Physical Therapy in the Intensive Care Unit

Deirdre L. Matt, PT, DPT, CCS

P524 Cardiopulmonary Practice Patterns, Spring 2021
1
Adverse effects of ICU stay
• Physical inactivity leads to muscular atrophy and
generalized weakness
– Sarcopenia, bone degradation
• Diaphragmatic weakness due to prolonged mechanical
ventilation
• Pressure ulcers
• Contractures
• Compromised cardiac and respiratory function
– Orthostatic hypotension, increased HR, decreased CO & SV
• DVT
• Infections
• Changes in mental status Delirium 2
ICU Delirium
The Diagnostic and Statistical Manual of Mental
Disorders (DSM IV) officially defines delirium as a
disturbance of consciousness with inattention
accompanied by a change in cognition or
perceptual disturbance that develops over a short
period of time (hours to days) and fluctuates over
time.

3
ICU Acquired Weakness
Intensive Care Unit Acquired Weakness (ICUAW) is an acute clinical
weakness that occurs in approximately 50% of ICU patients and is
directly attributable to their critical care stay where other causes of
weakness have been excluded. The condition is characterized by
diffuse limb and respiratory muscle weakness with a relative
sparing of the cranial/facial muscles and the autonomic nervous
system.
ICUAW is often a manifestation of immobility or a systemic
inflammatory response syndrome, especially in long-term ventilated
patients who have had systemic sepsis/multiorgan failure or
exposure to high-dose corticosteroids, neuromuscular blockers or
hyperglycaemia. It is associated with prolonged weaning from
mechanical ventilation, increased mortality/length of ICU stay and
long-term disability.

4
Post-Intensive Care Syndrome (PICS)
• Post-intensive care syndrome (PICS) is a group of problems that
people can experience after surviving a life-threatening illness.
More than half of all people who survive a hospital stay in the
intensive care unit (ICU) will have at least one of the problems
seen with PICS. People who develop PICS can experience any
combination of these symptoms. They may be entirely new
problems or worsening of problems that were present before the
critical illness.
• Physical symptoms include weakness, pain, shortness of breath,
and difficulty with movement or exercise.
• Mental health symptoms range from mild anxiety or irritability to
severe depression, sleep disturbances, and post-traumatic stress
disorder.
• Cognitive changes include difficulty thinking, remembering, or
concentrating.
5
 ABCDEF Bundle
A: Assess, prevent, and manage pain
B: Both SAT and SBT
– Spontaneous Awakening and Breathing Trial
C: Choice of analgesia and sedation
– Treating pain
D: Delirium: assess, prevent, and manage
– Lethargy, agitation, impaired memory
E: Early mobility and exercise:
– decreased length of stay, ventilation time, delirium
F: Family engagement and empowerment: 6
Mobilization vs. Rehabilitation
•Be a confident advocate for the profession and the
valuable services that we provide. There is a need to
educate ALL healthcare professionals.
•Our role is rehabilitative
– Because this ties in closely with mobilization, and we are the mobility
experts, these lines can become blurred
•Consider these things:
– Prior Level of Function
– Therapy Goals
– Am I providing a skilled intervention that others cannot
provide?
– Progression of mobility may simply be limited by their
medical status
7
PT Assessment in the ICU
• Prior level of • Positioning
function • Outcome Measures
• MMT • Reflexes/Tone
• ROM • Sensation
• Skin • Coordination
• Cognition • Vitals
• Auscultation – pre-/during/post-
mobility/activity

8
Physical Therapy in the ICU
• Not everyday will be about walking out in the hall
– Bed level activities can be just as valuable
• Don’t be afraid to ask for help
– ICU environment is a team
– Use your therapy support staff – tech, aide
– Ask your colleagues
•Rely on seasoned therapists – PT and OT
• Everything that is going on with a pt is not always in the
chart
– Know how to have valuable conversations with RN, RT,
and MD
– Utilize same language to be on the same page
9
Continuous Monitoring
• Blood Pressure (BP) • Electrocardiogram (5 lead ECG)
– External cuff (location) – Rate
– Arterial – Rhythm
•Wrist v Femoral line • Pulmonary Artery Pressure
• Heart Rate (bpm) (PAP)
– Telemetry – Pulmonary Artery Catheter
– Pulse oximeter (Swan-Ganz)

• Oxygen Saturation (SpO2) • Pulmonary Capillary Wedge

Pressure (PCWP)
• Temperature
• Central Venous Pressure (CVP)
• Intracerebral Pressure (ICP)

10
Considerations:
Oxygen Support System
• Ventilator Setting (rest vs. work mode)
– Timing treatment pre- vs. post-
extubation
• Heated Humidified High Flow Nasal
Cannula
Trach collar

Intubated Vapotherm Optiflow

11
Considerations: Drains
• Jackson-Pratt (JP Drain) – pulls excess fluid from the body
by constant suction
• Penrose - surgical device placed in wound to drain fluid; soft
rubber tube in wound to prevent fluid build up
• Chest Tube (CT) - removes either air or fluid in pleural
space; used for hemothorax, pneumothorax, chylothorax,
pleural effusion, empyema
• Nasogastric Tube (NG) - thru nostrils to the stomach, to the
duodenum used to decompression/rest GI system *monitor
for nausea when disconnected from suction
• Wound vac – assists in closure of wound by creating
negative pressure
• Catheter – urinary collection (Foley, Suprapubic) 12
Considerations: Lines
• Endotracheal Tube (ET) - inserted into trachea from oral
cavity for primary purpose of maintain airway to ensure
adequate oxygen and carbon dioxide exchange
• Tracheostomy Tube (trach) – inserted directly into trachea;
may or may not be connected to ventilator
• Central Venous Catheter
• Percutaneous Intravascular Central Catheter (PICC) -
delivers medications and other treatments directly to the
large central veins
• Arterial Line

13
Considerations: Lines
• Intravenous (peripheral IV) – administer medications
• Nasogastric tube feed (Corpak, Dobhoff) – provides
nutritional support; usually terminates in small bowel to
decrease aspiration/reflux risk
• Epidural/Patient Controlled Analgesic (PCA)
• Dialysis access –
– Continuous (CVVH/CRRT)
– Intermittent (HD)
• Extracorporeal Membrane Oxygenation (ECMO)
– Veno-Venous (VV) - R/L Femoral, R IJ, Pulmonary Artery
– Veno-Arterial (VA) – R/L Femoral, R IJ, Aorta

14
Considerations: Restraints

15
Considerations: Other devices

16
Precautions/Contraindications

17
 When is PT NOT appropriate?
• Patients who are medically unstable
– Respiratory
– Cardiovascular/circulatory
• Active myocardial ischemia
• Patients who are unresponsive
– “Medically-induced coma”
– Chemical paralysis
– Hypothermia protocol
• Is the treatment that you are providing ONLY able to be provided by a physical
therapist?
– Working to the level of your license
• May need to consult and advise nursing staff on positioning strategies and
mobility recommendations
– Keep in mind goals of treatment – while consultation may be appropriate,
continuing treatment may not
18
Yellow Flags – Rest and Re-Assess

• Vital signs
– Reaching danger zones
– Inappropriate responses to exertion
•May just need to rest then decrease workload
• Increasing arrhythmia (i.e., increasing number
of PVCs)
• Onset of mild to moderate signs and symptoms
such as dyspnea, LE fatigue, light-headedness

19
Red Flags – Stop
• Dangerous arrhythmias
– Monitors are not always correct
• Look at the pt!
• Check lines
– Check BP
• Signs/Symptoms
– New-onset chest pain
– Diaphoresis
– Syncope/near-syncope
– Worsening S3 heart sound/crackles in lung bases

20
Red Flags – Stop
• Vital signs
– Know your “stopping points”
•Max HR
•MAP goal
– Every pt is different
•think new MI vs. end-stage CHF
– Drop in BP signifies inability to maintain CO
•CHF/valve disease
– Restrictive lung disease — stop well BEFORE
reaching dangerous SpO2 level. They will continue to
drop further even when stopped for rest.
21
SPECIAL POPULATIONS II
CONTINUUM OF CARE
NICHE MARKETS
CARDIAC REHABILITATION
PULMONARY REHABILITATION
TO TREAT OR NOT TO TREAT

4/19/21
DISCHARGE PLANNING

• Poor discharge planning and failure to provide necessary services can result
in:
• Failure of patient to reach optimal health & functional status
• Increased cost to the hospital
• Decreased resource availability to others due to increased length of stay and
readmission
• Possible adverse events or conditions causing harm to the patient
DISCHARGE PLANNING

• Several factors are associated with poor post-discharge outcomes:

• Aged 80 years or older
• Inadequate support system
• Multiple, active chronic health problems
• History of depression
• Moderate to severe functional impairment
• Multiple hospitalizations during the prior 6 months
• Hospitalization within the past 30 days
• Fair or poor rating of health
• History of non-adherence to the therapeutic regimen
 DISCHARGE PLANNING
• The PT’s role:
• Discharge location:
• Home w/out PT: no functional deficits or pain and/or medically stable (no need for skilled PT)
• Home w/ OP referral: minor functional deficits or pain and has transportation
• Home w/ HH referral: minor functional deficits or pain and is considered homebound
• SNIF or sub acute: complex medical management, nursing and rehabilitation needs require
interdisciplinary team; able to tolerate 1.5 hours of therapy a day (PT, OT, SPT) likely SNIF d/c
(Medicare Part A benefactor)
• Acute rehab: complex medical management, nursing and rehabilitation needs require interdisciplinary
team; able to tolerate 3 hours of rigorous therapy a day (PT, OT, SPT) likely home d/c
• ECF w/ or w/out PT: 24-hour nursing care (Medicare Part B benefactor)
• LTAC w/ or w/out PT: medically complex, on ventilator, no clear d/c
• Home w/ hospice: terminally ill, 24 hour care (Medicare Part a benefactor)
CLINICAL DECISION MAKING
(COMPLEXITY)

Complexity Components Low Moderate High

History No personal 1-2 personal > 3 personal;
factors &/or factors &/or factors &/or
comorbidities comorbidities comorbidities
Examination *1-2 functional *3 functional *>3 functional
impairments impairments impairments
Clinical presentation Stable Evolving Unstable
Face to face time 20 30 45
needed (minutes)
CPT code 97161 97162 97163

*Functional impairment = limitation in body structure/function, activity, &/or participation

per the ICF
What if the patient has low, moderate, or high in different categories: choose the
complexity that is the “lowest” 1 low and 2 moderate = Low complexity
CASE 1
Patient is 62 year old male with history of CAD and HTN admitted with recurrent pituitary adenoma
and is now s/p transphenoidal resection and lumbar drain placed (nasal precautions). He was
independent with PLOF (community ambulator), married, lives in 2 story home (railing present). He
was oriented x3 and demonstrated limited activity tolerance due to increased head pain when up.
Pain was 2/10 in supine, 7/10 when up, and 3/10 back in supine. He was independent for bed
mobility, sit to/from stands, ambulation for 270ft with no assistive device, and ascending/descending
14 stairs with unilateral railing. Vitals were stable.
 CASE 2
• 42 year old male admitted following fall down 3 stairs due to dizziness resulting in right ankle
fx (now s/p ORIF, splint applied). He has no pertinent prior medical history. He is NWB on R LE
with no ROM to R ankle. He will remain NWB for 6 weeks. He was supervision for ambulation
and stairs with use of crutches (although gait was slow). He reported pain as 4/10 at rest and
5/10 during ambulation. Vitals were stable.
CASE 3
65 year old male with history of advanced COPD and pulmonary HTN admitted for COPD exacerbation and
pneumonia. He was also had elevated troponin and found to have NSTEMI. He was evaluated while intubated. He
is on 2L O2 at home, currently ventilated 50% FiO2 and sedated due to agitation. His POA/other family not
available at time of evaluation. There was no change in alertness throughout session, patient did not arouse due to
sedation.
-Total assist with ROM
-Elevated BP 159/72
 CASE 4
87 year old female with history of advanced Alzheimer’s and chronic sacral wound admitted from ECF with sepsis
and a stage 4 sacral wound (suspicious for osteomyelitis). She is bedbound at baseline (approximately 5 years) and
total assist for transfers with hoyer lift. Noted bilateral ankle and knee contractures during exam. Patient was
confused and unable to follow commands. Communication is difficult. She was total assist for bed mobility. PT wound
care was consulted for sacral wounds. Due to patient being at baseline in terms of mobility the patient was
discharged from mobility PT.
EVALUATION COMPLEXITY

• The hardest area is the clinical presentation (on IP’s, rarely stable if PT is needed)
• Don’t forget to consider
• Abnormal vital signs
• Cognition & fall risk (due to impulsivity and/or balance issues)
• Need for oxygen
• Nausea, dizziness or incontinence
• Fluctuations in pain levels
• Post-op restrictions – duration and difficulty patient has maintaining
• Plans for future surgeries
• Documenting your justification is key!
CARDIAC REHABILITATION

• The primary components of a comprehensive program are:

• Patient assessment
• Patient exercise training in 4 phases
• Patient education
• Program evaluation
• Maintenance
INCLUSION CRITERIA

• MI • End-stage renal disease

• Angina • Status post pacemaker insertion
• Post CABG • Cardiomyopathy
• Compensated heart failure • Peripheral vascular disease
• Cardiac surgery • Heart transplant
• High risk for CAD • High risk for diabetes
• High risk for HTN
CARDIAC PROGRAM – PHASE 1

• Physician referral • Consists of:

• Inpatient program • Patient & family education
• Self care evaluation
• <7-10 days • Continuous monitoring of vital signs
• Must be medically stable • Group discussions
• Exercise intensity, HR & RPE • Low level exercise
• AROM, ambulation, self care
• May be concluded with a low level
test
PT ROLE DURING IP CARDIAC REHAB

• Constant monitoring of HR, BP, ECG before, during and after each
session
• Develop program within guidelines of patient’s prescribed training HR
• Use of exertion scales to identify subjective intensity of exercise
• Promote proper technique and breathing patterns during exercise
• Progress activities based on patient’s response to exercise
CARDIAC PROGRAM – PHASE 2

• Begins immediately after hospitalization or in some cases 6 weeks after acute

episode
• Lasts for 3-6 months, 2-3 times per week
• Closely monitored, all activities supervised
• Includes;
• Exercise, education on risk factors, independent self monitoring

• Patient progresses when they do not need ECG monitoring and can self-monitor
CARDIAC PROGRAM – PHASE 3

• Continuation of Phase 2
• Lasts 6-12 months, 1 time per week
• Includes exercise, education, and counseling
• Review of risk factors
• Maximal symptom limited test can be performed to assess exercise intensity
required & make recommendations for self management
CARDIAC PROGRAM – PHASE 4

• Throughout patient’s lifetime

• Designed to promote health
• Requirements to participate;
• Independence with self monitoring
• Stable cardiac status
• No contraindications to exercise
• 5 MET capacity for activities
PT ROLE DURING OP CARDIAC REHAB

• Monitor HR, BP & ECG closely initially • Gradual progression

• Progress to self-monitoring of HR & RPE • Warm-up
• Aerobic activity, 20-60 mins
• Development of an exercise program should • Cool down
be based on a;
• symptom-limited treadmill test • Exercise may include;
• determined target HR • walking
• stationary bicycling
• low resistance isotonic strengthening*
• flexibility exercises
• Isometrics are contraindicated
RESISTANCE TRAINING GUIDELINES

• Can start:
• A minimum of 5 weeks post-MI, including 4 weeks of continuous program participation
• A minimum of 8 weeks post-CABG, including 3 weeks of continuous program participation
• A minimum of 2 weeks of consistent participation post-PTCA
RESISTANCE TRAINING GUIDELINES

• Pre-test: determine 1 repetition maximum (1-RM)

• Training: weights should be set at 30-50% of the 1-RM
• Dosage: 1 set of 8-10 reps for each major muscle group, 2-3 times per week
with day or rest between each workout
RESISTANCE TRAINING GUIDELINES

• Specific considerations:
• Exercise large muscle groups before small muscle groups
• Exhale during exertion phase of lift
• Increase loads by 5-10lbs when 12-15 reps can be performed comfortably
• Avoid straining, between 11-13 (on the 6-20 scale)
• Stop if signs of dizziness, palpitations, unusual shortness of breath, or angina
PULMONARY REHABILITATION

• The primary components of a comprehensive program are:

• Patient assessment
• Patient exercise training
• Patient education
• Program evaluation
• Maintenance

http://www.pulmonaryrehab.com.au/welcome.asp
PULMONARY REHABILITATION

• The primary aims of pulmonary rehabilitation

• To reduce disability and handicap of persons with chronic lung diseases.
• To restore patients to the highest possible level of independent functioning.

http://www.pulmonaryrehab.com.au/welcome.asp
INCLUSION CRITERIA

• Include patients who:

• Have stable chronic obstructive pulmonary disease or other respiratory conditions without
acute illness.
• Are willing to participate (even if they are current smokers).
EXERCISE PORTION OF PULMONARY
REHABILITATION
• Warm-up & cool-down
• Lower limb endurance (walking, cycling)
• Lower & upper limb strengthening (high weight, low repetition)
• Upper limb endurance (upper extremity ergometer)
• Inspiration muscle training (IMT)
• Length of time, 6-12 weeks
• Use supplemental oxygen as needed
EDUCATION PORTION OF PULMONARY
REHABILITATION
• Role and current use of medications
• Breathing techniques & airway clearance
• Exercise
• Nutrition
• Information on the lungs
• Coping with anxiety
• Energy conservation
MAINTENANCE PORTION OF PULMONARY
REHABILITATION
• If possible continue with one supervised session weekly
• Comprehensive HEP