Cardiorespiratory Physio

Introduction

One of the areas in which physiotherapists focus their services on is in the intensive care unit. In the Intensive Care Unit (ICU)/Intensive Therapy Unit (ITU) or High Dependency Unit (HDU), Physiotherapists focus much on cardiopulmonary/ cardiorespiratory parameters. Physiotehrapy interventions focusing on the cardiac/circulatory and pulmonary/breathing/respiratory parameters are generally called chest physiotherapy by the healthare pofessionals.

Definition of Cardiopulmonary/Cardiorespiratory Physiotherapy

Cardiopulmonary physiotherapy is an essential noninvasive medical intervention that prevents, reverses or mitigates insults to oxygen transport. It can avoid, delay or reduce the need for medical interventions such as supplemental oxygen mechanical ventilation, suctioning, bronchoscopy, chest tubes, surgery and medications.

Impact of Cardiopulmonary Physiotherapy:

  • Reduces morbidity
  • Reduces mortality
  • Improves function
  • Improves quality of life

Factors affecting oxygen transportation

To treat patients effectively, one must understand factors which affect oxygen transportation in the body. The following list is a broad category:

  • A disease process behind impared oxygen transporation (underlying pathology) such as an acute or chronic illness.
  • Immobility (restricted mobility and recumbency). This eliminates gravitational stimulation of the cardiopulmonary function.
  • External factors related to patient care
  • Internal factors related to the patient

Factors that may lead to oxygen transportation deficits and threats:

  • Problems with central control of breathing
  • Airway problems
  • Lung issues
  • Blood issues
  • Gas exchange issues
  • Respiratory muscle issues
  • Myocardial perfusion issues
  • Issues with the heart
  • Problems with tissue perfusion
  • Fluid volume excess
  • Fluid deficit excess
  • Tissue oxygenation issues

Physiotherapy intervention in cardiopulmonary problems

Scientifically it is proven that the human cardiopulmonary system work best when the body is upright and moving. This means that the most important interventions are ambulation and exercise. It is better to ambulate the patient if they can manage than to apply manual techniques and suctioning. Optimal treatment outcome requires selection, prioritization and application of those interventions with the greatest benefit-to-risk ratios. To effectivel manage patients, one must follow the hierarchy of treatment interventions. The following list is a hierarchy of physiotherapy treatment options, from the most effective to the least:

  • Mobilization(low-intensity exercise for typically acutely ill patients or those with severely compromised functional work capacity) and exercise: to elicit an exercise stimulus that addresses one of the three effects on the various steps in the oxygen transport pathway, or some combination.
    • Acute effects, e.g., increased alveolar ventilation, mucociliary transport and airway clearance
    • Long-term effects, i.e., enhanced oxygen transport efficiency at all steps in the pathway
    • Preventive effects, i.e., to counter negative effects of restricted mobility
    Mobilization augments ventilatuion/perfusion(V/Q) matching via distension and recruitment of lung zones with low ventilation and low perfusion.
  • Positioning:
    • improves oxygen transportation in acute cardiopulmonary dysfunction
    • improves oxygen transport in the post acute and chronic stages of cardiopulmonary dysfunction
    • prevent the negative effects of restricted mobility, particularly those that adversely dysfunction
  • Breathing control maneuvers: To augment alveolar ventilation, facilitate mucociliary transport, and stimulate coughing

    • These are coordinated with movement and body positioning to maximize alveolar ventilation, facilitate mucociliary transport and airway clearance, and stimulates coughing.
    • Pursed lip breathing facilitates increase in end-expiratory pressure and improve air flow limitation. Improves intrapulmonary gas mixing and gas exchange This reduces respiratory flow-rates, maintains airway patency and minimizes dynamic compression
    • Autogenic breathing maneuvers clear secretions from small to large airways with a cough at the end to clear secretions
    • Glossopharyngeal breathing
      • patients with high spinal cord lesion (injury) and conditions affecting nerves and muscles
      • can provide minimal support for patients who have been temporarily removed from ventilator
      • can sustain breathing for hours

      While prescribing breathing control maneuvers, the following should be given attention:

    • Starting position
    • Type of breathing control maneuvers
    • Depth of breathing
    • Rate of breathing
    • Duration of breathing
    • Frequency of breathing control sessions
    • Course and progression
  • Coughing maneuvers: To facilitate mucociliary clearance with the least effect on dynamic airway compression and adverse cardiovascular effects. The cough can be active and spontaneous cough with closed glottis, assisted cough by a therapist or by the patient herself and modified coughing interventions with open glottis, such as forced expiration, huffing.
  • Relaxation and energy conseravtion interventions: To minimize the work of breathing, of the heat, and undue oxygen demand overall
  • Range of motion exercises: To stimulate alveolar ventilation and alter its distribution
  • Postural drainage: To facilitate airway clearance using gravitational effects
  • Manual techniques: To facilitate airway clearance in conjunction with specific body positioning
  • Suctioning: To facilitate the removal of airway secretions collected centrally
  • Use of modalities and aids: To incorporate the use of those modalities and aids that enhance the preceding interventions Treadmill, ergometer, chair and bed pedals, treadmill, rowing machine

Prescription of cardiopulmonary intervention

Cardiopulmonary physiotherapy treatment prescription depends on the underlying cause of the cardiopulmonary problem. There are some parameters that must be considered while prescribing treatment to cardiopulmonary patients. The parameters include:
  • Type of mobilization and exercise
  • Intensity
  • Duration
  • Frequency
  • Course and progression

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References:

  1. Tecklin, Stephan Jan (2004) Cardiopulmonary Physical Therapy. 4th Edition. Mosby, USA
  2. Pryor, Jennifer A & Webber, Barbara, A (2001) Physiotherapy For Cardiac and Respiratory Problems. 2nd Edition. Harcourt Publishers Limited. Edinburgh, UK
  3. Hough, A (2001) Physiotherapy in Respiratory Care: A Problem-Solving Approach to Respiratory and Cardiac Management. 3rd Edition.Nelson Thornes. Cheltenham, UK
  4. Dean, E & Frownfelter, D (1996). Cardiopulmonary Physical Therapy. 3rd Edition. Mosby, St. Louis, Missouri, USA
  5. Reid, Darlene, W & Chung, F (2004).Clinical Management Notes and Case Histories in Cardiopulmonary Physical Therapy. 3rd Edition. SLACK, USA



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