Susan O sullivan Raymond Siegelman National Phy

2. Medical therapy: drugs aimed at reducing oxygen Cardiovascular Physical Therapy 151 demand on the heart and increasing coronary blood flow. improved left ventricular function, anginal relief. a. Nitrates (nitroglycerin): decrease preload b. Intravascular stents: an endopro the is (pliable through peripheral vasodilation, reduce myocardial oxygen demand, reduce chest dis- wire mesh) implanted postangiopla ty to pre- comfort (angina); may also dilate coronary vent restenosis and occlusion in coronary or arteries, improve coronary blood flow. peripheral arteries. b. Beta adrenergic blocking agents (e.g., propra- c. Coronary artery bypass graft (CABG): surgical nolol/Inderal): reduce myocardial demand by circumvention of an obstruction in a coronary reducing heart rate and contractility; control artery using an anastomosing graft (saphenous arrhythmias, chest pain; reduce blood pressure. vein, internal mammary artery); multiple grafts c. Calcium channel blocking agents (e.g., dilti- may be necessary; results in improved coro- azeml Cardizem, Procardia): inhibit flow of nary blood flow, improved left ventricular calcium ions; decrease heart rate, decrease con- function, anginal relief. tractility, dilate coronary arteries, reduce BP, d. Transplantation: used in end-stage myocardial control arrhythmias, chest pain. disease, e.g., cardiomyopathy, ischemic heart d. Antiarrhythmics (numerous drugs, 4 main disease, valvular heart disease. classes): alter conductivity, restore normal heart (1) Heteroptics: involves leaving the natural rhythm, control arrhythmias, improve cardiac output, (e.g., Quinidine, Procainarnide). heart and piggy-backing the donor heart. e. Antihypertensives (numerous drugs, 4 main (2) Orthotopic: involves removing the diseased types): control hypertension; goal is to main- tain a diastolic pressure less than 90 mmHg; heart and replacing it with a donor heart. decrease afterload, reduce myocardial oxygen (3) Heart and lung transplantation: involves demand, (e.g., Propranolol, Reserpine). f. Digitali (cardiac glycosides): increases con- removing both organs and replacing them tractility and decreases heart rate; mainstay in with donor organs. the treatment of CHF, (e.g., Digoxin). (4) Major problems post-transplantation are: g. Diuretics: decrease myocardial work (reduce rejection, infection, complications of preload and afterload), control hypertension, immunosuppressive therapy. (e.g., Lasix, Esidrix). e. Ventricular assist devices (VADs): an implanted h. Aspirin: decreases platelet aggregation, may device (accessory pump) that improves tissue prevent myocardial infarction. perfusion and maintains cardiogenic circula- i. Tranquilizers: decrease anxiety, sympathetic tion; used with severely involved patients, e.g., effects. cardiogenic shock unresponsive to medica- J. Hypolipidemic agents (6 major cholesterol- tions, severe ventricular dysfunction. lowering drugs): reduce serum lipid levels when 5. Thrombolytic therapy for acute myocardial infarc- diet and weight reduction are not effective, tion: medications administered to activate body's (e.g., Questran, Colestid, Zocor, Mevacor). fibrinolytic system, dissolve clot, and restore coro- nary blood flow, (e.g., Streptokinase, Tissue 3. Activity restriction: acute MI, CHF: limited, gen- Plasminogen Activator [TPA], Urokinase). erally to first 24 hours; or until patient is stable for 24 hours. IV. Peripheral Vascular Disease (PVD) 4. Surgical interventions. (Table 3-3) a. Percutaneous translurninal coronary angioplasty A. Arterial disease (PTCA): under fluoroscopy, surgical dilation of a blood vessel using a small balloon-tipped l. Arteriosclerosis obliterans (atherosclerosis): chronic, catheter inflated inside the lumen; relieves occlusive arterial disease of medium and large-sized obstructed blood flow in acute angina or acute vessels, the result of peripheral atherosclerosis. MI; results in improved coronary blood flow, a. Associated with hypertension and hyperlipi- demia; patients may also exhibit CAD, cere- brovascular disease, diabetes. b. Pulses: decreased or absent. c. Color: pale on elevation, dusky red on depend- ency. d. Early stages, patients exhibit intermittent clau-

152 a. Abnormal vasoconstrictor reflex exacerbated by exposure to cold or emotional stress; tips of fingers dication. Pain is described as burning, searing, develop pallor, cyanosis, numbness and tingling. aching, tightness, or cramping. e. Late stages, patients exhibit ischemia and rest b. Affects largely female . pain; ulcerations and gangrene, trophic c. Occlusive disease is not usually a factor. changes. B. Venous disease f. Affects primarily the lower extremities. 1. Varicose veins: distended, swollen superficial 2. Thromboangiitis obliterans (Buerger's disease): veins; tortuous in appearance; may lead to vari- chronic, inflammatory vascular occlusive disease cose ulcers. of small arteries and also veins. 2. Superficial vein thrombophlebitis: clot formation a. Occurs commonly in young adults, largely and acute inflammation in a superficial vein. males, who smoke. Localized pain; usually in saphenous vein. b. Begins distally and progresses proximally in 3. Deep vein thrombophlebiti (DVT): clot formation both upper and lower extremities. and acute inflammation in a deep vein. c. Patients exhibit paresthesias or pain, cyanotic a. Usually occurs in lower extremity, associated cold extremity, diminished temperature sensa- tion, fatigue, risk of ulceration and gangrene. with venous stasis (bedrest, lack of leg exercise), 3. Diabetic angiopathy: an inappropriate elevation of hyperactivity of blood coagulation, and vascular blood glucose levels and accelerated atherosclerosis. trauma; early ambulation is prophylactic, helps a. Neuropathy a major problem. eliminate venous stasis. b. Neurotrophic ulcers, may lead to gangrene and b. Signs and symptoms: may be asymptomatic amputation. early; inflammation, tenderness, pain, swelling, 4. Raynaud's disease or phenomenon: episodic warmth, skin discoloration. spa m of small arteries and arterioles. c. Homan's sign (test for DVT of calf vein ): calf TABLE 3-3 DIFFERENTIAL DIAGNOSIS: PERIPHERAL VASCULAR DISEASES CHRONIC ARTERIAL INSUFFICIENCY CHRONIC VENOUS INSUFFICIENCY Etiology arteriosclerosis obliterans thrombophlebitis atheroembolism trauma, vein obstruction venous hypertension Risk factors smoking varicose veins diabetes mellitus inherited trait hyperlipoproteinemia hypertension minimal to moderate steady pain aching pain in lower leg with prolonged standing or Signs & Symptoms: determined by location and degree of vascular involvement sitting (dependency) superficial pain along course of vein Pain severe muscle ischemialintermittent claudication: worse with exercise, relieved by rest muscle compartment tenderness rest pain indicates severe involvement venous dilatation or varicosity muscle fatigue, cramping, numbness edema: moderate to severe paresthesias over time liposclerosis: dark, cyanotic Location of pain usually calf, lower leg or dorsum of foot thickened, brown may occur in thigh, hip or buttock may lead to stasis dermatitis, cellulitis acute thrombophlebitis (DVT): Vascular decreased or absent pulses calf pain, aching, edema, muscle tenderness, 50% asymptomatic pallor of forefoot on elevation, may develop at sides of ankles, especially dependent rubor medial malleolus; gangrene absent Skin changes pale, shiny, dry loss of hair nail changes coolness of extremity Acute acute arterial obstruction: distal pain, paresthetic, pale, pulseless, sudden onset Ulceration may develop in toes or feet or areas of trauma; gangrene may develop Adapted from: Bickley, L and SZilagyi, P (2003). Bates Guide to Physical Examination and History Taking, 8th ed. Philadelphia, Lippincott Williams & Wilkins, 460-464.

pain with dorsiflexion of ankle; limited diag- Cardiovascular Physical Therapy 153 nostic reliability. d. May precipitate pulmonary embolism: presents ~ Cardiac Rehabilitation abruptly, with chest pain and dyspnea, also diaphoresis, cough, apprehension; requires (Table 3-4) emergency treatment, may be life threatening. A. Exercise Tolerance Testing e. Medical management: anticoagulation therapy, e.g., heparin; thrombolytic agents, (e.g., 1. Exercise Tolerance Test (ETT). (Graded Exercise Streptokinase); bedrest. Test). 3. Chronic venous insufficiency (deep). a. Purpose: to determine physiological responses a. Pain: none to aching pain on dependency. during a measured exercise stress (increasing b. Pul es: normal; difficult to take with edema. workloads); allows the determination of func- c. Color: normal or cyanotic on dependency. tional exercise capacity of an individual. d. Venous valvular insufficiency: from fibroelastic (1) Serves as a basis for exerci e prescription. degeneration of valve tissue, venous dilation. Symptom-limited ETT is typically adrnini - e. Muscle pump dysfunction. tered prior to start of Phase II outpatient car- f. Edema, impairment of fibrinolysis; may lead to diac rehabilitation program and following venous ulcer formation. cardiac rehabilitation as an outcome measure. g. Classification. (2) Used as a screening measure for CAD in Grade I: mild aching, minimal edema, dilated asymptomatic individuals. superficial veins. (3) ETT with radionuclide perfusion: assists in Grade II: increased edema, multiple dilated the diagnosis of suspected or established veins, changes in skin pigmentation. cardiovascular disease. Grade III: venous claudication, severe edema, b. Testing modes. cutaneous ulceration. (1) Treadmill and cycle ergometry (leg or arm C. Lymphatic disease tests) allow for precise calibration of the 1. Lymphadenopathy: enlargement of nodes, with or exercise workload. without tenderness. 2. Lymphedema: excessive accumulation of fluid due TABLE 3-4 CARDIOVASCULAR/PULMONARY to obstruction of lymphatics, causes swelling of PRACTICE PATTERNS the soft tissues in arms and legs. 3. Acute lymphangitis: acute bacterial infection Pattern A: Primary Prevention/Risk Reduction for spreading throughout lymph system; usually strep- Pattern B: Cardiovascular/Pulmonary Disorders tococcal. Pattern C: 4. Primary lymphatic disease: congenital. Impaired Aerobic Capacity/Endurance Associated with 5. Secondary lymphatic disease: acquired, due to Pattern D: Deconditioning trauma, surgery (radical mastectomy, femoro- Pattern E: popliteal by-pass), radiation, or disease (malignancy, Pattern F: Impaired Ventilation, Respiration/Gas Exchange, and infection). Pattern G: Aerobic Capacity/Endurance Associated with Airway Clearance Dysfunction Pattern H: Impaired Aerobic Capacity/Endurance Associated with Cardiovascular Pump Dysfunction or Failure Impaired Ventilation, Respiration/Gas Exchange Associated with Ventilatory Pump Dysfunction or Failure Impaired Ventilation, Respiration/Gas Exchange Associated with Respiratory Failure Impaired Ventilation, Respiration/Gas Exchange, and Aerobic Capacity/Endurance Associated with Respiratory Failure in the Neonate Impaired Circulation and Anthropometric Dimensions Associated with Lymphatic System Disorder From Guide for Physical Therapist Practice, 2nd ed. Phys Ther 81:9,2001

154 (2) RPE increases linearly with increasing exercise intensity and correlates closely to (2) Step test (upright or sitting) can also be used V02max and heart rate. for fitness screening, healthy population. (3) An important measure for individuals who c. ETT may be maximal or submaximal. do not exhibit the typical rise in HR with (1) Maximal ETT: defined by target end-point exercise (e.g., on medications that depress heart rate. HR, beta blockers). (a) Age-adjusted maximum heart rate (AAMHR): 220 minus age of individual. f. Pulse oximetry: measure arterial oxygen satu- (b) Heart-rate range (Karvonen formula): ration levels (Sa02) before, during, and after 60-80% (HR max - resting HR) + rest- exercise. ing HR = target HR. (2) Submaximal ETT: symptom-limited, used g. ECG changes with exercise: healthy individual. to evaluate the early recovery of patients (1) Tachycardia: heart rate increase is directly after MI, coronary bypass, or coronary proportional to exercise intensity and angioplasty. myocardial work. (2) Rate-related shortening of QT interval. d. Continuous ETT: workload is steadily progressed (3) ST segment depression, upsloping, less usually in 2 or 3 minute stages. than 1rom. (4) Reduced R wave, increased Q wave. e. Discontinuous ETT: allows rest in between (5) Exertional arrhythmias: rare, single PVC . workloads/stages, used for patients with more pronounced CAD. h. ECG changes with exercise: an individual with myocardial ischemia and CAD. 2. Monitoring: during exercise and recovery. (1) Significant tachycardia: occurs at lower a. Patient appearance, signs and symptoms of intensities of exercise. exertional intolerance; check for: (2) Exertional arrhythmias: increased frequen- (1) Persistent dyspnea. cy of ventricular arrhythmias during exer- (2) Dizziness or confusion. cise and/or recovery. (3) Anginal pain. (3) ST segment depre sion; horizontal or (4) Severe leg claudication. downsloping depression, greater than 1 rom (5) Excessive fatigue. below baseline i indicative of myocardial (6) Pallor, cold sweat. ischemia. (7) Ataxia, incoordination. (8) Pulmonary rales. i. Delayed, abnormal responses to exercise, occur b. Changes in HR: HR increases linearly as a hours later. function of increasing workload and oxygen (1) Prolonged fatigue. uptake (V02), plateaus just before maximal (2) Insomnia. oxygen uptake (V02max). (3) Sudden weight gain due to fluid retention. c. Changes in BP: systolic BP should rise with increasing workloads and V02; diastolic BP 3. Ambulatory monitoring (telemetry): continuou 24 should remain about the same. hour ECG monitoring; allows documentation of ST d. Rate-pressure product (RPP): the product of segment depression or elevation, silent ischemia, systolic BP and HR (the last two digits of a 5 arrhythmias associated with daily activity. digit number are dropped) is often used an index of myocardial oxygen consumption 4. Transtelephonic ECG monitoring: used to monitor ( M V 0 2) · patients as they exercise at home. (1) Increased MV02 is the result of increased coronary blood flow. 5. Determine activity level: METs (metabolic equiv- (2) Angina is usually precipitated at a given alents). RPP. a. MET: the amount of oxygen consumed at rest e. Rating of perceived exertion (RPE). (sitting); equal to 3.5 ml/Kg per min. (1) Original Borg scale: rates exercise intensity b. MET levels (multiples of resting V02) can be using numbers from 6 to 20, with descrip- directly determined during ETT: using collection tors from very, very light to very, very hard. and analysis of expired air; not routinely done. c. MET levels can be estimated during ETT dur- ing steady state exercise; the max V02

Cardiovascular Physical Therapy ISS achieved on ETI is divided by resting V02; a. Unstable angina. highly predictable with standardized testing b. Resting systolic BP >200 mmHg or resting modes. d. Can be used to predict energy expenditure dur- diastolic BP >110 mmHg evaluated on a case ing certain activities (Table 3-5). by case basis. B. Exercise Prescription c. Orthostatic BP drop of >20 mmHg with symp- 1. Contraindications for entry into inpatient/outpa- toms. tient exercise programs, from American College of d. Critical aortic stenosis. Sports Medicine, Guidelines for Exercise Testing e. Acute systemic illness or fever. and Prescription, 4th edition, Lea & Febiger, f. Uncontrolled atrial or ventricular dysrhyth- Philadelphia, 1995, p. 179. mias. g. Uncontrolled sinus tachycardia, >120 bpm. TABLE 3-5 METABOLIC EQUIVALENT (MET) ACTIVITY CHART INTENSITY ENDURANCE OCCUPATIONAL RECREATIONAL PROMOTING (70·kg Person) Too low in energy level Desk work, driving auto, calculating machine Standing, strolling (1 mph), flying, motorcycling, 1.5-2 METs operation, light housework, polishing furniture, playing cards, sewing, knitting 2-3 METs washing clothes 3-4 METs Too low in energy level Auto repair, radio and television repair, janitorial Level walking (2 mph), level bicycling (5 mph), 4·5 METs unless capacity is very low work, bartending, riding lawn mower, light billiards, bowling, skeet shooting, shuffleboard, powerboat driving, golfing with power cart, 5-6 METs woodworking canoeing, horseback riding at a walk 6-7 METs 7-8 METs Yes, if continuous and if Brick laying, plastering, wheelbarrow (100 Ib Walking (3 mph), bicycling (6 mph), horseshoe 8-9 METs target heart rate is load), machine assembly, welding (moderate pitching, volleyball (6-person, non-competitive), 10+ METs reached load), cleaning windows, mopping floors, golfing (pulling bag cart), archery, sailing vacuuming, pushing light power mower (handling small boat), fly fishing (standing in waders), horseback riding (trotting), badminton (social doubles) Recreational activities Painting, masonry, paperhanging, light Walking (3~ mph), bicycling (8 mph), table promote endurance; carpentry, scrubbing floors, raking leaves, tennis, golfing (carrying clubs), dancing (foxtrot), occupational activities hoeing badminton (singles), tennis (doubles), many must be continuous, lasting longer than 2 min calisthenics, ballet Yes Digging garden shoveling light earth Walking (4 mph), bicycling (10 mph), canoeing (4 mph), horseback riding (posting to trotting), stream fishing (walking in light current in waders), ice or roller skating (9 mph) Yes Shoveling 10 times/min (4.5 kg or 10 Ib), Walking (5 mph), bicycling (11 mph), competitive splitting wood, snow shoveling, hand lawn badminton, tennis (singles), folk and square mowing dancing, light downhill skiing, ski touring (2.5 mph), water skiing, swimming (20 yd/min) Yes Digging ditches, carrying 36 kg or 80 Ib, sawing Jogging (5 mph), bicycling (12 mph), horseback hardwood riding (gallop), vigorous downhill skiing, basketball, mountain climbing, ice hockey, canoeing (5 mph), touch football, paddleball Yes Shoveling 10 time/min (5.5 kg or 14 Ib) Running (5.5 mph), bicycling (13 mph), ski touring (4 mph), squash (social), handball (social), fencing, basketball (vigorous), swimming (30 yd/min), rope skipping Yes Shoveling 10 times/min (7.5 kg or 16 Ib) Running (6 mph = 10 METs, 7 mph = 11.5 METs, 8 mph = 13.5 METs, 9 mph = 15 METs, 10 mph = 17 METs), ski touring (5+ mph), handball (competitive), squash (competitive), swimming (>40 yd/min) From Fox, Naughton, Gorman. Mod. Concepts Cardiovascular Disease 1972 4:25. American Heart Association, with permission.

156 expenditure related to skill level. (4) Dancing, basketball, racquetball, competi- h. Uncompensated congestive heart failure. I. 3rd degree A-V heart block (without pacemaker). tive activities should not be used with high j. Active pericarditis or myocarditis. risk, symptomatic and low fit individuals. k. Recent embolism. (5) Early rehabilitation: activity is discontinu- 1. ThrombopWebitis. ous (interval training), with frequent rest m. Resting ST segment displacement >2 mm. periods; continuous training can be used in n. Uncontrolled diabetes (resting glucose >400 later stages of rehabilitation. (6) Warm-up and cool-down activities. mg/dL). (a) Gradually increase or decrease the o. Severe orthopedic problems that would prohibit intensity of exercise, promote circulato- exercise. ry and muscular adjustment to exercise. p. Other metabolic problems, such as acute thy- (b) Type: low intensity cardiorespiratory endurance activities, flexibility (ROM) roiditis, hyperkalemia, hypovolemia, etc. exercises, functional mobility activities. 2. Signs and symptoms below which an upper limit (c) Duration: 5-10 minutes. (d) Abrupt beginning or cessation of exer- for exercise intensity should be set, from American cise is not safe or recommended. College of Sports Medicine, Guidelines for (7) Resistive exercises: to improve strength Exercise Testing and Prescription, 1995, p. 184. and endurance in clinically stable patients. a. Onset of angina or other symptoms of cardio- (a) Usually prescribed in later rehabilitation, after a period of aerobic conditioning. vascular insufficiency. (b) Moderate inten ities are typically used b. Plateau or decrease in systolic blood pressure, (e.g., 40% of maximal voluntary con- traction). systolic blood pressure >240 rnmHg, or dias- (c) Monitor responses to resistive training tolic blood pressure>11 0 rnmHg. using rate-pressure product (incorpo- c. > 1 mm ST-segment displacement, horizontal rates BP, a safer measure). or downsloping. (d) Precautions: carefully monitor BP, d. Radionuclide evidence of LV dysfunction or avoid breath-holding, Valsalva response onset of moderate to severe wall motion abnor- (may dramatically increase BP and malities during exertion. work of heart). e. Increased frequency of ventricular arrhythmias. (e) Contraindicated for patients with: poor f. Other significant ECG disturbances, e.g., 2° or left ventricular function, ischemic 3° AV block, atrial fibrillation, SVT, complex changes on EKG during ETT, functional ventricular ectopy, etc. capacity less than 6 METs, uncon- g. Other signs/symptoms of intolerance to exercise. trolled hypertension or arrhythmias. h. Peak exercise HR should be approximately 10 (8) Relaxation training: relieves generalized bpm below the HR associated with any of the muscle tension and anxiety. above criteria. (a) Usually incorporated following an aer- 3. Guidelines for exercise prescription. obic training session and cool-down. a. Type (modality). (b) Assists in successful stress manage- (1) Cardiorespiratory endurance actIVIties: ment and life-style modification. b. Intensity: prescribed as percentage of function- walking, jogging, or cycling recommended al capacity revealed on ETT, within a range of to improve exercise tolerance; can be main- 40 to 85% depending upon initial level of fit- tained at a constant velocity; very low inter- ness; typical training intensity is 60-70% of individual variability. functional capacity; lower training intensities (2) Dynamic arm exercise (arm ergometry): may necessitate an increase in training dura- uses a smaller muscle mass, results in tion; most clinicians use a combination of HR, lower V02max (60-70% lower) than leg ergometry; at a given workload, HR will be higher, stroke volume lower; systolic and diastolic BPs will be higher. (3) Other aerobic activities: swimming, cross- country skiing; less frequently used due to high inter-individual variability, energy

RPE, and METs to prescribe exercise intensity Cardiovascular Physical Therapy 157 (eliminate problems that may be associated with individual mea ures). uous work pattern: walk 5 minutes, (I ) Heart rate. jog 3 minutes to achieve the desired intensity. (a) Percentage of maximum heart rate Varying skill level or stress of com- achieved on ETT; without an ETT, 220 petition may affect the known minus age is used (for upper extremity metabolic cost of an activity. work, 220 minus age minus 11 is used). Environmental stresses (heat, cold, 70-85 % HRmax closely corresponds to high humidity, altitude, wind, 60 to 80% of functional capacity or V02 changes in terrain such as hills) max. may affect the known metabolic cost of an activity. (b) Estimated HR max is used in cases c. Duration. where submaximal ETT has been given. (1) Conditioning phase may vary from 15 to 60 minutes, depending upon intensity; the (c) Heart rate range or reserve (Karvonen higher the intensity, the shorter the duration. formula, see previous description). (2) Average conditioning time is 20-30 min- more clo ely approximates the rela- utes for moderate intensity exercise. tionship between HR and V02 max. (3) Severely compromised individuals may Problems associated with use of HR benefit from multiple, short exercise ses- alone to prescribe exercise intensity. sions spaced throughout the day (e.g., 3-10 minute se sions). (d) Beta blocking or calcium channel block- (4) Warm-up and cool-down periods are kept ing medications: affect ability of HR to constant, e.g., 5-10 minutes each. rise in re ponse to an exercise stress. d. Frequency. (1) Frequency of activity is dependent upon inten- (e) Pacemaker: affects ability ofHR to rise sity and duration; the lower the intensity, the in re ponse to an exercise stress. shorter the duration, the greater the frequency. (2) Average: 3-5 sessions/week for exercise at (f) Environmental extremes, heavy arm moderate intensities and duration, e.g., >5 work, isometric exercise and Valsalva METs. may affect HR and BP responses. (3) Daily or multiple daily sessions for low intensity exercise, e.g., <5 METS. (2) Rating of Perceived Exertion, the original e. Progression. Borg RPE scale (6-20). (1) Modify exercise pre cription if: (a) RPE values of 12-13 (somewhat hard) (a) HR is lower than target HR for a given correspond to 60% of HR range. exercise intensity. (b) RPE of 16 (hard) corre ponds to 85% (b) RPE is lower (exercise is perceived as ofHR range. easier) for a given exercise. (c) Useful along with other measures of (c) Symptoms of ischemia (e.g., angina) do patient effort if beta-blockers or other not appear at a given exercise intensity. HR suppressers are used. (2) Rate of progression depends on age, health (d) Problems with use of RPE alone to status, functional capacity, personal goals, prescribe exercise intensity. preferences. Individuals with psychological (3) As training progresses, duration is increased problems (e.g., depre sion). first, then intensity. Unfamiliarity with RPE scale; may f. Consider reduction in exercise/activity with affect selection of ratings. (1) Acute illness: fever, flu. (2) Acute injury, orthopedic complications. (3) METs, or estimated energy expenditure (3) Progression of cardiac disease: edema, (V02)· weight gain, unstable angina. (a) 40-85% of functional capacity (maxi- mal METs) achieved on ETT. (b) Problems associated with use of METs alone to prescribe exercise intensity. • With high intensity activities (e.g., jogging), need to adopt a discontin-

158 e. ETT (thallium scan or symptom limited ETT): may be used to determine functional capacity (4) Overindulgence: e.g., food, caffeine, alcohol. prior to discharge, safely progress exercise (5) Drugs: e.g., decongestants, bronchodila- intensity greater than 5 MET . tors, atropine, weight reducers. 3. Patient and family education goal . (5) Environmental stressors: extremes of heat, a. Improve understanding of cardiac disea e, sup- port risk factor modification. cold, humidity; air pollution. b. Teach self-monitoring procedures, warning g. Exercise prescription for post-PTCA (percuta- signs of exertional intolerance, e.g., persistent dyspnea, anginal pain, dizziness, etc. neous transluminal coronary angioplasty). c. Teach general activity guidelines, activity pac- (1) Wait to exercise approximately 2 weeks ing, energy conservation techniques; home exercise program (HEP). post-PTCA to allow inflammatory process d. Teach cardiopulmonary resuscitation ( CPR). to subside. e. Provide emotional support. (2) Use post-PTCA ETT to prescribe exercise. h. Exercise prescription post-CABG (coronary 4 Home exercise program (HEP). artery bypass grafting). a. Low-risk patients may be safe candidates for (1) Limit upper extremity exercise while ster- unsupervised exercise at home. nal incision is healing. (1) Gradual increase in ambulation time: goal (2) Avoid lifting, pushing, pulling for 4 - 6 of 20-30 minute, 1-2x per day at 4-6 week post-surgery. weeks post MI. C. Phase 1: Inpatient Cardiac Rehabilitation (Acute) (2) Upper and lower extremity mobility exer- Length of stay is commonly 3 -5 days for uncompli- cises. cated MI (no post MI angina, malignant arrhythmias, b. Elderly, homebound patients with multiple or heart failure). medical problems may benefit from a home 1. Exercise/activity goals and outcomes. cardiac rehabilitation program. a. Initiate early return to independence in activi- c. Patients should be skilled in self-monitoring ties of daily living, typically after 24 hours or procedures. until the patient is stable for 24 hours; monitor d. Family training in CPR and AED (automated activity tolerance. external defibrillator); emergency lifeline for b. Counteract deleterious effects of bed rest: reduce some patients. risk of thrombi, maintain muscle tone, reduce orthostatic hypotension, maintain joint mobility. D. Phase 2: Outpatient Cardiac Rehabilitation c. Help allay anxiety and depression. (Subacute) d. Provide medical surveillance. 1. Exercise/activity goals and outcome . e. Provide patient and family education. a. Improve functional capacity. f. Promote risk factor modification. b. Progress toward full resumption of activities of 2. Exercise/activity guidelines. daily living, habitual and occupational activities. a. Program components: ADLs, selected arm and c. Promote risk-factor modification, counseling leg exercises, early supervised ambulation. as to lifestyle changes. b. Initial activities: are low intensity (2-3 METs) d. Encourage activity pacing, energy conserva- progressing to 3 -5 METs by discharge; RPE in tion; stress importance of taking proper rest fairly light range; HR increase of 10-20 bmp periods. above resting, depending on medications. c. Short exercise sessions, 2-3 time a day; grad- 2. Exercise/activity guidelines. ually duration is lengthened and frequency is a. Outpatient program: average of 36 visits allowed decreased. by most payers (3 times a week for 12 weeks). d. Post-surgical patients. (I) Patients at risk for arrhythmias with exercise, (1) Typically are progressed more rapidly than angina, other medical problems benefit post-MI. from outpatient program with availability (2) Greater emphasis is placed on upper of ECG monitoring, trained personnel, and extremity ROM. emergency support. (3) Lifting activities are restricted, generally for 6 weeks.

(2) Group camaraderie and support of program Cardiovascular Physical Therapy 159 participants may assist in risk-factor modi- fication and lifestyle changes. 3. Patient and family education goals: progression from phase 1 goals. (3) Frequency: 3-4 sessions/week. (4) Duration: 30-60 minutes with 5-10 minutes F. Exercise Prescription for Patients Requiring Special Considerations of warm-up and cool-down. 1. Congestive heart failure (CHF). (5) Programs may offer a single mode of train- a. Patients demonstrate significant ventricular dysfunction, decreased cardiac output, low ing (e.g., walking) or multiple modes using functional capacities. Classification (New York a circuit training approach (e.g., treadmill, Heart Association). cycle ergometer, arm ergometer); strength (1) Class I: mild CHF; no limitation in physi- training. cal activity (up to 6.5 METs); comfortable (6) Patients are gradually weaned from contin- at rest, ordinary activity does not cause uou monitoring to spot checks and self- undue fatigue, palpitation, dyspnea, or monitoring. anginal pain. (7) Sugge ted exit point: 9 MET functional (2) Class II: slight CHF; slight limitation in capacity (5 MET capacity is needed for physical activity (up to 4.5 METs); com- afe resumption of most daily activities). fortable at rest, ordinary physical activity b. Strength training is a recent addition to Phase 2 results in fatigue, palpitation, dyspnea, or programs. anginal pain. (1) Guidelines: after 3 weeks cardiac rehab; 5 (3) CIa s ill: marked CHF; marked limitation weeks post MI or 8 weeks post CABG. of physical activity (up to 3.0 METs); com- (2) Begin with use of elastic bands and light fortable at rest, less than ordinary activity weights (l -3 lbs). causes fatigue, palpitation, dyspnea, or (3) Progress to moderate loads, 12-15 comfort- anginal pain. able repetitions. (4) Class IV: severe CHF; unable to carry out 3. Patient and family education goals: progression of any physical activity (1.5 METs) without Phase 1 goals. discomfort; symptoms of ischemia, dysp- E. Phase 3: Community Exercise Programs (Post- nea, anginal pain present even at rest; acute, Post-Discharge from Phase 2 Program) increasing with exercise. I. Exerci e/activity goals and outcomes. b. Criteria for exercise training. a. Improve and/or maintain functional capacity. (I) Medically stable. b. Promote self-regulation of exercise programs. (2) Exercise capacity greater than 3 METs. c. Promote life-long commitment to risk-factor (3) Exercise-induced ischemia and arrhyth- modification. mias poor prognostic indicators. 2. Exercise/activity guidelines. c. Exercise training. a. Location: community centers, YMCA, or clini- (1) Use low intensities: (40-60% functional cal facilities. capacity); gradually increasing durations, b. Entry level criteria: functional capacity of 5 with frequent rest periods (interval training). METs, clinically stable angina, medically con- (2) Monitor with RPE (ratings of 12-14), ECG, trolled arrhythmias during exercise. BP, signs of exertional intolerance (dyspnea, c. Progression is from supervised to self-regula- fatigue); HR response may be impaired tion of exercise. (most patients on digoxin); heart rate limited d. Progres ion to 50-85% of functional capacity, to resting HR + 10-20 bpm; exercise HR 3-4 time /week, 45 minutes or more/session. >115 bpm generally contraindicated. f. Regular medical check-ups and periodic ETT (3) Exercise may exacerbate CHF: check for generally required. delayed responses of weight gain, edema g. Utilize motivational techniques to maintain lower extremities. compliance with exercise programs, life-style (4) Patients with CHF (capacities under 6 modification. METs) are not candidates for resistance h. Discharge typically in 6-12 months. training.

160 (b) Non-insulin dependent diabetes: 5 times/week recommended, with longer (5) Respiratory muscle training. Monitoring durations (40-60 minutes). Sa02 via pulse oximetry is advisable in some cases. (2) Exercise effects: lowers blood glucose lev- els; overall less insulin required. d. Emphasis on training in energy conservation, self-monitoring techniques. (3) Hypoglycemia may result with too much insulin (most common response to exer- 2. Cardiac Transplant. cise). a. Patients may present with: (a) Carefully monitor for signs of hypo- (1) Exercise intolerance due to extended inac- glycemia: acute fatigue, restlessness, tivity and convalescence. marked irritability and weakness; in (2) Side effects from immunosuppressive drug severe cases, mental disturbances, therapy: hyperlipidema, hypertension, obesity, delirium, coma (a life-threatening situ- diabetes, leg cramps. ation). (3) Decreased lower extremity strength. (b) Control by eating carbohydrate snacks (4) Increased fracture risk owing to long-term prior to or during prolonged exercise or corticosteroid use. by self-blood glucose monitoring and b. Heart rate alone is not an appropriate measure of placing insulin in a non-exercising exercise intensity (heart is denervated). Use RPE, body part (e.g., abdominal wall). METs, dyspnea scale. c. Use longer periods of warm-up and cool-down (4) Poorly controlled diabetes: lack adequate because the physiologic responses to exercise insulin, may lead to impaired glucose trans- and recovery take longer. port, ketosis, hyperglycemia (too much blood sugar). 3. Pacemakers and automatic implantable cardiovert- er defibrillators (AICD): devices programmed to (5) Proper footwear is important, especially pace heart rate (pacemaker) and/or deliver an elec- with changes associated with diabetic feet. tric shock if HR exceeds set limit (defibrillator). a. Should know setting for HR limit. (6) Jogging, jarring activities are contraindicat- b. ST segment changes may be common. ed in cases of advanced diabetic retinopathy. c. Avoid UE aerobic or strengthening exercises initially after implant. G. Possible Effects of Physical Training/Cardiac d. Electromagnetic signals (anti-theft devices) Rehabilitation may cause devices to fire (defibrillator), or 1. Decreased HR at rest and during exercise; slow down or speed up (pace maker). improved HR recovery after exercise. 2. Increased stroke volume. 4. Diabetes. 3. Increased myocardial oxygen supply and myocar- a. Patients demonstrate problems controlling dial contractility; myocardial hypertrophy. blood glucose, with associated cardiovascular 4. Improved respiratory capacity during exercise. disease, renal disease, neuropathy, peripheral 5. Improved functional capacity of exercising muscles. vascular disease and ulceration, and/or auto- 6. Reduced body fat, increased lean body mass; suc- nomic dysfunction. cessful weight reduction requires multifactorial b. Exercise testing. interventions. (1) May need to use sub-maximal ETT tests; 7. Decreased serum lipoproteins (cholesterol, triglyc- maximal tests precluded with autonomic erides). neuropathy. 8. Improved glucose tolerance. (2) With PVD/peripheral neuropathy, may 9. Improved blood fibrinolytic activity and coagula- need to shift to arm ergometry. bility. c. Exercise training. 10. Improvement in measures of psychological status (1) Use principles of exercise prescription: and functioning: self-confidence and sense of intensities of 40-85% functional capacity. well-being. (a) Insulin-dependent diabetes: daily exer- 11. Increased participation in exerci e; improved out- cise recommended, with shorter dura- comes with adherence to rehabilitation programming. tions (20-30 minutes). a. Decreased angina in patients with CAD: anginal

threshold is raised secondary to decreased Cardiovascular Physical Therapy 161 myocardial oxygen consumption. b. Reduced total and cardiovascular mortality in 4. Start chest compressions if no pul e. patients following myocardial infarction. a. Overall compression rate is about 100/minute c. Decrea ed symptoms of heart failure, for adults, infants, and child. improved functional capacity in patients with b. Compression-ventilation ratio is 30:2. Give left ventricular systolic dysfunction. cycles of 30 compressions and 2 breaths for d. Improved exercise tolerance and function in adults, one or two rescuers. Old guidelines patient with cardiac transplantation. called for 15 compressions and 2 breaths. For H. Basic Life Support (BLS) and Cardiopulmonary infant or child use 30:2 for single rescuer and Resuscitation (CPR) Revised Guidelines from 15:2 for 2 rescuers. American Heart Association: Circulation, 2005; c. Victim must be supported on a hard surface. 112:IV-12-IV-17. Place heel of one hand on the center of the ster- 1. Check for reponse. num right between the nipples; the other hand a. Tap the victim on shoulder and ask, \"Are you is placed on top of first hand. all right?\" d. Push hard and fast (lOO/min) and release com- b. If responds but is injuried, call for help (911) pletely; compression depth should be 11/2 to 2 c. If the victim is unresponsive, call for help (911; inches for adults (approximately 1/3 to 1/2 the in a hospital, call a \"code\"). Then begin CPR. depth of the chest for infant or child). d. Exceptions. Minimize interruptions in compressions. (1) Provide CPR first for adult victims of sub- e. Reevaluate patient's pulse after 1 minute and every 1-3 minutes thereafter. If pulse returns mer ion, trauma, or drug intoxication. but not breathing, continue with rescue breath- (2) Provide one minute of CPR for infants and ing only. f. Continue until defibrillator/AED arrives, children up to age 8 before calling 911. advanced life support (ALS) providers take 2. Open Airway: use head-tilt/cbin-lift maneuver. over, or victim starts to move. a. If trauma is suspected, use jaw thrust to open 5. Defibrillation!AED. airway; do not tilt head. a. All basic life support providers should be trained to use AED/defibrillator. b. Check for breathing by the look, listen and feel b. Follow instructions given by the device. method. If not breathing: c. If not shockable, resume CPR immediately for 5 cycles. Check rhythm every 5 cycles. 3. Start rescue breathing. d. For child 1-8 use pediatric AED system. a. Pinch nose shut and seal lips around the vic- Defibrillation not recommended for infants < 1 tim's mouth or mouth and nose if an infant. year of age. b. Mouth-to-Mouth Rescue Breathing: give 2 e. Continue until ALS providers take over or victim breath at 1 secondlbreath that make the chest starts to move. rise. c. Mouth-to-Barrier Device Breathing: place 6. Foreign-Body Airway Obstruction (choking). pocket face mask over victim's mouth and a. Check for signs of airway obstruction by a for- nose. Continue to tilt head and lift chin, give 2 eign body. \"Are you choking?\" \"Can you slow breaths into opening of pocket mask. speak?\" d. If sign of circulation are present but no normal (l) Universal distress signal: vieim clutches his breathing, provide re cue breathing at 10-12 or her neck with the thumb and index finger. breaths per minute for the adult (12-20 breaths (2) Difficulty speaking, high-pitched sounds per minute for the infant and child less than 8 while inhaling. years). (3) Poor, ineffective cough. e. Recheck pulse every 2 minutes. (4) Bluish skin color (cyanosis). f. Lay rescuers will no longer be taught to check b. Procedure for obstructed airway. for pulse. Lay rescuers should begin chest (1) If victim is conscious and standing, use compre ions in the absence of signs of circu- Heimlich maneuver. Make a fist with one lation (normal breathing, coughing, or move- hand, place thumb side of fist on victim's ment) or if unable/unwilling to give mouth-to- abdomen, below breast bone and above mouth rescue breathing.

162 c. Severe internal bleeding characteristics. (1) Ecchymosi (black and blue) in the injured navel. Grasp around victim with other hand area. and provide quick upward thrusts into the (2) Body part, especially the abdomen, may be victim's abdomen. Repeat until object is swollen, tender and firm. expelled. (3) Skin may appear blue, gray or pale and (2) If victim is unconscious, check airway, give may be cool or moi t. two breaths, and perform CPR. (4). Respiratory rate is increased. I. FirstAid (5). Pulse rate is increased and weak. 1. External Bleeding. (6) Blood pres ure is decrea ed. a. Minor bleeding. (7) Patient may be nauseated or vomit. (1) Usually clots within 10 minutes. (8) Patient may exhibit restlessness or anxiety. (2) If patient/client taking aspirin or NSAIDS, (9) Level of consciousness may decline. clotting time may be longer. b. Severe bleeding characteristics. e. Management of internal bleeding. (1) Blood spurting from a wound. (1) If minor, follow RICE procedure: rest, ice, (2) Blood fails to clot even after measures to compression, elevation. control bleeding have been taken. (2) Major internal bleeding. (3) Arterial bleed: high pressure, spurting, red (a) Summon advanced medical personnel. blood. (b) Monitor A,B,Cs and vital signs. (4) Venous bleed: low pressure, steady flow, (c) Keep the patient comfortable and dark red or maroon blood. quiet. Prevent either overheating or (5) Capillary bleed: low pressure, oozing, dark getting chilled. red blood. (d) Reassure patient or victim. c. Controlling external bleeding. (e) Administer supplemental oxygen if (1). Use standard precautions such as wearing available and nearby. gloves. (2) Apply gauze pads using firm pressure. If no 3. Shock (hypoperfusion). gauze available, use a clean cloth, towel, a a. Failure of the circulatory sy tern to perfu e gloved hand or patient's own hand. If blood vital organs. soaks through, do not remove any gauze, b. At first, blood is shunted from the periphery to add additional layers. compensate. (3) Elevate the part if possible unless it is (1) The victim may 10 e consciou ness as the deformed or it causes significant pain when brain is affected. elevated. (2) The heart rate increases resulting in (4) Apply a pressure bandage, such as roller increased oxygen demand. gauze, over the gauze pads. (3) Organs ultimately fail when deprived of (5) If necessary, apply pressure with the heel of oxygen. your hand over pressure points. The (4) Heart rhythm is affected, ultimately leading femoral artery in the groin and the brachial to cardiac arrest and death. artery in the medial aspect of the upper arm c. Types and causes of shock. are two such points. (1) Hemorrhagic-severe internal or external (6) Monitor A,B,Cs and overall status of the bleeding. patient. Administer supplemental oxygen if (2) Psychogenic-emotional tre causes blood nearby. Seek more advanced care as neces- to pool in body away from the brain. sary. (3) Metabolic-loss of body fluids from heat or 2. Internal Bleeding. severe vomiting or diarrhea. a. Could be the result of a fall, blunt force, trau- (4) Anaphylactic-allergic reaction from drugs, ma or a fracture rupturing a blood vessel or food or insect stings. organ. (5) Cardiogenic-MI or cardiac arrest results in b. Severe internal bleeding may be life-threaten- pump failure. ing. (6) Respiratory-re piratory illness or arrest

result in in ufficient oxygenation of the Cardiovascular Physical Therapy 163 blood. (7) Septic-severe infections cause blood ves- 2. Avoid excessive strain, protection of extremities sels to dilate. from injury and extremes of temperature. (8) Neurogenic-TBI, SCI or other neural trau- ma causes disruption of autonomic nervous 3. Bedrest may be required if gangrene, ulceration, system resulting in disruption of blood ves- acute arterial disease are present. sel dilation/constriction. d. Signs and symptoms. 4. Exercise training for patients with PVD: may result (1) Pale, gray or blue, cool skin. in improved functional capacity, improved peripheral (2) Increased, weak pulse. blood flow and muscle oxidative capacity. (3) Increased respiratory rate. a. Consider interval training (multistage discon- (4) Decreased blood pressure. tinuous protocol) with frequent rests. (5) Irritability or restlessness. b. Walking program, moderate intensity (40-70% (6) Diminishing level of consciousness. V02 max) and duration, 2-3 times/day, 3-7 (7) Nausea or vomiting. days/week. e. Care for shock. c. Exercise to the point of pain, not beyond. Use (I) Obtain a history if possible. scale for subjective ratings for pain. Record (2) Examine the victim for airway, breathing, time of pain onset. circulation and bleeding. d. Nonweight bearing exercise (cycle ergometry, (3) Assess level of consciousness. arm ergometry) may be necessary in some (4) Determine skin characteristics and perform patients; less effective in producing a peripher- capillary refill test of finger tips. al conditioning effect. (a) Capillary refill-squeeze fingernail for 2 e. Well fitting shoes essential; with insensitive feet, teach techniques of proper foot inspection seconds. In healthy individuals the nail and care. will blanch and tum pink when pres- f. Beta-blockers for treatment of hypertension or ure is released. If nail bed does not cardiac disorders may decrease time to claudi- refill and tum pink within 2 seconds, cation or worsen symptoms the cause could be that blood is being g. Pentoxifylline, dipyridamole, aspirin, and war- shunted away from the periphery to farin may improve time to claudication. vital organs or to maintain core tem- h. High risk for CAD. perature. (5) Treat any specific condition if possible- 5. Lower extremity exerci e. control bleeding, splint a fracture, Epi-Pen a. Modified Buerger-Allen exercises: postural for anaphylaxis and so on. exerci es plus active plantar and dor iflexion of (6) Keep the victim from getting chilled or the ankle; active exercises improve blood flow over-heated. during and after exercise; effects less pro- (7) Elevate the legs 12 inches unless there is nounced in patients with PYD. suspected spinal injury or painful deformi- b. Resistive calf exercises: most effective method ties of the lower extremities. of increasing blood flow. (8) Rea ure the victim and continue to moni- tor A, B, Cs. 6. Medical treatment. (9) Administer supplemental oxygen if nearby. a. Medications to decrease blood viscosity, pre- (10) Do not give any food or drink. vent thrombus formation e.g., heparin. (11) Summon more advanced medical care. b Vasodilators: controversial. c. Calcium channel blockers in vasospastic dis- VI. Peripheral Vascular Disease Management ease. A. Rehabilitation Guidelines for Arterial Disease 7. Surgical management. I. Encourage risk factor modification: cessation of a. Atherectomy, thromboembolectomy, laser smoking, weight control, glucose and lipid control. therapy. b. Revascularization: angioplasty or bypass grafting. c. Sympathectomy: results in permanent vasodi- lation, improvement of blood flow to skin. d. Amputation when gangrene is present.

164 B. Rehabilitation Guidelines for Venous Disease 1. Deep vein thrombophlebitis (DYT). Early stages may be asymptomatic; symptomatic patients demonstrate dull ache, pain, tenderness in calf; may also see slight edema or fever. a. Acute: patients on bedrest until signs of inflam- mation have subsided; elevation of involved leg. b. Anticoagulation medications. c. Exercise therapy contraindicated during acute phase; increases pain, potential to dislodge clot, progress to pulmonary embolism, potentially fatal. d. Ambulation permitted (with elastic stockings) after local tenderness and swelling resolve. 2. Chronic venous insufficiency (CYI). a. Yaries by severity. b. Focus on activation of \"muscle pump\"; venous stasis associated with prolonged bedrest or sit- ting with legs in dependent position contributo- ry to development of deep vein thrombosis. (I) Active and active-resistive lower extremity exercises: emphasis on muscle pump exer- cises (dorsiflexion/plantarflexion, foot cir- cles. (2) Periodic elevation of extremities, massage to improve flow. (3) Consider cycle ergometry in sitting or attached to foot of bed. (4) Early arnbulation as soon as patient is able to get out of bed, 3-4 times/day. c. Pressure wrapping: compression stockings d. Intermittent pneumatic compression: con- traindicated in acute thrombopWebitis. e. Patient education: meticulous skin care. f. Severe conditions with dermal ulceration: may require surgery (ligation and vein stripping, vein grafts, valvuloplasty). C. Rehabilitation Guidelines for Lymphatic Disease 1. Edema secondary to lymphatic dysfunction can be treated with intermittent pneumatic compression, extremity elevation. 2. Manual lymph drainage: massage and PROM can assist lymphatic flow. 3. Multilayered wrapping: low stretch bandages. 4. Stress good hygiene, skin care. 5. In severe cases, surgery to assist in lymph drainage.

CHAPTER 4 PULMONARY PHYSICAL THERAPY Julie Ann Starr I. Pulmonary Anatomy and Physiology c. Larynx: connects the pharynx to trachea, including the epiglottis and vocal cords. A. Bony Thorax 1. Anterior border is the sternum: manubrium, body, 2. Lower airways. xiphoid process. The lateral borders of the trachea a. The conducting airways, trachea to terminal run perpendicularly into the suprasternal notch. bronchioles, transport air only. No ga exchange The Angle of Louis (sternal angle), the bony ridge occurs. between the manubrium and body, is point of b. The respiratory unit: respiratory bronchioles, anterior attachment of the 2nd rib and tracheal alveolar ducts, alveolar sacs and alveoli. bifurcation. Diffusion of gas occurs through all of these 2. Lateral border is the ribcage. Ribs 1-6, termed true structures. or costosternal ribs, have a single anterior costo- chondral attachment to the sternum. Ribs 7-10, 3. Lung structures. termed false or costochondral ribs, share costo- a. Right lung divides into 3 lobes by the oblique chondral attachments before attaching anteriorly and horizontal fissure lines. Each lobe divides to the sternum. Ribs 11 and 12 are termed floating into segments, totaling 10 segments. or co tovertebral ribs, as they have no anterior b. Left lung divides into 2 lobes by a single attachment. oblique fissure line. Each lobe divides into seg- 3. Posterior border is the vertebral column, Tl ments, totaling 8 segments. through Tt2. 4. Shoulder girdle can affect the motion of the tho- 4. Pleura. rax. Provides attachments for accessory muscles a. Parietal pleura covers the inner surface of the of ventilation. thoracic cage, diaphragm and mediastinal bor- der of the lung. B. Internal Structures b. Visceral pleura wraps the outer surface of the I. Upper airways. lung including the fissure lines. a. Nose or mouth: entry point into the respiratory c. Intrapleural space is the potential space between system. The nose filters, humidifies and warms air. the two pleura that maintains the approximation b. Pharynx: common area used for both respiratory of the ribcage and lungs, allowing forces to be and digestive systems. transmitted from one structure to another.

166 lungs, and therefore, visceral pleura, parietal pleura, bony thorax into a position of exhala- c. Muscles of Ventilation tion (inward pull). b. Bony thorax pulls the thorax, and therefore 1. Primary muscles of inspiration produce a normal parietal pleura, visceral pleura and lungs into a resting tidal volume. position of inspiration (outward pull). a. Primary muscle of inspiration is the c. Muscular action pulls either outward or diaphragm. The diaphragm is a made of two inward, depending of the muscles used. hemidiaphragms, each with a central tendon. d. Resting End Expiratory Pressure (REEP) is the When the diaphragm is at rest, the hemidi- point of equilibrium where these forces are bal- aphragms are arched high into the thorax. anced. Occurs at end tidal expiration. When the muscle contracts, the central tendon E. Ventilation: refers to the movement of gas in and out is pulled downward, flattening the dome. The of the pulmonary system result is a protrusion of the abdominal wall dur- 1. Volumes. (Figure 4-1). ing inhalation. a. Tidal volume (TV): volume of gas inhaled b. Additional primary muscles of inspiration are (exhaled) during a normal resting breath. portions of the intercostals. b. Inspiratory reserve volume (lRV): volume of gas that can be inhaled beyond a normal resting 2. Accessory muscles of inspiration are used when a tidal inhalation. more rapid or deeper inhalation is required or in c. Expiratory reserve volume (ERV): volume of disease states. The upper 2 ribs are raised by the gas that can be exhaled beyond a normal rest- scalenes and sternocleidomastoid. The rest of the ing tidal exhalation. ribs are raised by levator costarum and serratus. d. Residual volume (RV): volume of gas that By fixing the shoulder girdle, the trapezius, pec- remains in the lungs after ERV has been torals, and serratus, can become muscles of inspi- exhaled. ration. 2. Capacities: two or more lung volumes added together. 3. Expiratory muscles of ventilation. a. Resting exhalation results from a passive relax- a. Inspiratory capacity (IRV + TV): the amount of ation of the inspiratory muscles and the elastic recoil tendency of the lung. Normal abdominal air that can be inhaled from REEP. tone holds the abdominal contents directly under the diaphragm, assisting the return of the ---1---r---ll~M..m. ,,',',''\" -------- diaphragm to the normal high domed position. b. Expiratory muscles, used when a quicker ~~__-(-- -::j TLC and/or fuller expiration is desired, as in exer- --------------~rFRC cise or in disease states. These are quadratus Maximal-exhaJatlOn lumborum, portions of the intercostals, mus- cles of the abdomen, and triangularis sterni. l___ JRV _ 4. Special populations: patients who lack functional =Figure 4-1: Lung volumes and capacities. IRV inspiratory abdominal musculature, e.g. patients with spinal cord injury. Due to the lack of abdmonial muscu- reserve volume;TV = tidal volume; ERV = expiratory reserve lature, the resting position of the diaphragm is lower in the thorax decreasing inspiratory reserve. = =volume; RV residual volume; IC inspiratory capacity; The more upright the body position, the lower the = =FRC functional residual capacity, VC vital capacity; TLC diaphragm and the lower the inspiratory capacity. The more supine, the more advantageous the posi- = total lung capacity. From, O'Sullivan S, Schmidt T: Physical tion of the diaphragm. An abdominal binder may be helpful in providing support to the abdominal Rehabilitation:Assessment and Treatment, 4th ed, F.A. viscera thereby assisting ventilation. Care must be taken not to constrict the thorax with the abdomi- Davis, 200 I, pg 447, with permission. nal binder. D. Mechanics of Breathing 1. Forces acting upon the rib cage. a. Elastic recoil of the lung parenchyma pulls the

b. Vital Capacity (IRV + TV + ERV): the amount Pulmonary Physical Therapy 167 of air that is under volitional control, conven- tionally measured as a forced expiratory vital b. PaC02: the partial pressure of carbon dioxide capacity (FVC). within the arterial blood, in health, 36 to 44 mmHg. Hypercapnea is a PaC02 greater than c. Functional Residual Capacity (ERV + RV): the 44 mmHg. Hypocapnea is a PaC02 below 36 mmHg. Removal or retention of CO2 by the amount of air that resides in the lungs after a respiratory system alters the pH of the body normal resting tidal exhalation. with an inverse relationship. An increase in the d. Total lung capacity (IRV + TV + ERV + RV): PaC02 decreases the body's pH. A decrease in the total amount of air that is housed within the the PaC02 rai es the body's pH. thorax during a maximum inspiratory effort. 3. Flow Rates. c. HC03-: amount of bicarbonate ions within the a. Forced Expiratory Volume in one second arterial blood, normally 23-30meq/ml. (FEV I): the amount of air exhaled during the Removal or retention of HC03- alters the pH of first second of FVC. In the healthy, at least the body with a direct relationship. An increase 75% of the FVC is exhaled within the first sec- in bicarbonate ions increase the body's pH. A ond (FEV llFVC x 100> 75%). decrease in bicarbonate ions decreases the b. Forced expiratory flow rate (FEF 25% to 75%) body's pH. is the slope of a line drawn between the points 25% and 75% of exhaled volume on a forced G. Ventilation (VE) and Perfusion (blood flow or Q). vital capacity exhalation curve. This flow rate Optimal respiration occurs when ventilation and per- i more specific to the smaller airways, and fusion (blood flow to the lungs) are matched. shows a more dramatic change' with disease Different ventilation and perfusion relationships exist: than FEV 1. 1. Dead Space: anatomical (conducting airways) or F. Respiration: the diffusion of gas across the alveolar- physiological (diseases uch as pulmonary capillary membrane emboli) dead space is a space that is well ventilat- 1. Arterial oxygenation: the ability of arterial blood ed but no respiration (gas exchange) occurs. to carry oxygen. 2. Shunt: no respiration occurs because of a ventila- a. Partial pressure of oxygen in the atmosphere tion abnormality. Complete atelectasis of a respi- (Pa02) at sea level is 760 mmHg (barometric ratory unit allows the blood to travel through the pressure) x 21 %=159.6 mmHg. pulmonary capillary without gas diffusion occur- b. The partial pressure of oxygen in the arterial ring. blood, Pa02, depends on the integrity of the pulmonary ystem, the circulatory system and 3. Effects of body position on ventilation perfusion the Pa02' In health, Pa02 at room air is 95-100 relationship. Gravity affects the distribution of mmHg. Hypoxemia: Pa02 less than 90. ventilation and perfusion. Hyperoxernia: Pa02 greater than 100. a. Upright position. c. Fraction of oxygen in the inspired air (Fi02) is (1) Perfusion is gravity dependent, i.e., more the percentage of oxygen in air based on a total pulmonary blood is found at the base of the of 1.00. The Fi02 of room air, approximately lung. 21 % oxygen, is written as .21. Supplemental (2) Ventilation. At the static point of REEP, the oxygen increases the percentage (greater than apical alveoli are fuller than those at the 21 %) of oxygen in the patient's atmosphere. base. During the dynamic phase of inspira- Supplemental oxygen is usually prescribed tion, more air will be delivered to the less when the Pa02 falls below 55-60 mmHg. filled alveoli at the bases, making the 2. Alveolar ventilation: ability to remove carbon greater change in VE at the bases. dioxide from the pulmonary circulation and main- tain pH. (3) Ventilation perfusion ratio (VIQ ratio): the a. pH indicates the concentration of free floating hydrogen ions within the body. Normal range ratio of pulmonary alveolar ventilation to for pH is 7.36-7.44. pulmonary capillary perfusion. In the upright position, the apices are gravity independent, having the lowest blood flow or Q. Although there is a relatively low VE, there is till more air than blood, resulting in a high V/Q ratio (dead space). The mid-

168 b. Past medical history that would alter physical exam or treatment plans, such as heart disease, dle zone of the lung have a more evenly long term steroid use. matched the amount of perfusion and ven- tilation. The bases are gravity dependent c. Current medications that can mask (steroids) or and therefore have the most Q. Although alter (beta blockers, bronchodilators) vital signs. there is a relatively high VE, there is more blood than air, resulting in a (relatively) d. Social habits. low V/Q ratio (shunt). (1) Smoking in pack years (number of packs b. Other body positions. Every body position cre- per day x number of years smoked). ates these zones: gravity independent, middle, (2) Alcohol consumption. and gravity dependent. The gravity independ- (3) Street drugs. ent area of the lung, despite the position of the body, will act as dead space. The gravity e. Functional and exertional activity level during dependent area of the lung will act as a shunt. periods of wellness, as well as with present illness. Body positions can be used for a variety of treatment goals: draining secretions, increasing f. Cough and sputum production. Record any ventilation, or to optimize ventilation perfusion changes from baseline because of present illness. relationships. H. Control of Ventilation. A complex system controls g. Family history of pulmonary disease (e.g., cystic the cycle of ventilation fibrosis). 1. Receptors (baroreceptors, chemoreceptors, irritant receptors, stretch receptors) within the body assist B. Tests and Measures in adjusting the ventilatory cycle by sending infor- 1. Vital signs. See Table 4-1 for normal values. mation to the controller. a. Temperature: normal (afebrile) 98.6°F, (37°C). 2. Central control centers (cortex, pons, medulla, and Core temperature increase indicates infection. autonomic nervous system) evaluate the receptors' b. Heart rate (HR): normal 60 to 100 bpm; tachy- information and send a message out to the ventila- cardia: HR greater than 100 bpm; bradycardia: tory muscles to alter the respiratory cycle in order HR less than 60 bpm. to maintain adequate alveolar ventilation and arte- c. Respirations. rial oxygenation. (1) Rate: in health is 12-20 breaths per minute. 3. Ventilatory muscles institute the changes deemed Tachypnea is a rate greater than 20 br/min. necessary by the central controllers. Apnea means no respirations. (2) Rhythm: regular or irregular. II. Physical Therapy Examination (3) Amplitude: shallow, deep. d. Blood pressure. A. Patient Interview: Information from the patient, the 2. Observation. patient's family, and the medical record a. Peripheral edema seen in gravity dependent 1. Chief complaint usually involves the loss of func- areas and jugular venous distension indicates tion (decreased ability to perform activities of possible heart failure. Right ventricular hyper- daily living [ADLs]) or discomfort (shortness of trophy and dilation (cor pulmonale) are com- breath [dyspnea]). mon sequelae to chronic lung disease. 2. Present illness. b. Body positions. Stabilizing the shoulder girdle a. Initial onset (sudden vs insidious) and progres- places the thorax in the inspiratory position and sion of primary problem. b. Anything that worsens or improves condition: TABLE 4-1 - NORMAL VALUES FOR INFANTS AND ADULTS positions, rest, medications. 3. Review the patient's history. PARAMETER INFANT ADULT a. Occupational history. Past occupational expo- sures for diseases such as asbestosis, silicosis, Heart Rate 120 bpm 60-100 bpm and pneumoconiosis. Present occupational Blood Pressure 75/50 mmHg <120/80 mmHg exposure to antigens within the workplace Respiratory Rate 40 br/min 12-20 br/min (hypersensitivity pneumonitis). PaO. 75-80 mmHg 80-100 mmHg PaCO. 34-54 mmHg 35-45 mmHg pH 7.26-7.41 7.35-7.45 Tidal Volume 20 ml 500 ml

Pulmonary Physical Therapy 169 allows the additional recruitment of muscles pain), changes in the underlying lung for inspiration (pectorals). and pleura (a patient with pleuritic pain c. Color: cyanosis, an acute sign of hypoxemia, is or pneumothorax), or changes in the a bluish tinge to nail beds and the areas around overlying skin (thoracic burn). eyes and mouth. (b) Thoracic excursion in health, measured d. Digital clubbing: a sign of chronic hypoxemia. at the base of the lungs from full inspi- The configuration of the distal phalanx of fingers ration to full expiration, is between 2 or toes becomes bulbous. and 3 inches. 3. Inspection and palpation: standard precautions (c) Inspect for scars, indicating potential should be used any time the therapist may come in adhesions to underlying soft tissue or contact with a patient's body fluid . Refer to Table surgical removal of structures within 6-1. Gloves are usually all that is needed during a the thorax. routine physical exam. 4. Auscultation. a. Neck. a. Intensity of inspiration and expiration will be (1) Observe the trachea: it should be in mid- quieter at the bases than the apex. (I) Vesicular (normal breath sound): a soft line, superior to the suprasternal notch. rustling sound heard throughout all of (2) Note the use of accessory muscles of venti- inspiration and the beginning of expiration. (2) Bronchial: a more hollow, echoing sound lation. normally found only over the right superior b. Thorax. anterior thorax. This corresponds to an area over the right main stem bronchus. All of (1) Changes in bony thorax (pectus excavatum, inspiration and most of expiration are heard carinatum). with bronchial breath ounds. (3) Decreased: a very distant sound not nor- (2) Observe anterior-posterior:lateral dimen- mally heard over a healthy thorax; allows ion. In health, there is a 1:2 ratio. With only some of inspiration to be heard. Often obstructive pulmonary disease, the lung associated with obstructive lung diseases. recoil force is decreased, resulting in a bar- b. Adventitious (extra) sounds. According to the reled chest and an increase in the A-P American Thoracic Society, there are only two dimension. adventitious breath sounds (1) Crackles (also termed rales, crepitations): a (3) The right and left thorax should be sym- metrical. (a) Symmetry, static and or dynamic, may be altered by changes in the bony tho- rax (scoliosis, scapular immobility, TABLE 4-2 - INTERPRETATION OF ABNORMAL ACID-BASE BALANCE TYPE pH PaCO, HCO,· CAUSES SIGNS AND SYMPTOMS Respiratory alkalosis t WNL Alveolar hyperventilation Dizziness, syncope, tingling, numbness, early tetany Respiratory acidosis t WNL Alveolar hypoventilation Early: anxiety, restlessness, Metabolic alkalosis dyspnea, headache WNL t Bicarbonate ingestion, vomiting, Late: confusion, somnolence, diuretics, steroids, adrenal disease coma Vague symptoms: weakness, mental dullness, possibly early tetany Metabolic acidosis WNL Diabetic, lactic. or uremic acidosis, Secondary hyperventilation prolonged diarrhea (Kussmaul breathing), nausea, lethargy, and coma J.From. The four basic conditions of acid-base balance. Rothstein Roy S, and Wolf S: The Rehabilitation Specialist's Handbook, 2nd ed FA Davis. Philadelphia. 1998, pg 529, with permission.

170 crackling sound heard usually during inspi- III IF lb~ IAV VC IC IRV ration that indicates pathology (atelectasis, Restrictive Normal Obstructive fibrosis, pulmonary edema). (2) Wheezes: a musical pitched sound, usually E~ Jn lLC~LFRC N IC IRV heard during expiration caused by airway RV obstruction (asthma, COPD, foreign body ERV N lLC aspiration). With severe airway constric- ERV tion, as with croup, wheezes maybe heard on inspiration as well. FRC c. Vocal sounds. (1) Normal transmission of vocal sounds. ERV = Expiratory reserve volume RV = Residual volume (a) As with breath sounds, vocal transmis- FRC = Functional residual capacity TLC = Total lung capacity IC = Inspiratory capacity TV = Tidal volume sion is loudest near trachea and main- IRV = Inspiratory reserve volume stem bronchi. (b) Words should be intelligible, though Figure 4-2: Lung volumes of a healthy pulmonary system softer and less clear at the more distal areas of the lungs. compared with the lung volumes and capacities found in (2) Abnormal transmission of vocal sounds restrictive and obstructive pulmonary disease. From Rothstein may be heard through fluid filled areas of J, Roy S, and Wolf S:The Rehabilitation Specialist's Handbook, consolidation, cavitation lesions or pleural effusions. 2nd ed FA Davis, Philadelphia, 1998, pg 509, with permission. (a) Egophony is a nasal or bleeting sound heard during auscultation. \"E\" sounds are transmitted to sound like \"A\". TABLE 4-3 - CLASSES OF RESPIRATORY IMPAIRMENT Roentgenographic CLASS I CLASS 2 CLASS 3 CLASS 4 appearance 0% IMPAIRMENT 20·30% IMPAIRMENT 40-50% IMPAIRMENT 60-90% IMPAIRMENT Usually nomnal but there May be nomnal or abnomnal May be nomnal but usually Usually is abnomnal may be evidence of healed is not or inactive chest disease including, for example, minimal nodular silicosis or pleura scars Dyspnea When it occurs, it is Does not occur at rest and Does not occur at rest but Occurs during such activities consistent with the seldom occurs during the does occur during the usual as climbing one flight of stairs Clr9J.trn$j1!fJC.ll_S_ OJ aj;Jlvitv. p'_eJfo_mnC!nc~_ of the usual activities of dailv. livinq, or walkinq, 100 v.ards on level activities of daily living. ground, on less exertion, or The patient can keep However, the patient can even at rest pace with persons of walk a mile at his own pace same age and body build without dyspnea although on level ground without he cannot keep pace on breathlessness but not level ground with others of on hills or stairs the same age and body build Tests of ventilatory function FEV1, FCV, MMV Not less than 85% of 70-85% of predicted 55-70% of predicted Less than 55% of predicted predicted Arterial oxygen Not applicable Not applicable Usually 88%* or greater Usually less than 88% at saturation at rest and after exercise rest and after exercise -88% saturation corresponds to an arterial Po. of 58mmHg, assuming the arterial pH is in the normal range. From Guides to the Evaluator of Permanent Impairment;The Respiratory System,JAMA, 1965, 194: 919, with permission.

(b) Bronchophony characterized by an Pulmonary Physical Therapy 171 intense, clear sound during ausculta- tion, even at the lung bases. partial pressure of oxygen in relation to the fraction of inspired oxygen. (c) Whispered pectoriloquy occurs when b. Electrocardiogram: see Chapter on Cardiovas- whispered sounds are heard clearly cular Physical Therapy for discussion. during auscultation. c. Sputum studies. (1) Gram stain: immediate identification of the 5. Radiographic examination. category of bacteria (Gram negative or a. Chest X-rays (CXR): a two dimensional radi- Gram positive) and its appearance (pairs, ographic film to detect the presence of abnor- chains, etc.). mal material (exudate, blood) or a change in (2) Culture and sensitivity: identifies the spe- pulmonary parenchyma (fibrosis, collapse). cific bacteria as well as the organism's sus- b. Computerized axial tomography (CAT scan): a ceptibility to various antibiotics. Results computer generated picture of a cross sectional available within a few days. plane of the body. (3) Cytology: reports the presence of cancer c. Ventilation perfusion (V/Q) scan: matches the cells in sputum. ventilation pattern of the lung to the perfusion d. Pulmonary function tests (PFTs): evaluate lung pattern to identify the presence of pulmonary volumes, capacities, and flow rates. Used to emboli. diagnose disease, monitor progression, and d. Fluoro copy: continuous X-ray beam allows determine the benefit of medical management. observation of diaphragmatic excursion. Refer to Figure 4-2 for changes with disease states. Refer to Table 4-3 for classification of 6. Laboratory tests: See Table 4-1 for normal values. respiratory impairments including PFT predicted a. Arterial blood gas (ABG) analysis indicates the values. adequacy of: e. Blood values. (1) Alveolar ventilation by determining pH, (1) White blood cell count (WBC) normal val- bicarbonate ion and partial pressure of car- ues: 4,000 to 11,000. bon dioxide. Table 4-2 presents the four (2) Hematocrit (Hct) normal values: 35 to 48. basic conditions of acid-base balance and (3) Hemoglobin (Hgb) normal values: 12.0 to the PaC02, pH and HC03- values that 16.0. accompany each condition. 7. Bronchoscopy: endoscope used to view, biopsy, (2) Arterial oxygenation by determining the wash, suction and/or brush the interior aspects of the tracheobronchial tree. TABLE 4-4 - GRADED EXERCISE 8. Exercise tolerance tests (ETT) (Graded Exercise TEST TERMINATION CRITERIA Test). See also chapter on Cardiovascular Physical Therapy. 1. Maximal shortness of breath. a. Evaluates an individual's cardiopulmonary response to gradually increasing exercise. 2. A fall in PaO, of greater than 20 mmHg or a PaO, less b. Determines the presence of exercise induced than 55 mmHg. bronchospasm by testing pulmonary function, particularly FEV 1 before and after ETT. 3. A rise in PaCO, of greater than 10 mmHg or greater than c. Documents the need for supplemental oxygen 65 mmHg. during an exercise program by analyzing arte- rial blood gas values throughout the ETT. 4. Cardiac ischemia or arrhythmias. ABGs also provide a criterion for test termina- tion. If arterial blood sampling is unavailable, 5. Symptoms of fatigue. pulse oximetry can be used to monitor the per- cent saturation of oxygen within the arterial 6. Increase in diastolic blood pressure readings of 20 mmHg, blood. Table 4-4 pre ents criteria for test termi- systolic hypertension greater than 250 mmHg, decrease in nation for patients with pulmonary disease. blood pressure with increasing workloads. 7. Leg pain. 8. Total fatigue. 9. Signs of insufficient cardiac output. 10. Reaching a ventilatory maximum. From Brannon, F, et al: Cardiopulmonary Rehabilitation: Basic Theory and Application, 3rd ed F.A. Davis, 1998, p 300. with permission.

172 intoxication, impaired con ciousness, neuro- muscular disea e, recent ane thesia. ID. Physical DysfunctionJImpairments b. Pertinent physical findings. (1) Symptoms begin shortly after aspiration A. Acute Diseases I. Bacterial Pneumonia. event (hours). a. Description: An intra-alveolar bacterial infec- (2) Cough may be dry at the onset, progress to tion. Gram positive bacteria is usually acquired in the community. Pneumococcal pneumonja producing putrid ecretions. (streptococcal) is the most common type of (3) Dyspnea. gram positive pneumonja. Gram negative bacte- (4) Tachypnea. ria usually develops in a host who has underly- (5) Cyanosis. ing chronic debilitating conditions, severe acute (6) Tachycardia. illness, and recent antibiotic therapy. Gram neg- (7) Wheezes and crackles with decreased ative infections result in early tissue necrosis and abscess formation. Common infecting breath sounds. organisms: Klebsiella, Haemophilus Influenza, (8) Hypoxemia, hypercapnea in severe cases. Pseudomonas Aeruginosa, Proteus, Serratia. (9) Chest pain over the involved area. b. Pertinent physical findings. (lO)Fever. (1) Shaking chills. (11)WBC count shows varying degrees of (2) Fever. (3) Chest pain if pleuritic involvement. leukocytosis. (4) Cough becoming productive of purulent, (12)CXR initially shows pneumonitis. Chronic blood streaked, or rusty sputum. (5) Decreased or bronchial breath sounds aspiration shows necrotizing pneumonia and/or crackles. with cavitation. (6) Tachypnea. 4. Tuberculosis (TB). (7) Increased white blood cell count. a. Description: Mycobacterium tuberculosis (8) Hypoxemia, hypocapnea injtially, hyper- infection spread by aerosolized droplets from capnea with increasing severity. an untreated infected host. Incubation period: 2 (9) CXR confirmation of infiltrate. to 10 weeks. Primary dj ea e lasts approxi- 2. Viral Pneumonia. mately 10 day to 2 weeks. Po t-primary infec- a. Description: An interstitial or intra-alveolar tion is reactivation of dormant tuberculous inflammatory process caused by viral agents bacillus which can occur years after the primary (influenza, adenovirus, cytomegalovirus, her- infection. Two weeks on appropriate antituber- pes, parainfluenza, respiratory syncytial virus, culin drugs renders the host non-infectious. measles). During the infectious stage, the patient must be b. Pertinent physical findings. isolated from others in a negative pressure (1) Recent history of upper respiratory infection. room. Anyone entering the room must wear a (2) Fever. protective TB mask and follow universal pre- (3) Chills. cautions. If the patient leaves the negative pres- (4) Dry cough. sure room, then the patient must wear the spe- (5) Headaches. ciaHzed mask to keep from infecting others. (6) Decreased breath sounds and/or crackles. Medication is taken for prolonged periods, 3- (7) Hypoxemia and hypercapnea. 12 months. There is an increased incidence of (8) Normal white blood cell count. TB in the patient population infected by HIV. (9) CXR confirmation of interstitial infiltrate. b. Pertinent physical finding of primary disease 3. Aspiration Pneumonia. can be unnoticed as it cau e only mild symp- a. Description: aspirated material causes an acute toms: sHght non-productive cough, low grade inflammatory reaction within the lungs. fever, and possible CXR changes consistent Usually found in patients with impaired swal- with primary disea e. lowing (dysphagia), fixed neck extension, c. Pertinent physical findings of po t primary infection are characterized by: (1) Fever. (2) Weight loss.

(3) Cough. Pulmonary Physical Therapy 173 (4) Hilar adenopathy: enlargement of the (a) Normal spirometry. lymph nodes surrounding the hilum. (b) Chronic symptoms (cough, sputum (5) Night sweat. (6) Crackles. production). (7) Hemoptysis: blood streaked sputum. (2) Stage 1(mild). (8) WBC shows increased lymphocytes. (9) CXR shows upper lobe involvement with (a) FEV /FVC < 70%. air-space densities, cavitation, pleural (b) FEV,> =80% predicted. involvement, and parenchymal fibrosis. 5. Pneumocystis Carinii pneumonia. (c) With or without chronic symptoms. a. Description: pulmonary infection caused by a (3) Stage 2 (moderate). protozoan in immunocompromised hosts. Most often found in patients following transplanta- (a) FEV\\IFVC < 70%. tion, neonates, or patients infected with HIV. (b) 50% <FEV\\< 80% predicted. b. Pertinent physical findings. (c) With or without chronic symptoms. (1) Insidious progressive shortness of breath. (4) Stage 3 (severe). (2) Non productive cough. (a) FEV \\IFVC < 70%. (3) Crackles. (b) 30% <FEV\\< 50%. (4) Weakness. (c) With or without chronic symptoms. (5) Fever. (5) Stage 4 (very severe). (6) Chest X-ray shows interstitial infiltrates. (a) FEV,IFVC < 70%. (7) Complete blood count (CBC) shows no (b) FEV, < 30% predicted. evidence of infection. (c) FEV,< 50% with chronic respiratory 6. SARS- Severe Acute Respiratory Syndrome. a. Definition: An atypical respiratory illness failure symptoms. caused by a coronovirus. Initial outbreak in (d) Pa02<60. southern Mainland China with world-wide (e) PaC02 > 50. spread to other areas such as Singapore, (f) Cor pulmonale. Toronto, Vietnam, and Hong Kong. (g) Increased jugular venous distention. b. Pertinent physical findings. c. Physical findings: findings increase in severity (1) High temperature. as the stage of disease advances. (2) Dry cough. (I) Cough/sputum production! hemoptysis. (3) Decreased white blood cells, decreased (2) Dyspnea on exertion. platelets, decreased lymphocytes. (3) Breath sounds decreased with adventitious (4) Increased liver function tests. sounds. (5) Abnormal CXR with borderline breath (4) Increased RR. sounds changes. (5) Weight loss/anorexia. 7. Refer to Table 6-2, Transmission-Based Precautions. (6) Increased A-P diameter of chest wall. B. Chronic Obstructive Diseases (7) Cyanosis. 1. Chronic obstructive pulmonary disease (COPD). (8) Clubbing. a. Description: according to the Global Initiative (9) Postures to structurally elevate shoulder for Obstructive Lung Disease (GOLD): COPD girdle. is a disease state characterized by airflow limi- (lO)CXR showing hyperinflation, flattened tation that is not fully reversible. The airflow diaphragms, hyperlucency. limitation is usually both progressive and asso- (11)ABG changes of hypoxemia, hypercapnea. ciated with an abnormal inflammatory response (12)PFTs showing obstructive disease, such as of the lungs to noxious particles or gases. decreased FEV I' decreased FVC, increased b. Stages. FRC and RV and decreased FEV,IFVC (1) Stage 0 (at risk). ratio. 2. Asthma. a. Description: increased reactivity of the trachea and bronchi to various stimuli (allergens, exer- cise, cold) and manifests by widespread nar- rowing of the airways due to inflammation, smooth muscle constriction and increased

174 (11)CXR shows increased markings, findings of bronchiectasis, and/or pneumonitis. secretions, that is reversible in nature. Even during remission, some degree of airway 4. Bronchiectasis. inflammation is present. a. Description: a chronic congenital or acquired b. Pertinent physical findings during exacerbation. disease characterized by dilatation of the (1) Wheezing, possible crackles, and decreased bronchi and excessive putum production. b. Pertinent physical findings. breath sounds. (I) Cough and expectoration of large amounts (2) Increased secretions of variable amounts. of mucopurulent secretions. (3) Dyspnea. (2) Frequent secondary infections. (4) Increased accessory muscle use. (3) Hemoptysis. (5) Anxiety. (4) Crackles, decreased breath sounds. (6) Tachycardia. (5) Cyanosis. (7) Tachypnea. (6) Clubbing. (8) Hypoxemia. (7) Hypoxemia. (9) Hypocapnea. Responding to hypoxemia, (8) Dyspnea. (9) CXR which shows increased bronchial there is an increased respiratory rate and markings with interstitial changes. Broncho- minute ventilation. This will decrease grams can outline bronchial dilatation but PaC02. With severe airway constriction, an are rarely needed. increase in minute ventilation cannot occur and hypercapnea can be found. 5. Hyaline membrane disease (also Respiratory (IO)Cyanosis. Distress Syndrome or RDS). (11)PFrs show impaired flow rates. a. Description: alveolar collap e in a premature (12)CXR shows hyperlucency and flattened infant resulting from lung immaturity, inade- diaphragms during exaccerbation. quate level of pulmonary surfactant. 3. Cystic fibrosis (CF). b. Pertinent physical findings within a few hours a. Description: a genetically inherited disease of birth. characterized by thickening of secretions of all (I) Respiratory distre s. exocrine glands, leading to obstruction (pancre- (2) Crackles. atic, pulmonic, gastrointestinal, etc.). CF may (3) Tachypnea. present as an obstructive, restrictive, or mixed (4) Hypoxemia. disease. Clinical signs of CF include: meconi- (5) Cyanosis. um ileus, frequent respiratory infections, espe- (6) Accessory muscle use. cially Staph Aureus and Pseudomonas (7) Expiratory grunting, flaring nares. Aeruginosa, inability to gain weight despite (8) CXR shows a classic granular pattern adequate caloric intake. Diagnosis is made by a (\"ground glass\") caused by distended ter- positive sweat electrolyte test. minal airways and alveolar collapse. b. Pertinent physical findings with exacerbation c. Physical therapy considerations: The increased of disease. work of breathing that handling a premature (1) Onset of symptoms usually in early child- infant might cau e mu t be carefully weighed hood. against any possible benefit that physical therapy (2) Dyspnea, especially on exertion. might have. (3) Productive cough. (4) Hypoxemia, hypercapnea. 6. Bronchopulmonary dysplasia. (5) Cyanosis. a. Description: an obstructive pulmonary disease, (6) Clubbing. often a sequela of premature infant with respi- (7) Use of accessory muscles of ventilation. ratory distress syndrome; results from high (8) Tachypnea. pressures of mechanical ventilation, high frac- (9) Crackles, wheezes, and/or decreased breath tions of inspired oxygen (Fi02) and/or infec- sounds. tion. The lungs show area of pulmonary imma- (1 0) Abnormal PFrs showing an obstructive turity and dysfunction due to hyperinflation. pattern, restrictive pattern or both.

b. Pertinent physical findings. Pulmonary Physical Therapy 175 (l) Hypoxemia, hypercapnea. (2) Crackles, wheezing, and/or decreased tional residual capacity, and total lung breath sounds. capacity. (3) Increased bronchial secretions. (9) CXR show reduced lung volumes, atelectasis (4) Hyperinflation. 3. Restrictive disease due to alterations in the neuro- (5) Frequent lower respiratory infections. muscular apparatus. (6) Delayed growth and development. a. Description: decreased muscular strength (7) Cor pulmonale. results in an inability to expand the rib cage, (8) CXR shows hyperinflation, low diaphragms, with multiple sclerosis, muscular dystrophy, atelectasis, and/or cystic changes. Parkinson's disease, spinal cord injury, or CVA. b. Pertinent physical findings. C. Chronic Restrictive Diseases: different etiologies (1) Dyspnea. typified by difficulty expanding the lungs causing a (2) Hypoxemia, hypocapnea (hypercapnea reduction in lung volumes with increasing severity). 1. Restrictive disease due to alterations in lung (3) Decreased breath sounds, crackles. parenchyma and pleura. (4) Clubbing. a. Description: fibrotic changes within the pul- (5) Cyanosis. monary parenchyma or pleura, as a result of (6) Reduced cough effectiveness. idiopathic pulmonary fibrosis, asbestosis, radi- (7) PFTs show reduced vital capacity, and total ation pneumonitis, oxygen toxicity. lung capacity. b. Pertinent physical findings. (8) CXR show reduced lung volumes, atelectasis. (1) Dyspnea. D. Bronchogenic Carcinoma: refers to a tumor which (2) Hypoxemia, hypocapnea (hypercapnea arises from the bronchial mucosa appears with severity). 1. Characteristics: smoking and occupational expo- (3) Crackles. sures are the most frequent causal agents. (4) Clubbing. a. Cell types are: Small cell carcinoma (oat cell) (5) Cyanosis. and non-small cell carcinoma (squamous cell, (6) PFTs reveal a reduction in vital capacity, adenocarcinoma, and large cell undifferentiated). functional residual capacity, and total lung b. Secondary changes due to the tumor include capacity. obstruction or compression of an airway, blood (7) CXR show reduced lung volumes, diffuse vessel, or nerve. interstitial infiltrates, and/or pleural thick- c. Local metastases are found in the pleura, chest ening. wall, mediastinal structures. Common distant 2. Restrictive disease due to alterations in the chest metastases are found in lymph nodes, liver, wall. bone, brain, and adrenals. a. Description: restricted motion of bony thorax, 2. Pertinent physical findings with pulmonary with diseases such as ankylosing spondylitis, involvement. arthritis, scoliosis, pectus excavatum, arthrogry- a. Unexplained weight loss. posis or the integumentary changes of the chest b. Hemoptysis. wall such as thoracic burns or scleroderma. c. Dyspnea. b. Pertinent physical findings. d. Weakness. (1) Shallow, rapid breathing. e. Fatigue. (2) Dyspnea. f. Wheezing. (3) Hypoxemia, hypocapnea (hypercapnea g. Pneumonia with productive cough due to air- with increasing severity). way compression. (4) Cyanosis. h. Hoarseness with compression of the laryngeal (5) Clubbing. nerve. (6) Crackles. I. Atelectasis or bacterial pneumonia with non- (7) Reduced cough effectiveness. productive cough due to airway obstruction. (8) PFTs show reduced vital capacity, func- 3. Management of bronchogenic cancer. a. Chemotherapy.

176 (2) Pertinent physical findings: all increase with the severity of injury. b. Radiation therapy. (a) Chest pain. c. Surgical resection if possible. (b) Dyspnea. 4. Physical therapy considerations. (c) Tracheal and mediastinal shift away a. Pneumonias that develop behind a completely from side of injury. (d) Absent or decrea ed breath ounds. obstructed bronchus cannot be cleared with (e) Cyanosis. physical therapy techniques. Hold treatment (f) Respiratory distress. until palliative therapy reduces the tumor size (g) Confinnation by CXR. and relieves the bronchial obstruction. (h) May have signs of blood loss. b. Possible fractures from thoracic bone metastasis with chest compressive maneuvers and cough- 3. Lung contusion. ing. a. Description: Blood and edema within the alve- c. Ecchymosis (bruising) in patients with low oli and interstitial space due to blunt chest trau- platelet count. ma with or without rib fractures. d. Fatigue which restricts other necessary activities. b. Pertinent physical findings: all increase with E. Trauma the severity of injury. 1. Rib fracture, flail chest. (1) Cough with hemoptysis. a. Description: fracture of the ribs usually due to (2) Dyspnea. blunt trauma. Flail chest is two or more frac- (3) Decreased breath ound and/or crackles. tures in two or more adjacent ribs. (4) Cyanosis. b. Pertinent physical findings. (5) Confirmation by CXR of ill defined patchy (1) Shallow breathing. densities. (2) Splinting due to pain (especially with deep F. Miscellaneous inspiration or cough). I. Pulmonary Edema. (3) Crepitation may be felt during the ventila- a. Description: excessive seepage of fluid from the pulmonary vascular system into the inter- tory cycle over fracture site. stitial space; may eventually cause alveolar (4) Paradoxical movement of the flail section edema. (1) Cardiogenic: results from increased pres- during the ventilatory cycle (inspiration, sure in the pulmonary capillaries associated the flail section is pulled inward; exhala- with left ventricular failure, aortic valvular tion, the flail moves outward). disease, or mitral valvular disease. (5) Confirmation by chest x-ray. (2) Non-cardiogenic: results from an increased 2. Pleural Injury. permeability of the alveolar capillary mem- a. Pneumothorax. branes due to inhalation of toxic fumes, (1) Description: air in the pleural space, usual- hypervolemia, narcotic overdose, or adult ly through a lacerated visceral pleura from respiratory distre syndrome (ARDS). a rib fracture or ruptured bullae. b. Pertinent physical findings. (2) Pertinent physical findings all increase (1) Crackles. with the severity of injury. (2) Tachypnea. (a) Chest pain. (3) Dyspnea. (b) Dyspnea. (4) Hypoxemia. (c) Tracheal and mediastinal shift away (5) Peripheral edema if cardiogenic. (6) Cough with pink, frothy secretions. from injured side. (7) CXR shows increa ed va cular markings, (d) Absent or decrea ed breath sounds. hazy opacities in gravity dependent areas (e) Increased tympany with mediate per- of the lung showing a typical butterfly pat- tern. Atelectasis is possible if the surfactant cussion lining is removed by alveolar edema. (f) Cyanosis. (g) Respiratory distress. (h) Confirmation by CXR. b. Hemothorax. (1) Description: blood in the pleural space usu- ally from a laceration of the parietal pleura.

Pulmonary Physical Therapy 177 UPPER LOBES Apical Segments UPPER LOBES Posterior Segments UPPER LOBES Anterior Segments Bed or drainage table flat. Bed or drainage table flat. Bed or drainage table flat. Patient lies on back with pillow under knees. Patient leans back on pillow at 30' angle against therapist. Patient leans over folded pillow at 30' angle. Therapist claps between clavicle and nipple on each side. Therapist claps with markedly cupped hand over area between clavicle and top of scapula on each side. Therapist stands behind and claps over upper back on both sides. RIGHT MIDDLE LOBE LEFT UPPER LOBE Lingular Segments LOWER LOBE Anterior Basal Segments Foot of table or bed elevated 16 inches. Foot of table or bed elevated 16 inches. Foot of table or bed elevated 20 inches. Patient lies head down on left side and rotates 1/4 tum Patient lies head down on right side and rotates 1/4 tum Patient lies on side, head down, pillow under knees. backward. Pillow may be placed behind from shoulder backward. Pillow may be placed behind from shoulder to hip. Knees should be flexed. to hip. Knees should be flexed. Therapist claps wtth slightly cupped hand over lower ribs. (Position shown is for drainage of left anterior basal Therapist claps over right nipple area. In females with Therapist claps wtth moderately cupped hand over left segment. To drain the right anterior basal segment, breast development or tenderness, use cupped hand nipple area. In females wtth breast development or tender- patient should lie on his left side in same posture). with heel of hand under armptt and fingers extending ness, use cupped hand with heel of hand under armptt forward beneath the breast. and fingers extending forward beneath the breast. LOWER LOBES Lateral Basal Segments LOWER LOBES Posterior Basal LOWER LOBES Superior Segments Segments Foot of table or bed elevated 20 inches. Bed or table flat. Foot of table or bed elevated 20 inches. Patient lies on abdomen, head down, then rotates X Patient lies on abdomen with two pillows under hips. tum upward. Upper leg is flexed over a pillow for support. Patient lies on abdomen, head down, wtth pillow under hips. Therapist claps over lower ribs close to spine on Therapist claps over middle of back at tip of scapula on Therapist claps over uppermost portion of lower ribs. each side. either side of spine. (Posttion shown is for drainage of right lateral basal segment. To drain the left lateral basal segment, patient should lie on his right side in the same posture). Figure 4-3: Positions used for postural drainage. From Rothstein J, Roy S, and Wolf S:The Rehabilitation Specialist's Handbook, 2nd ed FA Davis, Philadelphia, 1998, pg 534-535, with permission.

178 2. Pulmonary Emboli. mia), peritoneal fluid within the pleural space a. Description: a thrombus from the peripheral (ascites, cirrhosis) or interference of pleural venous circulation becomes embolic and reabsorption from tumor invading pleural lym- lodges in the pulmonary circulation. Small phatics. emboli do not necessarily cause infarction. b. Pertinent physical findings. b. Pertinent physical findings without infarction. (I) Decreased breath sounds over effusion; (1) History consistent with pulmonary emboli: deep vein thrombosis, oral contraceptives, bronchial breath sound may be pre ent recent abdominal or hip surgery, poly- around the perimeter of the effusion. cythemia, prolonged bed rest. Pleural friction rub may be possible with (2) Sudden onset of dyspnea. inflammatory process. (3) Tachycardia. (2) Mediastinal shift away from large effusion. (4) Hypoxemia. (3) Breathlessness with large effusions. (5) Cyanosis. (4) CXR shows fluid in the pleural space in (6) Auscultatory findings may be normal or gravity dependent areas of the thorax if show crackles and decreased breath greater than 300ml. sounds. (5) Pain and fever only if the pleural fluid is (7) Ventilation-perfusion scan showing perfu- infected (empyema). sion defects with concomitant normal ven- 4. Atelectasis. tilation. a. Description: collapsed or airless alveolar unit, c. Added pertinent physical findings consistent caused by hypoventilation secondary to pain with pulmonary infarction. during the ventilatory cycle (pleuritis, postop- (I) Chest pain. erative pain, or rib fracture), internal bronchial (2) Hemoptysis. obstruction (a piration, mucus plugging), (3) CXR shows decreased vascular markings, external bronchial compre sion (tumor or high diaphragm, pulmonary infiltrate, enlarged lymph node ), low tidal volumes (nar- and/or pleural effusion. cotic overdose, inappropriately low ventilator settings) or neurologic insult. 3. Pleural Effusion. b. Pertinent physical findings. a. Description: excessive fluid between the vis- (I) Decreased breath sounds. ceral and parietal pleura. The main causes of (2) Dyspnea. pleural effusion are increased pleural perme- (3) Tachycardia. ability to proteins from inflammatory diseases (4) Increased temperature. (pneumonia, rheumatoid arthritis, systemic (5) CXR with platelike streaks. lupus), neoplastic disease, increased hydrostat- ic pressure within pleural space (CHF), IV. Physical Therapy Intervention decrease in osmotic pressure (hypoproteine- Refer to Table 3-4 for Preferred Cardiopulmonary TABLE 4-5 . CONSIDERATIONS PRIOR Practice Patterns. TOTHE USE OF POSTURAL DRAINAGE A. Manual Secretion Removal Techniques 1. Postural drainage: placing the patient in varying Precautions to the use of Trendelenburg position (Head of bed tipped down positions for optimal gravity drainage of secre- 15 to 18 degrees) TABLE 4-6 - CONSIDERATIONS PRIOR Circulatory system Pulmonary edema, congestive heart failure, hypertension. TOTHE USE OF PERCUSSION AND SHAKING Abdominal problems Obesity, ascites, pregnancy, hiatal hernia, nausea and vomiting, recent food consumption. Neurologic system Recent neurosurgery, increased intracranial pressure, aneurysm General guidelines Pain made worse by the technique. precautions. Circulatory system Coagulation disorders Aneurysm precautions, hemoptysis. Pulmonary system Shortness of breath. Musculoskeletal system Increased partial thromboplastin time (Pn), increased Precautions to the use of sidelying position prothrombin time (PT), decreased platelet count (below 50,000), or medications that interfere with coagulation. Circulatory system Axillo-femoral bypass graft Fractured rib, flail chest, degenerative bone disease, bone Musculoskeletal system Humeral fractures, need for hip abduction brace, other situations metastases. that make sidelying uncomfortable, e.g., arthritis, shoulder bursitis.

tions and increased expansion of the involved seg- Pulmonary Physical Therapy 179 ment. (Figure 4-3). a. Indications for the use of postural drainage. position with clinically assessed improve- ment is a guideline. (1) Increased pulmonary secretions. (5) The force of percussion i one that causes (2) Aspiration. the patient's voice to quiver. (3) Atelectasis or collapse. 3. Shaking (Vibration): following a deep inhalation, b. Considerations prior to the use of the postural shaking is a bouncing maneuver applied to the rib drainage positions, (Table 4-5). These consid- cage throughout exhalation Shaking hastens the erations are not intended to imply absolute dan- removal of secretions from the tracheobronchial ger with their use, but rather a possible need for tree. Commonly used following percussion in the position modification. appropriate postural drainage position. c. Procedure. Modification of this technique may be necessary (1) Explain procedure to the patient. for patient tolerance. (2) Place patient in the appropriate postural a. Indications for the use of shaking. (1) Excessive pulmonary secretions. drainage position. (2) Aspiration. (3) Observe for signs of intolerance. (3) Atelectasis or collapse of an airway from (4) Duration of procedure can be up to 20 min- mucus plugging. b. Considerations prior to the application of utes per postural drainage position. shaking are similar to those of percussion. Typically, the duration equals the duration (Table 4-6). of the other manual techniques which are c. Procedure. being used in conjunction with postural (1) Explain procedure to the patient. drainage. (2) Place patient in the appropriate postural 2. Percussion: a force rhythmically applied with the drainage position. therapist's cupped hands to the specific area of the (3) Perform percussion, if appropriate. chest wall that corresponds to the involved lung (4) As the patient inhales deeply, the thera- segment. Percussion is used to increase the pist's hands are placed so that fingers are amount of secretions cleared from the tracheo- parallel to the ribs. bronchial tree. It is usually used in conjunction (5) As the patient exhales, the therapist's hands with postural drainage. provide a jarring, bouncing motion to the a. Indications for the use of percussion. ribcage below. (1) Excessive pulmonary secretions. (6) The duration of shaking depends on the (2) A piration. patient's need , tolerance, and clinical (3) Atelectasis or collapse due to mucous plug- improvement. Five to ten deep inhalations ging obstructing the airways. with the shaking technique is generally b. Considerations to weigh the possible benefits acceptable practice. Any more than ten of percussion against possible detriments prior would risk hyperventilation (increased VE to the application of this technique are listed in resulting in decreased PaC02) and less than Table 4-6. Modification of the technique may five might be ineffective. be necessary for patient tolerance. 4. Airway clearance techniques. c. Procedure. a. Cough: the patient should be asked to cough in (I) Explain procedure to the patient. the upright sitting position, if possible, after (2) Place patient in the appropriate postural each area of lung has been treated. Coughing is drainage position. effective in clearing secretions from the major (3) Cover the area to be percussed with a light- central airways. weight cloth to avoid erythema. b. Huff: huffing is more effective in patients with (4) Percuss over area of thorax which corre- collapsible airways, such as patients with sponds to the involved lung segment. The chronic obstructive di ea e ; it prevents the duration of percussion depends on the high intrathoracic pressure which causes pre- patient's needs and tolerance. Three to five mature airway closure. minutes of percussion per postural drainage

180 to damage the inner lining of the trachea. The usual suctioning time is between 10 (1) Ask patient to inhale deeply. and 15 seconds. (2) Immediately, the patient forcibly expels the (4) Complications associated with suctioning include: hypoxemia, bradycardia or tachy- air saying \"ha, ha\". cardia, hypotension or hypertension, c. Assisted cough: the therapist's hand(s) (or fist) increased intracranial pressure, atelectasis, tracheal damage, infection . becomes the force behind the patient's exhaled B. Independent Secretion Removal Techniques air. Assisted cough is used when the patient's I. Active cycle of breathing: an independent program abdominal mu cles cannot generate effective used to assist in the removal of the more peripher- cough (e.g. spinal cord injury). The amount of al secretions that coughing alone may not clear. force by the therapist is dependent upon patient a. Breath in a controlled diaphragmatic fashion. tolerance and abdominal sensation. b. Perform thoracic expansion exercises (with or (1) Position the patient against a solid surface; without percu ion and shaking). These are deep inhalations with a hold at the top if possible. supine with head of bed flat or in c. Controlled diaphragmatic breathing. (the Trendelenburg, or sitting with wheelchair patient is now to decide what is needed next. If against the wall or against the therapist. there are no secretions felt to be mobilized at (2) The therapist's hand is placed below the this time, then the patient returns to step b, then patient's subcostal angle (similar to hand c and re-assesses their situation. If the patient placement for the Heimlich Maneuver). believes there to be ecretions that can be (3) The patient inhales deeply. cleared, the patient moves on to step d, e, and f. (4) As the patient attempts to cough, the thera- d. Inhale a resting tidal volume. Contracting the pist's hand pushes inward and upward, abdominal muscles to produce one or two assisting the rapid exhalation of air. forced expiratory huffs from mid to low lung (5) Any secretions raised should be removed volume to raise secretions. by a suction catheter if expectoration is e. Huff from high lung volume or cough to clear. problematic. f. Controlled diaphragmatic breathing. d. Tracheal stimulation: used with patients who g. Repetition of these cycles are continued until are unable to cough on command, such as secretions are in large airways. infants, patients following brain injury or 2. Autogenic drainage: an independent program used stroke. to sense peripheral secretions and clear them with- (I) The therapist's fmger or thumb is placed out the tracheobronchial irritation from coughing. just above the suprasternal notch and a The amount of time spent in each of the following quick inward and downward pressure on phases is determined by where the patient feels the the trachea elicits the cough reflex. secretions. e. Endotracheal suctioning: used only when the a. The unstick phase: quiet breathing at low lung above airway clearance techniques fail to ade- volumes to affect peripheral secretions. quately remove ecretions. b. The collect pha e: breathing at mid lung vol- (1) Standard Precautions are employed since umes to affect secretions in the middle airways. contact with a patient's body fluid is c. The evacuation phase: breathing from mid to expected. high lung volumes to clear secretions from cen- (2) Equipment: suction catheters come in sizes tral airways. This pha e replaces coughing as of 14 French gauge (Fr), usually for an the means to clear secretions. adult, 10 Fr for older children, 8 and 5-6 Fr d. Repeat the steps which correspond to the area for young children and infants. Suction sys- of retained secretions until all ecretions are tem set at approximately 120 mmHg of removed from the airways. suction. Sterile glove/clean glove. 3. The FLUTIER device: an independent program (3) Procedure: the catheter is fed through using an external device that vibrate the airways either an artificial airway, oral airway, or the nares through the pharynx, larynx to the carina. When resistance is felt at the carina, the catheter is rotated and withdrawn. Suction is applied intermittently so as not

on exhalation to improve airway clearance. Pulmonary Physical Therapy 181 a. The patient breathes in through their nose or subcostal angle of the patient's thorax. around the mouthpiece of the flutter device. (4) Apply gentle pressure throughout the exha- b. A three second hold at the top of inhalation. c. Rapid forced exhalations through the Flutter lation phase of breathing. (5) Increase to firm pressure at the end of exha- device. d. Repeat between 4 and 10 times. lation. e. Huff or cough to clear secretions. (6) Ask the patient to inhale against the resist- f. Repeat until all secretions are removed from ance of the therapist's hand. the airways. (7) Release pressure allowing a full inhalation. 4. Low pre ure positive expiratory pressure (PEP) (8) Progress to independence of therapist's rna k: an independent exercise program that uses hand, in upright sitting, standing, walking, positive expiratory resistance via face mask to and stair climbing. assist in the removal of airway secretions. Low 2. Segmental breathing is used to improve ventilation pressure PEP measures 10 to 20 cm H20. to hypoventilated lung segments, alter regional a. Seated, the patient breathes at tidal volumes distribution of gas, maintain or restore functional residual capacity, maintain or improve mobility of with mask in place. chest wall and prevent pulmonary compromise. b. After approximately 10 breaths, the mask is a. Used with patients who have pleuritic, incision- al, or post trauma pain that is causing a decreased removed for coughing and clearing of secretions. movement in a portion of the thorax (splinting) c. The sequence is repeated until all secretions are and are at risk for developing atelectasis. b. Segmental breathing is inappropriate in cases removed from the airways. of intractable hypoventilation until the medical 5. High pressure positive expiratory pressure (PEP) situation is resolved (palliative therapy to reduce bronchogenic tumor size or a chest tube mask: an independent exercise program for to reduce a pneumothorax). patients with unstable airways that uses the high c. Procedure. expiratory pre ures via face mask to assist in the (1) Explain procedure to the patient. removal of airway secretions. High pressure PEP (2) Position the patient to facilitate inhalation uses the point of PEP between 50-120 cm H20 to a certain segment, such as postural where the patient is able to exhale a larger FVC drainage positions, upright sitting. with the rna k than without. (3) Apply gentle pres ure to the thorax over the a. Seated, the patient breathes at tidal volumes area of hypoventilation during exhalation. (4) Increase to firm pressure just prior to inspi- with mask in place. ration. b. After approximately 10 breaths, huffing from (5) Asks the patient to breathe in against the resistance of the therapist's hands. high to low lung volumes is performed with the (6) Release resistance allowing a full inhala- mask in place. tion. c. The equence is repeated until all secretions are 3. Sustained maximal inspiration (SMI) is used to removed from the airways. increase inhaled volume, sustain or improve alveo- C. Breathing Exercises lar inflation, maintain or restore functional residual I. Diaphragmatic breathing is used to increase venti- capacity. lation, improve gas exchange, decrease work of a. Used in acute situations for patients with post- breathing, facilitate relaxation, maintain or trauma pain, post-operative pain, acute lobar improve mobility of chest wall, prevent pulmonary collapse. compromi e. b. Procedure. a. Used with postoperative patients, post trauma (1) Inspire slowly through nose or pursed lips patients, and patient's with obstructive or to maximal inspiration. restrictive pulmonary lung diseases. (2) Hold maximal inspiration for three seconds. b. Procedure. (3) Passively exhale the volume. (I) Explain procedure to patient. (2) Po ition the patient semi-reclined (e.g., Semi-Fowler's position). (3) Place the therapist's hand gently over the

182 and department. (2) Extract pertinent patient information from (4) Incentive spirometers (devices used to measure and encourage deep inspiration) medical record and physical examination. can assist the patient in achieving maximal (3) Demonstrate secretion removal techniques inspiration during SMI. used postoperatively. 4. Pursed lip breathing is used to reduce the respira- (4) Teach breathing exercises, splinting, incen- tory rate, increase tidal volume, reduce dyspnea, decrease mechanical disadvantage of an impaired tive spirometry. ventilatory pump, improve gas mixing at rest for (5) Describe postoperative course, for exam- patients with COPD, and facilitate relaxation. a. Primarily used for patients with obstructive ple, site of incision, monitoring and thera- disease who experience dyspnea at rest or with peutic devices, levels of discomfort, treat- minimal activity/exercise, or who use an ineffec- ment times, hospital guideline for visitors. tive breathing pattern during activity/exercise. Information is tailored to the patient's b. Procedure. inquiries and level of understanding. (1) Slowly inhale through nose or mouth. (6) Perform secretion removal techniques as (2) Passively exhale through pursed lips (posi- required. tion the mouth as if blowing out candles). 2. Postoperative physical therapy sessions decrease Increases intrabronchial pressure. the number and severity of pulmonary complications. (3) Additional hand pressure from the therapist a. Description: prevent postoperative pulmonary applied to abdomen can be used to gently complications. prolong expiration. (1) Remove any residual secretions. (4) Abdominal muscle contraction can be used (2) Improve aeration. judiciously to increase exhaled volume. (3) Gradually increase activity. Care must be taken not to increase intratho- (4) Return to baseline pulmonary functioning. racic pressure which might produce airway b. Pertinent physical findings of postoperative collapse. pulmonary complications. (1) Increased temperature. 5. Abdominal strengthening can be used when (2) Increase in white blood cell count. abdominal muscles are too weak to provide an (3) Change in breath sounds from the preoper- effective cough. Abdominal splinting can be used ative evaluation. when the abdominal muscles cannot provide the (4) Abnormal chest X-ray. necessary support for the abdominal contents (5) Decreased expansion of the thorax. needed for passive exhalation, with high thoracic (6) Shortness of breath. and cervical spinal cord injuries. It is important to (7) Change in cough and sputum production. ensure that the binder does not restrict inspiration. c. Physical therapy considerations. a. Glossopharyngeal breathing (air gulping) can (1) Determine need for pain management. also be taught to assist coughing. (2) Choose appropriate intervention based on the individual patient's needs. D. Pre and Post Surgical Care (a) Secretion removal techniques. 1. Preoperative teaching and treatment decreases the (b) Breathing exercises to improve aera- number and severity of postoperative pulmonary complications. tion, incentive spirometry. a. Goals and outcomes. (c) Early mobilization. (1) Determine baseline cardiopulmonary function. E. Activities for Increasing Functional Abilities (2) Treat any existing condition which may 1. General conditioning. A prescription for exercise alter postoperative course. can be written to improve cardiopulmonary fitness (3) Educate patient and family regarding post- based on the results of an exercise tolerance test. operative course and physical therapy treat- Refer to Chapter 3 for more in-depth discussion. ment. a. Mode. Any type of aerobic activity which (4) Enhance compliance postoperatively. allows a graded workload can be used. Usually, b. Physical therapy considerations. a circuit program of multiple activities (bike, (1) Familiarize the patient with the therapist walking, arm ergometry, etc.) is used because

patients with pulmonary disease may be quite Pulmonary Physical Therapy 183 deconditioned. Patient preference should enter into the decision making process for mode of (5) Progression initially focused on increasing exercise. duration to 30 minutes, then increasing b. Intensity. Using the test data in Karvonen's for- intensity by using smaller apertures. mula [(Maximum Heart Rate - Resting Heart Rate) (40%-85%) + Resting Heart Rate] results 3. Paced breathing (activity pacing) is used to spread in safe range for exercise intensity. Most out the metabolic demands of an activity over time patients with pulmonary disorders will work in by slowing its performance. the upper end of the target heart rate range. a. Used with patients who becomes dyspneic dur- Ratings of Perceived Exertion scale is also used ing the performance of an activity or exercise. to monitor exercise intensity. b. Procedure. c. Duration. Using a high intensity for exercise, (1) Break down any activity into manageable the patient may need an intermittent exercise components that can be performed within program with rest periods for tolerance. the patient's pulmonary system's abilities. Progression is directed fIrst towards a duration (2) Inhale at rest. of 20 to 30 minutes of continuous exercise (3) Upon exhalation with pursed lips, complete before an increase in intensity is considered. the fIrst component of the desired activity. d. Frequency. The goal is 20 to 30 minutes of (4) Stop the activity and inhale at rest. exercise 3 to 5 times per week. If the duration (5) Upon exhalation with pursed lips, complete is less than 20 to 30 minutes, exercise must be next component of activity. performed more frequently (5 to 7 times per (6) Repeat steps (4) and (5) until activity is week). accomplished in full without shortness of 2. Inspiratory muscle trainers (IMTs) load the mus- breath. For example, stair climbing can be cles of inspiration by breathing through a series of done ascending one or more stairs on the graded aperture openings. By increasing strength exhalation phase of breathing, cease activi- and endurance of muscles of ventilation, the ty and breathe in at rest, then more stairs on patient will have increased efficiency of ventilato- exhalation, followed by another inhalation ry muscles, decreased work of breathing, at rest and so on. decreased po sibility of respiratory muscle fatigue, Whether or not this translated into 4. Energy conservation. The energy consumption of improved functional abilities has been cause for many activities of daily living can be decreased debate and has yet to be conclusively proven. with some careful thought and planning, making a. IMT is appropriate for patients with decreased seemingly impossible tasks po sible. For example, compliance, decreased intrathoracic volume, showering is difficult for the patient with pul- resistance to airflow, alteration in length ten- monary disease given the activity and the hot sion relationship of ventilatory muscles, humid environment that accompanies the task. decreased strength of the respiratory muscles. With a shower seat, hand held shower and use of a b. Procedure. terrycloth robe after showering, the patient does (1) Explain procedure to patient with emphasis not have to stand, hold their breath as often, nor dry off in the humid environment, thus reducing on maintenance of respiratory rate and tidal the energy cost of the activity. volume during training sessions. (2) Determine maximum inspiratory pressure V. Medical and Surgical Management of (MIP). Pulmonary Disease (3) Choose an aperture opening which requires 30% to 40% of MIP (intensity), and allows A. Surgical Management 15 to 30 minute training per session. 1. Types of surgeries to remove diseased lung por- (4) Ask patient to breathe through device while tions. maintaining respiratory rate and tidal vol- a. Pneumonectomy: removal of a lung. ume for at least 15 minutes. b. Lobectomy: removal of a lobe of a lung. c. Segmental resection: removal of a segment of a lobe. d. Wedge resection: removal of a portion of a seg- ment of a lobe.

184 heart rate, arrhythmias, gastrointe tinal distress, nervousness, headache and eizure. Blood lev- e. Lung volume reduction surgery (LVRS) or els need to be drawn to ensure medication effect pneumectomy, removes large emphysematous, without causing toxicity. Examples are amino- non-functioning areas of the lung in order to phylline and theophylline. restore more normal thoracic mobility and 2. Anti-inflammatory agents: u ed to decrease improve gas exchange of the healthier remaining mucosal edema, decrease inflammation, reduce lung. airway reactivity. a. Steroids: These drugs are used for maintenance 2. Types of incisions. of airway and should be taken on a regularly a. Midstemotomy. The sternum is cut in half scheduled basis. They are not to be used for the lengthwise and the ribcage retracted. Used in acute onset with breakthrough symptoms. most heart surgeries. The sternum is wired These drugs can be administered systemically together at the close of surgery; therefore, or topically (MDI). Side effects of systemic physical therapy should encourage full upper administration are increased blood pressure, extremity range of motion postoperatively. sodium retention, muscle wasting, osteoporo- b. Thoracotomy. Used for most lung resections. sis, GI irritation, and hypercholesteremia. The The incision follows the path of the fourth main side effect of inhaled teroid i thrush, a intercostal space. Full range of motion should fungal infection of the mouth and throat. be encouraged postoperatively. Examples are Vanceril (MDI), Azmacort (MDI), Prednisone (po) [by mouth] and B. Medical Management Solumedral (IV). 1. Bronchodilator agents. b. Leukotriene Receptor Antagonist: blocks a. Beta-2 agonists (sympathomimetics): mumcs leukotrienes that are released in an allergic the activity of the sympathetic nervous system reaction. Inhibits airway edema and smooth which will produce bronchodilation. Also can muscle contraction without being a steroid. It cau e increase in heart rate and blood pressure. has additive benefits when used in conjunction Given topically through a metered dose inhaler with other anti-inflammatories. An example of (MDI), unwanted systemic effects are reduced. this drug is Montelukast - Singulair. Most of the drugs in this category are termed c. Cromolyn Sodium: an antiallergic drug. rescue drugs as they are to be used primarily for Prevents release of mast cell (i.e., histamine) immediate relief of breakthrough symptoms of after contact with allergen . U ed prophylacti- chest tightness, wheezing and shortness of cally to prevent exercise-induced bronchospasm breath. Examples of re cue Beta 2 agonists are and severe bronchial asthma via oral inhala- Ventolin, Alupent, Maxair, Albuterol. Newer tion. It is not to be used as a rescue drug during treatment options include a Beta-2 agonist for acute situations. Frequent inhalation can result maintenance. They are long acting inhaled in hoarseness, cough, dry mouth and bronchial bronchodilators that may decrease the need for irritation. Symptoms of overdosage include rescue drugs, and decrease the need for inhaled paradoxical bronchospasm. Brand names anti-inflammatories. An example of this type of include Intal. Beta-2 maintenance drug is Serevent. 3. Antibiotics: to control infection. b. Anticholinergics: inhibit the parasympathetic a. Categories: culture and sensitivity results are nervous system. Inhibiting the parasympathetic used to prescribe the most effective antibiotic. sy tern can also cause an increase in heart rate (I) Penicillins. and blood pressure along with bronchodilation. (2) Erythromycins. Side effects can include lack of sweating, dry (3) Tetracyclines. mouth and delusions. These drugs are adminis- (4) Cephalosporins. tered by MDI with minimal side effects. They (5) Aminoglycosides. should be used on a regular schedule to main- b. Side effects. tain bronchodilation. An example of this cate- (1) Allergic reactions, stomach cramps, nausea, gory of drug is Atrovent. c. Methylxanthines: produce smooth muscle relax- vomiting and diarrhea. ation but their use is limited due to the serious toxicity of increased blood pressure, increased

VI. Intensive Care Unit Management: Physical Pulmonary Physical Therapy 185 therapy i employed in the ICU for pulmonary care ranted. These lines limit mobility only by the length (secretion removal or improved aeration) and early of the tubing. If this line becomes di lodged, immedi- mobility (range of motion, positioning, therapeutic ate finn pressure needs to be applied to or above the exerci e, transfers, ambulation). The following pro- arterial insertion site to stop bleeding. vides a brief de cription of some equipment frequent- E. Monitors/Oscilloscopes ly encountered when treating a patient in the ICU. 1. Continuous EKG with a reported heart rate. 2. Blood pressure reading either periodic using non- A. Mechanical Ventilation: maintain an adequate VE for patient who cannot do so independently. Requires invasive cuff (NIBP) or continuous using a trans- intubation with an endotracheal (oral), nasotracheal ducer attached to the arterial line (ABP). (nasal) or tracheal (through a tracheostomy directly 3. Continuous oxygen saturation (Sa02) with pulse into the trachea) tube. Endotracheal and nasotracheal wave. Sa02 is the percent saturation of oxygen in tubes are only taped into place. Tracheal tube may be the arterial blood. It is a non-invasive measure- sutured in place. Tubes or mechanical ventilation pose ment that relates to the Pa02 on the S-shaped no contraindications to physical therapy treatment. A curve called the oxyhemoglobin desaturation patient who is intubated can ambulate using a curve. Normal levels are 98% to 100% saturated. mechanical resuscitator bag to maintain ventilation. It The pulse oximeter utilizes a finger sensor (or an is sometimes easier to use a stationary device, e.g., ear sensor) to obtain a consistent reading. peddler, to exercise a patient who needs a ventilator. F. Supplemental Oxygen: increases the Fi02 (up to When moving a patient who is intubated, care should 1.0) of the patient's environment. A portable oxygen be taken that excessive tension is not placed on the cylinder attached to the oxygen delivery device, (can- tube. Alteration in the placement of the tube (either a nula, mask or even a manual resuscitator bag attached drop inward or a puU outward) could be detrimental to to the endotracheal tube) can be used during mobility optimal ventilation. If tube movement is suspected, a training to provide supplemental oxygen for the nurse or respiratory therapist should check the place- patient. Supplemental oxygen is indicated if Sa02 is ment of tube. If the tube is dislodged, a physician, less than 88% or Pa02 is less than 55 mmHg regard- often an anaesthesiologist, needs to replace the tube. less of activity level. Monitor the patient's Sa02 to assure adequate oxygenation with increased activity. B. Chest Thbes: u ed to evacuate air or fluid trapped in Oxygen must be prescribed by a physician. It is con- the intrapleural pace. The chest tubes are sutured in sidered a form of medication. place, making them secure. There are no contraindi- cations to physical therapy treatment with a chest Portions of the review of pulmonary anatomy and physiology tube. If the chest tube is connected to a suction device mobility is limited only by the length of the tubing: have been preViously published in Starr, J. Pulmonary System Portable suction machines can be used to allow increased mobility. If the tube is dislodged during (Ch. 7) in Meyers, R (ed): Saunders Manual of Physical Therapy treatment, cover the defect and seek assistance. Practice,WB Saunders Co, Philadelphia, 1995. C. IVs: Intravenous catheters used to deliver medications. There are no contraindications to physical therapy treatment with IV lines; however, the upper extremity hould not be raised above the level of the IV med- ication for any length of time or backflow of blood may occur. Rolling IV poles allow for mobility. Most IV pump have a battery back up system to allow the patient to be mobile. D. Arterial Lines: catheters that are placed within the arterial ystem, usually the radial artery. The tubing is connected to a pressure pack that exceeds arterial pressure 0 the line does not back up with blood. Caution to maintain patency during moving is war-

CHAPTER 5 INTEGUMENTARY PHYSCIAL THERAPY Susan B. O'Sullivan I. Integumentary System Contains lymphatics, blood vessels, nerves and nerve endings, sebaceous and sweat glands. A. Skin or Integument c. Subcutaneous tissues: underneath dermis; con- 1. External covering of the body, the largest organ sists of loose connective and fat tissues; pro- y tern of the body (15% to 20% of body weight). vides insulation, support, and cushion for skin; 2. Functions of skin. stores energy for skin. a. Protection of underlying body structures d. Underneath subcutaneous layer: muscles and against injury or invasion. fascia. b. Insulation of body. 4. Appendages of the skin. c. Maintenance of homeosta is: fluid balance, a. Hair. regulation of body temperature. (1) Terminal hair: coarse, thick, pigmented, d. Aids in elimination: small amounts of urea and salt are excreted in sweat. e.g., scalp, eyebrows. e. Synthesizes vitamin D. (2) Vellus hair: short, fine, e.g., arms, chest f. Receptors in dermis give rise to cutaneous sen- b. Nails: nail plate, lunula (whitish moon), proxi- sations. mal nail fold/cuticle, lateral nail folds. 3. Consists of three layers. c. Sebaceous glands: secrete fatty substance a. Epidermis: outer, most superficial layer; con- through hair follicles; on all kin surfaces tains no blood vessels. Comprised of two lay- except palms and soles. ers of stratified epithelium. d. Sweat glands. (1) Stratum corneum is outermost, horny layer, (1) Eccrine glands: widely distributed, open on comprised of non-living cells. (2) Stratum lucidum, comprised of living cells; skin; help control body temperature. produces melanin responsible for skin (2) Apocrine glands: found in axillary and gen- color. b. Dermis (corium): inner layer comprised prima- ital areas, open into hair follicles; stimu- rily of collagen and elastin fibrous connective lated by emotional stress. tissues. Mucopolysaccharide matrix and elastin B. Circulation fibers provide elasticity, strength to skin. 1. Blood flows through arteries to capillaries of the skin. a. Increased blood flow with an increase in oxy-

188 d. Management: antibiotics; elevation of the part; cool, wet dressings. hemoglobin to skin capillaries causes redden- ing of the skin. e. If untreated, lymphangitis, gangrene, abscess, b. Peripheral cyanosis is due to reduced blood and sepsis can occur. flow to skin and loss of oxygen to tissues (changes to deoxyhemoglobin) and results in a f. The elderly and individuals with diabetes, darker and somewhat blue color. wounds, malnutrition, or on steroid therapy are c. Central cyanosis is due to reduced oxygen level at increased risk. in the blood; causes include advanced lung dis- ease, congenital heart disease, abnormal hemo- 4. Abscess: a cavity containing pus and surrounded globins. by inflamed tissue. a. The result of a localized infection. II. Common Skin Disorders b. Commonly a staphylococcal infection. b. Healing typically facilitated by draining or A. Dermatitis (eczema) incising the abscess. I. Inflammation of the skin with itching, redness, skin lesions. C. Viral Infections 2. Causes: 1. Herpes I (herpes simplex): itching and soreness a. Allergic or contact dermatitis: e.g., poison ivy, followed by vesicular eruption of the skin on the harsh soaps, chemicals, adhesive tape, etc. face or mouth; a cold sore or fever blister. b. Actinic: photosensitivity, reaction to sunlight, 2. Herpes II: common cause of vesicular genital ultraviolet. eruption. c. Atopic: etiology unknown, associated with a. Spread by sexual contact. allergic, hereditary, or psychological disorders. b. In newborns may cause meningoencephalitis, 3. Stages. may be fatal. a Acute: red, oozing, crusting rash; extensive 3. Herpes Zoster (shingles): caused by varicella- erosions, exudate, pruritic vesicles. zoster virus (chickenpox); reactivation of virus b Subacute: erythematous skin, scaling, scattered lying dormant in cerebral ganglia or ganglia of plaques. posterior nerve roots. c Chronic: thickened skin, increased skin mark- a. Pain and tingling affecting spinal or cranial ing secondary to scratching; fibrotic papules, nerve dermatome; progresses to red papules and nodules; postinflarnmatory pigmentation along distribution of infected nerve; red changes. Course can be relapsing. papules progressing to vesicles develop along a 4. Precaution or contraindication to some physical dermatome. therapy modalities; avoid use of alcohol. b. Usually accompanied by fever, chjJ]s, malaise, 5. Medical management aimed at inflammation: top- GI disturbances. ical or systemic therapy. c. Ocular complications with C.N.ill involve- 6. Daily care includes hydration and lubrication of ment: eye pain, corneal damage; loss of vision. skin. with C.N.V involvement. d. Postherpetic neuralgic pain: may be intermit- B. Bacterial Infections tent or constant; lasts weeks; occasionally I. Bacteria typically enter through portals in the skin, intractable pain lasting for months or years. e.g., abrasions or puncture wounds. e. Management: no curative agent, anti-viral 2. Impetigo: superficial skin infection caused by drugs slow progression; symptomatic treat- staphylococci or streptococci; associated with ment for itching and pain, e.g., systemic corti- inflammation, small pus-filled vesicles, itching; costeroids. contagious; common in children and the elderly. f. Contagious to individuals who have not had 3. Cellulitis: suppurative inflammation of cellular or chicken pox. connective tissue in or close to the skin. g. Heat or ultrasound contraindicated: can increase a. Tends to be poorly defined and widespread. severity of symptoms. b. Streptococcus or staphylococcus infection 4. Warts: common, benign, infection by human common; can be contagious. papilloma viruses (HPV ). c. Skin is hot, red and edematous. a. Transmission is through direct contact;

autoinoculation is possible. Integumentary Physical Therapy 189 b. Common warts: on skin, especially hands and violet light; combination UV light with oral fingers. photosensitizing drugs (Psoralen). c. Plantar wart: on pressure points of feet. 2. Lupus erythematosus: chronic, progressive d. Management: cryotherapy, acids, electrodesicca- inflammatory disorder of connective tissues; char- acteristic red rash with raised, red, scaly plaques. tion and curettage; over-the-counter medications. Forms include: 5. Contagious, observe standard precautions. a. Discoid lupus erythematosus (DLE): affects D. Fungal Infections only skin; flare-ups with sun exposure; lesions 1. Ringworm (Tinea Corporis): fungal infection can resolve or cause atrophy, permanent scar- ring, hypo-or hyperpigmentation. involves the hair, skin, or nails; forms ring-shaped b. Systemic lupus erythematosus (SLE): chronic, patches with vesicles or scales; itchy; transmission systemic inflammatory disorder affecting mul- is through direct contact. Treated with topical or tiple organ systems including skin, joints, kid- oral antifungal drugs (e.g., Griseofulvin). neys, heart, nervous system, mucous mem- 2. Athlete's foot (Tinea Pedis): fungal infection of branes; can be fatal; commonly affects young foot, typically between the toes; causes erythema, women. Symptoms can include fever, malaise, inflammation, pruritus, itching and pain. Treated characteristic butterfly rash across bridge of with antifungal creams. Can progress to bacterial nose, skin lesions, chronic fatigue, arthralgia, infections, cellulitis if untreated. arthritis, skin rashes, photosensitivity, anemia, 3. Transmi ion is person-to-person or animal-to- hair loss, Raynaud's phenomenon. person; ob erve standard precautions. c. Management: no cure; topical treatment of skin E. Parasitic Infections lesions (corticosteroid creams); salicylates or 1. Caused by insect and animal contacts. indomethacin with fever and joint pain; 2. Scabies (mites) burrow into skin causing inflam- immunosuppressive agents (cytotoxic agents) mation, itching, and possibly pruritis. Treated with with life-threatening disease. scabicide. d. Observe for side-effects of corticosteroids: 3. Lice (pediculosis): a parasite that can affect head, edema, weight gain, acne, hypertension, bruis- body, genital area; bite marks, redness, and nits. ing, purplish stretch marks; long-term use of Treatment with special soap or shampoo. corticosteroids is associated with increased 4. Transmission is person-to-person or can be sexual- susceptibility to infection (immunosuppressed ly transmitted. Avoid direct contact; observe stan- patient); osteoporosis, myopathy, tendon rup- dard precautions. ture, diabetes, gastric irritation, low potassium. F. Immune Disorders of the Skin 3. Scleroderma: a chronic, diffuse disease of connec- 1. Psoriasis: chronic disease of skin with erythema- tive tissues causing fibrosis of skin, joints, blood tous plaques covered with a silvery scale; common vessels, and internal organs (GI tract, lungs, heart, on ears, scalp, knees, elbows, and genitalia. kidneys). Usually accompanied by Raynaud's phe- a. Common complaints: itching and pain from nomenon. Progressive systemic sclerosis (PPS) is a relatively rare autoimmune form. dry, cracked lesions. a. Skin is taut, firm, edematous, firmly bound to b. Variable course: exacerbations and remissions subcutaneous tissues. b. Limited disease/skin thickening: symmetrical are common. skin involvement of distal extremities and face; c. May be associated with psoriatic arthritis, joint slow progression of skin changes; late visceral involvement. pain, particularly of mall distal joints. c. Diffuse disease/skin thickening: symmetrical, d. Etiological factors: hereditary, associated immune widespread skin involvement of distal and proximal extremities, face, trunk; rapid pro- disorders, certain drugs. gression of skin changes with early appearance e. Precipitating factors: trauma, infection, preg- of visceral involvement. d. Management: no specific therapy; supportive nancy and endocrine changes; cold weather, smoking, anxiety and stress. f. Management: no cure; topical preparations (corticosteroid, occlusive ointments, coal tar); systemic drugs (methotrexate). g. Physical therapy intervention: long-wave ultra-

190 margins; presents as a flat red area, ulcer or nodule. Grows more quickly, common on sun- therapy can include corticosteroids, vasodila- exposed areas, face and neck, back of hand. tors, analgesics immunosuppressive agents. Can be confined (in situ) or invasive to ur- e. Physical therapy slows development of con- rounding tissues; can metastasize. tracture and deformity. c. Malignant melanoma: tumor arising from f. Precautions with sclerosed skin, sensitive to melanocytes (cell that produce melanin); pressure; acute hypertension may occur, stress superficial spreading melanoma (SSM) most regular BP checks. common type. 4. Polymyositis (PM): a disease of connective tissue (I) Cljncial manifestations: \"ABCDs\" characterized by edema, inflammation, and degen- eration of the muscles; dermatitis is associated (a) asymmetry: uneven edges, lopsided. with some forms. (b) borders: irregular, poorly definted a. Affects primarily proximal muscles: shoulder and pelvic girdles, neck, pharynx; symmetrical edges. distribution. (c) color: vaiations or changes in color, b. Etiology unknown; autoimmune reaction affecting muscle tissue with degeneration and black, brown, red, or wrote. regeneration, fiber atrophy; inflammatory infil- (d) diameter: larger than 6mm. trates. (e) evolving: changing in color, size, shape. c. Rapid, severe onset: may require ventilatory Can also see irritation, itchjng, or tender- assistance, tube feeding. d. Cardiac involvement: may be fatal. ness e. Management: medication (corticosteroids and (2) Risk factors: family hjstory, intense sun immunosuppressants). f. Precautions: additional muscle fiber damage exposure, individuals with fair skin and with too much exercise; contractures and pres- freckles. sure ulcers from inactivity, prolonged bedrest. (3) Treatment i surgical resection. Prognosis G. Skin Cancer depends on extent of invasion. 1. Benign tumors. d. Kaposi's sarcoma (KS): lesions of endothelial a. Seborrheic keratosis: proliferation of basal cell origin with red, or dark purple/blue mac- cells leading to raised lesions, typically multi- ules that progress to nodules or ulcers; as oci- ple lesions on trunk of older individuals; ated with itching and pain. untreated unless causing irritation, pain; can be (I) Common on lower extremities; may removed with cryotherapy. b. Actinic keratosis: flat, round or irregular involve internal structures producing lesions, covered by dry scale on sun-exposed lymphatic obstruction. skin. Precancerous: can lead to squamous cell (2) Increased incidence in individuals of carcinoma. central European descent, and with c. Common mole (benign nevus): proliferation of AIDS-associated immunodeficiency. melanocytes, round or oval shape, sharply defined H. Skin Trauma borders, uniform color, < 6mm, flat or raised. Can 1. Contusion: injury in which skin is not broken, a change into melanoma: signs include new bruise. Characterized by pain, swelling, and dis- swelling, redness, scaling, oozing or bleeding. coloration. Immediate application of cold may 2. Malignant tumors. limit effects. a. Basal cell carcinoma: slow growing epithelial 2. Ecchymosis: bluish discoloration of skin caused basal cell tumor, characterized by raised patch by extravasation of blood into the subcutaneous with ivory appearance; has rolled border with tissues; the result of trauma to underlying blood indented center. Rarely metastasizes, common vessels or fragile vessel walls. on face, in fair-skinned individuals. Associated 3. Petechiae: tiny red or purple spots on the skin that with prolonged sun exposure. result from tiny hemorrhages within the dermal or b. Squamous cell carcinoma: has poorly defined submucosal layers; pinpoint. 4. Abrasion: scraping away of kin a a result of injury or mechanical abrasion (e.g., dermabrasion). 5. Laceration: an irregular tear of the skin producing a torn, jagged wound.

III. Examination of Integumentary Integrity Integumentary Physical Therapy 191 A. Patient/Client History advanced lung disease, congenital heart 1. Complete history: age, sex, race/ethnicity, social! disease, venous obstruction. health habits, work, living, general health status, (2) Exanline lips, oral muco a, tongue for blue medical/surgical. color (central causes) or nails, hands, feet 2. Current condition(s)/ chief complaint(s). (peripheral causes). 3. Functional tatus/activity level. c. Pallor (lack of color, paleness). 4. Medications. (1) Can indicate anemia, internal hemorrhage, 5. Clinical tests. lack of exposure to sunlight. 6. Risk factor assessment. (2) Temporary pallor seen with arterial insuffi- ciency and syncope, chills, shock, vasomo- B. Examination tor instability, or nervousness. 1. Techniques include observation, palpation, photo- d. Yellow: indicates jaundice, liver disease: look graphic assessment, and thermography. for yellow color in sclera of eyes, lips, skin. 2. Pruritus: itching; common in diabetes, drug hyper- With increased carotene intake (carotenemia), sen itivity, hyperthyroidism. look for yellow color of palms, soles, and face. 3. Urticaria: smooth, red, elevated patches of skin, e. Liver spots: brownish-yellow spots may be due hives; indicative of an allergic response to drugs or to aging, uterine and liver malignancies, preg- infection. nancy. 4. Rash: local redness and eruption on the skin, typi- f. Brown: increased pigmentation, sometimes cally accompanied by itching; seen in inflamma- associated with venous insufficiency. tion, skin disea es, chronic alcoholism, vasomotor 10. Changes in skin temperature: correlates with inter- disturbances, pyrexia, medications, e.g., diaper nal temperature unless skin is exposed to local rash, heat rash, drug rash. heat or cold. 5. Xeroderma: excessive dryness of skin with shed- a. Examine with backs of fingers for generalized ding of epithelium; can indicate deficiency of thy- warmth or coolness. roid function, diabetes. (1) Abnormal heat can indicate febrile condi- 6. Edema: can indicate anemia, venous or lymphatic tion, hyperthyroidism, mental excitement, obstruction, inflammation; cardiac, circulatory, or excessive salt intake. renal decompensation. (2) Abnormal cold can indicate poor circula- a. Determine activities and postures that aggra- tion or obstruction, e.g., vasomotor spasm, vate or relieve edema. venous or arterial thrombosis, hypothy- b. Palpation, volume, and girth measurements. roidism. 7. Changes in nails. b. Examine temperature of reddened areas: local a. Clubbing: thickened and rounded nail end with warmth may indicate inflammation or cellulitis. spongy proximal fold; indicative of chronic 11. Hydrosis. hypoxia secondary to heart disease, lung can- a. Moist skin (hyperhidrosis), increased perspira- cer, cirrhosis. tion, can indicate fevers, pneumonic crisis, b. White spots seen with trauma to nails. drugs, hot drinks, exercise. 8. Changes in skin pigmentation, tissue mobility, b. Dry skin (hypohidrosis) can indicate dehydra- skin turgor and texture. tion, ichthyosis, or hypothyroidism. a. Wrinkling may be due to aging or prolonged c. Cold sweats: can indicate great fear, anxiety, immersion in water, dehydration. depression or disease (AIDS). b. Blistering. 12. Changes in hair: note quality, texture, distribution. 9. Changes in skin color. a. Alopecia: hair loss. a. Cherry red: indicative of carbon monoxide poi- b. Hypothyroidism see thinning hair; hyperthy- soning. roidism see silky hair. b. Cyanosis: lightly bluish, grayish, slatelike dis- 13. Presence of lesions: note unusual growths. coloration. a. Note anatomic location and distribution, i.e., gen- (1) Indicative of lack of oxygen (hemoglobin); eralized or localized?, Exposed or non-exposed can indicate congestive heart failure, surface?, Symmetrical or asymmetrical?

192 ru Physical Therapy Intervention for Impaired b. Type. Integumentary Integrity. (1) Flat spot: macule (small, up to 1.0cm), patch (1.0 cm or greater). (Table 5-1) (2) Palpable elevated solid mass: papule A. Patient/client-related instruction (small, up to 1.0 cm), plaque (elevated, 1.0 cm or larger), nodule (marble-like lesion), 1. Enhance disease awareness, healthy behaviors. wheal (irregular, localized skin edema, e.g., 2. Assist patient to avoid harsh soaps, known irri- hives). (3) Elevated lesions with fluid cavities: vesicle tants, temperature extremes, exacerbating factors (up to 1.0 cm, contains serous fluid, e.g., or triggers. herpes simplex); bulla or blister (1.0 em or 3. Enhance ADLs, functional mobility and safety. larger, contains serous fluid, e.g., 2nd 4. Enhance self-management of symptoms. degree burn); pustule (contains pus, e.g., B. Infection Control Practices acne). 1. (Table 5-2). 2. (Table 5-3). c. Color. C. Therapeutic Exercise C. Body Composition 1. Strengthening and ROM exercises. 2. Aerobic conditioning. a. Height, weight. 3. Body mechanics, postural awareness training. b. Body mass index; skinfold thickness. 4. Gait, locomotion, and balance training. D. Other Systems S. Aquatic therapy. 1. Circulation (arterial, venous, lymphatic) D. Functional training a. Heart rate, rhythm, sounds. 1. ADL training (basic and instrumental). b. Blood pressures and flow. 2. Activity pacing and energy conservation; stress c. Superficial vascular responses. management. 2. Respiratory. 3. Skin and joint protection techniques. a. Respiratory rate. 4. Instruct in safe use of assistive and adaptive b. Respiratory pattern. devices. 3. Sensory. 5. Prescription, application, and training in u e of a. Superficial sensations: sharp/dull discrimina- orthotic, protective, or supportive devices. E. Manual lymphatic drainage, therapeutic massage tion, temperature, light touch, pressure. F. Dressings and topical agents ( ee section on wound b. Deep sensations: proprioception, kinesthesis. care) c. Pain and soreness. G. Electrotherapeutic modalities Refer to Chapter 10. 3. Musculoskeletal. 1. Electrical muscle stimulation (EMS). a. Gross range of motion (ROM) including mus- 2. High voltage pulsed current (HVPC). cle length. TABLES-I b. Gross strength. PREFERRED PRACTICE PATTERNS: INTEGUMENTARY 4. Neuromuscular. a. Coordination, PATTERN A: Primary Prevention/Risk Reduction for Integumentary Disorders b. Gait, locomotion, balance. E. Functional PATTERN B: Impaired Integumentary Integrity Associated with Superficial 1. Examine. Skin Involvement a. Activities, positions, postures that produce or PATTERN C: Impaired Integumentary Integrity Associated with Partial reduce trauma to skin. Thickness Skin Involvement and Scar Formation b. Safety during functional activities. c. Assistive, adaptive, protective, orthotic or pros- PAffiRN 0: Impaired Integumentary Integrity Associated with Full-Thickness Skin Involvement and SCar Formation thetic devices that produce or reduce skin trau- ma. PAffiRN E: Impaired Integumentary Integrity Associated with Skin d. Likelihood of trauma to skin. Involvement Extending into Fascia, Muscle, or Bone and Scar Formation From Guide to Physical Therapist Practice, ed 2. Phys Ther 81 :595- 688,2001

3. Transcutaneous electrical nerve stimulation Integumentary Physical Therapy 193 (TENS): relief of pain. (1) Hypertrophic scar: a raised scar that stays H. Physical agents and modalities Refer to Chapter 10. within the boundaries of the burn wound; 1. Sound agent : ultrasound, phonophoresis. characteristically red, raised, firm. 2. Hydrotherapy: aquatic therapy, whirlpool tanks. 3. Light agents: ultraviolet. (2) Keloid scar: a raised scar that extends 4. Mechanical modalities: compression therapies. beyond the boundaries of the original burn wound; red, raised, firm. V. Burns 4. Subdermal burn (fourth-degree): complete A. Tissue injury or destruction: results from thermal, destruction of epidermis, dermis, subcutaneous chemical, electrical, or radioactive agents. tissues; also involves muscle and bone; e.g., elec- trical burn; prolonged contact with flame. B. Pathophysiology: bum wound consists of three zones. a. Extensive tissue damage; destruction of vascu- 1. Zone of coagulation: cells are irreversibly injured, lar system, may lead to additional necrosis. cell death occurs. b. Course unpredictable. 2. Zone of stasis: cells are injured; may die without c. Requires extensive surgery; amputation may be specialized treatment, usually within 24-48 hours. necessary. 3. Zone of hyperemia: minimal cell injury; cells d. Additional complications likely with electrical should recover. burns, e.g., ventricular fibrillation, acute kid- ney damage, spinal cord damage. C. Degree of burn: burns are classified by severity, lay- ers of skin damaged. D. Extent of burned area 1. Superficial burn (first degree): damage is to epi- 1. Rule of Nines for estimating burn area (estimates dermis only. are for adult patients). a. Characterized by erythema, slight edema, ten- a. Head and neck 9% derness; no blistering. b. Anterior trunk 18% b. Full healing in 3-7 days. c. Posterior trunk 18% 2. Superficial partial thickness burn (second-degree d. Arms: each 9% bum): epidermis and upper layers of dermis are e. Legs: each 18% damaged. f. Perineum 1% a. Characterized by blisters, inflammation, severe 2. Percentages vary by age (growth) for children: use pain. Lund-Browder charts for estimating body areas. b. Healing in 7 to 21 days. 3. Classification by percentage of body area burned. 3. Deep partial thickness bum (second-degree burn): a. Critical: 10% of body with third degree burns severe damage to epidermis and dermis with injury and 30% or more with second degree; compli- to nerve endings, hair follicles, and sweat glands. cations common, e.g., respiratory involvement, a. Characterized by red or white appearance, smoke inhalation. edema, blistering, severe pain. b. Moderate: less than 10% with third degree b. Healing occurs through scar formation and burns and 15-30% with second degree. reepithelialization, in 21-28 days. c. Minor: less than 2% with third degree burns 4. Full thickness burn (third-degree): complete and 15% with second degree burns. destruction of epidermis, dermis, and subcuta- neous tissues, may extend into muscle. E. Complications of burn injury a. Characterized by white, gray, or black 1. Infection: leading cause of death; gangrene may (charred) appearance; dry surface, edema, develop. eschar (scab or dry crust); little pain (nerve 2. Shock. endings are destroyed). 3. Pulmonary complications. b. Removal of eschar; grafting is necessary due to a. Smoke inhalation injury from inhalation of hot destruction of dermal and epidermal tissue. gases, smoke poisoning; results in pulmonary c. Risk of infection is increased. edema and airway obstruction; suspect with d. Hypertrophic scarring and wound contracture are burns of the face, singed nose hairs. likely to develop without preventive measures. b. Restrictive lung disease from burns of the trunk. c. Pneumonia.

194 fluid loss, protects the wound. (2) May additionally limit ROM. 4. Metabolic complications: increased metabolic and 2. Establish and maintain airway, adequate oxygena- catabolic activity results in weight loss, negative tion, respiratory function. nitrogen balance, decreased energy. 3. Monitor. a. Arterial blood gases, serum electrolyte levels, 5. Cardiac and circulatory complications: fluid and urinary output, vital signs. plasma loss results in decreased cardiac output. b. Gastrointestinal function: provide nutritional support. F. Burn healing 4. Pain relief, e.g., Morphine sulfate. 1. Epidermal healing: retention of viable cells allows 5. Prevention and control of infection. for epithelialization to occur (epithelial cells grow a. Tetanus prophylaxis. and proliferate, migrate to cover the wound). b. Antibiotics. a. Protection of epithelial cells is critical. c. Isolation, sterile techniques. b. Loss of sebaceous glands can result in drying 6. Fluid replacement therapy. and cracking of wound; protection with mois- a. Prevention and control of shock. turizing creams important. b. Post shock fluid and blood replacement. 2. Dermal healing: results in scar formation (injured 7. Surgery. tissue is replaced by connective tissue); scars are a. Primary excision: surgical removal of the initially red or purple, later become white. eschar. a. Inflammatory phase: characterized by redness, b. Grafts: closure of the wound. edema, warmth, pain, decreased range of (1) Allograft (homograft): use of other human motion; lasts 3-5 days. b. Proliferative phase: fibroblasts form car tissue skin, e.g., cadaver skin; temporary graft (deeper tissues); characterized by wound con- for large burns, used until autograft is avail- traction; reepithelialization may occur at able. wound surface if viable cells remain. (2) Xenograft (heterograft): use of skin from c. Maturation phase: scar tissue remodeling lasts other species, e.g., pigskin; a temporary up to 2 years. graft. (1) Hypertrophic scar may result. (3) Biosynthetic grafts: combination of colla- (2) Keloid scar may result; more common in gen and synthetics. young women and those with dark skin. (4) Cultured skin: laboratory grown from patient's own skin. G. Emergency burn management (5) Autograft: use of the patient's own skin. 1. Immersion of burned part in cold water (if less (6) Split-thickness graft: contain epidermis than half the body burned and injury is immedi- and upper layers of dermis from donor site. ate); cold compresses may also be used. (7) Full-thickness graft: contains epidermis 2. Cover burn with sterile bandage or clean cloth; no and dermis from donor site. ointments or creams. c. Surgical resection of scar contracture, e.g., Z- plasty (a surgical incision in the form of the H. Medical management letter Z used to lengthen a burn car). 1. Asepsis and wound care. I. Physical therapy goals, outcomes, and interventions a. Removal of charred clothing. 1. Burn wound care. Infection control techniques at b. Wound cleansing. all times. c. Topical medications (antibacterial agents): can a. Immersion in hydrotherapy tank. be applied without dressings (open technique); (1) Debridement: the excision of loose, reapplied daily. charred, dead skin. (1) Silver nitrate: acts only on surface organ- (2) Wet removal of dressings. isms; applied with wet dressings; requires (3) ROM exercises, early mobilization. frequent dressing changes. (4) Anti-infection agents are added to assist in (2) Silver sulfadiazine: common topical agent. infection control. (3) Sulfarnylon (mafenide acetate): penetrates through eschar. d. Occlusive dressings (closed technique): dress- ings are applied on top of a topical agent. (1) Prevents bacterial contamination, prevents

Integumentary Physical Therapy 195 b. Sharp debridement: excIsion of eschar using deformities. sterilized surgical instruments (forceps, (1) Anterior neck: common deformity is flex- scalpel, scissors). ion; stress hyperextension; position with c. Autolytic dressings or enzyme use are other firm (plastic) cervical orthosis. selective mean to help remove eschar. (2) Shoulder: common deformity is adduction and internal rotation; stress abduction, flex- 2. Rehabilitation: prevent or reduce the complica- ion, and external rotation; position with an tions of immobilization. axillary splint (airplane splint). a. Exerci e to promote deep breathing and chest (3) Elbow: common deformity is flexion and expansion; ambulation to prevent pneumonia. pronation; stress extension and supination; b. Positioning and splinting to prevent or correct TABLE 5-2 - STANDARD PRECAUTIONS HANDWASHING PATIENT-CARE EQUIPMENT 1. Wash hands after touching blood, body fluids, secretions, excretions, and 1. Handle used patient-care equipment soiled with blood, body fluids, contaminated items, whether or not gloves are worn. secretions, and excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of 2. Wash hands immediately after removing gloves, between patient con- microorganisms to other patients or environments. tacts, and when otherwise indicated to reduce transmission of microor- ganisms. 2. Ensure that reusable equipment is not used for the care of another patient until it has been cleaned and reprocessed appropriately. 3. Wash hands between tasks and procedures on the same patient to prevent cross-contamination of different body sites. 3. Ensure that single-use items are discarded properly. 4. Use plain (nonantimicrobial) soap for routine handwashing. ENVIRONMENTAL CONTROL 5. An antimicrobial agent or a waterless antiseptic agent may be used for 1. Follow hospital procedures for the routine care, cleaning, and disinfec- specific circumstances (hyperendemic infections) as defined by Infection tion of environmental surfaces, beds, bedrails, bedside equipment, and Control. other frequently touched surfaces. GLOVES LINEN 1. Wear gloves (clean, unsterile gloves are adequate) when touching blood, 1. Handle, transport, and process used linen soiled with blood, body fluids, body fluids, secretions, excretions, and contaminated items; put on clean secretions, and excretions in a manner that prevents skin and mucous gloves just before touching mucous membranes and nonintact skin. membrane exposures and contamination of clothing, and avoids transfer of microorganisms to other patients or environments. 2. Change gloves between tasks and procedures on the same patient after contact with materials that may contain high concentrations of microor- OCCUPATIONAL HEALTH AND BLOODBORNE PATHOGENS ganisms. 1. Prevent injuries when using needles, scalpels, and other sharp instru- 3. Remove gloves promptly after use, before touching uncontaminated items ments or devices; when handling sharp instruments after procedures; and environmental surfaces, and before going on to another patient; when cleaning used instruments; and when disposing of used needles. wash hands immediately after glove removal to avoid transfer of microorganisms to other patients or environments. 2. Never recap used needles, or otherwise manipulate them using both hands, or use any other technique that involves directing the point of a MASK AND EYE PROTECTION OR FACE SHiElD needle toward any part of the body; rather, use either a one-handed \"scoop\" technique or a mechanical device designed for holding the nee- 1. Wear a mask and eye protection or a face shield to protect mucous dle sheath. membranes of the eyes, nose, and mouth during procedures and patient-care activities that are likely to generate splashes or sprays of 3. Do not remove used needles from disposable syringes by hand, and do blood, body flUids, secretions, and excretions. not bend, break, or otherwise manipulate used needles by hand. GOWN 4. Place used disposable syringes and needles, scalpel blades, or other sharp items in appropriate puncture-resistant container for transport to 1. Wear a gown (a clean, unsterile gown is adequate) to protect skin and the reprocessing area. prevent soiling of clothing during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, 5. Use mouthpieces, resuscitation bags, or other ventilation devices as an secretions, and excretions. alternative to mouth-to-mouth resuscitation. 2. Select a gown that is appropriate for the activity and the amount of fluid PATIENT PLACEMENT likely to be encountered. 1. Use a private room for a patient who contaminates the environment or 3. Remove a soiled gown as soon as possible and wash hands to avoid who does not (or cannot be expected to) assist in maintaining appropri- transfer of microorganisms to other patients or environments. ate hygiene or environmental control. 2. Consult Infection Control if a private room is not available. From Centers for Disease Control, Hospital Infection Control Practices Advisory Committee. Part II Recommendations for Isolation Precautions in Hospitals. February 1997.

196 position in extension with posterior arm (2) Post-grafting: discontinue exercise for 3-5 splint. days to allow grafts to heal. (4) Hand: common deforrrtity is a claw hand (intrinsic minus position); stress wrist e. Massage to help reduce scar formation, e.g., extension (15°), MP flexion (70°), PIP and deep friction massage. DIP extension, thumb abduction (intrinsic plus position); position in intrinsic plus f. Resistive and strengthening exercises to correct position with resting hand splint. loss of muscle mass and strength. (5) Hip: common deforrrUty is flexion and adduction; stress hip extension and abduc- g. Increase activity tolerance and cardiovascular tion; position in extension, abduction, neu- endurance, e.g., ambulation. tral rotation. (6) Knee: common deforrrtity is flexion; stress h. Promote independence in activities of daily liv- extension; position in extension with poste- ing, all functional mobility skills. rior knee splint. (7) Ankle: common deforrrtity is plantarflex- i. Elastic supports to help control edema; pres- ion; stress dorsiflexion; position with foot- sure garments to help prevent hypertrophic ankle in neutral with splint or plastic ankle- scarring or keloid formation. foot orthosis. c. Edema control: elevation of extremities, active j. Management of chronic pain. ROM. 3. Provide emotional support. d. Active and passive exercise to promote full range of motion. VI. Wounds (1) Combine with dressing changes, hydrotherapy; medication doses. A. Venous Ulcer (Table 5-4). 1. Etiology: associated with chronic venous insuffi- ciency; valvular incompetence history of DVT, venous hypertension. 2. Location: can occur anywhere in lower leg; common over area of medial malleolus, sometimes lateral. 3. Clinical features. a. Pulses: normal. TABLE 5·3 • TRANSMISSION-BASED PRECAUTIONS AIRBORNE PRECAUTIONS CONTACT PRECAUTIONS In addition to Standard Precautions, use Airborne Precautions, or the In addition to Standard Precautions, use Contact Precautions, or the equivalent, for patients known or suspected to be infected with serious equivalent, for specified patients known or suspected to be infected or illness transmitted by airborne droplet nuclei (small-particle residue) that colonized with serious illness transmitted by direct patient contact (hand remain suspended in the air and that can be dispersed widely by air cur- or skin-to-skin contact) or contact with items in patient environment. rents within a room or over a long distance (for example, Mycobacterium tuberculosis, measles virus, chickenpox virus). 1. Isolation room. 1. Respiratory isolation room. 2. Wear gloves when entering room; change gloves after having contact with infective material; remove gloves before leaVing patient's room; wash 2. Wear respiratory protection (mask) when entering room. hands immediately with an antimicrobial agent or waterless antiseptic agent. After glove removal and handwashing, ensure that hands do not 3. Limit movement and transport of patient to essential purposes only. Mask touch contaminated environmental items. patient when transporting out of area. 3. Wear a gown when entering room if you anticipate your clothing will DROPLET PRECAUTIONS have substantial contact with the patient, environmental surfaces, or items in the patient's room, or if the patient is incontinent or has diarrhea, In addition to Standard Precautions, use Droplet Precautions, or the ileostomy, colostomy, or wound drainage not contained by dressing. equivalent, for patients known or suspected to be infected with serious Remove gown before leaving patient's room; after gown removal, ensure illness microorganisms transmitted by large particle droplets that can be that clothing does not contact potentially contaminated environmental generated by the patient during coughing, sneezing, talking, or the perform- surfaces. ance of procedures (for example, mumps, rubella, pertussis, influenza). 4. Single-patient-use equipment. 1. Isolation room. 5. Limit movement and transport of patient to essential purposes only. Use 2. Wear respiratory protection (mask) when entering room. precautions when transporting patient to minimize risk of transmission of microorganisms to other patients and contamination of environmental 3. Limit movement and transport of patient to essential purposes only. surfaces or equipment. Mask patient when transporting out of area. From Centers for Disease Control, Hospital Infection Control Practices Advisory Committee. Part II Recommendations for Isolation Precautions in Hospitals. February 1997.

Integumentary Physical Therapy 197 b. Pain: none to aching pain in dependent position. ulcer can develop. c. Color: normal or cyanotic in dependent posi- e. Diabetic Ulcer tion. Dark pigmentation may appear, liposcle- rosis (thick, tender, indurated, fibrosed tissue). 1. Etiology: diabetes, associated with arterial disease d. Temperature: normal. and peripheral neuropathy; caused by repetitive e. Edema: present, often marked. trauma on insensitive skin. f. Skin changes: pigmentation, stasis dermatitis may be pre ent; thickening of skin as scarring 2. Location: occurs where arterial ulcers usually develops. appear; or where peripheral neuropathy appears g. Ulceration: may develop, especially medial (plantar aspect of foot). ankle; wet, with large amount of exudate. h. Gangrene: absent. 3. Clinical features. 4. Staging for venous, arterial, and diabetic ulcers a. Pain: typically not painful; sensory loss usually uses partial- and full-thickness classifications. present. B. Arterial Ulcer b. Pulses: may be present or diminished. I. Etiology: associated with chronic arterial insuffi- c. Absent ankle jerks with neuropathy. ciency; arteriosclerosis obliterans; atheroem- d. Sepsis common; gangrene may develop. bolism; hi tory of minor non-healing trauma. 2. Location: can occur anywhere in lower leg; com- D. Pressure Ulcer (decubitus ulcer, bedsore) mon in mall toes, feet, on bony areas of trauma 1. Etiology: lesions caused by unrelieved pressure ( hin). resulting in ischemic hypoxia and damage to 3. Clinical features. underlying tissue. a. Preceded by signs of arterial insufficiency; 2. Contributory factors: prolonged pressure, shear pulses poor or absent. forces, friction, repetitive stress, nutritional defi- b. Pain: often severe, intermittent claudication, ciency, and maceration (softening associated with progressing to pain at rest. excessive moisture). c. Color: pale on elevation; dusky rubor on 3. Risk factors. dependency. a. Elderly, debilitated, or immobilized individuals. d. Temperature: cool. b. Decrease blood flow from hypotension or e. Skin changes: trophic changes (thin, shiny, microvascular disease: diabetes, atherosclerosis. atrophic skin); loss of hair on foot and toes; c. Neurologically impaired skin: decreased sensa- nails thickened. tion. f. Ulceration: of toes or feet; can be deep. d. Cognitive impairment. g. Gangrene: black gangrenous skin adjacent to 4. Clinical features. a. Location: occurs over bony prominences, i.e., sacrum, heels, trochanter, lateral malleoli, ischial areas, elbows. b. Color: red, browniblack, or yellow. TABLE 5-4 . DIFFERENTIAL DIAGNOSIS:ARTERIAL VERSUS VENOUS ULCERS ULCERS ARTERIAL VENOUS Etiology Arteriosclerosis obliterans Valvular incompetance Artheroembolism Venous hypertension Appearance Irregular, smooth edges Irregular: dark pigmentation, sometimes fibrotic Min. to no granulation Good granulation Location Usually deep Usually shallow Distal lower leg: toes, feet Distal lower leg Pedal Pulses Lat. malleolus Med. malleolus Pain Ant. tibial area Drainage Decreased or absent Usually present Associated Gangrene Painful, especially if legs elevated Little pain, comfortable with legs elevated Associated Signs Moderate to large amounts of exudate May be present Absent Trophic changes Edema Pallor on foot elevation Stasis dermatitis Dusky rubor on dependency Possible cyanosis on dependency

198 c. Localized infection. (1) Type: serous (watery-like serum), purulent d. Pain: can be painful if sensation intact. (containing pus), sanguinous (containing e. Inflammatory reponse with necrotic tissue: blood). hyperemeia, fever, increased WBC. (2) Amount: dry, moderate, or high exudate. f. If left untreated, will progress from superficial (3) Odor. (4) Consistency: e.g., macerated ulcer (softened simple erosion to involvement of deep layers of skin and underlying muscle and bone. tissues, due to high fluid environment). 5. Graded by stages of severity (tissue damage). e. Identify color and tissues involved. (Table 5-5). E. Examination of Wounds (1) Clean red wounds: healthy granulating 1. Complete history, risk factor assessment. wounds (in need of protection); absence of 2. Physical examination. necrotic tissue. a. Determine location of wound: use anatomic landmarks. (2) Yellow wounds: include slough (necrotic or b. Assess size: (length, width, depth, wound area). dead tissue), fibrous tissue. (1) Use clear film grid superimposed on wound (3) Black wounds: covered with eschar (dried for size. necrotic tissue). (2) Insert sterile cotton tip applicator into (4) Indolent ulcer: ulcer that is slow to heal; is deepest part of wound for depth; indicate not painful. gradations of depth from shallow to deep. c. Examine for tunneling (rimming or undermin- (5) Check to see if fascia, muscle, tendons, or ing): underlying tissue destruction beneath bone involved. intact skin. (1) Evaluate for sinus tracts (communication f. Determine temperature: indicative of inflam- with deeper structures); associated with mation. Use temperature probe (thermistor) to unusual or irregular borders. detect surface temperature. (2) Sinogram (radiographic imaging studies). d. Determine wound exudate (drainage). g. Determine girth. (1) Use circumferential measurements of both TABLE 5-5 - STAGING OF PRESSURE ULCERS involved and non-involved limbs; refer- enced to bony landmarks. STAGE CHARACTERISTICS (2) Use volumetric measurements: measure water displacement from filled volumeter. Stage I Nonblanchable erythema of intact skin. May include changes in: skin temperature (warm or h. Examine viability of periwound tissue. cool); tissue consistency (firm or boggy). and/or (1) Halo of erythema, warmth, swelling may sensation (pain, itching). indicate infection (cellulitis). (2) Maceration of surrounding tissues due to Stage II Partial-thickness skin loss: involves epidermis, moisture (urine, feces) or wound drainage dermis, or both. Ulcer is superficial. Presents increases risk for wound deterioration and clinically as an abrasion, blister, or shallow crater. enlargement. (3) Trophic changes may indicate poor arterial Stage III Full-thickness skin loss: involves damage to or nutrition. necrosis of subcutaneous tissue. May extend (4) Cyanosis may indicate arterial insufficiency. down to, but not through, underlying fascia. Presents clinically as a deep crater. i. Determine sensory integrity, risk for trauma or pressure breakdown. Stage IV Full-thickness skin loss: involves extensive destruction, tissue necrosis, or damage to muscle, J. Examine for signs of infection. bone, or supporting structures. Undermining (1) Bacterial culture: is to identify colonization and sinus tracts may be present. and infection; culture wound site only. (2) Observations, palpation. Consortium for Spinal Cord Medicine: Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury, Paralyzed Veterans of k. Wound scar tissue characteristics: banding, pli- America,August 2000, with permission. ability, texture. 1. Photographic records of wound appearance aid narrative descriptions. Use marker pen to out- line wound edges on transparent dressing with a calibrated grid to provide a measuring scale.

Integumentary Physical Therapy 199 F. Wound Care (3) Topical anesthetics and analgesics: e.g., 1. Infection control. lidocaine, lignocaine, etc. a. Wounds are cultured; antibiotic treatment regi- men prescribed. b. Hand washing of health care practitioners. (1) Topical antimicrobial agents: e.g., silver c. Sterile technique. nitrate, silver sulfadiazine, erythromycin, d. Vacuum-assisted closure (VAC). gentamycin, neomycin, triple antibiotic, etc. (2) Anti-inflammatory agents: e.g., corticosteroids, (1) An open-cell foam dressing placed into the hydrocotisone, ibuprofen, indomethacin, etc. wound. (2) Controlled subatmospheric pressure (typi- cally 125 mm Hg below ambient pressure) TABLE 5-6 - METHODS OF PRESSURE ULCER DEBRIDEMENT METHOD DEFINITION INDICATIONS CONTRAINDICATIONS Autolytic A selective method of natural debridement • Individuals on anticoagulant therapy • Infected wounds promoted under occlusive or semiocclusive • Individuals who cannot tolerate • Wounds of immunosupressed moisture-retentive dressings that results in solubilization of necrotic tissue only by other forms of debridement individuals phagocytic cells and by proteolytic and • All necrotic wounds in people who • Dry gangrene or dry ischemic collagenolytic enzymes inherent in the tissues. are medically stable wounds Enzymatic A selective method of chemical debridement • All moist necrotic wounds • Ischemic wounds unless that promotes Iiquefication of necrotic tissue • Eschar after cross-hatching adequate vascular status has by applying topical preparations of proteolytic • Homebound individuals been determined or collagenolytic enzymes to those tissues. • People who cannot tolerate surgical Proteolytic enzymes help loosen and remove • Dry gangrene slough or eschar while collagenolytic enzymes debridement • Clean, granulated wounds digest denatured collagen in necrotic tissue. Mechanical A nonselective method of debridement that • Wounds with moist necrotic tissue • Clean, granulated wounds not only removes foreign material and devitalized or foreign material present or contaminated tissue by physical forces (wet- to-dry gauze dressing, dexlranomers, pulsatile lavage with suction or Whirlpool), but may also remove healthy tissue as well. Sharp A selective method of debridement using sterile • Scoring and/or excision of leathery • Clean wounds instruments ( scalpel, scissors, forceps, silver eschar • Advancing cellulitis with sepsis nitrate stick) that sequentially removes only • When infection threatens the necrotic wound tissue without anesthesia and • Excision of moist necrotic tissue with little or no bleeding induced in viable tissue. individual's life • Individual on anticoagulant therapy or has coagulopathy Surgical The most efficient method of debridement. It • Advancing cellulitus with sepsis • Cardiac disease, pulmonary is nonselective and is performed by a physician • Immunocompromised individuals disease, or diabetes or surgeon using sterile instruments (scalpel, • When infection threatens the scissors, forceps, hemostat, silver nitrate • Severe spasticity sticks) in a one-time operative procedure. The individuals life • Individuals who cannot tolerate procedure usually removes most, if not all, • Clean wounds as a preliminary necrotic tissue, but may also remove some surgery healthy tissue in what is termed wide excision. procedure to surgical wound • Individuals who have a short Because there may be associated pain and/or closure line. bleeding, the individual may require anesthesia, • Granulation and scar tissue life expectancy and the procedure will likely require an may be excised • Quality of life cannot be operating or special procedures room. improved From Consortium for Spinal Cord Medicine: Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury. Paralyzed Veterans of America. August 2000. with permission.

200 (c) Discontinue whirlpool when ulcer is clean. is applied via specialized device. (3) Helps to control chronic edema, increases e. Do not use harsh soaps, alcohol-based prod- ucts, or harsh antiseptic agents; may erode localized blood flow, and removes infec- skin. tious material. 2. Surgical intervention. 5. Wound debridement: removal of necrotic or infected a. Indicated for excising of ulcer, enhancing vas- tissue that interferes with wound healing. (Table 5-6). cularity and resurfacing wound (grafts), and a. Allows examination of ulcer, determination of preventing sepsis and osteomyelitis. extent of wound. b. May be indicated for stages III and IV ulcers. b. Decreases bacterial concentration in wound; 3. Hyperbaric oxygen therapy (HBO). improves wound healing. a. Patient breathes 100% oxygen in a sealed, full c. Decreases spread of infection, i.e., cellulitis or body chamber with elevated atmospheric pres- sepsis. sure (between 2.0 and 2.5 atmospheres absolute, ATA). 6. Wound dressings: topical products that protect the b. Hyperoxygenation reverses tissue hypoxia and wound from contamination and trauma; permit facilitates wound healing due to enhanced sol- application of medications; absorb drainage; ubility of oxygen in the blood. debride necrotic tissue; and enhance healing. c. Contraindicated in untreated pneumothorax (Table 5-7) - Characteristics of Some Major and some antineoplastic medications (e.g., Dressing Categories. Doxorubicin, DisulfIram, Cisplatin, Mafenide a. Moisture-retentive (occlusive) wound dress- acetate). ings: maintain a moist environment; wound tis- 4. Wound cleansing: removal of loose cellular debris, sue fluid is maintained in contact with tissues metabolic wastes, bacteria and topical agents that and cells; facilitates autolytic debridement, retard wound healing. wound healing (reepithelialization) with less a. Cleanse wounds initially and at each dressing pain. change. (1) Alginate dressings: e.g., Sorbsan, Kaltostat. b. Normal saline (0.9% NaCl) recommended for (2) Transparent fIlm dressings: e.g., Bioclusive, most ulcers; non-toxic effects in wound. OpSite. c. Cleansing topical agents: contain surfactants that (3) Foam dressings: e.g., LYOfoam, Flexzan. lower surface tension. Limited use, may be toxic (4) Hydrogel dressings: e.g., Second Skin, to healing tissues, e.g., povidone-iodine solution, Clearsite. sodium hypocWorite solution, Dakin's solution, (5) Hydrocolloid dressings: e.g., DuoDerm, acetic acid solution, hydrogen peroxide. Curaderm. d. Delivery systems. b. Gauze dressings. (1) Minimal mechanical force: cleansing with (1) Standard gauze (not impregnated). gauze, cloth or sponge. (2) Impregnated gauze: e.g., Telfa pad, Vaseline (2) Irrigation. Petroleum Gauze. (a) Using syringe, squeezable bottle with c. Semirigid dressings: Unna boot is a pliable, nonstretchable dressing impregnated with oint- tip or battery-powered irrigation ments; e.g., zinc oxide, calamine, and gelatin. device (pulsatile lavage); loosens wound debris and removes it by suction. 7. Edema management. (b) Safe and effective irrigation pressures a. Leg elevation and exercise (ankle pumps). range from 4 to 15 psi. b. Compression therapy: to facilitate movement (3) Hydrotherapy (i.e., whirlpool). of excess fluid from lower extremity. (a) Indicated for ulcers with large (1) Compression wraps: elastic or tubular amounts of exudate, slough, and bandages. necrotic tissue. (2) Paste bandages, e.g., Unna boot. (b) Increases circulation; assists in (3) Compression stockings, e.g., Jobst. debridement of wounds or removal of (4) Compression pump therapy. dressings. 8. Electrical stimulation for wound healing (see

chapter 10). Integumentary Physical Therapy 201 a. Uses capacitive coupled electrical current to (3) Dynamic devices: use if patient cannot transfer energy to a wound, improve circulation, assume a variety of positions; examples facilitate debridement, enhance tissue repair. include alternating pressure air mattresses, b. Continuous waveform application with direct fluidized air or high-air-loss bed. current. c. High-voltage pulsed current (HVPC). (4) Seating supports: use for chair-bound or d. Microcurrent electrical stimulation (MENS). wheelchair-bound patients; examples e. Alternating/Biphasic current. include cushions made out of foam, gel, air, 9. Nutritional considerations. or some combination. a. Delayed wound healing associated with malnu- trition and poor hydration. e. Avoid restrictive clothing, clothing with rough b. Provide adequate hydration: eight 8-oz glasses textures, hard fasteners, studs, etc. Avoid tight- of noncaffeine fluids per day unless contraindi- fitting shoes, socks, splints, orthoses. cated. c. Provide adequate nutrition: frequent high calo- f. Avoid maceration injury. rie/high-protein meals; energy intake (25 to 35 (1) Prevent moisture accumulation and tem- kcal/kg/body weight) and protein (1.5 to 2.5 perature elevation where skin contacts sup- gm/kg body weight). port surface. d. Patients with trauma stress and burns require (2) Incontinence management strategies: use higher intake . of absorbent pads, brief or panty pad; 10. Injury prevention or reduction. scheduled toileting and prompted voiding; a. Daily, comprehensive skin inspection, paying ointments, creams, and skin barriers pro- particular attention to bony prominences (e.g., phylactically in perineal and perianal areas. sacrum, coccyx, trochanter, ischial tuberosities, medial or lateral malleolus). g. Patient and caregiver education. b. Therapeutic positioning to relieve pressure and (1) Mechanisms of pressure ulcer development. allow tissue reperfusion. (2) Daily skin inspection. (1) In bed: turning or repositioning schedule (3) Avoidance of prolonged positions. (4) Repositioning, weight shifts, lifts. every 2 hours during acute and rehabilita- (5) Safety awareness during self-care. tion phases. (6) Safety awareness with use of devices and (2) In wheelchair: wheelchair push-ups every equipment. 15 minutes. (7) Importance of ongoing activity/exercise c. U e techniques to ensure skin protection, avoid program. friction, shear or abrasion injury. (1) Lifting, not dragging. (2) Use of turning and draw sheets; trapeze, manual or electric lifts. (3) Use of cornstarch, lubricants, pad protec- tors, thin film dressings, or hydocolloid dressings over friction risk sites. (4) Use of transfer boards for sliding wheel- chair transfers. d. Pressure-relieving devices (PRDs). (1) Reduce tissue interface pressures. (2) Static devices: use if patient can assume a variety of positions; examples include foam, air, or gel mattress overlays; water- filled mattresses; pillows or foam wedges, protective padding (heel relief boots)