Cardio Alexandra Hough 2nd Edition
Cardio Alexandra Hough 2nd Edition
Cardio Alexandra Hough 2nd Edition
Respiratory Care
For Roger
Physiotherapy in
Respiratory Care
A problem-solving approach to
respiratory and cardiac management
Second edition
ALEXANDRA HOUGH
Freelance lecturer, Senior Physiotherapist, Whittington Hospital, London,
former Senior Lecturer, North London School of Physiotherapy
Preface ix
Acknowledgements ix
Acknowledgements
Profound thanks to the patients who have taught me much over the years. I
am also indebted to Veronica Bastow for her perceptive insights, Clare Pain
for her wisdom, John Widdicombe for his meticulous scrutiny of the
physiology and Mel CaIman for his cartoons.
Heartfelt thanks also to Alison Brown, Fiona Bryden, Joy Conway, Diana
Davis, Stephanie Enright, Nicky Harvey, Bernadette Henderson, Avril
Imison, Sue Pirrie, Marylin Place, Carolyn Roskell, Irene Rowbottom and
Judith Sweeney, for their specialist advice.
And to the students with whom it has been my privilege to work and learn,
thank you.
Royalties from this publication to be donated to
the Campaign Against the Arms Trade.
1. Overview of physiology in relation
to clinical practice
Introduction Arterial blood gases
Defence introduction
nose oxygen dissociation curve
pharynx hypoxia and hypoxaemia
bronchoconstriction acid base balance
mucociliary escalator Oxygen delivery, consumption and
cough extraction
other lung defences Effect of ageing
Control clinical implications
Mechanics Effect of obesity
the respiratory musCles clinical implications
pressures Effect of smoking
resistance clinical implications
compliance Effect of exercise
work of breathing clinical implications
inspiratory muscle weakness and Effect of bed rest
fatigue clinical implications
Ventilation Effect of sleep
Diffusion clinical implications
Perfusion Recommended reading
Ventilation/perfusion relationships
• closure of the glottis and trapping of air in particles circumvent these and other defences
the lungs at powerful positive pressures of because of their peculiar shape.
up to 300 mmHg, narrowing the trachea Soluble particles enter the bloodstream and
and main bronchi by 60% (Rees 1987). are thereby cleared from the lungs, along
• sudden opening of the glottis, causing air with other unsavoury substances picked up
to explode outwards at up to 70 mph by venous blood from peripheral vascular
(Brannon et al1993), thus shearing secre- beds. The entire blood volume passes
tions off the airway walls. through the lungs, which detoxify foreign
substances, perform a range of metabolic
Coughing is accompanied by violent functions and act as a filter to protect the
swings in intrapleural pressure and blood arterial system, particularly the vulnerable
pressure (BP), which cause long segments of coronary and cerebral circulations, from
airway to collapse. For most people, the unwanted chemicals.
airways re-open with a subsequent deep
breath, but for those unable to take a deep
breath, they stay closed for lengthy periods 1.3 CONTROL
(Nunn et al1965). Despite high pressures, the Breathing is normally controlled with such
lung is protected from overdistension and exquisite sensitivity that oxygen and CO2 in
barotrauma by muscle action to buttress the the blood are maintained within precise
chest wall. limits despite unpredictable inputs. Clusters
The beneficial effects of coughing are to of neurones in the pons and medulla receive
expel sputum and inhaled irritants from large and integrate a multitude of stimuli from the
airways as far as the 10th generation (Pavia rib cage, lungs, chemoreceptors, metabolic
1991). Beyond this, airflow cannot attain and other systems, then discharge impulses
sufficient speed to expel secretions. Adverse to the respiratory muscles. Exercise and
effects, such as bronchospasm and exhaus- postural change are two of the disturbances
tion, may follow sustained bouts of cough- that are perceived by the respiratory centre,
ing. The cough mechanism is inefficient in with immediate responses. Respiratory
people with obstructive airways disease control occurs at a subconscious level, but
because they have poor expiratory flow rates can be overridden by reflexes or voluntary
and airways that collapse on expiration. action, such as speech, laughter, emotion,
Coughing may fail in the presence of coma, pain, sudden cold, some pathological states
neuromuscular disease or postoperative and breathing exercises.
pain. It is weakened if the glottis is bypassed
by intubation or tracheostomy.
1.4 MECHANICS
Pharynx
stimulate surfactant production and help
Rapid
turbulent maintain compliance .
Bronchioles
•
Bronchi
flow
Slow
Conditions of low compliance include
bronchospasm, stiff lungs, a stiff chest wall,
laminar low lung volume and disorders of surfactant
~ production, such as the neonatal and adult
Alveoli-====:::::::::!-:....:....~~:....:....--:..~....c:::=f==IO=W=
7 respiratory distress syndromes.
Gas exchange surface Static compliance is measured during a
of 300 million alveoli
breath-hold so that equilibrium is achieved
Figure 1.2 Increase in total cross-sectional area of between alveolar pressure and mouth
airways as they subdivide. pressure, alveoli being filled to a volume
determined by their regional compliance.
1.4.3 Resistance Dynamic compliance is measured during
breathing and normally approximates static
Resistance is present whenever there is air- compliance, but may be less in diseased
flow through a vessel because gas slides lungs if regional variations in compliance and
against the vessel walls and over itself. resistance mean that alveolar filling is not
Airflow resistance depends mainly on the completed within the inspiratory period.
calibre of the airway; The site of greatest
airflow resistance is the upper respiratory
tract, where total cross-section is narrowest 6
and airflow most turbulent (Fig. 1.2). The
nasal route resists airflow more than the oral
route, which is why we breathe through the Lung
mouth when breathless or exercising. volume 3
(Iitres)
1.4.4 Compliance
Compliance = change in volume o
change in distending pressure
o 2
Compliance is the ease with which the lung Inflating pressure (em H2 0)
inflates. It is represented by the relationship
Figure 1.3 Pressure-volume curve describing
between pressure and volume, which is lung compliance, showing how more pressure is
curved rather than linear (Fig. 1.3). The lung needed to increase lung volume at either extreme
is least compliant, i.e. stiffest, at either of inflation. Examples are atelectasis for a low
extreme of lung volume, as is a balloon, so it volume state and emphysema for hyperinflation.
is difficult to inflate alveoli that are closed or
hyperinflate those that are fully open.
Compliance is related partly to tissue elasti- 1.4.5 Work of breathing
city but mostly to surfactant in alveolar fluid.
Work is done during inspiration to overcome
This acts like detergent to decrease surface
the resistive, elastic and inertial forces of air-
tension and prevent the alveolar walls stick-
flow, lungs and chest wall. Work of breathing
ing together after being deflated, as happens
(WOB) can be defined in several ways:
when a plastic bag is wet inside. Surfactant
stabilizes the lungs by preventing small • amount of pressure generated to move a
alveoli collapsing and emptying their con- certain volume of gas,
tents into large alveoli. Regular deep breaths • transpulmonary pressure x tidal volume
6 Overview of physiology in relation to clinical practice
• oxygen consumed by the respiratory contractility. The signs of fatigue and weak-
muscles. ness are similar (p. 27), but the distinction is
important because treatment is different.
Normally, breathing is surprisingly
Weakness is failure to generate sufficient
efficient, helped by the slippery fluid which
force in an otherwise fresh muscle, as occurs
lines moving surfaces such as the alveoli and
in neuromuscular disorders, disuse atrophy
pleura. WOB uses 1-4% of total body oxygen
or malnourishment. It is associated with a
consumption at rest, but up to 40% in people
chronic decrease in strength and sometimes a
with chronic obstructive pulmonary disease
chronic increase in PaC02 . It is not reversible
(COPO) during exercise (Pilbeam 1992, p.
by rest, but is treated by addressing the cause
80).
and, if appropriate, encouraging activity.
Deep breathing at double tidal volume can
Fatigue is defined as reduced force gener-
quadruple the elastic WOB (Haas and Axen
ated by a muscle after it has been overloaded.
1991, p. 17), while rapid shallow breathing
It is associated with a relatively abrupt
increases the resistive work, i.e. WOB against
decrease in respiratory muscle strength and
air flow resistance (Nunn 1987, p. 109). Most
sometimes abrupt increase in PaC02 . It is
patients find the right balance, but some need
treated by rest. Loss of tension generation in
assistance to find the optimal breathing
muscle can be due to failure of any of the
pattern to minimize their WOB.
links in the physiological chain. Failure
WOB can be assessed by measuring the
within the central nervous system (CNS) is
oxygen cost of breathing (Tobin and Yang
called central fatigue and failure beyond the
1990), which is the oxygen consumed by the
CNS is called peripheral fatigue.
respiratory muscles.
Fatigue differs from weakness in that even
a normal muscle can become fatigued with
1.4.6 Inspiratory muscle weakness and
sufficient effort. Both fatigue and weakness
fatigue
may occur in respiratory failure or during
Inspiratory muscle fatigue is less common weaning from mechanical ventilation.
than systemic muscle fatigue because the
diaphragm has a large reserve capacity. It 1.5 VENTILATION
differs from other skeletal muscles in its
Breathing (or ventilation) is the act of
automatic function and capacity for a lifetime
moving gas in and out of the lungs, i.e.
of sustained action against elastic and resist-
inspiration and expiration.
ive loads instead of irregular action against
Respiration is (a) the exchange of gases
inertial loads. It is equipped for this by a high
between the environment and tissue
proportion of fatigue-resistant fibres and the
cells (external respiration at alveolar/
unusual way in which perfusion increases
capillary level and internal respiration at
instead of decreases during contraction
capillary/tissue level), and (b) regulation
(Anzueto 1992). But it is thought that fatigue
of acid-base, metabolic and defence func-
may occur if energy demand exceeds supply,
tions of the respiratory system.
as when WOB is increased by severe airways
obstruction. Fatigue serves a protective func- Gas that moves in and out of the lungs is
tion to avoid depletion of enzymes, and made up of alveolar ventilation, which is the
procedures that encourage patients to over- fresh air that gets into the alveoli and
use fatigued muscles can cause damage participates in gas exchange, and dead space
(Goldstone and Moxham 1991). People with ventilation (VD), which does not contribute to
COPO may have inspiratory muscle fatigue gas exchange. Most dead space is made up of
or weakness, both of which impair muscle anatomical dead space (Fig. 1.4), which is air
Diffusion 7
Perfusion Ventilation
gradient gradient
Perfusion Ventilation
gradient gradient
Pressure
from
abdominal
contents
1.8 VENTILATION/PERFUSION
RELATIONSHIPS
It is no good having a well-ventilated alveo-
lus if it is not supplied with blood, nor a well-
Figure 1.6 Lung volumes in the lateral position, perfused alveolus that is not ventilated. Fresh
showing greater volume change, i.e. greater air and blood need to be in the same place at
ventilation, in the lower lung on inspiration. the same time for gas exchange to occur. The
(From Nunn, J.F. (1987) Applied Respiratory
matching of these two essentials is expressed
Physiology, 3rd edn, Butterworth-Heinemann,
Oxford, with permission.)
as the ratio of alveolar ventilation to per-
fusion (VA/Q). Both ventilation and perfusion
increase down the lung, but there is a steeper
functions as a sheet of blood enwrapping
increase in perfusion, so that the VA/Q ratio
the air sacs.
decreases from an overventilated apex to an
2. The pulmonary circulation has only one-
overperfused base.
tenth the resistance of the systemic circula-
When ventilation is reduced, an ingenious
tion, yet it has the unusual ability to
mechanism called hypoxic vasoconstriction
further reduce resistance, in response to a
limits VA/Q mismatch. Hypoxia, e.g. in the
rise in pressure, by increasing the calibre
lung bases, causes local shutdown of vessels
of capillaries and recruiting others that are
and forces blood to flow to better ventilated
closed (West 1994). Such a low pressure
upper regions (upper lobe diversion). This
system is very responsive to gravity, and
becomes counterproductive when lung dis-
there is a steep perfusion gradient from
ease is severe and hypoxia is global, because
top to bottom of the lung (Fig. 1.5). In the
generalized vasoconstriction increases pul-
base of the upright lung, the greater
monary artery pressure.
volume of blood may lead to some airway
closure. In the apex, arterial pressure
1.9 ARTERIAL BLOOD GASES
barely overrides alveolar pressure. The
vulnerable vessels collapse in upper lung P0 2 - partial pressure or tension of oxygen.
regions if this balance is disturbed, as Pa02 - partial pressure of oxygen in
when hypovolaemic shock reduces arterial arterial blood, representing the oxygen
pressure, or mechanical ventilation in- dissolved in plasma (normal: 11-14 kPa
creases alveolar pressure. Perfusion is or 80-100 mmHg).
10 Overview of physiology in relation to clinical practice
Sa02 - extent to which haemoglobin in Pa02 (Hodgkin 1993, p. 66), nor does it
arterial blood is saturated with oxygen, necessarily correlate with airflow obstruction.
representing the capacity of blood to A low PaOz is normal in people who smoke,
carry oxygen (normal: 95-98%). have respiratory disease or are elderly.
Oxygen content - total amount of oxygen Neither oxygen tension nor saturation tell
in blood, i.e. oxygen in both plasma and exactly how much oxygen is being carried in
haemoglobin. blood. The Pa02 describes only the 3% of
PaC02 - partial pressure of COz in arterial oxygen dissolved in plasma. It determines
blood, basis of respiratory acid-base the extent to which haemoglobin (Hb) can be
balance (normal: 4.7-6.0 kPa or saturated with oxygen and reflects the pres-
35-45 mmHg). sure needed to push oxygen from air to blood
HC0 3 - bicarbonate ion concentration, and blood to tissue cells. The SaOz describes
basis of metabolic acid-base balance the 97% of oxygen that is bound to Hb. An
(normal: 22-26 mmolll). anaemic person may have a normal SaOz but
pH - inverse of log of hydrogen ion deliver a subnormal load of oxygen. Only the
concentration, which reflects acid-base oxygen content describes the total amount of
balance and responds to metabolic or oxygen that is carried in the blood, being
respiratory change but cannot differen- related to PaOz, SaOz and Hb, but in practice
tiate between them. Low pH corres- its value is assumed from the PaOz or SaOz.
ponds to acidosis, high pH to alkalosis None of these terms give a measure of
(normal: 7.35-7.45). oxygenation at tissue level.
Hypoxaemia - deficiency of oxygen in
arterial blood, i.e. PaOz < 8 kPa
(60 mmHg), SaOz < 90%. 1.9.2 Oxygen dissociation curve
Hypoxia - deficiency of oxygen at tissue The relationship between SaOz and PaOz is
level, the final common pathway for expressed by the oxygen dissociation curve,
cardiorespiratory pathology (more which represents the normal variation in the
important than hypoxaemia but more amount of oxygen that combines with Hb. Its
difficult to measure). peculiar shape represents the protective
Hypocapnia/hypocarbia - deficiency of mechanisms that function in both health and
COz in arterial blood. disease (Fig. 1.7).
Hypercapnia/hypercarbia - excess COz in
arterial blood. Upper flat portion of the curve
Pulmonary shunt - blood that enters pul-
monary veins and systemic arterial At the plateau of the curve, the combination
system without going through ventilated of oxygen with Hb is favoured by a high POz,
areas of lung. and its stability is not unduly disturbed by
changes in arterial P02 . In health, this
encourages loading of oxygen in the high
1.9.1 Introduction
POz environment of the lung, and discour-
Arterial blood gas measurements give an ages unloading of oxygen before blood
indication of ventilation, gas exchange and reaches the capillary bed. In disease, a drop
acid-base status. Readings are relevant when of Pa02 to 10.7 kPa (80 mmHg) hardly affects
related to previous values, the clinical state of the amount of oxygen in the blood.
the patient and the level of inspired oxygen. Hb cannot be more than fully saturated, so
Resting PaOz does not reflect PaOz during that oxygen therapy is unhelpful for people
exercise, nor predict accurately nocturnal with a high Pa02, and hyperventilation of
Arterial blood gases 11
Pulmonary
embolus
Normal Atelectasis Consolidation
, - - - - - - - - - - . .yr - - - - - - - ' )
Wasted
Shunt or wasted perfusion
ventilation
(t VA/O) (t VA/O)
Figure 1.8 Alveoli and surrounding capillary network, showing
how abnormal ventilation or perfusion can upset VA/Q balance.
of shunted venous blood with oxygenated caused by hypoventilation and that caused
blood is known as venous admixture. Some by other alterations in gas exchange (Gray
degree of shunt is normal due to part of the and Blalock 1991):
bronchial circulation mingling with pulmon-
• hypo- or hyperventilation shows a normal
ary venous drainage. Extra-pulmonary shunt
PA-a0 2,
may also occur, e.g. congenital heart disease
• diffusion defects cause a normal gradient
may cause right-to-Ieft intracardiac shunting
at rest, a decrease on 100% oxygen but
of unoxygenated blood.
an increase on exercise,
Wasted ventilation occurs when a perfu-
sion defect causes an increase in alveolar
• VAIQ abnormalities show an increased
gradient.
dead space, resulting in VAIQ mismatch in
• PA-a02 increases with age.
the other direction (Fig. 1.8). Pulmonary
embolism is an example because fresh gas is
Clinical features
delivered to non-perfused alveoli.
Hypoventilation leads to a fall in Pa02 that Table 1.1 shows how the body responds to
is roughly equivalent to the increase in hypoxia and hypercapnia. The brain is the
PaC02· organ that can least sustain oxygen depriva-
Diffusion abnormalities are rare, the tion, and normally responds to hypoxia by
hypoxaemia caused by disorders such as progressive signs:
pulmonary oedema or fibrosing alveolitis
Pa02 < 7.3 kPa (55 mmHg) memory
being due to VAIQ mismatch more than
defect, impaired judgement,
impaired diffusion.
< 5.3 kPa (40 mmHg) - tissue damage,
Normally, alveolar oxygen tension is
< 4 kPa (30 mrnHg) - unconsdousness,
slightly greater than arterial oxygen tension,
< 2.7 kPa (20 mmHg) - death.
the difference in tension being called the
alveolar-arterial oxygen difference (PA-a02). The circulatory response to acute hypoxia is
This can distinguish between hypoxaemia increased cardiac output and improved blood
Arterial blood gases 13
Table 1.1 Clinical features of hypoxaemia and piratory failure in a patient who has
hypercapnia maintained the ability to ventilate ade-
Hypoxaemia Hypercapnia quately,
• normal Pa02 with ~ PaC02 - hypervent-
Cyanosis Flapping tremor of ilation, e.g. emotion, hyperventilation
hands syndrome, painful arterial puncture.
Tachypnoea Tachypnoea
The three above examples could, in reverse
Tachycardia ~ Tachycardia ~ order, represent a developing asthma attack.
arrhythmiaslbradycardia bradycardia
If we reduce our minute ventilation, PaC02
Peripheral Peripheral vasodilation rises and Pa02 falls, but the reverse is not
vasoconstriction leading to warm hands true. Increased ventilation will blow off
Headache PaC0 2 but Pa02 is maintained because Hb
Restlessness ~ Drowsiness ~ cannot be supersaturated.
confusion ~ coma hallucinations ~ coma
Sweating
1.9.4 Acid-base balance
Body cells and chemical reactions are acutely
sensitive to the acidity or alkalinity of their
flow to the brain, respiratory muscles and environment, and any deviation from the
liver, at the expense of reduced flow to gut, normal slight alkalinity of body fluids is
skin and bone (Kuwahira 1993). Worsening fiercely resisted, at whatever cost, by several
hypoxia leads to arrhythmias. Long-term homeostatic mechanisms. These work to
sufferers compensate by developing poly- dispose of the acids that are continually
cythaemia (p. 53). produced by the body's metabolic processes.
Hypercapnia reflects hypoventilation,
which is due to respiratory depression, Regulation
severe weakness, fatigue or an attempt
to avoid fatigue by reducing ventilation The buffer system acts as a chemical sponge
and inspiratory muscle overload (Green and which neutralizes acids or bases by means of
Moxham 1993). Both hypoxaemia and hyper- reactions that give up or absorb hydrogen
capnia lead to reduced endurance of the ions, all within seconds. The base-buffer
diaphragm (Tobin 1988). equation depends on the dissociation of
carbonic acid in solution, which acts as a sink
for hydrogen ions:
Blood gas patterns
H+ + HCO-3 ~ H 2C03 ~ H 20 + CO2
Pa02 is affected by one or a combination of
The lungs then present an avenue for the
the 'causes of hypoxaemia' mentioned on
escape of CO2 that has been made available
p. 11. PaC02 is affected only by ventilation
by this equation. Hyper- or hypoventilation
because CO2 is freely diffusible and is not
can stabilize the acid-base balance within
altered by iTA/Q changes. PaC02 is therefore
1-15 minutes. The kidneys eliminate acid but
used to assess ventilatory adequacy. Exam-
take several days to normalize pH. When pH
ples of blood gas abnormalities are:
is restored to normal, the acidosis or alkalosis
• ~ Pa02 with t PaC02 - hypercapnic is known as fully compensated.
respiratory failure, e.g. exacerbation of Acid-base balance is affected if the removal
chronic lung disease, of CO2 from the lungs is abnormal (respir-
• ~ Pa02 with ~ PaC02 - hypocapnic res- atory acidosis or alkalosis) or production of
14 Overview of physiology in relation to clinical practice
CO2 from the tissues or elimination else- that pH normalizes. Respiratory and meta-
where is abnormal (metabolic acidosis or bolic factors are often combined, and com-
alkalosis). plex compensations can occur.
Cause, effect and recognition of acid-base
Interpreta tion imbalance are shown in Table 1.2. Examples
are the following:
It is best to look first at pH. Low pH means
acidosis and high pH means alkalosis. Bicar- • pH 7.3, PaC02 6.5 kPa (49 mmHg), HCO-3
bonate and base excess (BE) indicate the 30 mmoVI- compensated respiratory aci-
extent of renal compensation and quantify dosis, since both PaC02 and HCO-3 are
the metabolic component of acid-base distur- increased but pH is low.
bance. High bicarbonate or base excess • pH 7.5, PaC02 4 kPa (30 mmHg), HCO-3
means metabolic alkalosis and low bicarbon- 18 mmoVl - compensated respiratory
ate or 'base excess means metabolic acidosis. alkalosis, since both PaC02 and HCO-3
If pH and PaC02 change in opposite are decreased but pH is high.
directions, it is usually a respiratory problem. • pH 7.48, PaC02 6.1 kPa (46 mmHg),
A change in pH due to respiratory or HCO-3 30 mmoVl - compensated meta-
metabolic disturbance is usually offset by a bolic alkalosis, since both PaC02 and
compensatory change in the other system so HCO-3 are increased and pH is high.
Effect of ageing 15
Functional residual f\ f\ f\ f\
capacity (FAG) _ _ LV__V_ V_.L
Increased CV,
e.g. smoking,
Closing ------------I4-+--+-.j........J'r--l--+J ageing
volume (CV)
Decreased FAC,
e.g. obesity,
supine posture
Figure 1.9 Factors that shift tidal breathing into the closing
volume range, leading to airway closure in lung bases during
quiet breathing.
because a greater pressure is needed to reduced lung and chest wall compliance
overcome the resistance of hardening Oenkins and Moxham 1991). Hypercapnia is
arteries. also a risk (Begin 1991). In the lateral
Lung compliance does not alter with age, position, the normal downwards ventilation
which accords with the concept that lung gradient is reversed because of lung compres-
'elasticity' is largely determined by surface sion from the abdomen (Hurewitz 1985),
tension (Nunn 1987, p. 34). leading to less ventilation in the well-
perfused bases, itA/Q mismatch and some-
times reduced Pa02. Exercise demands high
oxygen consumption. Breathing patterns
1.11.1 Clinical implications tend to be rapid and shallow. Obesity
During mobilization, time is needed when increases the risk of cardiovascular disease,
assisting elderly patients out of bed in case of hypertension, diabetes, digestive diseases
postural hypotension. During deep breath- and some cancers (Chen et aI1993).
ing, collateral ventilation can be exploited Obesity does not ensure adequate protein
with an end-inspiratory hold (p. 113). During stores, and hospitalization can worsen the
exercise training, an ageing cardiovascular nutritional status of obese people. People
system is less able to adapt to the stress of with lung diseases may be obese from inact-
exercise. During weaning from mechanical ivity, and overweight from steroid medica-
ventilation, extra help is needed because lung tion.
volume is especially compromised by the
supine posture and low tidal volumes. When
interpreting blood gas readings, a healthy 1.12.1 Clinical implications
60-year-old has a Pa02 of about 10.7 kPa
(80 mmHg), thereafter losing 1 mmHg for Postural drainage is inadvisable in obese
each year of age. people because of the extra load on the
diaphragm and risk of atelectasis. After
surgery, an obese patient should barely have
1.12 EFFECT OF OBESITY emerged from anaesthesia before the physio-
The obese and the elderly share a tendency therapist becomes involved in pain control
towards poor basal ventilation. People who and positioning. Exercise tolerance is impaired
are overweight show lower lung volumes by fat infiltration of muscle and a heavy work
(especially expiratory reserve volume) and load.
Effect of smoking 17
who smoke marijuana have shown greater threshold is reached, demand exceeds supply
physiological stability than those who do not and lactic acidosis develops, with a dis-
(Dreher et al 1994). proportionate increase in minute ventilation
relative to oxygen consumption.
Pa02 changes little in people with normal
1.13.1 Clinical implications
lungs because of a matched increase in
Motivate, educate and cajole. ventilation and perfusion. For people with
obstructive lung disease, Pa02 usually drops,
and for those with restrictive disease, Pa02
1.14 EFFECT OF EXERCISE
can fall dramatically due to diffusion limita-
During exercise, oxygen delivery, consump- tion (Wagner 1992). Inspiratory muscle fat-
tion and extraction increase, extra oxygen igue may develop in people with respiratory
being delivered to the heart and skeletal disease. Subjectively, exercise can be experi-
muscles by several mechanisms: enced as incapacitating, joyful or somewhere
in between.
1. Ventilation can increase from 6 Vmin to
The effect of training is to reduce blood
over 200 Vmin (Salazar 1991). At low-
lactate levels for a given amount of exercise
intensity exercise, deeper breathing
and lessen requirements for oxygen uptake,
makes the largest contribution to minute
CO2 output and ventilation. Training causes
ventilation, while at high intensity, rapid
more complete oxygen extraction, a lower
breathing is the main contributor.
heart rate at rest and reduced BP on exercise
2. Cardiac output can increase fourfold in
(Casaburi 1992).
an unconditioned young adult, and up to
sixfold in a fit male (Epstein 1993), mostly
due to rapid heart rate. Systolic blood 1.14.1 Clinical implications
pressure increases in proportion to oxy-
When encouraging patients to exercise,
gen consumption and may reach over
accurate judgement is needed to achieve
200 mmHg in a healthy man. Diastolic
optimum activity without losing the patient's
pressure increases slightly during iso-
co-operation or causing oxygen desaturation.
tonic exercise and significantly during
isometric exercise (Salazar 1991).
3. Vascular resistance drops precipitately, 1.15 EFFECT OF BED REST
and in the lungs, previously closed capil-
Immobility reduces lung volumes and can
laries are recruited, primarily in the
lead to postural hypotension, constipation,
apices, and other capillaries become dis-
urine retention, osteoporosis, depression and
tended. Muscle blood flow increases 25-
deconditioning (Mulley 1993). Saltin et al
fold (Epstein 1993).
(1968) showed that 20 days' bed rest can
4. Oxygen extraction can increase 20-fold
reduce work capacity by 30%, returning to
(Epstein 1993).
normal only after 3 weeks of intensive exer-
5. Bronchodilation occurs in normal lungs,
cise. Muscles lose 20% strength per week
6. Mucus transport increases (Mier et al
(Sciaky 1994). Loss of gravitational stimulus
1990).
to the cardiovascular system causes a neg-
Cardiovascular delivery of oxygen to the ative fluid balance within 24 hours and is also
peripheral muscles imposes the primary limit a major cause of deconditioning. Reduced
to exercise in normal subjects (Hsia 1993). circulating blood volume and impaired vaso-
When blood flow becomes inadequate to constrictive ability cause postural hypoten-
maintain aerobic metabolism, the anaerobic sion, increased work of the heart and
Recommended reading 19
increased work of breathing (Dean and Ross patency of the upper airway, leading to
1992). Loss of plasma volume increases the greater airflow resistance (Henke 1992),
risk of deep vein thrombosis (Sciaky 1994). • ~ VT by 25% during REM sleep (Nunn
Deterioration occurs more rapidly in the 1987, p. 304),
respiratory and cardiovascular systems than • for people whose respiratory system is
the musculoskeletal systems, and recovery is already compromised, diaphragmatic
slower than deterioration (Dean and Ross fatigue and sometimes nocturnal respir-
1992). The more immobile the patient, the atory failure. People at risk of sleep-
higher the risk of developing respiratory disordered breathing are those with
complications and pressure sores. COPD (Fletcher 1992), and those who
are elderly or obese. Sleep itself is
disturbed by breathlessness and cough-
1.15.1 Clinical implications
ing.
If immobility is caused by pain, fatigue or
depression, these should be addressed, e.g. 1.16.1 Clinical implications
by analgesia, rest or a listening ear, so that People on home oxygen should use it continu-
they do not prevent mobilization. ously during the night because the normal
If immobility is unavoidable for medical
nocturnal drop in 5a02 can be damaging for
reasons, regular position change reduces people who are already chronically hypoxae-
some of the complications of bed rest. Passive mic. Hospitalized patients on oxygen should
and/or active exercise are necessary and maintain this at night, sometimes with a
encouragement of upright positions minim- higher flow rate. Death from lung disease
izes orthostatic intolerance. usually occurs at night.
Introduction Palpation
Background abdomen
ward reports and meetings chest expansion
notes and charts percussion note
Subjective assessment hydration
symptoms trachea
functional limitations Exercise testing
Observation tests by the physiotherapist
apparatus tests in the laboratory
sputum Chest X-ray
general appearance systematic analysis
colour lateral film
hands other tests
oedema checklist
chest shape Respiratory function tests
breathing rate working definitions
breathing pattern airways obstruction
jugular venous pressure lung volumes
Auscultation respiratory muscle function
technique gas transfer
breath sounds oxygen consumption and carbon dioxide
added sounds production
voice sounds Recommended reading
explanations are needed because the public Breathlessness signifies increased work of
perception of physiotherapy is often limited breathing. It is abnormal if inappropriate to
to football and backache. Patients need to be the level of activity. Causes can be pulmon-
given the opportunity to define their ary, cardiovascular, metabolic or neuro-
problems and how these influence their muscular. It may be related to posture.
lifestyle. It is worth building up rapport at Patients often deny breathlessness if it has
this stage to encourage accuracy and set the developed gradually, but it is significant if
foundations for a co-operative relationship. they need to pause during undressing or
Respect for a patient's opinions is a potent talking, or if they cannot walk and talk at the
motivating factor. same time. A key question at each visit can be
a comparative measurement for that indivi-
dual, e.g. how much can you do at your best/
2.3.1 Symptoms worst? What are you unable to do now
How long have symptoms been trouble- because of your breathing?
some? What is their frequency and duration? Subjectively, questions on breathlessness
Are they getting better or worse? What are could include: What does your breathing feel
aggravating or relieving factors? like? What makes it better or worse? How
The four cardinal symptoms of chest dis- does it affect your life? Patients describe their
ease are wheeze, pain, breathlessness and breathlessness with expressions such as
cough with or without sputum. tightness, smothering, gasping or hunger for
A wheeze increases the work of breathing. air. They can usually identify the quality as
The feeling should be explained to patients as well as the intensity of breathlessness (Wil-
tightness of the chest on breathing out, not son and Jones 1991). Details of breathlessness
just noisy, laboured or rattly breathing. Is the measurement are in Chapter 6.
wheeze aggravated by exertion or allergic Breathlessness that increases in supine can
factors, suggesting asthma? It is confirmed be caused by lung or heart problems. In lung
objectively with the stethoscope. disease, pressure on the diaphragm from the
Is there pain? Chest pain can be musculo- abdominal viscera compromises breathing. In
skeletal, cardiac, alimentary or respiratory in heart disease, breathlessness on lying down
origin. Many patients associate chest pain is called orthopnoea and is caused by the
with heart attacks, and anxiety may modify inability of a poorly-functioning left ventricle
their perception and description of it. Chest to tolerate the increased volume of blood
pains that are relevant to the physiotherapist returning to the heart. Paroxysmal nocturnal
are: dyspnoea is breathlessness at night caused
by orthopnoeic patients sliding off their
• pleuritic pain which is sharp, stabbing and pillows during sleep, leading them to seek
worse on deep breathing and coughing; relief by sitting up over the edge of the bed.
it is caused by pleurisy, some pneu- Breathlessness due to lung or heart disorders
monias, spontaneous pneumothorax or can be distinguished by peak flow readings
pulmonary embolism, (McNamara 1992), auscultation, X-ray signs
• angina pectoris which is a paroxysmal or exercise testing.
suffocating pain due to myocardial Cough is abnormal if it is persistent,
ischaemia, painful or productive of sputum. It may be
• raw central chest pain, worse on coughing, related to inflammation, irritation, habit or
which is caused by tracheitis and asso- serious disease, but is often underestimated
ciated with upper respiratory tract infec- by smokers and people who swallow their
tion. sputum. Suggested questions are:
Observation 23
• What started off the cough? Fatigue is closely associated with breath-
• Is there sputum? lessness (Kellner, et al 1992) and depression
• If so, what is the sputum like? (Small and Graydon, 1992), which can reduce
• Has it changed in quality or quantity? motivation and the ability to co-operate. How
• Is there sometimes blood? does the patient feel about the disease? This
• Does the cough occur at night (suggesting question provides the opportunity for
asthma and/or gastro-oesophageal re- patients to describe their feelings. Anxiety is
flux)? common if symptoms are unpredictable.
• Does it cause pleuritic pain? Other distressing factors are frustration,
embarrassment, restricted social function and
A cough that is associated with eating or a feeling of loss of control. If the patient
drinking may be a sign of repeated minor spends the day flopped in front of the TV, is
aspiration of stomach contents, especially in this because of preference, exercise limitation
people who are weak or elderly. Chronic or depression?
persistent cough may be associated with Details of previous experience with physio-
postnasal drip or gastro-oesophageal reflux therapy will give an indication of which
(Ing et al 1992), and a dry cough can be interventions have been beneficial. If the
caused by asthma, interstitial lung disease, patient is unable to give a history, relatives
recent viral infection, hyperventilation syn- can be questioned, bearing in mind that they
drome, ACE inhibitor drugs or mucosal may identify fewer problems and see them
irritation following removal of an endo- from a different perspective. A questionnaire
tracheal tube. The patient can be asked to is an efficient way of gaining more detail
cough in order to check for weakness or pick about symptom-related problems, functional
up sounds that may be missed by the activity and the patient's emotional reaction
stethoscope but stimulated by a cough. to the disease (Table 6.1, p. 151).
Other relevant symptoms are fatigue and Details of assessment specifically for chronic
weakness, one or both of which may be problems are given in Chapter 6.
present. It is useful to adopt the practice of
asking patients the cause of their symptoms
because their perceptions are often surpris- 2.4 OBSERVATION
ingly accurate. Preliminary observation of the breathing rate
and breathing pattern should be made before
2.3.2 Functional limitations the patient is aware of the physiotherapist's
presence. Detailed observation can then be
Problems with activities of daily living, undertaken.
finance, employment and housing loom large
for people with respiratory disease. What is
2.4.1 Apparatus
the level of daily exercise? Is the patient
employed? How many stairs are there at Is the patient using oxygen? Is it being used
work or home? Is the environment well- as prescribed? Is the humidifier working
heated, smoky, dusty? Does the patient live effectively? Are drips, drains and chest
alone, eat well, smoke? Is it difficult to shop, drains in order?
bathe, dress? What support is available?
Limitation of activity is not in itself an
2.4.2 Sputum
accurate indicator of respiratory disease
because of many variables, but a change in Sputum production is always abnormal
activity level is noteworthy. because daily secretions are swallowed in
24 Assessment of the respiratory patient
healthy people. Serous secretions are pro- Breathless people characteristically brace
duced in pulmonary oedema. They are frothy their arms so that their shoulder girdle
because of a mixture of air and liquid, and muscles can work as accessory muscles of
sometimes pink if blood has squeezed into respiration. Is the patient obese, thus com-
the alveoli. Chronic bronchitis is character- promising diaphragmatic function, or cach-
ized by sticky grey mucoid sputum, which is ectic, indicating poor nutrition and
like raw egg white. Asthmatic people may weakness? If the patient is unkempt, does
produce tenacious mucoid sputum, some- this reflect difficulty with self-care or a mea-
times containing thick plugs. Purulent spu- sure of how the disease has affected self-
tum is thick, usually coloured and often esteem? Is the patient restless or incoherent,
infected; if yellow, it signifies infection or the possibly due to hypoxaemia?
excess eosinophils seen in asthma; if green, For mobile patients, the gait gives an
it signifies infection or may have lingered indication of mood, breathlessness, co-
in the airways awhile as in bronchiectasis. ordination, fatigue, shoulder girdle tension
Foul-smelling green sputum occurs with or a tense rigid posture with lack of arm
pseudomonas infection. swinging during walking.
Haemoptysis is expectoration of sputum
containing blood, which can be an alarming
experience for the patient. It varies in severity 2.4.4 Colour
from slight streaking to frank bleeding. It is
Pallor is associated with anaemia, reduced
bright red if fresh, pink if mixed with
cardiac output or hypovolaemic shock. A
sputum, or rusty brown if it is old blood.
plethoric appearance is due to the excess red
Causes are:
blood cells of polycythaemia. Cyanosis is
• pulmonary carcinoma, blue colouration due to unsaturated haemo-
• pulmonary tuberculosis, globin in the blood, caused by lung or
• bronchiectasis, cardiovascular disease.
• pulmonary embolus, Central cyanosis is evident at the mouth,
• lung abscess, lips and tip of the tongue, but it is an
• pulmonary oedema or mitral stenosis, unreliable guide to hypoxaemia and can be
• pneumococcal pneumonia, identified at 5a02 levels that vary between
• blood clotting abnormality, 72% and 95% (Martin 1990). Its detection
• trauma such as intubation, tracheostomy, depends on skin pigmentation, patency of
lung contusion or frequent tracheal suc- vessels, ambient lighting, keeness of the
tion. observer's eye and the level of haemoglobin
Haematemesis occurs when blood is in the blood. It may be masked by anaemia or
vomited, and may be confused with haemop- exaggerated in polycythaemia. Cyanosis
tysis. It is characterized by acidity and dark should be viewed as a warning rather than a
red blood which resembles coffee grounds, measurement, and its absence should not
and it may be accompanied by melaena lead to a false sense of security.
(digested blood passed per rectum) or nau- Peripheral cyanosis shows at the fingers,
sea. toes and ear lobes, and signifies a problem
with circulation rather than gas exchange.
Stagnant blood gives up its available oxygen
2.4.3 General appearance
and the peripheries appear blue as a result of
Does the posture suggest fatigue, pain, a cold environment or pathology, such as
altered consciousness or respiratory distress? peripheral vascular disease.
Observation 25
Horizontal
fissure Rlung
} only
Oblique fissure U~,L+.r:?'o~oc::."
~-v+-#-- Middle lobe
Lower lobe
Right
Left upper
upper lobe
lobe
Figure 2.1 Lateral and posterior views of the lobes and fissures of
the lung.
Observation 27
overcoming the resistance of obstructed The following three signs indicate inspir-
airways and the mechanical disadvant- atory muscle fatigue, weakness and/or over-
age of a hyperinflated chest. load (Mador 1991):
2. Indrawing or recession of soft tissues of • abdominal paradox, as described above,
the chest wall on inspiration, caused by • rapid shallow breathing, which reduces
excessive negative pressure in the chest, elastic loading (Mador 1991),
which sucks in supraclavicular, supra- • less commonly, alternation between ab-
sternal and intercostal spaces. dominal and rib cage movement so that
3. Forced expiration with active contraction each muscle group can rest in turn,
of abdominal muscles, which compresses which is similar to shifting a heavy
the airways and increases the work of suitcase from hand to hand.
breathing yet further (Ninane et al1992).
It does not speed expiratory flow (Tobin Exhaustion is presaged by t RR with i
1988). PaC02. This is a danger sign which indicates
4. Pursed lip breathing, which is adopted that the patient may need some form of
to stabilize the airways internally and mechanical assistance.
delay expiratory collapse. However, it Periods of apnoea with waxing and waning
increases the overall work of breathing of the rate and depth of breathing is called
(Roa 1991), offers no mechanical advant- Cheyne-Stokes breathing when regular, and
28 Assessment of the respiratory patient
ataxic breathing when irregular. These indic- creates a faint strangled sound at the mouth
ate neurological damage, but Cheyne-Stokes on inspiration, known as stridor, a serious
breathing is also associated with end-stage sign denoting laryngeal or tracheal obstruc-
heart failure, or may be normal in some tion. Stridor is a warning that nasopharyn-
elderly people. Irregular breathing often geal suction should be avoided and the
occurs in normal REM sleep. Sighing respira- patient's head kept elevated to minimize
tion may indicate hyperventilation syn- oedema. Crackles heard at the mouth should
drome. be cleared by coughing in order to prevent
them masking other sounds during auscul-
tation.
2.4.10 Jugular venous pressure
The internal jugular vein acts as a manometer
2.5.1 Technique
tube in connection with the right atrium,
indicating raised pressure if the right The underlying lobes and fissures (Fig. 2.1)
ventricle is unable to empty effectively. In should be visualized in order to avoid pitfalls
advanced lung disease associated with pul- such as listening optimistically for breath
monary hypertension, increased pulmonary sounds over the kidney. The diaphragm of
vascular resistance impedes emptying of the the stethoscope is used for the high frequen-
right ventricle so that the jugular vein cies of breath sounds and the bell for the low
becomes engorged. frequencies of heart sounds. The ear pieces
To observe the jugular vein, the patient is face forwards into the ears. The patient is
asked to lie at 45° with the head symmetrical asked to breathe through the mouth, but not
and supported to minimize accessory muscle rapidly because this causes light-headedness.
activity. Elevated venous pressure is indic- Each area of lung is compared on alternate
ated by jugular venous distension, and a sides. Hairy chests create their own crackles,
flickering impulse in the jugular vein repre- which can be eliminated by wetting the chest.
sents the jugular venous pressure OVP). If The patient is best positioned sitting
the JVP is more than 3-4 cm above the level upright over the edge of the bed with arms
of the sternal angle, the patient usually has forward to protract the scapulae and over-
right heart failure. lying muscles. Leaning forward from long-
JVP is above normal if active abdominal sitting can be used as a compromise, but this
contraction on expiration raises the intra- position squashes the lung bases so that
thoracic pressure. It is below normal in breath sounds over this important area may
dehydrated patients. It may not visible in be indecipherable. In patients who cannot sit
obese patients. up, side-lying can be used, with due allow-
ance for the difference in sound transmission
between top and bottom lungs. The dia-
2.5 AUSCULTATION
phragm of the stethoscope should be wiped
Auscultation is used to verify observed and off with alcohol between patients (Breath-
palpated findings before and after treatment. nach et al 1992).
Prior to reaching for the stethoscope, it is
worth listening for sounds at the mouth,
2.5.2 Breath sounds
which are barely audible in a person with
normal lungs. Noisy breathing indicates Breath sound intensity indicates either
obstructive airways disease, which causes regional ventilation or factors which affect
airflow turbulence. A monophonic (single transmission of the sounds. The term 'breath
note) wheeze generated in the upper airways sounds' is more accurate than 'air entry',
Auscultation 29
Sound generation
.
Sound transmission
because air may enter the lung but trans- Bronchial breathing is an abnormal sound
mission of the sound can be blocked. that is distinguished by:
Breath sounds are generated by turbulent
• a hollow blowing quality on expiration,
airflow in the large airways, then transmitted
• a long expiration,
through air, fluid and tissue to the chest wall,
• a pause between inspiration and expira-
each substance filtering the sound to a
tion.
different degree. Breath sounds are not
generated beyond lobar or segmental bronchi It is heard over consolidation, which acts
because the total cross-sectional area is too acoustically like a lump of liver in the lung,
large to create turbulence (Jones 1995). Breath the solid medium transmitting sounds more
sounds may be normal, abnormal or dimin- clearly than normal lung because there are no
ished. air-filled alveoli to filter the sound (Fig. 2.3).
Normal breath sounds were called vesicu- Bronchial breathing is also heard over areas
lar in the past, when it was thought that they of collapse if the airway is patent. It can be
were generated in the alveoli. It is now simulated by listening over the trachea of a
known that alveolar air diffuses rather than person with normal lungs, and sometimes
flows and that alveoli filter rather than over the upper lobes because of their proxim-
generate breath sounds, thus creating a ity to the trachea.
muffled sound. Normal breath sounds have a A high-pitched form of bronchial breathing
shorter softer expiration than inspiration and is heard over the upper level of a pleural
are quieter in the base of the lung, which has effusion. The surface of the liquid augments
a greater volume than the apex, thus atten- transmission of sound in the same way that
uating the sound. the sound of a radio is clearer when listening
30 Assessment of the respiratory patient
from the bath with ears just above the water. tion or secretions, or when a group of airless
Low pitched bronchial breathing may be alveoli spring open. They are principally
heard over fibrotic lung tissue. heard on inspiration, and their timing
Diminished breath sounds are heard if: depends on the source. Early-inspiratory
crackles arise in the large airways and are
• the patient is obese, in a poor position or
heard in COPD. Mid-inspiratory crackles
not breathing deeply,
are characteristic of bronchiectasis. Late-
• there is no air entry to generate the sound,
inspiratory crackles originate in peripheral
e.g. atelectasis with occluded airway,
airways as they open at the end of inspira-
• there is air entry but insufficient airflow to
tion, and are associated with pneumonia,
generate sound, e.g. acute asthma,
fibrosis or pulmonary oedema. The weight of
emphysema (Schreur et al 1992).
the lung itself causes a degree of airway
• there is air entry but transmission of sound
closure so that late-inspiratory crackles may
is deflected by an acoustic barrier, such
be heard in dependent regions, especially in
as the air/solid or airlfluid interface of a
elderly obese people who have been recum-
pneumothorax or pleural effusion (Fig.
bent for some time. Late-inspiratory crackles
2.3).
are sometimes called fine crackles, Velcro
Both diminished and bronchial breath crackles or crepitations. Both inspiratory and
sounds indicate loss of functioning lung expiratory crackles are heard in bronchi-
volume. ectasis (coarse) and fibrosing alveolitis (fine).
If breath sounds are inaudible over the
chest of a person with acute asthma, he or Wheeze
she should be transferred to an intensive care
Wheezes are generated by vibration of the
unit where mechanical ventilation is available
wall of a narrowed airway as air rushes
if needed. This 'silent chest' is a danger sign
through. Expiratory wheeze, combined with
because airflow is reduced to the point of
prolonged expiration, is usually caused by
ventilatory failure.
bronchospasm. Wheeze on both inspiration
and expiration can be caused by other forms
2.5.3 Added sounds of airways obstruction such as mucosal
oedema, pulmonary oedema, sputum,
Added sounds are superimposed on the tumours and foreign bodies. Understanding
intensity of breath sounds and are more the timing is relevant because bronchospasm
obvious, and so can mask the breath sounds. might be exacerbated by certain interven-
If added sounds are louder on one side of the tions, while sputum clearance might benefit
chest than the other, this may be due to i from these same interventions. A monopho-
added sounds on the same side, or ~ breath nic wheeze can mean local airway obstruction
sounds on the other side. Non-respiratory from a foreign body or tumour.
sounds occur independently of the breathing
cycle and may be transmitted from the ab- Pleural rub
domen, voice or water in humidifier tubing.
Inflammation with roughening of the pleural
Crackles surface occurs in pleurisy, producing a
pleural rub which sounds like boots crunch-
Crackles indicate secretions or parenchymal ing on snow, stronger on inspiration than
disease (Piirila et al 1991) and are created expiration. The sound is localized, but is best
when air is forced through airways which heard over the lower lobes because excursion
have been narrowed by oedema, inflamma- of the pleura is greater basally.
Palpation 31
capacity, so it is best measured objectively patient is suitable for lung surgery (Pollock et
by walking or stair climbing. This gives an aI1993).
accurate indication of an individual's
progress, but is not a good comparison Shuttle test
between patients. Observation of the patient For a more accurate and reproducible walk-
during walking also provides information on ing test, the shuttle test is used. This is
the quality of movement and degree of incremental, externally paced, needs no prac-
fatigue. tice walk and is less dependent on motivation
and encouragement. Patients are asked to
2.7.1 Tests by the physiotherapist walk around a 10 m oval circuit with two
cones at each end to prevent an abrupt tum.
Six-minute distance The speed of walking is dictated by a taped
Patients are asked to walk for six minutes as bleep which is increased each minute. The
fast as reasonably possible along a measured tape (see Appendix C) also gives standard-
flat corridor. Stopping to rest is allowed, but ized instructions. The physiotherapist walks
patients should feel at the end that they have alongside for the first minute to help the
performed to their maximum capacity. The patient establish the initial speed. The end
physiotherapist can tell the patient when point of the test is decided by the patient
each minute is completed, but should not when symptoms are too great, or by the
walk alongside because this might influence physiotherapist if the patient fails to com-
their speed. If an oximeter is necessary, the plete a circuit in the time allowed (Singh
physiotherapist carries it while walking just 1992).
behind. Oximetry is useful because resting
5a02 is not a predictor of exercise desatura- 2.7.2 Tests in the laboratory
tion or breathlessness (Mak et al 1993).
Exercise testing based on treadmill walking
The data to record are the six-minute
or cycle ergometry are unfamiliar to patients,
distance, time taken to rest, symptoms and
unreliable in relation to everyday activity
5a02' If de saturation occurs, the heart rate is
(Mak et al 1993), and less related to exercise
noted at that point so that desaturation can
capacity than breathlessness (Wijkstra 1994).
be avoided in future. Limitations such as
However, measurable workloads can be
orthopaedic or neurological problems are
imposed in the laboratory while monitoring
noted so that exercise programmes can be
minute ventilation, CO2 output, heart rate,
individualized.
BP, 5a.02, blood gases and oxygen consump-
At least one practice walk is needed,
tion (V0 2 ). This helps to highlight the inter-
followed by a 20-minute rest before the test
action between various systems involved in
walk. Repeat tests should be performed at
oxygen delivery to the tissues.
the same time in relation to any broncho-
Maximum oxygen consumption (V0 2max )
dilator drugs.
indicates the anaerobic threshold, i.e. the
oxygen consumption before the start of lactic
Stair climbing
acid production. It reflects the ability of the
The stair climbing test is done under the cardiopulmonary system to deliver oxygen to
same conditions, and involves counting the muscles and the ability of the muscles to use
number of stairs that can be climbed up and it. It is an exhausting test that entails increas-
down in two minutes. Stair climbing is also ing the work load until a plateau V0 2 is
used to assess cardiopulmonary reserve, a reached. V0 2max is a reliable guide to aerobic
climb of at least five flights indicating that the capacity in normal subjects, but of limited use
Chest X-ray 35
Pulmonary
artery
in patients with respiratory disease if their chest infection than pyrexia, and pneu-
peak exercise levels are limited by breathless- monia may have been resolved for weeks
ness. or even months while X-ray signs still
Exercise testing can help determine the linger.
cause of exercise limitation. If breathlessness 2. A normal X-ray does not rule out disease.
is the limiting factor, there is probably respir- Its contribution is anatomical and interpre-
atory impairment. If a person reaches the tation is often by inference, e.g. the
anaerobic threshold early, i.e. at less than structural changes of emphysema are
40% predicted V0 2maxl or if maximum pre- more apparent than the hypersecretion
dicted heart rate is reached early, limitation is of chronic bronchitis, and postoperative
probably due to cardiovascular disease. patients with reduced lung volume and
Many respiratory patients have cardiovascu- oxygenation may have normal X-rays
lar involvement, and both respiratory and (Weiner 1992).
cardiac patients are often unfit. 3. The two-dimensional representation of a
Three-dimensional object can obscure the
relationship between certain structures
2.8 CHEST X-RAY
and limit the accurate location of lesions.
The X-ray provides a unique insight into the It is customary to refer to zones rather
state of the lungs and chest wall, but physio- than lobes unless a lateral film is available
therapists should not fall into the trap of to pinpoint the site.
'treating the X-ray' because there are several
If possible, a postero-anterior (P A) view is
limitations:
taken, in which the source of rays is behind
1. X-ray findings lag behind other measure- the patient (Fig. 2.4). This makes for an
ments, e.g. they are a later indication of optimum view of the lungs, the patient
36 Assessment of the respiratory patient
2.8.1 Systematic analysis Figure 2.5 Low flat diaphragm, narrow heart
and dark lung fields of emphysema.
It is worth using a systematic approach to
examine the film. This may feel cumbersome
chest. This check avoids misinterpretation
at first, but will become second nature and
about displacement of the heart.
lead to quick and accurate identification of
problems.
Trachea
Preliminary checks The dark column of air overlying the upper
The patient's name and the date should be vertebrae represents the trachea, which is in
checked. Then the projection is checked to the midline down to the clavicles and then
see whether it is a PA or AP film. This avoids displaced slightly to the right by the aortic
misinterpretation about the heart or dia- arch before branching into the main stem
bronchi. It is displaced for similar reasons as
phragm.
The exposure is then checked, an under- displacement of the heart.
exposed film appearing too white and an
Heart
over-exposed film too black. Correct expos-
ure means that it is just possible to dis- The size, position and borders of the heart
tinguish the space between vertebrae are observed. The transverse diameter is
through the heart shadow. This avoids mis- normally less than half the internal diameter
interpretation about the density of tissues. of the chest in the PA film. An apparently big
The symmetry is correct if the medial ends heart could be due to ventricular enlarge-
of the clavicles are equidistant from the ment, pulmonary hypertension or poor
spinous processes, which appear as tear-drop inspiratory effort. A narrow heart is caused
shapes down the spine. If the patient is by hyperinflation, in which the diaphragm
rotated towards either side of the plate, the pulls down the mediastinum (Fig. 2.5), or it
heart shadow is shifted towards that side may be normal in tall thin people.
because the heart is near the front of the The heart normally lies slightly to the left of
Chest X-ray 37
Hila
Pulmonary vessels and lymph nodes make
up the hilar shadows, the left hilum being Figure 2.6 Opacity of both lower zones suggests
slightly higher than the right. Hila are ele- consolidation. The right side also shows the
vated by fibrosis, atelectasis or lobectomy of hemidiaphragm shifted upwards and horizontal
the upper lobe, and depressed by lower lobe fissure shifted downwards, consistent with right
atelectasis. Ring shadows near the hilum are lower lobe atelectasis.
normal large airways seen end-on. Bilateral
enlargement is associated with pulmonary by hyperinflation, excess doming caused by
hypertension, and unilateral enlargement fibrosis and blurring of the smooth surface
raises suspicions of malignancy. caused by lung or pleural abnormality.
The costophrenic angle provides the first
Diaphragm clue to problems that hide behind the dome
of the diaphragm. The normally acute angle
On full inspiration, the height of the dia-
may be obliterated by the meniscus of a small
phragm should be level with the 6th rib
pleural effusion, or the patchy shadow of
anteriorly, 8th laterally and 10th posteriorly
consolidation.
(Fig. 2.1), with the left side slightly lower
Air under the left hemidiaphragm is in the
than the right because it is pushed down by
stomach and therefore normal. Air under the
the heart. A low, flat diaphragm suggests
right is only normal following abdominal
emphysema (Fig. 2.5). An elevated dia-
surgery or if the colon is displaced above the
phragm could be (1) positional as in an AP
liver, otherwise it may indicate a subphrenic
film, (2) physiological due to lack of a full
abscess or perforated gut.
inspiration, or (3) pathological due to abdom-
inal distension or generalized lung fibrosis. If
Lung fields
one side of the diaphragm is raised, this
could be due to atelectasis (Fig. 2.6), a Normal lung contains air and is dark. A film
paralysed hemidiaphragm or excess gas in that is too dark suggests hyperinflation (Fig.
the stomach. 2.5). A localized dark area bounded laterally
The shape of the diaphragm should be by the chest wall and medially by the thin
rounded and smooth. Flattening is caused line of the visceral pleura, and containing no
38 Assessment of the respiratory patient
nipple shadows can produce an apparent oblique fissure may be visible. Clear spaces
opacity. Rolls of fat pressed against the plate indicate where the lungs touch.
may be visible. Subcutaneous emphysema
shows up along the fibres of chest wall 2.8.3 Other tests
muscles.
Fluoroscopy
Visualization of moving structures is
2.8.2 Lateral film
achieved by fluoroscopy, which projects the
A lateral film is needed if accurate postural image on to a monitor. Diaphragmatic
drainage is required, e.g. for bronchiectasis paralysis can be identified in this way.
or an abscess, or to show up lesions that are
concealed behind the diaphragm or heart. Radionuclide imaging
The lateral film shows the lungs superim- A VIQ scan is a map of the distribution of
posed so that some structures are not easily ventilation and perfusion in the lung. The
distinguishable, but other structures can be patient first inhales a radioactive gas, and is
identified which cannot be seen on the then injected with radioactive material. The
straight film (Fig. 2.13). The hilum is at the distribution of each is traced by radiation
centre of the film, and the aorta is seen detectors on the chest, and the two images
arching above and behind the heart. The projected and compared. Areas of poor per-
white borders of the scapulae and the dark fusion but good ventilation are diagnostic of
outline of the trachea can be seen, and the pulmonary emboli (Fig. 2.14) or thrombosis.
Chest X-ray 41
Sternum
Hilum
Heart
R hemidiaphragm
L hemidiaphragm
Costophrenic
angle
and always in restrictive disorders. It reflects sum of the four primary lung volumes (VT,
the ability to breathe deeply .and cough, IRV, ERV, RV).
indicating inspiratory and expiratory muscle Normal: 3-81.
strength. Less than 11 suggests an ineffective
cough. It is subject to day-to-day fluctuations. Functional residual capacity (FRC)
(Fig. 2.16)
Normal value: 3--6 1, or approx 80% of TLC.
This is the volume of gas remaining at the
Forced vital capacity (FVC) end of a tidal exhalation. It is a useful
indicator of lung volume because it does not
As above but with forced exhalation.
depend on effort. It reflects the resting
Normal: equal to Vc. position when the inward pull of lung elastic
copo: FVC < VC because the manoeuvre recoil is balanced by the outward pull of chest
causes airway collapse. wall recoil- a comfortable place to be. Active
exhalation is necessary if further reduction in
Forced expiratory volume in one second lung volume is required.
(FEV1) FRC decreases with restrictive disorders
and increases with air trapping or hyper-
This is the volume of gas expelled in the first
inflation, the ratio of FRC to TLC being an
second by a forced exhalation from a full
index of hyperinflation. The normal large
inhalation. It is a similar measurement to peak
capacity is needed to dilute extreme changes
flow, but more accurate and closely related to
in alveolar oxygen tension with each breath.
the development of obstructive lung disease.
As with any forced manoeuvre, it is difficult for Normal in standing: 40% of TLC, i.e.
breathless patients and may bring on bron- approx 1-31.
chospasm in susceptible patients. It is subject Normal in supine: up to 2.2 1.
to day-to-day fluctuations. copo: up to 80% of TLC.
Normal: 70-80% of VC, or approx 2-4 1.
Tidal volume (V,.)
Severe airways obstruction (e.g. hyper-
capnic patients): < 60% predicted. This is the volume of air inhaled and exhaled
during one respiratory cycle.
FEV11FVC
Normal: 10% of TLC, i.e. approx
This expresses FEV1 in relation to vital 300-800 ml.
capacity, and is more accurate for diagnosis
than FEV 1 alone. Inspiratory reserve volume (IRV) (Fig. 2.15)
Normal: 70-80, i.e. FEV1 = 70-80% ofFVC. This is usually kept in reserve; IRV is the
Moderate airflow obstruction: 50-60%. extra volume of gas that can be inhaled
Severe airflow obstruction: 30% (both voluntarily from end-inspiratory tidal
values reduced but greater drop in FEV1) volume. It is increased during deep breathing
Restrictive disease: up to 100% (both exercises.
values reduced but greater drop in FVC).
Expiratory reserve volume (ERV) (Fig. 2.15)
Total lung capacity (TLC) (Figs. 2.15 and
This is the extra volume of gas that can be
2.16)
exhaled voluntarily from end-expiratory tidal
This is the total volume of gas in the lungs volume. It is decreased with obesity, ascites
after maximum inspiration, i.e. the or after upper abdominal surgery.
Respiratory function tests 45
I
Maximal inhalation
II
(3500 ml)
JVml1
I VC
--j
(4500 ml)
- _VT - - _ _
TLC
___ @O_O_mQ _ _ _ _ _ __ _ _ (6000 ml)
I Resting expiratory level
TLC TLC
1n{Cnn~nnn
RV
RV TLc'lUV ~UUUL.
Normal
1 1
Obstructive
1 RJ
Restrictive
defect with defect
hvperinflation
Residual volume (RV) (Figs. 2.15 and 2.16) collapse, i.e. the lungs never empty com-
pletely. RV increases with air trapping and
This is the volume of gas remaining in the age. The ratio of RV to TLC is an index of
lungs after maximum exhalation. It cannot be hyperinflation.
measured directly. It is inhaled with the first
breath at birth and not exhaled until death Normal: 20-30% of TLC.
because the chest wall prevents total lung Airways obstruction: approx. 75% of TLC.
46 Assessment of the respiratory patient
Peak flow
Normal CO PO Asthma
t
~
0
li1
.0.
~ w
x
~
0 0
u:::
~
0
li1
.0.
Cfl
c:
tt Lung volume
t Restrictive disease
TLC RV
nitrogen-free oxygen and measuring the PEEP (p. 55) causes an underestimation
expired nitrogen. of MIP (Aldrich 1993).
3. Transdiaphragmatic pressure is a more
TLC and RV can be measured by using one accurate measurement obtained by com-
of these measurements plus spirometry. paring oesophageal (pleural) and gastric
(abdominal) pressures, using swallowed
balloons (Green and Moxham 1993).
2.9.4 Respiratory muscle function
4. Phrenic nerve stimulation or reduced
Increased strength - ability to generate relaxation rate of muscle are relatively
greater force. accurate measurements (Green and Mox-
Increased endurance - ability to generate ham 1993).
the same work for a longer time. 5. Nocturnal hypercapnia indicate that
inspiratory muscle strength is below 30%
Respiratory muscle strength is related to of normal (Green and Moxham 1993).
exercise capacity (Wijkstra 1994). The tech-
nique used to test muscle strength must be Respiratory muscle endurance is difficult to
meticulous and the patient position standard- measure and cannot necessarily be inferred
ized because normal values vary 10-fold due from strength. It is assessed by MVV, which
to variability between subjects, different is also influenced by co-ordination, pulmon-
ary mechanics and effort (Bardsley et aI1993).
diaphragmatic lengths and different test pro-
cedures (McKenzie 1994). The following tests
are available:
2.9.5 Gas transfer
1. Vital capacity is a simple measurement,
but insensitive and non-specific. Small Gas transfer (transfer factor), is the ability of
pressures are required to inflate the lung, the lungs to transfer gas from alveoli to
therefore a fall in VC only occurs with capillary blood, and is measured by the total
severe muscle weakness. The outcome is lung transfer capacity for carbon monoxide
influenced by effort, fitness and com- (TLCO). The patient takes a single deep
pliance of the lung and chest wall. breath of a gas that includes carbon mon-
oxide, breath-holds for 10 seconds, then
2. Maximum static mouth pressure (Chat-
exhales. The amount of expired carbon
ham et a11994) is also simple to measure.
monoxide indicates its passage across the
Maximal inspiratory pressure (MIP),
alveolar-capillary membrane.
indicating diaphragmatic strength, is
Reduced TLCO indicates VA/Q abnormal-
measured from RV or FRC. Maximal ity, low haemoglobin, or diffusion that is
expiratory pressure (MEP), indicating the impaired by damage to the pulmonary capil-
strength of the abdominals and inter- laries, lung tissue or alveolar-capillary mem-
costals, is measured from TLC. A pres- brane. TLCO is closely correlated with
sure gauge or transducer is connected to exercise limitation (Wijkstra 1994) and breath-
a mouthpiece, the patient inhales or lessness due to emphysema or lung fibrosis
exhales sharply, keeping a firm lip seal (O'Donnell and Webb 1992). In emphysema it
and taut cheeks, and the best of three may be 50% of normal (Brannon et aI1993). It
efforts is recorded. For non-paralysed is reduced in anaemia and increased in
ventilated patients, MIP can be measured polycythaemia.
by briefly occluding the airway with a Diffusion of oxygen is influenced by factors
one-way valve (Truwit 1992). Intrinsic other than diffusion per se, which is why the
50 Assessment of the respiratory patient
Table 2.3 Checklist of major points of terms 'gas transfer' or 'transfer factor' are
pulmonary assessment used. These are broad measures incorporat-
Patient's notes ing not just diffusion properties, but also the
history (past, present, family, social) influence of alveolar volume and capillary
investigations blood. The old term 'diffusing capacity' is less
Charts accurate because it encompasses only the
temperature passage of gas from blood to alveoli.
arterial blood gases
medication
oxygen prescription 2.9.6 Oxygen consumption and carbon
peak flow dioxide production
fluid balance
BP V0 2 and VC0 2 are measured by analysis of
Subjective assessment inhaled and exhaled gas volumes. When
symptoms compared with predicted values for age
functional limitations and sex, aerobic and anaerobic contributions
Apparatus to metabolic activity can be assessed.
oxygen
humidification Table 2.3 summarizes the main aspects of
oximeter assessment.
drips
chest drains
Sputum RECOMMENDED READING
Observation Curtis, J.R, Deyo, RA. and Hudson, L.D. (1994)
posture Health-related quality of life among patients
colour with COPD. Thorax, 49, 162-70.
hands Earis, J. (1992) Lung sounds. Thorax, 47, 671-2.
oedema Hodgkinson, D.W, O'Driscoll, B.R, Driscoll, P.A.
chest shape et al. (1993) Chest radiographs. Br. Med. J., 307,
breathing rate 1202-6, 1417.
breathing pattern Holleman, D.R. (1995) Does the clinical examination
Palpation predict airflow limitation? JAMA, 273, 313-19.
abdomen McCord, M. and Cronin, D. (1992) Operationaliz-
expansion ing dyspnea: focus on measurement. Heart
percussion note Lung, 21, 167-79.
hydration Mootoosamy, I.M. (1993) Computed tomography
Auscultation scanning of the thorax. Br. J. Hosp. Med., 50
breath sounds (213), 95--105.
added sounds Quanjer, P.H. (1993) Lung volumes and forced
voice sounds ventilatory flows. Eur. Respir. J., 6(suppl.), 5-40.
Exercise tolerance Stiesmeyer, J.K. (1993) A four-step approach
Chest X-ray to pulmonary assessment. Am. J. Nurs., 93(8),
22-8.
3. Respiratory disorders
(a)
~ §
Elastic recoil affecting
alveolus
----'~-
\/
(b)
,
Fibrosis
Mucus
Inflammation
,,,
I
I
Bronchospasm
Floppy airways
due to loss of Loss of elastic
tethering effect recoil and
of elastic recoil breakdown of
alveolar wall
smokers' cough in the early stages, but once Risk factors are male sex and poverty (both
it has occurred for three months per year for associated with smoking), occupation, hous-
two years, it becomes the inadequate, but ing, climate and childhood respiratory illness
traditional, definition of chronic bronchitis. (Clarke 1991).
Causes Pathophysiology
Smoking is the major cause of chronic bron- Repeated inhalation of pollutants causes irri-
chitis, although other pollutants contribute. tation of the sensitive lining of the airways,
Obstructive disorders 53
. .""rnn.';~
V,IO
l
Hypoxaemia
~p"'mo",~
I /
Polycythaemia vasoconstriction
('~Tble,
Pulmonary vascular
l' Viscosity remodelling
of blood
(irreversible)
Pulmonary
hypertension
/
l
Cor pulmonale
l
Right heart failure
!
Left heart failure
normal among smokers, who may not seek cyanotic appearance and crackles on auscul-
medical advice until the lungs are considera- tation (Piirila et al 1991). FEVl declines by
bly damaged. 60-120 ml a year (Hodgkin 1993, p. 65) and is
Patients then gradually develop breathless- a useful indicator of obstruction but relates
ness, which should be routinely measured in weakly to functional impairment (Mahler
COPD patients (Mahler 1995), reduced exer- 1995). X-ray signs may be insignificant or may
cise tolerance and fatigue. Sleep is no longer show a feathery appearance, upper lobe
recuperative but is disturbed by breathless- diversion and later the enlarged heart of cor
ness, while nocturnal oxygen desaturation pulmonale.
plays a role in progression of the disease. The appearance of peripheral oedema is a
Objectively, there is a rich tapestry of signs, turning point in the disease process, indicat-
such as laboured breathing, a plethoric or ing a Pa02 < 7.3 kPa (55 mmHg) (Stewart
Obstructive disorders 55
Shortened
muscle fibres
r Decreased
diaphragmatic
.~
~ Medial orientation of
curvature diaphragmatic fibres
Figure 3.5 The detrimental effects of hyperinflation on the mechanics of
breathing. (From Tobin, M. (1988) Respiratory muscles in disease. Clinics in
Chest Medicine, 9, 264, with permission.)
• compensate for this inefficient muscle con- emphysematous diaphragm often labours
traction, under further handicaps, such as malnutri-
• compensate for loss of the 'bucket handle' tion, so diaphragmatic weakness is common
action of the ribs (Fig. 3.5), (Duranti 1995). Malnourishment is caused by
• compensate for reversed action of rib cage excess energy demand due to the work of
elastic recoil, which in the hyperinflated breathing, and impaired energy supply due
chest is directed inwards rather than to difficulty in eating when breathless. It
outwards, thus resisting instead of leads to cannibalization of the respiratory
assisting inspiration (Fig. 3.5), muscles for their protein, further impairing
• sustain inspiratory muscle action so that ventilation. Malnutrition also accelerates the
high lung volumes are maintained, process of emphysema itself (Schlichtig and
alveoli being opened at a high point on Sargent 1990).
the pressure-volume curve (Fig. 1.3), Two types of emphysema are described,
• assist expiration, which has become active although they may coexist. Centrilobular
in an attempt to squeeze air out through emphysema affects the respiratory bron-
floppy airways on expiration. chioles, leaving the alveoli relatively
unscathed. Panlobular/panacinar emphys-
People with emphysema are doubly bur-
ema is associated with severe alphal-
dened because airways resistance makes it
antitrypsin deficiency and affects the alveoli
harder to breathe, while hyperinflation im-
themselves, causing more extensive destruc-
pairs the capacity of the inspiratory muscles
tion. Breakdown of lung tissue may lead to
to handle the added load. The flat diaphragm
the formation of bullae (see Glossary), which
works paradoxically and becomes expiratory
occasionally require laser ablation (Barker
in action, the lower ribs being drawn in on
et al1993) or surgery (Nickoladze 1992).
inspiration (Hoover's sign). Some patients
can only inhale by lifting up their entire rigid
Clinical features
rib cage with their accessory muscles.
Normal muscle is able to respond to Emphysema shares many of the features of
increased load by hypertrophy, but an chronic bronchitis. Its hallmarks are breath-
Obstructive disorders 57
Figure 3.6 Patients with (a) pink puffer and (b) blue bloater
characteristics of COPD. (From Brewis, R.A.L. (1977) Lecture Notes
in Respiratory Disease, Blackwell, Oxford, with permission.)
high as the PP patient (Clague and promise airway function (Wanner 1990), and
Calverley 1990). Some BB patients may physiotherapy is often required to help the
tolerate a PaCO z of over 12 kPa patient clear secretions and reduce the work
(90 mmHg) for years (Hodgkin 1993, p. of breathing.
436). Medical management of COPD is dis-
cussed in Chapter 4, and physiotherapy
It was originally thought that repeated
management in Chapters 5 and 6.
hypoventilation in BB patients desensitized
their chemoreceptors to hypercapnia so that
they became dependent on low oxygen ten- 3.2.4 Asthma
sion as a stimulus to breathe. But more recent
studies put the blame on respiratory muscle Asthma is more common, more serious and
fatigue, the patient 'choosing' the wise option more treatable than is generally thought.
to hypoventilate (Begin, 1991). PP patients Mortality increased by one-third during the
sometimes show a tendency to rush at 1980s (Lawrence 1995), and the disease kills
activities, and breathless management tech- on average five people a day in England and
niques are particularly effective (Chapter 6). Wales (Pinfer and Garrard 1993), many of
Half of all COPD patients aged over 50 them young. Asthma is now the only treat-
years have cardiovascular disorders (Hodg- able life-threatening condition in the Western
kin 1993, p. 66) because of related pathology world with a rising death rate, with up to
and the mutual association with smoking. 86% of asthma deaths being preventable
Cardiac function plays a significant role in (GRASSIC 1994). People die because they,
oxygen delivery in people with COPD. their relatives or doctors do not see asthma as
Despite preservation of blood gases and more a potentially fatal disease, or grasp the
efficient tissue oxygen extraction in the PP importance of prevention, or recognize de-
patient, oxygen delivery is impaired because terioration.
of reduced cardiac output (Donahoe et al Asthma is a chronic inflammatory con-
1992). Low cardiac output prolongs pulmon- dition of the airways, characterized by undue
ary transit time, which further allows these responsiveness to stimuli that are normally
patients to escape hypoxaemia. BB patients innocuous, a mechanism known as hyper-
have more unsaturated arterial blood, but reactivity. It is distinguished by the vari-
often have normal cardiac output and may be ability and reversibility of its presentation,
less hypoxic at tissue level. In other words, which makes evaluation of severity difficult.
'pink puffers' may be only superficially pink It shares with COPD the common pathology
and 'blue bloaters' only superficially blue. of small airways obstruction, but the differ-
These terms are hardly complimentary and ences are shown in Table 3.1. Patients suffer
are not appropriate bedside terminology, but recurrent airway narrowing, which usually
are useful as graphic descriptions of indivi- reverses spontaneously or with treatment.
dual responses to COPD. Physical examination is a hit-and-miss
Exacerbation of COPD occurs when the affair because of the episodic nature of the
severity of signs and symptoms increases, condition and the fact that the symptoms
especially breathlessness, airways obstruc- of wheeze, breathlessness and cough are
tion and sputum production (Ball 1995). common respiratory complaints. Diagnosis is
Causes are viral infection, sometimes bacter- made from a history of recurrent acute
ial infection, or non-microbial inflammation attacks and confirmed by respiratory function
due to pollution or allergy, which may be tests. If the peak flow varies by 15%, either
moderated by steroids. Secretions may com- diurnally, after exercise, or after broncho-
Obstructive disorders 59
dilator treatment, this is considered diagnos- delayed, does not always prevent conti-
tic of asthma. nuing asthma.
11
(Trigger)
11
Asthma attack
Some factors may be cause, effect or both. would be indicated by spirometry alone (Ferrer
Anxiety, depression and social isolation are et al 1993). Persistent inflammation leads to
associated with asthma (Ramsay 1994), and fibrosis of the airway walls and irreversibility.
gastro-oesophageal reflux (GOR) is common
Oack 1995) due to microaspiration of acid into Classification and clinical features
the upper airway triggering bronchospasm,
and/or reflux being caused by relaxation of Mild chronic asthma manifests as an inter-
the smooth muscle of the cardiac sphincter mittent dry cough, often at night, or a
due to bronchodilators (Miles and Ayres morning wheeze once or twice a week. Peak
1993). flow varies by less than 25%. Even when
Allergic asthma, known as extrinsic, is asymptomatic, peripheral airways resistance
common during early life in atopic people. can be fives times normal (Wagner 1992), and
Intrinsic asthma occurs with normal IgE severe attacks are possible.
levels, develops in adulthood, is more fulmi- Severe chronic asthma means frequent
nant and less responsive to treatment. exacerbations and symptoms that signific-
Inflammation and hyperreactivity lead to antly affect quality of life. Peak flow varies by
airways obstruction by: more than 25%. Daily anti-inflammatory
drugs are required. The most severe form is
• mucosal oedema,
unstable or brittle asthma, which shows
• bronchospasm,
greatly fluctuating peak flows, persistent
• gelatinous mucus plugging.
symptoms despite multiple drug treatments,
The more severe the asthma attack, the and unpredictable severe falls in lung func-
greater the small airways obstruction (as tion, often without a known precipitating
shown by iTA/Q mismatch), compared with factor (Garden and Ayres 1993).
large airways obstruction (as shown by spiro- Acute asthma reflects failure of preventive
metry). Small airways obstruction lasts management or exposure to a noxious stimu-
longer than large airways obstruction, and it lus. The large airways are obstructed by
is suggested that more prolonged anti- bronchospasm and the small airways by
inflammatory medication should be given than oedema and mucus plugging. Asthma
Obstructive disorders 61
Danger
kPa T
I
Pa0 2
Normal range
~TTTTTT~~~~~~777777~~~~~~~777777~~C02
f-L"<-L...<...L.<'-"-'~I-L-<"""".e:=.LL.L.I<-~~<...L..<""£""'-f-':...L...<:"'£"'£..L.L.LL.j<-.L..L.L.L.L.<...L..'-4- Normal range
o~------~~------~--------~--------~------~
Normal Mild-moderate Severe Acute
asthma asthma respiratory
failure
attacks are associated with breathlessness, Severe acute asthma may present in one of
rapid breathing and abdominal paradox. The two ways. Most commonly, the condition
work of breathing is increased by airflow develops slowly, often after several weeks of
resistance up to 15 times normal (Mador wheezing. Alternately, the attack is sudden,
1991) and hyperinflation to keep the narrow especially if there has been poor drug control,
airways open (Wheatley 1990). Hyper- and this so-called asphyxic or catastrophic
inflation renders the diaphragm ineffectual attack can be fatal within minutes.
and the inspiratory muscles are forced to Deterioration can be deceptive, and para-
work throughout inspiration and expiration. doxically the patient may appear less dis-
VAle? mismatch reduces Pa02, and rapid tressed as the condition worsens. Medical
breathing reduces PaC02 • If oximetry shows help should be sought if the patient shows:
5a02 below 92%, respiratory failure is likely • respiratory rate> 25/min, then decreasing
and blood gas monitoring is required (Car- as the patient tires,
ruthers and Harrison 1995). • t PaC02 as the patient tires (Fig. 3.8),
The effort to breathe out against obstructed • heart rate> 110, then bradycardia if the
airways is reflected in prolonged expiration, patient deteriorates,
as shown by decreased peak flow readings. • peak flow < 40% of the predicted value, or
Patients feel as if they are struggling to < 200 Vmin if the predicted value is not
breathe through a narrow straw, and many known,
are extremely frightened. • ~ response to bronchodilator, i.e. < 10%
improvement in peak flow or FEVl ,
All one's strength, that one feels becoming • difficulty in speaking,
weaker and weaker, is concentrated into one last • loss of wheeze, and silent chest on auscul-
effort to take one slight breath that will allow the tation if the airflow is too slow to oscillate
respiration to continue. the airways, indicating worsening
Ruiz 1993 obstruction or failing ventilatory muscle
62 Respiratory disorders
function, with decreased respiratory exercise, and on cold days a scarf worn over
effort and exhaustion, the mouth to warm the inspired air.
• pallor and sweating, Nocturnal asthma occurs in 80% of asth-
• pulsus paradoxus (the difference between matics (Douglas 1993), interferes with sexual
the highest and lowest systolic blood intercourse and causes a marked early morn-
pressure) < 10 mmHg, ing dip in peak flow (Fig. 3.9). Many people
• cyanosis, which represents a life- develop tolerance to nocturnal symptoms,
threatening attack (Carruthers and Har- and lack of awareness of the treacherous
rison 1995), diurnal variation leads to underdiagnosis and
• exhaustion, confusion, drowsiness, coma. avoidable deaths. Suggested trigger factors
are either an exaggerated bronchial response
Very breathless patients cannot produce to cold bedrooms, gastro-oesophageal reflux,
reliable peak flow readings, and for those too reduced lung volume in the supine posture,
breathless to speak, the peak flow meter can
allergens in bedding, the timing of drug
exacerbate bronchospasm (Fanta 1992). Vent-
administration or hormonal circadian
ilatory failure during severe acute asthma is
rhythms.
usually attributed to inspiratory muscle fa-
Occupational asthma may take weeks or
tigue, but sudden deaths without obvious even years to develop. Symptoms usually
exacerbation of airflow obstruction have been
worsen during the week and ease at week-
associated with impaired respiratory drive ends, but some patients may need several
related to depressed mood (Allen et aI1994).
days of not working before improvement is
Status asthmaticus is an imprecise term noticed, which confuses the diagnosis.
that is sometimes used interchangeably with
severe acute asthma, but specifically
Education and prevention
describes an asthma attack prolonged over 24
hours, leading to dehydration and exhaus- Self-management can prevent the majority of
tion. When the term is used accurately it does asthma deaths and allow most people with
not mean the most dangerous form of acute stable chronic disease to be largely free of
asthma, which can lead to rapid death symptoms rather than accept them as inevit-
(Kallenbach et al 1993). able. Education based on booklets and peak
Exercise-induced asthma is present in 80% flows improves knowledge but does not
of asthma sufferers, and in some is the only necessarily change behaviour, and personal
manifestation. Hyperventilation during exer- instruction has been found the most effective
cise, especially in cold weather, leads to approach (Make 1994). Substantial changes in
evaporation, hyperosmolality and cooling of behaviour have been shown, for example, by
airway surface liquid, and then broncho- a brief three-hour education programme in
spasm (Widdicombe 1992). Bronchospasm the community for those recently discharged
normally occurs ~10 minutes after exertion, (Yoon et aI1993). Patients are more motivated
recovery is usually complete 30 minutes later, when the emphasis is on management of
and a refractory period of about an hour symptoms rather than general knowledge
follows in 50% of patients (Sterk 1993). (Osman et al 1994).
Bronchospasm can also occur during exertion The advantage of education during hos-
(Beck et al 1994). Warm-up and cool-down pitalization is that motivation is greatest
periods help to prevent the rapid airway during an acute episode. The disadvantages
rewarming which can cause oedema. Other are that there is often little time, and informa-
preventive measures include i3Tstimulants or tion may not be easily absorbed during this
sodium cromoglycate taken 20 minutes before anxious period. It is best to motivate patients
(a) (b)
Moo lues Wed lhur Fri sat Sun Mon lues Wed lhur Fri Sat Sun Mon lues Wed lhur Fri sat Sun Moo lues Wed lhur Fri sat Sun
AllPII jAMPII jAM~ ~PM AM PM ~PM ~PM ~PM AM PM ~PM AM PM ~PM f'Mi"" ~~M ~fM ~ PN ~PM ~PM ~P'
7 7
650
5 5
I
~ ~ ~ X ~ ~
4 4
4
J( J( )C
3 X " teo ...
3
3 \i \t V
2 2
2uu 2
tou 1
tuu 1
ou ..
(c) (d)
7001+=~=+~~~~~~~~~~+=~~~~~~~~~
6501+-~-+~~~~~~~~~~+-~~~+-~-+~~~ 6501+--+-+-1--l-'-+-~++++-+--+-+-1--l-
600 600t--t--+-t--+-t--+-t--+-f-++~+-+--4--rl-f-+-f-+-f-+-4--1-l
5.0 I
500
450 IIIII
400
350
300 300
~J.X!::
pc
250 250
*f1K
2, tn114f
200 i i
It!>U 150
1 l00
50 tiH I
o I I
Figure 3.9 Serial peak flow readings: (a) normal diurnal variation, (b) increased diurnal variation indicative of chronic
asthma, (c) early morning dip, representing nocturnal asthma and/or impending asthma attack, (d) steroid trial
demonstrating significant reversibility. (From Hubbard, J. (1992) Use of the peak flow meter in asthma, Resp. Dis. Pract.,
9(4). Reproduced by kind permission of Hayward Medical Communications Ltd, 44 Earlham Street, London WC2H 9LA.)
64 Respiratory disorders
in the acute phase, provide sufficient infor- 5. Understanding the action and adminis-
mation for them to understand that preven- tration of drugs, and the importance of
tion is the key, help them identify their own taking preventive drugs, such as
needs and offer some follow-up education. steroids, even when feeling well. At
Collaborative self-management has shown present fewer than half of asthmatics
the following outcomes (Make 1994): take their drugs as prescribed (Couriel
1994b).
• t accident and emergency department 6. Mastering relaxation (Freedberg et al
visits and hospitalization, 1987).
• t medication use, 7. Stress reduction by techniques such as
• t symptoms, biofeedback (Peper 1992), meditation
• t compliance with treatment, (Lehrer et aI1986), hypnotherapy (Mor-
• t quality of life. rison 1988a) or yoga (Singh et al 1990).
Acupuncture can reduce the need for
Education should include the following: medication, and homeopathy is useful if
the trigger is identified (Lewith 1995).
1.Identification of precipitating factors Complementary therapies are reviewed
using a diary (Fig. 3.10) to identify the by Lane and Lane (1991).
individual pattern of asthma, then 8. For those with nocturnal asthma, trying
prevention when possible, e.g. inten- different sleeping positions, room tem-
sive vacuum cleaning and special peratures, drug timings and a stress-
bedding to protect against house dust free period before bed.
mite (Owen et al 1990), avoiding insect- 9. Avoidance of room humidifiers, which
icides, keeping pets out of bedrooms, nurture the house dust mite and collect
avoiding the not-uncommon scenario of moulds.
an inhaler in one hand and a cigarette in 10. Prevention of gastro-oesophageal reflux
the other. (p. 87).
2. For people with stable asthma, twice- 11. Learning the warning signs of an
daily peak flow readings are encour- exacerbation, e.g. reduced exercise
aged, using peak flow diaries available tolerance, waking at night, prolonged
from drug manufacturers. Plans to wheeze after waking, declining or vari-
short-circuit the referral system and self- able peak flows, reduced effectiveness
admit to hospital should be prearranged of bronchodilator.
if the peak flow is less than 40% of 12. Individual written guidelines on how to
the patient's normal after· medication. respond to warning signs, and an
Comprehensive prehospital care can understanding of when to increase drug
reduce asthma deaths to zero (Cochrane dosage, take oral steroids, or seek med-
1995). ical assistance, e.g:
3. For women with a family history of (a) if the peak flow falls < 70% of the
asthma, minimal intake of allergenic patient's normal, take regular bron-
foods during pregnancy and while chodilators and double inhaled ster-
breast feeding, and similar care of the oids,
baby's diet in the first year of life. (b) if the peak flow falls < 50%, start
4. Food exclusion diets in appropriate oral steroids and contact the doctor,
patients, which can reduce medication (c) if the peak flow falls < 40%, seek
by over a half (Lewith 1995). urgent advice (CourieI1994b).
Obstructive disorders 65
ASTHMA DIARY
Times when I felt extra breathless or wheezy
13. Advice for high-risk patients is to keep porarily to compensate for the slow
with them at all times their devices for breath,
self-administration of drugs, informa- • adjust the rate as breathing becomes com-
tion bracelet (BTS 1990) and a note from fortable and there is less hunger for air, a
their GP for ambulance personnel to hunger which will also be modified by
administer unrestricted oxygen. Spare feeling in control,
inhalers should be kept in the car and at • observe and modify any muscle tension,
work. • gradually increase the depth of breathing
14. Joining an organization, such as the in three different segments, progressing
National Asthma Campaign, which upwards from abdominal, lateral costal
provides diary cards and educational and upper chest expansion, then reduce
material (Appendix C). the depth in reverse order,
• recheck muscle tension,
• progress to unsupported sitting and stand-
Breathing techniques ing positions.
Certain breathing manoeuvres can be used to The physiotherapist can start by breathing
aid relaxation and give patients some control. alongside the patient, but the aim is for
Patients can practice them regularly and put patients to recognize their ability to manage
their own condition.
them into practice when an attack is anticip-
ated. The emphasis is on gentle changes in
Exercise
breathing, not deep breathing which can
exacerbate bronchospasm (Lim et al1989). All Asthma and exercise have a difficult relation-
patients should be encouraged to find their ship. Exercise can directly trigger an acute
own forms of relaxation and stress manage- episode, but numerous asthmatic athletes
ment, e.g. the profound relaxation achieved have won Olympic medals, and aerobic
with meditation has shown positive outcomes training, with bronchodilator prophylaxis,
(Fried 1993, p. 234). has shown the following outcomes:
Girodo et al (1992) show how simple • ~ bronchospasm, i peak flow, ~ wheeze
relaxed abdominal breathing can reduce the (Dean et al 1988),
intensity of symptoms and increase physical • ~ breathlessness (Cochrane and Clark
activity. Innocenti (1974) describes how 1990),
patients can gain control by learning to • i work capacity (Gong 1992),
change back and forth between abdominal • i confidence (Robinson et al1992),
and upper chest breathing, and to alter, • ~ exercise-induced asthma by greater fit-
breath by breath, the rate and depth of ness, which reduces minute ventilation
breathing. Weissleder (1976) claims that asth- at high intensity work loads (Cochrane
matic attacks can be aborted by teaching the and Clark 1990).
'complete breath technique', which consists
of the following instructions, with the patient Other physical measures
in supported sitting:
It has been claimed that the inspiratory
• listen to and feel the quality of your muscles can be damaged during an acute
breathing, including any wheeze, attack and that this risk can be reduced by
• inhale through your nose, slowly enough strengthening these muscles. Six months of
to eliminate the wheeze, while increas- inspiratory muscle training, using a pressure-
ing the depth of your breathing tem- threshold device for half-an-hour five days a
Obstructive disorders 67
(Bennett 1991) and oral or intravenous ster- ture points: CV.17 between the nipples, Co.4
oids (Neville et alI991). Antibiotics are rarely on the dorsal thumb web, Li.3 on the dorsal
indicated. space between first and second metatarsals, to
The characteristics of asthma make it sus- be pressed or massaged alternately each side.
ceptible to non-compliance with treatment. It Vibrators over the chest wall can aid
is a chronic condition with long periods of relaxation. Some find it helpful to cuddle a
remission, drug regimes may show no imme- not-too-hot hot water bottle. Some benefit
diate benefit and inhalers are conspicuous from rhythmic slow percussion to help pro-
and sometimes difficult to operate. Education mote relaxation. Other techniques to reduce
that considers the patient's individual needs, the work of breathing are described in
health beliefs and lifestyle is likely to suc- Chapter 5.
ceed, especially with adolescents. Mucus mayor may not be a problem
(Strunk 1993). Slow percussion has the bene-
Physical management of an asthma attack fit of both promoting relaxation and clearing
secretions. If secretions are too thick to shift,
Fear of an acute episode is reduced if the warm humidification with normal saline may
patient is given the following advice: be indicated (Phillips and Millard 1994), but
1. Sit upright, or lean slightly forwards this can increase airflow resistance in children
resting the arms on a table, or sit astride a or those with severe airways obstruction, so
chair backwards with the arms resting on close observation for de saturation or bron-
the chair's back. chospasm is required.
2. Sit near fresh but not cold air. Patients who continue to tire will need
3. Drink sips of warm liquid. mechanical assistance. Low-to-medium levels
4. Breathe through the nose unless breath- of CPAP will relieve the inspiratory muscles
lessness makes this impossible. from their relentless work of holding open the
5. If there is dizziness with tingling hands obstructed airways (Shivaram et al 1987). If
and feet, try to slow down the breathing. CPAP is not available, IPPB can be used to ease
6. Practise previously-learned techniques of the work of breathing. If positive pressure aids
relaxation, abdominal breathing and are needed, the radiograph should be checked
control over breathing. These should be in case of pneumothorax. Mechanical ventila-
begun at the first intimation of an acute tion for asthma is discussed in Chapter 11 and
episode. asthma in children in Chapter 12.
7. Raise the resting respiratory lung volume
by starting inspiration slightly early, 3.2.5 Bronchiectasis
which may help to open the narrowed
airways (Innocenti 1974). The extra elas- Bronchiectasis is characterized by chronic
tic work imposed by hyperinflation is irreversible dilatation and distortion of the
offset by less airflow resistance so that bronchi. This originates from an inflammat-
total work is reduced (Wheatley 1990). ory insult, e.g.:
However, many patients will have • inhalation of unwanted material such as
already achieved optimal hyperinflation gastric contents or a peanut,
spontaneously, and close observation of • severe respiratory infection, particularly if
the patient's breathing pattern is required repeated.
if this technique is chosen.
The incidence of bronchiectasis is di-
Relatives can be shown how to apply minishing in countries where living stand-
acupressure to the bronchospasm acupunc- ards are rising and children are vaccinated
Obstructive disorders 69
DAMAGED AIRWAYS
(bronchiectasis)
~ ~
Airways _ _ _ _ _ _
Inflammation
)
obstruction
~ Bronchospasm
Infection
thick mucus
t
ABNORMAL GENE
(cystic fibrosis)
against diseases such as whooping cough ous quantities of purulent sputum are pro-
and measles. duced, sometimes with haemoptysis caused
The pathophysiology involves destruction by mucosal ulceration. Radiological signs, if
of the elastic and muscular components of present, are usually localized, showing paral-
the airway walls. This is most damaging if it lel tramlines representing thickened airway
occurs in early childhood before the respirat- walls and cystic ring shadows representing
ory tract is fully developed. The warm, moist dilated airways seen end-on. There may be
environment within the lung combines with patchy areas of overinflation, consolidation
excess mucus to set up a vicious cycle of and atelectasis.
infection, destroyed cilia, disorganized air- Medical treatment is based on the liberal
ways, persistent inflammation and further prescription of antibiotics, which help control
obstruction (Fig. 3.12). Infection and inflam- infection but not the persistent inflammation
mation release toxic chemicals which inter- which may be progressively destroying the
fere with lung defences. Inflammation can airways (Shum et al 1993). Other drugs are
cause bronchospasm, which augments the inhaled steroids, which reduce inflammation
cycle. The process may be complicated by and the volume of sputum (Elborn et aI1992),
abscess formation. A third to a half of and bronchodilators for patients with
patients show progressive destruction demonstrable hyperreactive airways. Surg-
(Munro 1992), leading to pulmonary hyper- ical resection is occasionally indicated for
tension and cor pulmonale. localized and disabling disease.
Clinical features include coarse wheezes Physiotherapy is by education in sputum
and crackles, due to secretions and collapsing clearance. Hydration must always be
airways on expiration (Piirila et al 1991), attended to, and an exercise programme may
finger clubbing, dyspnoea and fatigue. be sufficient for moderate disease, but other
Coughing is less efficient than normal measures (Chapter 5) are needed for most
because of corrugated airways, but volumin- patients. Much encouragement is needed to
70 Respiratory disorders
help patients set up a life-long programme then become caught up in a vicious cycle that
that is both effective and suited to their is similar to that in bronchiectasis (Fig. 3.12),
lifestyle. Thereafter occasional checks are but set off by tenacious mucus which encour-
needed. ages bacterial adherence. CF is progressive,
whereas the course of bronchiectasis varies.
3.2.6 Cystic fibrosis (CF) Infection is commonly caused by bacteria,
but viruses and fungi play undervalued roles.
CF is a chronic progressive obstructive dis- The patient's own inflammatory mediators
order affecting the exocrine glands. It is the directed against the colonizing organisms not
commonest lethal inherited disease among only fail in their task, but actually cause
white people. It is acquired as an autosomal tissue breakdown, a by-product of which is
recessive disorder, so that only people who excess DNA within the cells, leading to even
have two faulty genes - one from each parent thicker secretions. The viscid mucus, instead
- develop the disease. Two carriers have a of helping clear bacteria, impairs defence,
one-in-four chance of having an affected baby and intractable infection becomes established
and a two-in-four chance that a baby will be a in early life, leading to a smouldering course
carrier. The pattern of CF management has of bacterial colonization punctuated by
been changed by identification of the rogue exacerbations.
gene, prenatal diagnosis and transplantation. The range of bacteria is curiously re-
A child born with CF in the 1990s is expected stricted, but Staphylococcus aureus causes signi-
to survive to middle age, but the disease is ficant damage, and acquisition of Pseudomonas/
still eventually fatal, and treatment is aimed Burkholderia cepacia poses a particular threat
primarily at improving the quality of life. because the organism is unresponsive to
With skilled management, a high proportion many antibiotics and its presence may herald
of adults live fulfilled lives. The diagnosis is rapid deterioration and premature death
suspected if infants show failure to thrive or (Govan et al 1993). Preventive measures
repeated chest infections. Suspicions are against cepacia include segregation and mini-
heightened if a blood test reveals increased mal social contact, at great personal cost for
levels of the antibody IRT (Harris 1991), and those who have previously socialized freely.
confirmation is by a test for abnormally salty Even sibling separation is tolerated by some
sweat. families.
Aggravating factors are inflammation,
Pathophysiology
especially in severe disease, and broncho-
In most cells the abnormal gene is dormant, spasm. Malnutrition contributes to impaired
but in epithelial cells it is switched on. This respiratory defence and is related to deterior-
impairs ion and water transport across epi- ating lung function, leading to a spiral of
thelial surfaces of the body, causing dehydra- decline in both. Pneumothorax occurs in up
tion of secretions and obstruction of various to 10% of children and 20% of adults, due to
body lumens. In the gut there is malabsorp- rupture of a subpleural bleb or bulla (Noppen
tion secondary to pancreatic insufficiency, et aI1994).
and in the lungs sodium and chloride ions As more patients are surviving to adult-
cannot escape from the epithelial cells into hood, new clinical difficulties have arisen.
the airways in order to maintain hydration of Liver and gall bladder problems develop,
mucus, which becomes thick and sticky. pancreatic fibrosis can lead to diabetes and
The respiratory component determines the dehydration, and vasculitis can affect joints,
quality of life and is the usual cause of death. skin and brain. Bronchial artery hypertrophy
The lungs are structurally normal at birth, may lead to pulmonary haemorrhage. Respir-
Obstructive disorders 71
atory and cardiac failure eventually super- their child is unlikely by adolescence to have
vene. a mother.
In later stages, FEV1 declines, Pa02 falls
Clinical features and eventually PaC02 rises. The inexorable
deterioration is anticipated by patients, who
Coughing and spluttering like an old man does each respond in their individual way. They
not endear one to the general public, and neither often form strong attachments to each other,
does the popular misconception that one is which provide comradeship but can be
scattering infections round like confetti ... My devastating when one of them dies.
fingers are like spoons and I can't wear nail
polish ... It doesn't do too much for one's Medical management
confidence to know that one has probably got
halitosis - so I tend to talk to people sideways Prevention Screening is possible at three
on . .. stages. Carrier screening helps when making
Hall 1984 decisions about reproduction, and if two
carriers want to have a child, they can be
This fictionalized account of the experience of offered in vitro fertilization, genetic screening
CF underlines the antisocial nature of the and implantation of a healthy embryo. Pre-
disease. Clinical features include incessant natal diagnosis provides information on
coughing, delayed puberty, flatus, increasing which to base decisions about continuing a
breathlessness and relentless weariness. pregnancy. Neonatal screening leads to early
Breath sounds are clear in the early stages, diagnosis and more effective treatment.
becoming wheezy as a bronchiolitis-like pro- Screening usually occurs only after the birth
cess develops in the small airways, then of the first, unexpected, cystic child or if there
exhibiting widespread crackles. Other signs is a family history of CF.
are similar to bronchiectasis, with the addi- Research into gene therapy is proceeding
tion of small stature and sometimes hepato- at a dizzy pace and if successful could
megaly and GOR. Growth is stunted because provide a virtual cure for the disease by
of energy imbalance, energy supply being halting it in its tracks. The accessibility of the
reduced by malabsorption and often anor- airway makes CF suitable for gene therapy,
exia, and energy demand increased by excess which involves inhalation of a normal copy of
work of breathing. The fact that patients do the gene to sufficient lung epithelial cells to
not often look ill means that they have to replace the defective gene. Treatment would
cope with others not expecting them to suffer be required monthly because of the turnover
fatigue and other invisible problems (Eigen of these cells, and the damage that had
et aI1987). already occurred would not be reversible.
The radiograph is normal at first, then
shows patchy opacities in the apical regions, Education When a baby with CF is born,
then signs of widespread bronchiectasis,
education for the parents should begin imme-
emphysema and, finally, cor pulmonale. If diately:
chest pain occurs, it may be due to pleural
inflammation, strain from excessive coughing • no smoking in the home,
or pneumothorax. Exacerbation is indicated • CF children are of normal intelligence and
by weight loss or worsening respiratory signs should go to normal schools,
and symptoms. • within their limitations they should take
Males are sterile. Women can have chil- part in normal physical activities,
dren at some medical risk to themselves, but • they are not infectious,
72 Respiratory disorders
• they should share with their healthy Nutrition Malnutrition is associated with
siblings the disciplines and standards of poor survival (Heijerman 1993). Nutritional
the family, support is essential in childhood to prevent
• the lifelong treatment routine is time con- impaired growth, and a calorie intake up to
suming, and preplanning can ensure 150% of normal is the goal. Enzyme supple-
attention for siblings and prevent isola- ments are usually required throughout life to
tion for the family. make up for pancreatic insufficiency. Supple-
mentary feeds may be used in advanced
Self-help groups are valued by adolescents, disease.
young adults and parents.
Surgery Pneumothoraces are managed by
Medication At present the backbone of chest tube drainage if minor, but recurrent
medical management is an unremitting on- pneumothoraces require thoracoscopic pleur-
slaught against bacterial infection. Antibiotics odesis (Noppen et al 1994). More intrusive
are used aggressively, but complete eradica- intervention precludes future lung trans-
tion of infection is impossible. High doses are plants because of pleural adhesions.
required to compensate for difficulty in reach- Transplantation of heart, lung and/or liver
ing the lung through areas of poor perfusion can transform a chair-ridden patient into an
or obstructed airways. Access is by peri- active individual within weeks of the opera-
pheral or central venous line or subcutaneous tion. Most of the pulmonary problems of CF
venous reservoir (Davies et al 1991), often can be eliminated because donor lungs do not
managed from home with back-up support. have the genetic abnormality. But the
Nebulized antibiotics are preferred by some obstacles are formidable, including the stress
patients, but are time consuming, polluting of waiting, life-long immunosuppressive
and variable in effect (Mukhopadhyay et al drugs for the successful, and dashed hopes
1994). for the unsuccessful (Whitehead and Leval
The drug DNase is a clone of the gene 1994). Selection criteria include life expect-
responsible for breaking down DNA, and ancy < 2 years, oxygen dependence, FEV1
when given as an aerosol can reduce secre- < 30% predicted, cor pulmonale and high
tion viscosity and improve pulmonary func- motivation. The availability of transplanta-
tion by 10-15% (Hardy 1993). It is also tion has raised difficult moral issues. Gentle
helpful if there is intractable atelectasis (Shah palliative management may now be sup-
et al 1994). Aerosolized alpharantitrypsin planted by vigorous gastrostomy feeding,
helps replenish the patient's defences (Briars mechanical ventilation and other heroics to
and Warner 1993). Aerosolized amiloride, a keep an increasingly desperate patient alive.
sodium channel blocker, helps restore Patients must be free to make their own
normal hydration to secretions but requires choices, especially in the later stages.
up to four treatments a day and has been Options include nocturnal oxygen therapy
challenged as no better than inhaled saline (Coates 1992), nasal ventilation (Regnis 1994)
(Middleton et al 1993). Anti-inflammatory or palliation.
therapy may reduce the inflammation asso-
ciated with infection (Konstan et al 1990). Physiotherapy
Asthma is often present, and bronchodilators
improve lung function if hyperreactivity can Once cystic fibrosis has been diagnosed,
be demonstrated (Eggleston 1991). Mucolytic physiotherapy is started immediately, with
drugs are considered ineffective in CF (Fiel the intention of minimizing the cycle of
1993). excess secretions and airway damage. Physio-
Obstructive disorders 73
therapy is the most gruelling and least (Abbott et al 1994). It usually complements
tolerated aspect of treatment and shows other techniques, but in less severe cases can
adherence rates below 50% (Abbott et al be the primary treatment (Andreas son et al
1994). Daily treatment regimes produce no 1987). Patients with severe disease are less
immediate improvement in well-being, and likely to benefit, partly because of fatigue and
sputum is the only reinforcement to encour- partly because little extra tidal volume can
age this repetitive task. Parents of CF chil- be superimposed on hyperinflated lungs.
dren are compliant with treatment, but less Swimming is especially beneficial, but
than half of CF adults believe physiotherapy patients should choose their favourite
to be effective (Fong 1994), and some physio- activity, which may be trampolining for
therapists consider that it is not necessary for children and weight-lifting or jogging for
all patients (Samuels et alI995). Treatment to adults.
clear secretions is best individualized accord- Exercise training has the added benefit of
ing to patient preference, and should achieve improving breathlessness, well-being, clin-
maximum effectiveness with mInimUm ical status and lung function (Dodd 1991). For
burden on an already stressed family. training, patients exercise to a pulse rate of
Physiotherapy should take place after any 50-75% of that obtained during maximum
prescribed bronchodilator treatment to open exercise capacity, with the duration and
the airways, and before nebulized antibiotics frequency tailored to the individual but aim-
to encourage absorption through mucus- ing at a minimum 30 minutes four times a
filled airways. Details of sputum clearance week. Successful exercise training requires
techniques are in Chapter 5, with aspects regular contact with a physiotherapist and
specific to CF outlined below. commitment from patient and family.
Positive expiratory pressure, the active Inspiratory muscle endurance is normally
cycle of breathing techniques and autogenic elevated because of the extra work required
drainage are popular because they allow to breathe through obstructed airways, but it
independence. has been claimed that inspiratory muscle
If postural drainage is the chosen treat- training improves exercise tolerance (Sawyer
ment, drainage time is about 15 minutes in and Clanton 1993).
younger children, more in older patients or Interesting data have emerged suggesting
if there are excessive secretions. Length of that abdominal breathing with biofeedback
time depends on fatigue, patient preference, can reduce airways obstruction (Delk et al
whether there are scant or copious secretions 1993).
and the effectiveness of other measures. The optimal frequency for physiotherapy is
History and symptoms should be checked for not known (Eigen et alI987), but it is usually
GOR, because the head-down postural performed twice daily, with variations
drainage position exacerbates symptoms and depending on quantity of secretions and
should be avoided (Button et al 1994). Per- whether there is remission or exacerbation.
cussion and vibrations can be included if Treatment is best continued until sputum is
they produce more sputum or the patient no longer expectorated or a rest is needed.
finds them effective. Some authorities Both parents should be given advice and
consider them unnecessary (Sutton et al support until children are able to manage
1985), but the combination of all three tech- themselves, with a check on treatment tech-
niques has shown positive outcomes (Reis- niques every three months. Early independ-
man 1988). ence should be encouraged, with young
Exercise has the advantage that most children actively participating in their treat-
patients enjoy it and will actually do it ment, and lO-year-olds encouraged to stay
74 Respiratory disorders
with friends overnight and do their own Measures to prevent cross-infection include
treatment. Older children are advised against separate treatment areas, scrupulous hand
cough suppression, by which they some- washing, single patient use of PEP and flutter
times conceal their illness from peers. devices and the covering of sputum pots.
The 'best' treatment is not always the most Longer life spans mean that osteoporosis is
effective in the teenage years, when it may emerging as a problem in young adults
not be followed. Management is best nego- (Bachrach et al1994), sometimes represented
tiated, with the physiotherapist 'complying' by increased kyphosis. Loss of bone mineral
with the patient's wish rather than the other is due to steroids, chronic respiratory acidosis
way round. People with CF are particularly and, for older patients, the limited diets that
worth listening to because they are medically were advised in the past.
streetwise and understand much about their It is not known if short periods of oxygen
treatment. When patients are hospitalized, de saturation are harmful, but those with an
motivation is enhanced by simple measures FEVl < 50% predicted are likely to desaturate
such as offering a choice of treatment times during exercise. They need supervised exer-
and techniques. cise testing and should exercise at a level that
avoids desaturating by more than 5% or an
Outcome measures are based on quality-of-
absolute level below 80% (Dodd 1991). In
life measures such as exercise tolerance,
advanced disease, added oxygen allows
questionnaires or well-being scales (Oren-
longer periods of exercise and may limit
stein and Kaplan, 1991).
pulmonary hypertension (Marcus 1992).
Fluids and free access to the salt shaker are
Precautions needed in hot weather because of the high
Patients should not be prevented from salt concentration in sweat.
coughing, but also not exhorted unnecess-
arily, because excessive coughing causes 3.2.7 Primary ciliary dyskinesia
collapse of central airways with impairment
Primary ciliary dyskinesia is often misdiag-
of sputum clearance (Zapleta et al1983), and
nosed as CF. It is an inherited condition
may accelerate emphysematous changes. The
characterized by an uncoordinated and in-
active cycle of breathing provides a more effectual ciliary beat, causing recurrent infec-
controlled means of sputum clearance, tion of ears, sinuses and lungs. It is suspected
although it still causes a degree of airway in children with a perpetually runny nose,
closure. glue ear and frequent chest infections. Regu-
When using CP AP or nasal ventilation lar physiotherapy delays the onset of
(Chapter 5), high pressures are not necessary bronchiectasis (Baum 1990).
for respite from fatigue and should be
avoided because of the risk of pneumothorax.
If haematemesis develops from oesoph- 3.2.8 Allergic bronchopulmonary
ageal varices associated with liver cirrhosis, aspergillosis
all physiotherapy, except abdominal breath- Aspergillosis is an infection manifesting
ing, is contraindicated until bleeding is mainly in the lung as allergic broncho-
controlled. pulmonary aspergillosis, which is an allergic
Blood streaking of sputum is common in reaction to the Aspergillus fungus. It occurs in
CF and should be disregarded, but frank 10% of people with CF, up to 20% of
haemoptysis should be reported and physio- asthmatics and often in cavitating lung dis-
therapy temporarily halted. eases, such as TB.
Restrictive disorders 75
Patients present with malaise, weight loss, hypoxaemia persists despite 40% oxygen
fever, haemoptysis and a cough productive (Brett and Sinclair 1993). There is overlap
of brown, rubbery mucus casts sometimes in between different types of pneumonia, but
the shape of the bronchial tree. The disorder the usual classifications are described below,
may continue for years with episodes of with an explanation of modified physiother-
pulmonary infiltration and wheezing, some- apy when appropriate.
times leading to fibrosis and cor pulmonale.
Treatment is by inhaled steroids (Seaton Bronchopneumonia
1994), antifungal agents delivered broncho-
scopically or percutaneously, or for those Bronchopneumonia is patchy and scattered,
with adequate lung function, surgical re- often favouring the lower lobes. It is common
section Gackson et al 1993). in the immobile and elderly. Early signs are
dullness to percussion and barely-perceptible
fine crackles which persist despite deep
3.3 RESTRICTIVE DISORDERS breathing. Physiotherapy is based on hydra-
tion and early mobility. Other measures may
3.3.1 Pneumonia be needed to increase lung volume or
Pneumonia is acute inflammation of lung improve gas exchange. When the disease is
parenchyma, which fills alveoli with inflam- resolving, some patients need assistance or
matory products, creating consolidation. advice to clear secretions.
When alveoli are filled with something other
than air, this is termed consolidation. The Lobar pneumonia
precipitating factor for pneumonia is a breach When pneumonia is confined to a lobe,
in lung defences by infective or chemical localized pleuritic pain and bronchial breath-
agents. The disease is a common cause of ing are added features. Physiotherapy is as
death because of its predilection for the above plus relief of pain, for example, by
elderly and immunosuppressed. Other risk transcutaneous nerve stimulation.
factors are heart disease, acute stroke, poor
nutrition, smoking and alcoholism. Pneumocystis carinii pneumonia (PCP)
Clinical features are fever, chills, breath-
lessness and often dehydration. If localized, If a person's defence mechanisms are weak-
the affected area shows decreased expansion, ened by HIV or medication given after organ
a dull percussion note, bronchial breath transplant, he or she is vulnerable to oppor-
sounds, opacity on X-ray and sometimes a tunist infection by organisms that are not
pleural rub. There may be a dry cough at normally pathogenic. PCP is a manifestation
first, which can become productive of puru- of this and is a common first AIDS-defining
lent and sometimes rusty blood-stained spu- illness in people with HIV, especially in those
tum. The structure of the lung is preserved who smoke.
and complete resolution is possible, although Invading organisms damage the alveolar
sensitized nerve endings sometimes leave a lining, and a foamy exudate interferes with
dry, irritating cough. gas exchange. Clinical features include a dry
Treatment is by oral or intravenous fluids, cough, breathlessness, hypoxaemia and the
oxygen if indicated and antibiotics if there is features of stiff lungs. Patients are wasted
bacterial infection. In the acute stage when from diarrhoea, malabsorption, dysphagia
consolidation is not yet resolved, physio- and mouth ulcers. They mayor may not
therapy is limited to positioning for VAIQ be pyrexial, because immunocompromised
matching (p. 111) and sometimes CPAP if people cannot always mount a fever in
76 Respiratory disorders
response to infection. Some pa.tients may be test is oxygen de saturation during exer-
reluctant to take a full inspiration in case it cise (Chouaid et aI1993).
brings on coughing or pleuritic pain. Auscul- 2. Physiotherapists may be involved in
tation may be normal or show fine scattered administering nebulized drugs to the
crackles. The radiograph may be normal at lung parenchyma. A nebulizer is needed
first, if immune deficiency delays the appear- that can deliver particle sizes of 2-5 J.Lm
ance of an inflammatory response, but later and incorporates a filter to reduce en-
signs are a perihilar haze, progressing to dif- vironmental contamination. The room
fuse symmetrical shadowing and air broncho- needs an extractor fan or venting system.
grams (Fig. 2.10). Reduced peak flows some- It is best that patients lie down to ensure
times indicate a degree of bronchospasm. that the upper lobes are not excluded
Sudden deterioration raises suspicions of a (Thomas et al 1990). The side-effects of
pneumothorax. coughing and bronchospasm can be
Drug treatment is most effective if started reduced by prior bronchodilator inhala-
early. High-dose steroids, co-trimoxazole or tion (Harrison and Laube 1994).
pentamidine are given. 3. Patients need support when in the grip of
acute breathlessness because they are
Physiotherapists are involved in the
intensely frightened and often think that
following ways:
they are dying. Physical assistance is
1. Diagnostic procedures, such as bron- described on p. 154. Positioning depends
choscopy, can be avoided by using the on the patient's choice, but when breath-
more comfortable technique of inducing lessness is severe, minimal handling is
sputum from the lower respiratory tract preferred. Reassurance can be given
for analysis. After starvation and mouth because although AIDS patients know
cleaning to reduce oral contamination, that they have a fatal disease, death
20-30 ml of hypertonic (3-5%) saline is rarely occurs during episodes of acute
ultrasonically nebulized over 10-20 breathlessness.
4. Help with mobilization may be needed
minutes. This irritates the airways to
because of weakness.
produce secretions, and the hypertonic-
5. Immune function can be improved by
ity of the saline draws water into the
relaxation and exercise which incorpor-
airways (Miller et aI1991). The patient is ates endurance and strengthening (Lang
asked to breathe through an open mouth 1991).
during nebulization, to take occasional 6. Neuropathic pain can be relieved by
deep breaths and gargle with sterile massage, which is especially important in
water before coughing so that oral patho- this group of people, to whom touch is
gens do not contaminate the specimen. still sometimes denied.
Side-effects are bronchospasm, breath- 7. CPAP (p. 115) at pressures of 5-10 cmH20
lessness, oxygen desaturation and nau- improves gas exchange in patients with
sea. TB is common in patients with HIV, severe PCP (Miller and Semple, 1991)
and a well-ventilated room is needed to and buys time for discussion with the
minimize cross-infection from coughing. patient about further treatment. If
Ideally, two sputum specimens are necessary, some patients may choose
obtained because the second is thought mechanical ventilation while antimicro-
to originate from deeper in the lung. The bial drugs have time to work. Ventilated
sputum should be clear, non-purulent patients with PCP rarely have a secretion
and resemble saliva. A simpler diagnostic problem, and physiotherapy is based on
Restrictive disorders 77
asymptomatic or toxic, depending on the ical stress than the base because the weight of
offending organism and volume of pus. Early the lung pulls down on it. A spontaneous
intervention for acute empyema reduces the pneumothorax often occurs in this region,
risk of chronicity and protracted treatment. especially in tall, thin young men who are
Local and systemic antibiotics are indicated. thought to grow faster than their pleura is
Pus can be drained and the lung re-expanded able to keep up with. Although 'spontan-
by continuous drainage into an underwater eous', many patients are smokers and have
seal system (p. 192) or, for easier mobility, blebs on X-ray (Light 1993).
into a drainage bag. The pus may be thick
and require aspiration with strong suction or Secondary pneumothorax A pneumo-
lavage. Other options are open drainage with thorax may occur secondary to puncture from
rib resection, or for an established empyema a fractured rib, inaccurate insertion of a
with a thickened pleura, a full thoracotomy cannula, high-volume positive pressure vent-
with decortication (Kaplan 1994). Patients ilation, or rupture of an emphysematous
needing surgery are often malnourished and bulla.
debilitated.
Tension pneumothorax A pleural tear
sometimes functions as a valve so that air
3.3.5 Pneumothorax
enters the pleural space but cannot escape,
When the pneumothorax happened I was totally causing a pneumothorax under tension.
conscious of the puncturing of the thorax, the Increasing pressure displaces the media-
unbearable pain, the cold sweat, being afraid stinum and impairs venous return, causing
that the final moment would come quicker than respiratory distress and circulatory collapse.
the help that you could give me. Recognition and management is discussed on
Ruiz 1993 p.263.
of pleural air fourfold (Light 1993). Recur- X-ray shows apparent hyperinflation because
rence is less likely if sclerosing agents the chest wall becomes fixed in an inspiratory
are instilled through the chest drain. Sur- position.
gical intervention (p. 185) is necessary if these If a patient has generalized muscle weak-
measures fail or if the condition is bilateral. ness, this usually involves the respiratory
Physiotherapy is based on mobilization muscles. Respiratory muscle weakness may
and regular position change. Lying on the go undetected if limb weakness reduces
side of the pneumothorax may help seal the mobility, and ventilatory failure may arrive
leak and facilitate lung expansion (Zidulka et unexpectedly (Tobin 1988). The most
alI982), but this is uncomfortable if there is a important step in assessment of inspiratory
chest drain, and might cause de saturation muscle weakness is to think of it as a
with a large pneumothorax because of VAIQ possibility.
mismatch (p. 111). Bilateral paralysis or severe weakness of
Mobilization should be particularly rigor- the diaphragm show the following signs:
ous if the cause is, for example, a stab wound
(Senekal 1994), but not too enthusiastic • orthopnoea unexplained by heart disease,
immediately after surgery in case the pleura • accessory muscle activity unexplained by
becomes unstuck. lung disease,
Precautions include avoidance of positive • paradoxical inward abdominal motion
pressure techniques (CPAP, intermittent posit- during inspiration, especially in supine
ive pressure breathing or bag-squeezing) if when the impaired diaphragm is unable
there is no chest drain. to counteract the weight of the abdom-
inal contents,
• postural fall in VC of about 50% in supine
3.3.6 Neuromuscular and skeletal compared with upright (Tobin and Yang
disorders 1990),
• symptoms of nocturnal hypoventilation,
Impairment of respiratory drive, muscle such as disturbed sleep, morning head-
power or rib cage mechanics restricts expan- ache and daytime somnolence,
sion and reduces vital capacity. These con- • less-specific symptoms, such as breathless-
ditions may also impair secretion clearance ness or recurrent chest infections.
because of a weak cough and reduced mech-
anical movement of the lung (Mier et alI990). Bilateral diaphragmatic paralysis is like
removing a portion of the chest wall. When
Pathophysiology and clinical features upright, patients exhale by contracting the
abdominal muscles, which push up the
Skeletal disorders such as kyphoscoliosis diaphragm, then relaxing them to allow
upset the configuration of the diaphragm and passive inspiration. Breathing difficulties
force it to work from an inefficient position worsen during sleep.
against the load of a stiff chest wall. Unilateral diaphragmatic p~ralysis shows
Ankylosing spondylitis is a systemic dis- nocturnal hypoxaemia due to V AIQ mismatch
ease which affects breathing because of a in supine, unilateral abdominal paradox on
rigid thoracic cage and kyphotic spine. Chest sniffing, and one raised hemidiaphragm on
wall compliance is impaired, but lung com- X-ray, this last sign being more obvious than
pliance and diaphragmatic movement are with bilateral paralysis.
preserved, although occasionally fibrosis and Severe cases of neuromuscular and skeletal
bullous disease damage the lung. The chest disorders may lead to type II respiratory
82 Respiratory disorders
reexpanded by cryotherapy, laser resection, so long as the correct antibiotic is given and
localized radiotherapy, stenting to splint positioning is accurate and thorough to avoid
open the airway or a combination of these dissemination of infection.
(Rudd 1994). Stenting may cause an irritating
cough, which can be eased by nebulized
bronchodilators. 3.4.3 Sleep apnoea
A spreading tumour may obstruct the Sleep apnoea occurs when breathing stops
superior vena cava, causing oedema, head- for periods of more than 10 second~ during
ache, difficulty breathing, sometimes stridor sleep. Nocturnal oxygen saturation may drop
and faintness on bending down. Drugs, to 75%, which stimulates the cortex, and the
radiotherapy and raising the head of the bed subsequent arousal is accompanied by spec-
may temporarily relieve the symptoms. tacular snoring. A typical night includes 300-
Kaposi's sarcoma (KS) is a vascular tumour 400 such events (Davies and Stradling 1993).
which affects the skin and connective tissue, The patient's quality of life is affected by
and occurs in immunocompromised people. morning headaches due to CO2 retention,
Pulmonary KS affects the parenchyma, daytime sleepiness, poor concentration and a
lymph nodes or pleura, and manifests as disgruntled spouse. The condition may lead
hypoxaemia, pleural effusion, nodular signs
to respiratory failure, cor pulmonale, and
on X-ray, breathlessness and sometimes res-
pulmonary and systemic hypertension (Okabe
piratory failure. Up to a quarter of people
1995). It often goes unrecognized, and phy-
with AIDS develop KS (Miller et al 1992),
siotherapists may be the first to suspect the
representing late-stage disease and a poor
condition. Sleep apnoea is less common in
prognosis.
Mesothelioma arises in the mesothelial women, possibly because progesterone is a
respiratory stimulant. Ten per cent of patients
cells of the peritoneum, pericardium or
pleura. It is caused by asbestos exposure and with sleep apnoea have COPD, usually those
is always fatal. In the pleura it is associated with the blue bloater pattern (Chaouat 1995).
with malignant pleural effusion and chest The condition is exacerbated by smoking
pain. (Wetter 1994) and high alcohol intake (Jalleh
Physiotherapists may be involved at any 1993).
stage of cancer from sputum induction (Kha- Obstructive sleep apnoea (OSA) is due to
jotia 1991) through surgery to care of patients nocturnal upper airway obstruction despite
in the terminal stages. Weakness and fatigue respiratory effort, and worsens as the night
are common accompaniments to the disease progresses (Charbonneau 1994). It is the
and its various treatments. commonest form of the condition and is
usually associated with obesity, which vir-
tually chokes patients in their own fat when
3.4.2 Abscess muscle tone wanes at night.
Lung abscess is a focal collection of pus Restrictive sleep apnoea occurs in people
within the lung parenchyma, caused either whose breathing is already impaired by
by inhalation of septic material or airway disorders such as scoliosis, ankylosing spon-
blockage. It leads to cavitation and necrosis. dylitis or diaphragmatic paralysis. For those
Patients may have a swinging pyrexia, and who have little respiratory reserve, the
the X-ray often shows a ring shadow and normal inhibition of accessory muscle action
fluid line (Fig. 2.12). Medical treatment is by during sleep leads to apnoea.
antibiotics. Physiotherapy is effective if the Central sleep apnoea is caused by abnormal
abscess is open, postural drainage being safe central nervous system control of breathing,
84 Respiratory disorders
THANK you
Associated conditions include the Pickwick-
ian or obesity-hypoventilation syndrome,
which is a severe form of OSA seen in
markedly obese people, and nocturnal hypo-
for
tv OT SNORI NG.
ventilation which is an exaggeration of the
normal reduction in respiratory drive at night
but is not the same as sleep apnoea.
Diagnosis of sleep apnoea used to be a
rarified activity in a few specialized centres,
but is now commonly made from symptoms,
history and sleep studies in hospital or at
home. Sleep apnoea can worsen in hospital
because of sedative drugs, the supine
position and sleep deprivation.
Management of OSA is firstly by weight
loss, alcohol and smoking cessation, and
avoidance of sleeping supine. Nocturnaloxy-
gen therapy is usually unhelpful (Stewart
and Howard 1992).
The upper airway can be splinted open
pneumatically at night with CPAP, using
suggested pressures of 7.5-2.5 cmH2 0 (Mil-
jeteig and Hoffstein 1993). CPAP relieves
symptoms and can reverse other problems
associated with OSA, such as impotence and strategies to avoid falling asleep while
Cheyne-Stokes breathing, as well as acting as driving.
a catalyst to weight loss which itself may
allow discontinuation of the CPAP (Bradley 3.4.4 Inhaled foreign body
1993). Education and attention to comfort are
necessary to ensure compliance with CPAP. Inhaled objects usually find their way into the
Some patients who cannot tolerate CPAP right lung because of the more vertical
manage with various contraptions, such as a direction of the right main bronchus. Clinical
nasopharyngeal airway, tongue retainer or signs include stridor and, if there is complete
mandibular positioning device. More invas- obstruction, atelectasis due to absorption of
ive options include tracheostomy, which is trapped air. The occasional brave physiother-
poorly tolerated, reconstructive surgery, apist may attempt to remove the object with
which is often disappointing, and laser ther- accurate postural drainage (Crogan 1991) but
apy, which is showing some success (Mac- most avoid this because of the risk of shifting
Dougald 1994). the offending object to a more dangerous
Central sleep apnoea may be helped by location. More usually the foreign body is
drugs to reduce REM sleep or stimulate removed by bronchoscopy, following which
respiration, supplemental CO2 therapy (Badr there may be inflammatory secretions or
et al 1994) or nocturnal nasal ventilation localized collapse that need attention from
(Bott et al 1992). All patients must devise the physiotherapist.
Other disorders 85
3.4.5 Pulmonary tuberculosis (TB) heart rate and BP (Fried 1993). Specific
disorders are discussed below.
TB is not a disease of the past. The incidence
is now increasing in the UK and USA, and
Cardiovascular disease
new drug-resistant strains are emerging.
One-third of the world's population is Neighbourly relations between heart and
infected by the TB bacillus, which may lung are reflected in their integrated response
become active if the host's defence mechan- to each other's disorders, especially when
isms are compromised by, for example, poor intravascular pressures are affected.
living conditions or HIV infection. The HIV Heart failure is the inability of cardiac
pandemic has added a new dimension to TB, output to meet the body's metabolic
which is the only disease likely to be trans- demands. It is not a diagnosis in itself but a
mitted from AIDS patients to the community. response to heart or lung disease or heart
TB of the lung is the commonest form of surgery. It may be acute or chronic and is
the disease, causing three million deaths a suspected if a patient with predisposing
year, which is more than any other infection factors develops fatigue, breathlessness or
(Empey 1993a). Coughing disseminates
oedema. Survival rates are lower than for
infected aerosol, which can remain sus-
many cancers (Dargie 1994). Left ventricular
pended in the air for hours. Symptoms are
failure (LVF) is the commonest reason for
fever, night sweats, cough, haemoptysis and
breathlessness. The X-ray may show cavitat- heart failure and is usually caused by coron-
ing lesions, especially in the apices, and for ary heart disease. The failing left ventricle
miliary TB, scattered small nodules. forces up pressure in the left atrium and the
The tubercle bacillus is slow growing and pulmonary vascular system behind it, lead-
tough, needing six months of treatment with ing to pulmonary oedema (extravascular
a combination of powerful antibacterial water in the lungs). Interstitial pulmonary
drugs. The patient is no longer infectious oedema barely affects lung function, but if
after two week's treatment providing the the lymphatics become overloaded, fluid is
sputum is clear of bacillus. The physiother- squeezed into the alveoli, causing alveolar
apist's role is usually confined to eliciting oedema, a widened PA-a02 gradient and
sputum specimens and devising ways to hypoxaemia. Non-cardiogenic pulmonary
encourage exercise in an isolation cubicle. loedema can be caused by fluid overload or
Some patients may need help in bringing up increased capillary permeability due to shock
secretions. Simple paper or cloth masks are or severe infection, independent of left heart
not adequate; large pleated masks should be function.
worn and changed between patients (Philips The main symptom of LVF with pulmon-
1992). ary oedema is breathlessness caused by
stimulation of J receptors, leading occasion-
ally to a misdiagnosis of asthma, from which
3.4.6 Pulmonary manifestations of
the confusing term 'cardiac asthma' has
systemic disease
arisen. Breathlessness due to pulmonary
The respiratory system is influenced by most oedema is distinguished by orthopnoea and
systemic disturbances, e.g. fever increases paroxysmal nocturnal dyspnoea. Fine
minute volume, anaemia hinders oxygen crackles are heard on auscultation at the lung
delivery, metabolic acidosis or alkalosis bases due to the popping open of alveoli
affects breathing and malnutrition pre- squashed by peribronchial oedema. The X-
disposes to infection. Breathing itself affects ray shows an enlarged heart and the signs
86 Respiratory disorders
described on p. 43, which are often apparent severe cases, embolectomy. It is unlikely that
before clinical signs. any physiotherapy treatment could dislodge
Treatment of LVF is by dealing with the the clot and, if so, the clot would move safely
cause where possible, plus oxygen, veno- with the blood flow into a smaller vessel, but
dilator drugs to reduce filling pressures and liaison with medical staff is advisable before
diuretics. The role of the physiotherapist is active intervention because of the unstable
limited to giving symptomatic relief by posi- nature of the condition.
tioning the patient upright, with support of
the feet to prevent the inexorable slide down Renal disease
the bed. The supine posture, that anathema
Kidney disease and its treatment affect most
for physiotherapists, is particularly unhelpful
body systems, the respiratory system being
for patients with an enlarged heart because of
influenced by any of the following:
compression of the left mid- and lower lung
zones (Wiener et al 1990). If mechanical • fluid overload, leading to pulmonary
ventilation is necessary, patients rarely oedema and sometimes pleural effusion,
require physiotherapy other than positioning • breathlessness associated with metabolic
and attention to limbs. acidosis or pulmonary oedema,
Right ventricular failure is caused by LVF, • muscle wasting due to steroids and ur-
valvular disease of the left heart or chronic aemia,
hypoxic conditions, such as COPO, which • opportunistic chest infection due to ster-
lead to pulmonary hypertension and im- oids and other drugs following trans-
paired emptying of the right ventricle. The plantation,
term congestive heart failure means right • sleep apnoea associated with end stage
and left heart failure with congestion in the renal disease (Kimmel et al 1989).
pulmonary and systemic circulations.
Patients in renal failure are supported by
Pulmonary embolus (PE) is a blood clot in
one of the following:
the pulmonary vasculature. Secondary blood
supply from the bronchial circulation usually 1. Haemofiltration, which removes toxins
keeps lung tissue viable, but this blood and excess fluid slowly and requires
exudes into alveoli, causing haemoptysis and moderate anticoagulation.
an inflammatory reaction which manifests as 2. Renal dialysis or haemodialysis, which is
a sharp, localized pleuritic pain, pleural rub, faster and can cause rapid BP changes,
breathlessness and pallor. Massive embolism pulmonary and systemic inflammatory
causes circulatory collapse. PE is difficult to changes, wheezing, hypoxaemia due to
diagnose clinically, but is suspected in capillary blockage, and bleeding due to
anyone who complains of chest pain and anticoagulation.
breathlessness, especially if there is hypox- 3. Peritoneal dialysis, in which alkaline
aemia, haemoptysis, pleural rub or evidence solution is run into the peritoneum, left
of deep vein thrombosis (p. 172). X-ray signs there until waste products have passed
are non-specific, but occasionally a wedge- into it through the semi-permeable peri-
shaped lesion can be identified. A VIQ scan toneum, then drained out. This pro-
shows a perfusion defect (Fig. 2.14). Imme- cedure causes minimal haemodynamic
diate management is by giving oxygen and disturbance, but restricts basal ventila-
placing the patient supine, thus boosting tion and is now less used. Physiotherapy
venous return to the left heart which is should coincide with the end of the
deprived of pulmonary artery flow (Gray emptying cycle to ensure free diaphrag-
1992). Treatment is by heparin infusion or, in matic movement.
Other disorders 87
Precautions when working with patients surprisingly rapid once the toxin-producing
on renal support are to treat lines for vascular liver has been removed. Indeed, some
access with respect, to be watchful of fluid patients may be so poisoned by their own
volume changes or hypertension and to be liver that the offending organ is removed
aware of the risk of bleeding if patients are even if no donor is immediately available.
anticoagulated. When caring for people who have alcoholic
liver disease or liver damage from intended
Liver disease paracetamol overdose, physiotherapists need
The connection between liver disorders and to put aside judgements about 'self-inflicted'
respiratory care include the following: conditions.
ance of late evening meals, large meals, mmHg) as well as PaOz < 60 mmHg. It is
stooping, bending, smoking, alcohol or caf- caused by failure of the respiratory pump and
feine, weight reduction if appropriate, drug can be acute, e.g. severe acute asthma, or
review and avoidance of aminophylline, chronic, e.g. advanced COPO. Type II failure
which relaxes the cardiac sphincter. is also known as ventilatory failure, and is the
outward clinical manifestation of muscle
3.4.7 Chest infection weakness or fatigue. If acute, it is accompan-
Infection from viruses, bacteria or fungi can ied by a fall in pH because there has been no
occur anywhere from the upper respiratory time for renal compensation.
tract to the lung parenchyma. These are The process of respiration includes com-
known non-specifically as chest infections. ponents other than gas exchange in the lung,
The term encompasses anything from acute but the term 'respiratory failure' is reserved
bronchitis, a common and usually self- for disorders that result in a disturbance of
limiting viral infection of the upper bronchial arterial blood gases only. Respiratory insuffi-
tree, to life-threatening pneumonia. Features ciency is when adequate gas exchange is
include fever, malaise and cough. maintained but at great cost to the breathing
Chest infections are a common cause of mechanism (Pilbeam 1992, p. 76).
exacerbation of lung disease, causing excess
secretions and impaired mucociliary clear- RECOMMENDED READING
ance (Wilson 1988). Those people most at risk
are the young, the old, the immunocom- BTS (1993) Guidelines for management of asthma:
promised and those with chronic lung dis- a summary. Br. Med. /., 306, 776--82.
ease. Antibiotics may help bacterial and some Cochrane, G.M. (1995) Acute severe asthma.
fungal infections, but are ineffective against Thorax, 50, 1-2.
Gross, N.J. (1990) Chronic obstructive pulmonary
viral infections. Physiotherapy is required if disease: current concepts and therapeutic
patients are unable to clear their secretions. approaches. Chest, 97, 195-13S.
Henderson, A. (1994) Chronic respiratory failure.
3.4.8 Respiratory failure Practitioner, 238, 345-50.
Hunninghake, G.W. (1995) Approaches to the
The main function of the respiratory system
treatment of pulmonary fibrosis. Am. J. Respir.
is to secure gas exchange, and respiratory Crit. Care Med., lSI, 915-18.
failure is the inability to maintain blood gases MacFarlane, J. (1995) Acute pneumonia in the
within certain limits. Type I (hypoxaemic) hospital patient. Hosp. Update, 19-23.
respiratory failure is failure of oxygenation, McClure, J. (1993) The role of physiotherapy in
represented by a PaOz < 8 kPa (60 mmHg). It HIV and AIDS. Physiotherapy, 79, 388-93.
is due to failure of the gas exchanging function Michie, J. (1994) An introduction to lung cancer.
Physiotherapy, 80, 844-7.
of the respiratory system and can be acute, e.g.
Parker, A.E. and Young, C.S. (1991) The physio-
pneumonia, or chronic, e.g. COPO. therapy management of cystic fibrosis in chil-
Type II (hypoxaemic and hypercapnic) dren. Physiotherapy, 77, 584--6.
respiratory failure is failure of ventilation, Woodhead, M.A. (1992) Management of pneu-
represented by a PaCO z > 6.7 kPa (50 monia. Respir. Med., 86, 459-69.
4. General management
For chronic lung disease, nocturnal mon- guarantee its arrival at the mitochondria.
itoring is needed for accurate prescription Tissue hypoxia is often assumed when there
because daytime oxygen saturation bears is a low Pa02, but this can be misleading if
little relation to nocturnal saturation (Moh- oxygen delivery is hindered, for example by
senin 1994). polycythaemia, impaired cardiac output,
Contrary to tradition, oxygen is not indic- anaemia or hypoperfusion.
ated for uncomplicated myocardial infarction If hypoxaemia is due to physiological
without hypoxaemia (Leach and Bateman shunt, benefit from oxygen therapy is limited
1993), nor should it be used as a tonic for because the shunted blood does not 'see' the
breathlessness (Stewart and Howard 1992). oxygen. A shunt above 50% renders oxygen
Breathlessness and hypoxaemia often coexist therapy virtually useless.
but have different mechanisms, and oxygen
for resting breathlessness is considered an
4.2.3 Complications
expensive placebo (Leach and Bateman 1994).
The following exceptions may apply: 1. High concentrations of inspired oxygen
may impair the respiratory drive in
• supplementary oxygen may reduce breath-
people with acute hypercapnic COPD
lessness during exercise in a proportion
(p. 93).
of patients, independent of resting Pa02
2. Oxygen toxicity is an inflammatory re-
(Leach and Bateman 1994), but oxygen
sponse of lung tissue following exposure
is unhelpful before or after exercise
to 100% oxygen for between 40 hours
(Williamson 1993),
and seven days (Heulitt 1995). All organs
• terminally ill patients who are breathless
can be harmed by excess oxygen, but the
may find some relief with oxygen ther-
lung is exposed to the highest P0 2 •
apy.
Oxygen toxicity impairs the actions of
Many patients are both hypoxaemic and cilia, macrophages and surfactant, and
breathless, but oxygen should be prescribed the patient experiences substernal pain,
for the hypoxaemia, not the breathlessness. cough and dyspnoea. Vital capacity
A subjective feeling of wanting air is not drops, and a syndrome of stiff lungs and
an indication for oxygen, and prescription progressive hypoxaemia develop. The
'as required' makes no physiological sense. risk of oxygen toxicity is increased by
People do not feel a physical need for oxygen high-volume ventilation and malnutri-
as they do for food because chemoreceptor tion, but pre-existing lung disease affords
signals are not consciously appreciated (Hol- some protection (Durbin 1993). If oxygen
land 1991). Education is more beneficial than toxicity is suspected, monitoring by Pa02
the psychological crutch of an expensive is advisable because the shape of the
drug. dissociation curve means that meas-
Oxygen should be administered continu- urements of Sa02 at high levels of oxy-
ously unless hypoxaemia has been demon- genation are relatively insensitive.
strated only in specific situations such as 3. Blindness may be caused if neonates are
sleep, eating or exercise (AARC 1992a). given high concentrations of oxygen
(Chapter 12).
4. For mechanically ventilated patients who
4.2.2 Limitations
are receiving low tidal volumes and low
Oxygen therapy is not just aimed at making cycling pressures, 'absorption atelectasis'
the patient pink. It does not improve ventila- can occur if more than 70% oxygen is
tion, nor does pushing oxygen into the throat given (Pilbeam 1992, p. 239). Absorption
Oxygen therapy 91
Room air
j ~~
~ . o~
oJ
Patient
7=0
Oxygen--
j
Room air
of oxygen from the alveoli exceeds re- mask to dilute the oxygen. The fractional
plenishment of alveolar gas during in- inspired oxygen concentration (F 10 2 ) varies
spiration, and the lungs are no longer with the patient's own flow: the more rapid
held open by a cushion of inert nitrogen. the ventilation, the lower the F10 2 . This
5. Discomfort can be caused by drying of provides inaccurate (uncontrolled) oxygen,
mucous membranes, eye irritation or a but flow rates of 6-8 lImin provide approx-
sense of being smothered. The sight of a imately 40-50% oxygen (Gribbin 1993). The
patient attempting to 'oxygenate' his or flow rate should be maintained above 6 lImin
her forehead is a familiar sign of this to avoid rebreathing CO2 . These masks are
problem. suitable when accurate concentrations are not
6. Oxygen is not addictive, but dependency necessary, e.g. after routine surgery.
occurs when patients rely on their oxy-
gen unnecessarily. High flow (fixed perfonnance> masks
7. Oxygen creates a fire hazard by support-
ing combustion. These masks, also known as venturi masks,
flood the patient with a prescribed gas
Smoking is banned. mixture at flow rates greater than the indivi-
dual's demand, even for breathless patients
4.2.4 Delivery devices with high inspiratory flows. This minimizes
rebreathing of expired air from the mask,
The nasal specs caused so many problems; they even if it is loosely fitted, and delivers a
kept falling out or were too tight. They were one relatively accurate F10 2, as specified on the
of the most uncomfortable appliances, yet better mask. Oxygen rushes from a nozzle and
than the mask which seemed to suffocate you. entrains an exact proportion of room air so
Ludwig 1984 that a fixed concentration is delivered. This
concentration depends on the size of the
Low flow (variable perfonnance> masks
entrainment ports and oxygen flow through
These masks, also known as simple masks, the nozzle (Fig. 4.1).
deliver only a portion of the patient's inspired Venturi masks can deliver up to 60%
gas. They provide a flow rate that is less than oxygen, but are more accurate at lower
the patient's inspiratory flow and allow room percentages (Fulmer 1984). Large capacity
air to be sucked in through the edges of the masks are often used because they act as
92 General management
I
24% O2
I
28%02
I
Pa02 < 6kPa, Pa02 > 6kPa, Pa02 > 6kPa,
PaC02 rise PaC0 2 rise PaC02 stable
I
PaC02 < 6 kPa, Pa02 < 6kPa,
Observe
danger of giving too much oxygen is usually Patients with acute problems other than
overestimated, with patients often deprived exacerbation of COPD, e.g. those with pneu-
of much-needed oxygen. Hypoxaemia kills monia or acute asthma, need generous levels
more people than hypercapnia. of 60% or more oxygen.
Intermittent oxygen therapy given in the Patients on acute oxygen therapy should
acute phase of COPD, especially for hyper- not have their mask removed except for
capnic patients (Fig. 4.3), is like pulling a expectoration or other brief reason, especially
drowning man out of the water and then hypercapnic COPD patients and people after
pushing him under again. CO2 is stored in heart surgery when the body is adjusting to
the body in larger quantities than oxygen, so its new haemodynamic status. During recov-
if the inspired oxygen is allowed to fall, CO2 ery, oximetry can be used to monitor with-
crowds out oxygen and causes a sharp drop drawal of oxygen therapy (King and Simon
in Pa02 (Collins 1976). 1987).
Oxygen therapy 95
No oxygen
PaC02 7.3L--------------
Pa0 2 6.7
_ _ _ _ _ _ _ _ _ _ _ _ __
~
Uncontrolled oxygen
Intermittent oxygen
On Off
Controlled oxygen
PaC02 7.3t=====-_ _
Pa02 6.7
-=======:
Figure 4.3 Effects of different forms of oxygen administration on
blood gases (in kPa) in COPD patients in acute hypercapnic
respiratory failure: (a) continued deterioration, (b) blunting of
respiratory drive leads to further PaC02 retention, (c) gradual
hypercapnia and rapid hypoxaemia, (d) normalization of blood
gases.
96 General management
::71
Usual COPD
Nutritional depletion aggravates the emphys- weight- 68 exacerbations
ematous process (Sahebjami 1993) weakens 66
inspiratory muscles, increases the oxygen
~
1:/
64
cost of breathing (Donahoe et al 1992),
increases the risk of infection (Fitting 1992),
decreases exercise capacity (Schols et aI1991),
causes depression and apathy (Allison 1995),
damages lung tissue (Sridhar 1995), impairs
A D 1 2 3 4 5 6 7 8 9101112
ciliary motility, impairs respiratory drive,
Time (months)
depletes surfactant (Ryan et al 1993) and
reinforces this whole unhappy process by Figure 4.4 Weight of a patient with severe
blunting hunger. COPD, showing beneficial effect of nutritional
support and detrimental effect of exacerbations.
A = admission, D = discharge. (Source:
4.3.3 Management Donahoe, M. and Rogers, R.M. (1990)
Nutritional assessment and support in COPD.
Nutrition therapy should be a routine pre- Clin. Chest Med., 11, 487-504, with permission.)
ventive measure for all people with capo
and not left until debilitated patients have
• dairy foods, which many patients claim
cannibalized the protein from their own
increases the viscosity of their mucus, a
respiratory muscles. Education includes the
claim which now has some objective
following suggestions:
validity (Enderby 1995),
• eat multiple small meals, preferably six • caffeine, which has a potentiating role in
times a day, peptic ulceration, to which people with
• clean your teeth or use a mouth wash capo are susceptible (Hodgkin and
before meals if inhaled drugs or sputum Petty 1987),
have left a bad taste, • additives, spicy food and alcohol (Hodgkin
• if breakfast is difficult, try liquidizing it, 1993).
• eat fruit and vegetables every day to
Alcohol increases pulmonary hypertension
improve intake of vitamin C, which
and hypercapnia in capo (Jalleh et al1993),
helps prevent infection, reduces inflam-
causes snoring in normal people, sleep
mation and mops up oxidants in tobacco
apnoea in snorers (Chan 1990), and impairs
smoke (Sridhar 1995),
ciliary action and immune function in every-
• take liquids separately from meals,
one else (Hodgkin 1993, p. 113).
• avoid hard or dry food, or add sauces such
Supplementary feeds provide concentrated
as gravy or custard,
nutrition orally or nasogastrically, and are
• avoid gas-forming foods, useful for patients with exacerbation of dis-
• make use of high-energy drinks, such as ease. Patients with advanced disease may
homemade milk shakes and fresh fruit
need supplementary feeding even in the
juice,
chronic state (Fig. 4.4). Nasogastric feeds are
• meals should be leisurely, enjoyable and best given at night to encourage daytime
taken sitting up with elbows on the table
eating. Slow continuous infusions help to
to stabilize accessory muscles.
prevent excess metabolic activity which can
Patients can be advised to experiment with increase energy expenditure by 24% and
reducing or abstaining from: cause de saturation (Ryan et aI1993). High-fat,
Drug therapy 99
I
Corticosteroids
Beclomethasone Inhaler/nebulizer Hoarse voice
(Becotide, Beclovent) Oropharyngeal candidiasis
Budesonide (Pulmicort)
Fluticasone (Flixotide)
Prednisone Oral ~ Osteoporosis
Prednisolone Fluid retention
i infection risk
Hydrocortisone Intravenous/oral ~ Obesity
Muscle atrophy
Bruising in the elderly
Hyperglycaemia
Cataract
Delayed healing
Retarded growth
Bronchodilators
I I I
~z-agonists
Salbutamol (Ventolin) Inhaler/nebulizer Tremor
Terbutaline (Bricanyl) Slow release capsule Tachycardia
Salmeterol (Serevent) Intravenous
Anticholinergics
Ipratropium (Atrovent) Inhaler/nebulizer Dry mouth
I
Xanthines
!
Theophylline ~ Intravenous Headache
Aminophylline Oral Gastric ulcer
Slow release capsule Insomnia
Nausea and vomiting
Arrhythmias
Nasty taste
effects with long-tenn use. Increased problem with low-dose therapy. Both
breathlessness due to steroid-induced undertreatment and side-effects can be
muscle atrophy may be mistakenly minimized by high dosage and early
ascribed to deterioration of the disease and weaning (acute disease), or alternate day
lead to increased steroid dosage (Gallagher dosing (chronic disease), and by taking
1994). the drug first thing in the morning.
Concern about side-effects tempts pre- Patients as well as doctors may become
scribers to nibble ineffectively at the 'steroid phobic'.
Drug therapy 101
4.4.3 Drugs to treat bronchospasm and increase the risk of death from asthma
(Barrett 1995). The side-effect of trembling
Response to bronchodilators is usual in
hands and tachycardia can impair function in
asthma, occasional in chronic bronchitis and
severely breathless people.
rare in emphysema. All patients on broncho-
Anticholinergic (antimuscarinic) drugs,
dilators should have a peak flow chart until
such as ipratropium, cause bronchodilation
the response is confirmed, and patients
by blocking the effect of acetylcholine on
under review need a drug trial (Spence 1991)
autonomic nerve endings. They primarily
with peak flow and symptom monitoring.
affect the larger airways and have a slow
This will identify reversible bronchospasm,
onset of 30--45 minutes. They tend to be used
defined as improvement in peak flow or FEV 1
for older people, those with COPD or those
by at least 15% or by 150 ml (Dekker et al
who do not respond to 132-stimulants. How-
1992). Measurements are taken 10 minutes
ever, individuals show different response
after salbutamol and 20 minutes after ipratro-
patterns and may respond better to 13z-
pium bromide (Rimington et al1994). A drug
stimulants, anticholinergics or both together.
trial also pinpoints which drug, combination
Theophylline and its derivatives, such as
of drugs, dosage and route of administration
aminophylline, are part of the xanthine
are indicated.
group of drugs which have an interesting
Both sympathetic (adrenergic) and para-
variety of effects. They bronchodilate, reduce
sympathetic (cholinergic) receptors have
inflammation, moderately boost inspiratory
been identified in bronchial smooth muscle.
muscle action and the immune system,
Sympathomimetics are versatile drugs
improve gas exchange and lung function
which mimic the action of the sympathetic
(Mulloy 1993), promote mucociliary clearance
nervous system, stimulating 132-receptors in
and reduce pulmonary hypertension (Banner
the bronchial smooth muscle and dilating the
1994). It now seems likely that bronchodila-
airways, especially the smaller airways. 13z-
tion is less responsible for the anti-asthma
stimulants are also known as l3z-adrenergics
properties of these drugs than the effects on
or l3z-agonists. Examples are:
the inflammatory or immune responses.
• salbutamol: onset of action seven minutes, The theophyllines are too insoluble to be
peak effect 20 minutes, duration of given by inhalation, and precise dosage is
action four to eight hours, required because of side-effects. Slow-release
• salmeterol: onset 15 minutes, peak one preparations are used to control nocturnal
hour, duration 12 hours. asthma and continuous intravenous therapy
can be used for people with brittle asthma.
The long-acting 132-stimulants, such as sal- Clearance rates are increased in smokers and
meterol, can be prescribed regularly, have a children, and decreased in elderly people and
greater effect on quality of life (Juniper 1995), those with viral infection or heart failure.
and are particularly useful in controlling If both l3z-stimulants and anticholinergics
nocturnal asthma and protecting against the are prescribed, the anticholinergic is taken
effects of brittle asthma. The short-acting first to open up the large airways and pro-
drugs, such as salbutamol, should be taken vide better access for the l3z-stimulants
symptomatically rather than regularly, apart (Mathewson 1993). If both bronchodilator
from prophylactic use before exercise- and preventive drug are prescribed, the
induced bronchospasm. bronchodilator should be taken first to ensure
132-stimulants are prescribed freely and maximum penetration of the preventive
sometimes mindlessly. Unnecessary use can drug. However, complicated instructions can
worsen the course of COPO (Postma 1991) demotivate patients, and it is more important
102 General management
that the drugs are taken than that the exact damaged vasculature. Side-effects include
sequence be adhered to. skin reactions and the emergence of resistant
organisms because of interference with the
friendly flora of the respiratory tract.
4.4.4 Drugs to treat breathlessness
• reduced effe~tive.ness in breathless people. Other inhalers such as the autohaler (Fig.
~hose rapId airflow favours deposition 4.5) co-ordinate drug release with inhalation.
m the upper airways only, Details of technique are available from the
• loss of much of the drug to the atmos- manufacturers.
p~ere, stomach and pharynx, although Dry powder inhalers release powdered
hIgh .doses compensate for this and drug on inspiration and require minimal co-
nebulizer.s such ~s the yentstream can be ordination and no breath-holding. The dis-
used whIch dehver hIgh dosages (Lip- advantages are that some children and
worth 1995). people with bronchospasm cannot generate
Large particles (> 12 IJ.m in diameter) are the required flow to release the drug, and the
lost in the mouth and pharynx. Small par- powder is sensitive to moisture unless stored
ticles « 2 IJ.m) are deposited in the alveoli in foil blisters. Individual disadvantages are
and are used for antibiotic and pentamidine that the Rotahaler and Diskhaler are fiddly to
delivery. Particles from 2-12 IJ.m target the operate, and the Turbohaler has no carrier
bronchi and bronchioles and nebulizers pro- powder or propellant to indicate to the
ducing this size are used for bronchodilators patient that the dose has been delivered.
and steroids (Manthous 1994). The tasks of Spacers are chambers between the patient
patient education and assessment for deli- and inhaler which show the following ad-
very systems may fall to the physiotherapist. vantages:
• propellants and large particles drop out in
Inhalers the chamber, thus reducing local side-
Pressurized inhalers deliver an aerosol by effects of steroids (Everard et al 1992),
creating a suspension of active drug in a • aerosol momentum is slowed so that less is
propellant. lost by impaction on the back of the
The metered dose inhaler (MDI) is portable throat,
and cheap, but many patients find it difficult • less co-ordination is required between
to co-ordinate inhalation with manual trig- drug release and inhalation because the
gering of the device. Keeley (1994) claims that drug remains suspended in the spacer
poor inhaler technique is the main cause of until the patient breaths in, although
failed drug treatment. The principles of good maximum dosage is gained with early
technique are the following: inhalation (O'Callaghan 1993),
• high doses can be delivered during an
1. Shake the inhaler, hold it upright and acute episode.
remove the cap.
2. Sit upright; exhale fully. Spacers should always be used for children
3. Seal the lips around the mouthpiece, using steroids (Barry 1994), and aerosols can
breathe in through the mouth, pressing be delivered to infants by a soft face mask
the top of the cannister just after initiat- attached to a spacer (Everard et aI1992). The
ing the breath; inhale slowly and deeply. large pear-shaped spacers, such as the Nebu-
4. Hold the breath for five seconds before haler or Volumatic, are cumbersome, but
exhaling. they simulate the aerosol cloud from an
5. If more than one dose is prescribed, 30 inhaler and are the most efficient type.
seconds should be allowed between Bronchodilation can be further enhanced by
puffs because each puff cools the can- using a PEP device (p. 136) at 10-15 cmH2 0
nister and reduces its efficiency. In cold connected to the spacer (Frischknecht 1991).
temperatures, the cannister should be Problems for patients with inhalers are:
prewarmed in the pocket. • difficulty in understanding instructions,
Drug therapy 105
Metered dose
inhaler Autohaler
Pressurized
inhalers
Dry powder
inhalers
Diskhaler
Nebuhaler Volumatic
~------J I I~
Large volume
spacers
Aerochamber
• the need for co-ordination and/or manual can create excess pressures in the
dexterity, system,
• confusion about when to use which (c) after use, to wash and rinse the inside
inhaler, e.g. mistaken use of steroids on to prevent encrustation by salt from
a symptom-related basis. the saline, then dry with a tissue or
air from the compressor to minimize
Nebulizers infection risk.
A jet nebulizer transforms a drug in solution Drugs can be mixed in the nebulizer except
into a mist of droplets that can be inhaled. for ipratropium bromide with budesonide.
Oxygen or air is forced at high velocity Tapping the device when the liquid is begin-
through a narrow tube, sucking the dissolved ning to fizz increases the delivered dose by
drug into the gas stream and impacting it on 38% (Everard et al 1994); this is unnecessary
a baffle to create droplets. with the high doses used for bronchodilation
and simply extends treatment time, but is
Method useful for drugs such as antibiotics. Adding a
PEP device appears to improve the effective-
1. If the patient does not need oxygen, use ness of nebulizer delivery (Gradwell 1994).
an air compressor because the higher the For home nebulizer therapy, laboratory
relative humidity of the driving gas, the measurements are not adequate (Hosker
more stable the particle size (Hodgkin 1995) and a three-week home trial is needed
1993, p. 209). for patients who remain symptomatic despite
2. Select a mouthpiece if possible, because regular inhaler use. A typical trial would
nose breathing filters the drug and comprise nebulized saline, nebulized sal-
reduces lung deposition by one-quarter butamol and then nebulized salbutamoll
(Salmon et al1990), and aerosol escaping ipratropium mixture six-hourly, each for one
from a mask can cause eye irritation. If week. Symptoms and twice daily peak flows
the patient prefers a mask or is too are monitored, and a positive nebulizer trial
breathless to use a mouthpiece, ask the is defined as a 15% increase in peak flow
patient to mouth-breathe through the during a week on active treatment compared
mask. with the week on saline (Goldman et al1992).
3. Have the patient sitting upright in a chair The first dose is best administered in hospital
or in side lying, to maximize basal de- in case of side-effects such as cardiac arrhyth-
position. Some nebulizers do not func- mias. Trials can also be done with steroids or
tion sideways. other delivery methods, such as an MOl with
4. Fill to 4 ml, diluting with normal saline if spacer. If patients use nebulizers at home,
necessary, and set the flow rate to they must be given adequate assessment,
~ lImin (Hodgkin 1993, p. 209), unless
advice and back up servicing.
a compressor is used, which has a preset
flow rate.
Disadvantages and precautions
5. Advise the patient: 1. There is a wide variation in aerosol
(a) to intersperse tidal breathing with output and treatment time between
deep breathing and breath-holds at different nebulizers (Loffert 1994).
end-inspiration to improve deposi- 2. Nebulization cools the inspired gas,
tion (Hess 1994), creating a risk of bronchospasm.
(b) when using a mouthpiece, not to 3. Angina or hypoxaemia may occur with
obstruct the excess air inlet, which nebulized salbutamol (Simpson 1993).
Bronchoscopy and biopsy 107
4. 'Horrifying tales' of bacterial contamina- The device needs to adapt to a child's lack of
tion and inadequate servicing have been co-ordination, low inspiratory flow rate,
reported when used at home (Lane 1991). short inspiratory time and reduced ability to
5. Patient compliance may be hindered by a breath-hold. The following are suitable:
lengthy time to complete nebulization.
6. Patients may rely on repeated use when • metered dose inhaler - 10 years upwards,
airways are acutely obstructed and nebu- • dry powder inhaler (which needs a high
lization is ineffective, possibly leading to inspiratory flow rate) - 5 years upwards,
increased asthma deaths (Lane 1991). • inhaler with spacer - 3 years upwards,
7. The inspired gas must be accurate. Acu- • inhaler with spacer and mask - 0-2 years
tely hypoxaemic asthmatic patients (Cogswell 1994).
require high FI 0 2 levels, and acute
hypercapnic COPD patients may require Children may need to tilt up the large
air, sometimes with oxygen via a nasal spacers during inhalation to open the valve.
cannula. Masks may be frightening for babies, and it
helps if the cheek is stroked gently with the
Indications mask first, or if it is used when the baby is
asleep, or if the parent holds the mask. A
The following may be suited to nebulizers: useful stand-by in case other equipment does
1. People who are too breathless to use an not work is a disposable coffee cup with the
inhaler, such as during an asthma attack, inhaler inserted through a hole in the bottom,
so long as overreliance does not occur but care should be taken that the drug does
when medical assistance is indicated. not blow into the child's eyes.
2. Antibiotics and antifungal drug delivery.
3. Delivery of high drug doses if these
4.5 BRONCHOSCOPY AND BIOPSY
cannot be delivered by inhaler, e.g. for
some people with severe COPD, a Access to the bronchial tree for diagnostic or
quarter of whom benefit from high-dose therapeutic purposes is gained with a
bronchodilation (Hosker 1995). fibreoptic bronchoscope, which is passed
through the nose and into the airway under
Inhaler or nebulizer? local, nebulized or general anaesthesia. Diag-
nostically, biopsies or washings can be taken
Patients often love nebulizers. They look
impressive, do not need respiratory gym- to locate malignant lesions or identify paren-
nastics for co-ordination, and produce more chymallung disease. Therapeutically, foreign
rapid results because 10-50 times the drug bodies can be removed and tumours or
dose is prescribed compared with inhalers. stenoses treated.
The reason for this excessive difference in Bronchoscopy is rarely justified as a substi-
dosage is unclear (Lewis 1985), but there is no tute for physiotherapy in clearing secretions
reason why large quantities cannot be deliv- (Brooks-Brunn 1995) because it only reaches
ered by inhalers with spacers. According to the larger airways, cannot cope with tena-
Hess (1994), nebulizers are less convenient, cious secretions, does not reverse the under-
less efficient and twice as expensive as lying process and is complicated by
inhalers. hypoxaemia, discomfort, bronchospasm,
Children may fare better with inhalers infection, haemorrhage, pneumothorax, sub-
because nebulized bronchodilators can para- cutaneous emphysema or arrhythmias. How-
doxically increase wheezing (Yuksel 1994). ever, bronchoscopy may be appropriate if
108 General management
there is intractable sputum retention with no Crompton, G. (1995) Drug delivery: matching
air bronchogram on X-ray, i.e. with blocked devices to patients. Practitioner, 239, 206--8.
central airways. To re-expand atelectatic Goldman, J.M., Teale, C. and Muers, M.F. (1992)
areas, it is best combined with selective Simplifying the assessment of patients with
chronic airflow limitation for home nebulizer
insufflation of air (Susini et al 1992) or
therapy. Respir. Med., 86, 33-8.
followed by physiotherapy. Hobbs, J. (1995) On patients and inhalers. Respir.
Bronchoalveolar lavage involves washing Dis. Practice, 12(1), 8-12.
up to 200 ml of warmed saline through the Leach, R.M. and Bateman, N.T. (1993) Acute
bronchoscope when it is wedged into a oxygen therapy. Br. J. Hosp. Med., 49, 637-44.
bronchus, then aspirating this along with Leach, R.M. and Bateman, N.T. (1994) Domiciliary
fluid and cells from the lower respiratory tract oxygen therapy. Br. J. Hosp. Med., 51, 47-54.
Lin, Y.-Z. (1995) Metered dose inhaler and nebu-
for diagnostic or research purposes. Hypox-
liser in acute asthma. Arch. Dis. Child, 72, 214-
aemia and other side-effects are greater with 18.
lavage than for bronchoscopy alone. Paton, J. (1994) The safety of inhaled steroids in
childhood asthma. Practitioner, 238, 322-4.
RECOMMENDED READING Rees, J. and Price, J. (1995) Treatment of chronic
asthma. Br. Med. J., 310, 1459-63.
Barrett, T.E. (1995) Inhaled j3-adrenergic receptor Sridhar, M.K. (1995) Nutrition and lung health.
agonists in asthma: more harm than good? Am. Br. Med. J., 310, 75-6.
J. Respir. Crit. Care Med., 151, 574-7. Thompson, J. (1994) Misuse of metered-dose
Cahalin, L.P. and Sadowsky, H.5. (1995) Pulmon- inhalers in hospitalized patients. Chest, lOS,
ary medications. Phys. Ther, 75, 397-414. 715-17.
5. Physiotherapy management
Introduction Methods to clear secretions
Methods to increase lung volume sputum in perspective
controlled mobilization hydration, humidification and
positioning nebulization
breathing exercises mobilization and breathing exercises
mechanical aids postural drainage (PO)
Methods to decrease the work of manual techniques
breathing active cycle of breathing techniques
sleep (ACBT)
stress reduction autogenic drainage (AD)
positioning mechanical aids
breathing re-education cough
mechanical aids nasopharyngeal suction
minitracheostomy
Recommended reading
care, especially when prophylaxis is the aim. diaphragm is free from abdominal pres-
It is used in its own right or in conjunction sure (Fig. 5.2). Compared to supine, this
with other techniques, and no physiotherapy position not only increases lung volume,
treatment should be carried out without but also improves gas exchange and
consideration of the position in which it is reduces the work of breathing (Dean
performed. 1993). It can also be used for sleeping.
Lung volume is related to displacement of 2. Half-lying in bed rapidly becomes the
the diaphragm and abdominal contents, and slumped position for most patients as
most volumes are responsive to positioning. they slide down the bed. This should be
FRC increases sequentially from supine to avoided unless necessary for a specific
standing (Fig. 5.1). medical reason or to reduce pain.
The following principles apply: Manoeuvres to increase volume, such as
1. Patients who are confined to bed should deep breathing, are ineffective in half-
spend a proportion of their time on their lying because of competition from the
side, lying well forwards so that their abdominal contents.
3. The supine position is least helpful for phragm has to work less hard against the
lung volume, especially in elderly people load of the viscera.
and those with respiratory disease. • airflow resistance is lower in side-lying
4. When sitting a patient out after treat- compared to supine (Barnas et alI993).
ment, a foot stool is inadvisable unless
After treatment, the physiotherapist
the patient has ankle oedema, a recent
should explain to nursing staff why the
vein graft or requests it.
patient has been left in a specific position,
The VAIQ ratio is also responsive to posi- and that this should be maintained until the
tioning. Ventilation and perfusion are usually patient wants to move or it is time to turn.
well matched because the better ventilated Night staff should be included in educational
lower areas of lung are also better perfused programmes, and an oximeter can be used to
(p. 9). People with one-sided pneumonia, demonstrate the effectiveness of positioning.
thoracotomy or other unilateral disorder Accurate positioning and regular position
show an accentuation of the normal down- change should be incorporated into a
ward ventilation gradient if they lie on their patient's management plan 24 hours a day.
side with the affected lung uppermost. Perfu-
sion is, as always, greater in dependent 5.2.3 Breathing exercises
areas, and VAIQ match is therefore enhanced
in this position, often resulting in a dramatic Breathing exercises to increase lung volume
improvement in gas exchange (Fishman should be performed in cycles of three or four
1981). breaths so that (1) maximum effort is put into
The rule of thumb that the affected lung each breath, (2) dizziness from overbreathing
should be uppermost is relevant for other is avoided and (3) shoulder tension is dis-
situations as well as for optimizing gas couraged.
exchange. For example, it promotes comfort
following thoracotomy or chest drain inser-
tion, and facilitates postural drainage when
indicated. Atelectatic areas are best posi-
tioned uppermost to encourage expansion.
Exceptions to the 'bad lung up' rule are:
• recent pneumonectomy (p. 185),
• large pleural effusion (p. 79),
• bronchopleural fistula in case any un-
savoury substances drain into the
unaffected lung,
• occasionally, if there is a large tumour in a
main stem bronchus, positioning the
patient with this side uppermost
obstructs the bronchus, causing breath-
lessness and desaturation.
Other functions are affected by position-
ing, for example:
Once inflated, alveoli stay open for about
• lung compliance increases and work of an hour, so that patients should be asked to
breathing decreases progressively from perform at least 10 deep breaths every wak-
supine to standing, because the dia- ing hour (Bartlett et al 1973). This is a tall
Methods to increase lung volume 113
order for those whose minds are distracted ized' breathing exercises do not make physio-
by the events and uncertainties of hospital logical sense because humans are unable to
life, so patients are best advised to remember deform individual portions of the chest wall
their exercises by linking them to the arrival selectively (Martin et aI1976), but patients can
of food and drink trolleys or routines such as still be found obediently performing strap
hourly fluids. exercises, unilateral breathing (which usually
involves subtle side flexion) and basal costal
Deep breathing Low-volume areas of lung breathing. Even if localized breathing was
are relatively non-compliant, so optimum physically possible, the way in which the two
conditions are needed to ensure that deep layers of pleura slide on each other means
breaths do not just fill easily inflated regions that the lung would respond generally rather
but reach poorly ventilated regions, which than locally to an increase in volume. Distri-
are often the lower lobes. The following will bution of ventilation is related only to
facilitate this: position, gas flow, lung volume and patho-
• accurate positioning, usually side-lying logy (Menkes and Britt 1980).
inclined towards prone, Between each cycle of breaths, it takes a
• comfort and relaxation, few moments for the patient to resume a
• relief of pain, nausea, dry mouth, fatigue, relaxed rhythm and be ready for the next
anxiety, cycle. The breathing rate and pattern should
• avoidance of distractions or conversation, be checked, and the patient may need praise
• minimal breathlessness, e.g. patients must or a change in instruction before proceeding.
have time to get their breath back after Patients should not be engaged in conver-
turning. sation while regaining their rhythm.
Patients are then asked to breathe in Deep breathing increases lung compliance,
deeply, comfortably and slowly through the reduces VAIQ mismatch, decreases dead
nose, and sigh out through the mouth. A space, replenishes surfactant (Melendez
demonstration is often the best way of ex- 1992) and can prevent desaturation (Ruggier
plaining an action that is normally automatic. et al 1994). The term 'thoracic expansion
Some patients respond better when asked to exercises' is synonymous with deep breath-
take a long breath rather than a deep breath. ing, but inhalation must be assured as well as
Breathing through the nose warms and thoracic expansion, and if this terminology is
humidifies the air but doubles resistance to used with patients it needs to be explained.
airflow, so some patients prefer to mouth-
breathe. End-inspiratory hold
People usually breathe deeper when they
breathe slower. This reduces airway turbu- Air can be tempted into poorly ventilated
lence and encourages distribution to depend- regions by interspersing every few deep
ent regions (Reid and Loveridge 1983). Breath- breaths with breath-holds for three seconds
less people require a special approach and at full inspiration, which may boost collateral
should not be asked to breathe slowly (p. ventilation and distribute air more evenly
156). between lung segments. Observation will
The physiotherapist's hands can be placed identify whether this is effective and com-
over the basal area for monitoring purposes fortable or, conversely, if it disturbs the breath-
and for patient reassurance, but not with any ing pattern. Accurate instruction and close
assumption that this magically redistributes observation are needed to prevent shoulder
ventilation to the underlying lung. 'Local- girdle tension. This technique is unsuitable
114 Physiotherapy management
for breathless people who should not be • rest the dominant hand on your abdomen,
asked to hold their breath. with elbows supported and, keeping
your shoulders relaxed, allow the hand
Single percussion to rise gently, while visualizing air filling
the abdomen like a balloon (the area to
When a patient is breath-holding at full be expanded is sometimes best identified
inspiration, a single manual percussion by first sniffing, which protrudes the
manoeuvre with one hand sends an oscillat- abdomen),
ing wave through the lung that in some • sigh the air out,
patients further encourages alveoli to open. • gradually increase the depth of breathing
while maintaining relaxation,
Sniff • check that the shoulders remain relaxed
Even after a full inspiration, it is often and heavy,
possible to squeeze in a wee bit more air and • progress to side-lying and relaxed standing
further augment collateral ventilation by if appropriate.
means of one sniff at end-inspiration. Scept- Variations include:
ical patients can be won over by a reminder
that however packed a rush-hour under- • putting the other hand on the non-moving
ground train seems to be, an extra person can upper chest to compare it with move-
always be crammed in. A sniff also promotes ment of the abdomen,
a diaphragmatic pattern of muscle recruit- • imagining a piece of elastic round the waist
ment. stretching during inhalation,
• incorporating incentive spirometry in
Abdominal breathing order to give feedback to the patient on
the larger volume inhaled (Peper 1992).
Augmented abdominal movement during • for non-surgical patients, positions can be
inspiration leads to slower, deeper breathing, taken up in which it is almost impossible
less turbulence, reduced dead space and not to breathe abdominally, for example,
shoulder girdle relaxation. In the past, the in standing placing the hands on the
term 'diaphragmatic breathing' was used to back of the hips with elbows pushed
describe this pattern, but greater abdominal backwards or, for the energetic, taking to
excursion does not imply greater diaphrag- the floor on all fours.
matic contribution to breathing (Gosselink
Abdominal breathing increases lung
1995). The term 'breathing control' is syn-
volume but it is not thought to alter the
onymous with abdominal breathing.
distribution of ventilation (Martin et alI976),
It is useful to think of encouraging rather
but the slow deep breathing that it incorpor-
than teaching this form of breathing so that it
ates favours airflow to dependent regions
becomes a natural outcome after certain
(Fixley 1978).
instructions rather than an effort. The patient
is asked to relax comfortably, starting in a
Neurophysiological facilitation
symmetrical position, such as sitting. The
manoeuvre is first explained and demon- Non-alert patients breathe shallowly and
strated unhurriedly, avoiding words like monotonously and tend to develop patchy
'push', 'pull', 'try' and 'harder'. If relaxed atelectasis, which is best prevented by posi-
abdominal breathing has not started natur- tioning. Neurophysiological facilitation is
ally, then the patient is taken through the more short term, but is useful for
following instructions: spontaneously-breathing patients who are
Methods to increase lung volume 115
unable to tum, e.g. following acute head breath sustained while holding them up. The
injury. This technique uses tactile and pro- third ball is a control and should not be raised
prioceptive stimulation to increase reflexly because this causes tension. It is still possible
the rate and depth of breathing (Bethune to cheat by taking short sharp breaths,
1991). Examples are: especially with the Triflo. A suggested proto-
col is the following:
1. Perioral pressure, which is firm pressure
applied just above the patient's lip and 1. A demonstration is given using a separ-
facilitates a deeper than average breath. ate device.
The pressure is maintained for as long as 2. Patients should be relaxed and posi-
the patient is required to deep breathe, tioned as for deep breathing, in either
but often the effect is continued for some side-lying or sitting upright in a chair.
minutes afterwards. 3. After sealing the lips around the mouth-
2. Intercostal stretch, which is pressure piece, the patient inhales slowly and
applied bilaterally downwards to the deeply. Throughout the procedure the
upper border of a rib in order to stretch patient watches the incentive spirometer,
the intercostal muscle and increase but the physiotherapist watches the
gradually the depth of breathing. patient in order to monitor the breathing
pattern.
Rib springing 4. After exhalation, shoulder girdle relaxa-
A more crude technique is rib springing, tion is rechecked.
which is chest compression followed by Those on oxygen should have the mask
overpressure and quick release at end- kept close to their nose when using the
expiration. This may cause a deeper sub- device, or nasal cannulae can be used. People
sequent inspiration, but heavy pressure can with tracheostomies can be accommodated
cause airway closure. with a connecting tube. Once the technique is
faultless, patients are asked to practise 10
5.2.4 Mechanical aids times an hour.
If previous measures are ineffective, a variety The same effect can theoretically be
of mechanical aids are available to increase obtained without the device, but the incent-
lung volume. Physiotherapists are ideally ive of using a device often results in greater
suited to match people to machines because inhaled volume and more controlled flow.
of their patient-handling skills and under- However, individuals vary, and observation
standing of physiology. of chest expansion shows whether a sus-
tained maximal inspiration is best with or
Incentive spirometry without an incentive spirometer. An advant-
age is that its presence on the bedside locker
The flow and volume achieved by a sustained acts as a memory aid. A disadvantage is that
deep breath can be facilitated by an incentive it is unsuitable for breathless patients.
spirometer, which gives visual feedback on
performance. Inspiration should be slow and Continuous positive airway pressure (CPAP)
controlled. This is encouraged in the Coach
by holding a marker steady between two For spontaneously breathing patients who
arrows (indicating flow), and sustaining an cannot muster the breath for incentive spiro-
end-inspiratory hold while a disc descends metry, assistance to lung inflation and
(indicating volume). In the Triflo two out of improved gas exchange can be given by
three plastic balls should be raised and the pneumatically splinting open the airways
116 Physiotherapy management
with continuous positive pressure. A CPAP high enough to maintain adequate gas
device delivers a constant flow of gas during exchange, usually starting at 5-12.5
both inspiration and expiration which cmH20.
exceeds the flow rate of patients even when 3. The system is set up, allowing patients to
they are breathless. It is like patients putting assist with putting on the mask if poss-
their head out of the window of a car moving ible in order to reduce anxiety. Simultan-
at speed. eously the on/off dial is turned on.
4. The flow and oxygen are turned up. The
The system The components needed to flow should be sufficient to maintain an
generate and withstand the high flows and open CPAP valve, even during a deep
pressures of a CP AP system are illustrated in breath. This can be checked by ensuring
Fig. 5.3. A flow generator connects to the that there is a continuous gas outflow
oxygen supply, entrains air through a filter to from the valve throughout the respirat-
give 30-100% oxygen, and generates a gas ory cycle, and ensuring that the mask has
flow of up to 120 lImin. For generators not a firm but comfortable seal. Fine tuning
equipped with variable oxygen, a fixed flow trims the flow to just above the patient's
of 30% oxygen is produced. peak inspiratory flow, without causing
The patient breathes through a face mask, distress, so that there is just a small
nasal mask, mouthpiece (for intermittent use) outflow at the valve on inspiration.
or T-piece (for intubated patients). Positive 5. The outflow should be rechecked after
pressure is maintained by a threshold resis- the patient has settled, because relaxa-
tor, known as a CPAP or PEEP valve, which tion changes the breathing pattern. The
is independent of flow. Preset valves provide oximeter should be rechecked after
constant pressures from 2.5-20 cmH20. A changing the flow, and F10 2 adjusted if
spare valve at 5 cmH2 0 above the threshold appropriate.
pressure acts as a pop-off safety valve in case 6. Regular checks should be made of the
the system becomes obstructed. An oxygen mask seal and comfort, the valve, oxi-
analyser monitors the F10 2 , and an oximeter meter and the fluid level and temperature
monitors the patient's response. A humidifier of the humidifier.
is not necessary if a nasal mask is used,
The high flow means that it is usually
treatment is brief and the patient is well
immaterial if air escapes through the mouth
hydrated. More often, a humidifier is
when using a nasal mask. However, if
required, which has to be highly efficient to
excessive air escapes, the mouth can be
cope with the high flows generated, or else
closed by a chin strap or soft collar. Some
two humidifiers can be incorporated into the
patients prefer periodic CPAP, in which the
system (Harrison et alI993).
device is applied, say, every hour for 30
breaths.
Method Suggested guidelines are the fol-
lowing:
Effects When the above steps are followed
1. Patients using a full face mask should be and comfort assured, CPAP can increase FRC
in a high dependency area or kept under (Fig. 5.4), improve gas exchange, prevent
constant observation because of the atelectasis and avoid the need for intubation
danger of vomiting and difficulty in and mechanical ventilation (Keilty and Bott
expectoration. 1992). A sustained pressure of > 15 cmH2 0
2. A valve is chosen that provides a pres- is required to re-expand atelectatic lungs
sure low enough to be comfortable, but (Andersen et al 1980).
Air entrainment
via filter at rear
Air at 85 I/min
OUTFLOW
Oxygen at 15 IImin -..
r-
. On/off Inspiration:
50 IImin
Flow Expiration:
adjustment 30 IImin
WHISPERFLOW
GENERATOR .
Oxygen
adjustment
Inspiration:
5 em H,o
50 IImin
aboveCPAP
to patient
pressure
PATIENT
Expiration:
°Og 30 IImin
from patient
il7.01 0
HUMIDIFIER
Oxygen
analyser
Figure 5.3 CPAP circuit set up to deliver approximately 33% oxygen. (Diagram courtesy of Medicaid Ltd.)
118 Physiotherapy management
T ,
pensating with higher flows or pressures,
j J, or by using a Medicaid customized
bridge (see CPAP, Appendix C).
It
3. Some patients find exhalation difficult,
especially if there is loss of lung or chest
1 wall elasticity, which might force them to
FRG use more active expiration. If this cannot
FRG I be remedied by adjusting the dials,
t '----_ _-----' t CPAP should be discontinued.
Figure 5.4 Effect of CPAP on lung volumes.
4. CO2 retention can occur if a hypercapnic
VT = tidal volume, FRC = functional residual patient breathes with a small tidal
capacity. volume due to a high pressure valve,
especially with a small mask.
5. Because of the tight mask seal, a high
F10 2 is readily achieved. This can obscure
Complications A mouthpiece creates few
a deteriorating condition because it is
problems, but is limited in effectiveness and
easy to keep nudging up the inspired
can only be used intermittently. A full face
oxygen to maintain oxygen saturation. If
mask is associated with the most complica-
a progressively increasing percentage of
tions. A nasal mask aims for maximum
oxygen is found to be necessary, the
effectiveness with minimum complications
patient is in danger because removal of
and allows the patient to talk and cough.
the mask may precipitate desaturation. If
Complications with nasal or full face masks
the patient is not already in an intensive
are the following:
care unit, transfer is advisable.
1. Discomfort is common, and uncomfort- 6. At pressures > 20-25 cmH2 0, gas can be
able patients restrict their depth of forced into the stomach, causing discom-
breathing. Individual adjustment of the fort and restricted breathing. The risk is
mask is needed to prevent discomfort, reduced with a nasogastric tube.
claustrophobia or gas blowing into the 7. Eating and drinking are contraindicated
eyes. The bridge of the nose should be because high flow may cause aspiration,
protected before rather than after a pres- but patients using a nasal mask can drink
sure sore has developed, especially in carefully through a straw.
patients who are hypotensive, hypo- 8. With a full face mask, coughing without
volaemic or have thin skin due to ageing removing the mask can create high pres-
or long-term steroid therapy. If the mask sures. This can damage the ears and, in
seal is inadequate, it often helps to put people with emphysema or late-stage CF,
the dentures in. Nasal masks feel less risk creating a pneumothorax.
suffocating than a full face mask. 9. Cardiac output response varies. Pres-
2. For patients unable to remove the mask sures of 5-10 cmH2 0 have no effect in
rapidly by themselves, there is danger most people, but for those with severe
of aspiration of gastric contents. A naso- heart failure, cardiac output can be in-
gastric tube and head elevation reduce creased by reducing afterload (DeHoyos
the risk, but patients should be oriented 1995).
and not suffering from nausea or vomit-
ing. A nasogastric tube may interfere Precautions CPAP should not normally be
with the mask seal, but this can be used in the presence of:
Methods to increase lung volume 119
Flowrate
f-'--"""I!t Inspiratory
Inspiratory - --f..fiI- i pressure
sensitivity
Manual - - - - - l-l
control
Pressure ----t----+-++
gauge
Mouthpiece
/
Exhalation
valve
pressure gauge. Active expiration causes it to check for leaks at the mouth, reduce the
exceed the preset pressure, while an inade- pressure or increase the flow rate.
quate seal at the mouth means that the With the Bird, the air-mix switch is pulled
system is unable to reach that pressure. out to entrain air, delivering 40% oxygen to
Prolonged expiration indicates the need to the patient. For patients who require higher
Methods to increase lung volume 121
Table 5.1 Comparison of mechanical aids to Table 5.2 Measures to optimize the balance
increase lung volume between energy supply and demand
Incentive spirometry Measures to i energy Measures to ! energy
Full patient participation supply demand
End-inspiratory hold
Physiologically sound distribution of ventilation Nutrition management i Sleep, ! stress
Minimal supervision Oxygen therapy Positioninglbreathing
Minimal infection risk re-education
Quiet Fluid and electrolyte Mechanical assistance
Cheap management
CPAP O 2 delivery to Exercise training
Face or nasal mask inspiratory muscles Inspiratory muscle
Used continuously or periodically (e.g. haemoglobin, training
Can accommodate breathless patient cardiac output)
Can accommodate tired patient
Can accommodate uncooperative patient
Used for raising FRC rather than tidal volume 5.3.1 Sleep
Patient can talk and cough (nasal mask)
Positive pressure is continuous There's no peace, no let up with this thing, you
IPPB can't even escape when you go to bed, it's with
Mouthpiece or face mask you 24 hours a day.
Used periodically patient quoted by Williams 1993
Can accommodate breathless patient
Can accommodate tired patient The only treatment for fatigue is rest. This
Can accommodate semiconscious patient can be achieved in various ways, but most
Used for raising tidal volume rather than FRC satisfactorily by sleep. One of the cruel iron-
Positive pressure on inspiration only ies of breathlessness is that it often interferes
with sleep. Fragmentation of sleep impairs
respiratory performance, blunts response to
hypercapnia and hypoxaemia and reduces
5.3 METHODS TO DECREASE THE inspiratory muscle endurance (Neilly 1992).
WORK OF BREATHING Sleep deprivation in respiratory patients is
due to breathlessness and coughing, and is
Work of breathing (defined on p. 5) is
aggravated in hospitalized patients by noise
increased with breathlessness. Chapter 6 and anxiety. Physiotherapists should avoid
describes the management of chronic breath- waking patients unnecessarily, ensure that
lessness in detail. This section provides an their treatment does not cause fatigue and
overview and emphasizes acute breathless- contribute to the teamwork required to allow
ness, although there is much overlap. adequate sleep.
Patients are often caught in the pincer of
decreased ventilatory capacity and increased
ventilatory requirements. The basic principle 5.3.2 Stress reduction
of reducing the work of breathing is, there- Relaxation is achieved indirectly by position-
fore, to optimize the balance between energy ing, sensitive handling and reducing
supply and demand, as summarized in Table unnecessary muscle tension. Some of the
5.2. relaxation and stress reduction strategies
Measures to increase energy supply are described in Chapter 6 can be used for people
discussed in Chapter 4. who are acutely breathless.
Methods to decrease the work of breathing 123
Individuals should experiment with differ- swallowing, safer and more convenient (Bach
ent positions. Some find the forward leaning 1994).
positions claustrophobic, others unpredict-
ably de saturate in different positions. Oxi- Effects
metry can be used as biofeedback.
For acute patients, mechanical assistance
If breathlessness is due to pulmonary
unloads the inspiratory muscles, reduces
oedema, the upright supported sitting
breathlessness and, in COPD, can reduce
position is preferred because hydrostatic
mortality (Bott et al 1993). For chronic
pressure is more relevant then diaphragmatic
mechanics. patients, mechanical rest over a period of
months allows fatigued muscles to recover
Some severely distressed people are
and improves their endurance, although the
relieved by being held closely and rocked.
underlying disorder is unchanged. Continu-
The combination of support and rhythmic
ing improvement suggests that there is a
movement soothes and relaxes them.
gradual resetting of the respiratory centre so
that ventilation improves. Patients often fall
5.3.4 Breathing re-education asleep as soon as the procedure begins,
indicating relief of sleep deprivation.
If patients do not spontaneously adopt an
efficient breathing pattern, they may benefit Indications
from instruction in abdominal breathing
(p. 114), but without progress to side-lying Patients who may benefit from mechanical
because the aim is not to increase lung support include those with the following:
volume. Other forms of breathing re- • severe chronic obstructive or restrictive
education are described on p. 156, but for respiratory disorder, e.g. advanced
some patients in the grip of acute breathless- hypercapnic COPD, kyphoscoliosis,
ness, this is like a person with normal lungs neuromuscular disorder,
attempting to alter his or her breathing • exacerbation of capo or CF, especially
pattern while running upstairs. with a rising PaC02,
• acute asthma, to reduce the effort of
5.3.5 Mechanical aids maintaining active hyperinflation by
imposing passive hyperinflation,
From our very first night she made a quite • in tandem with acute oxygen therapy
startling difference to my life. Just one night when Pa02 > 7 kPa (52 mmHg) cannot
converted me to the joys and thrills of home be maintained without PaC02 rising
ventilation. above 10 kPa (75 mmHg) (Donner and
Brooks 1990 Howard 1992),
• those weaning from mechanical ventilation
Non-invasive mechanical support can
or awaiting transplantation,
provide inspiratory muscle rest for people
• those requiring mechanical ventilation but
who are burdened with excessive work of
refusing intubation.
breathing in both the acute and chronic state.
Ventilation is delivered by positive pressure For people with chronic disease, nocturnal
via mask or mouthpiece, or by negative ventilation is used when possible because
pressure using the natural airway. Compared this compensates for the loss of accessory
with mechanical ventilation via intubation or muscle activity during sleep and is less
tracheostomy, patients find non-invasive disruptive to everyday life. These patients
ventilation comfortable, easier for speech and may well be up and about in the daytime, but
Methods to decrease the work of breathing 125
live in a precarious balance that leaves them mechanical ventilation is threatened and if
unable to respond to an increase in energy IPPB or NIPPV (see below) are not available.
demand.
Compared to intubation or tracheostomy, Nasal intermittent positive pressure
non-invasive mechanical ventilation does not ventilation (NIPPy)
protect the airway and provides no direct
access to the trachea for suction. Acute or chronic inspiratory muscle fatigue
can be relieved by NIPPV, which delivers a
For the first time in months I felt reasonably predetermined volume or pressure by nasal
clear-headed, my thinking felt keener, I no mask either automatically or in response to
longer fell asleep in mid-sentence, my headaches patient effort. Full face masks can also be
disappeared . .. Over the following months, as used but are less comfortable and may retain
my strength slowly returned, my posture and
CO2 •
balance noticeably improved.
Brooks 1990
Effects Patients with acute respiratory fail-
IPPB ure can be spared intubation and mechanical
ventilation, one study showing happily alert
Work of breathing can be reduced by IPPB so patients having their blood gases corrected in
long as the patient is relaxed and does not five hours (Lapidus et al1993). High concen-
attempt to assist the machine. The upright trations of oxygen can be entrained even with
supported sitting position is often preferred, hypercapnic COPD patients because of the
and the flow rate should be turned up to fit in safety backup of a pre-set breathing cycle
with the breathing rate of a breathless irrespective of respiratory drive.
patient. The instructions on p. 119 are For patients with chronic disorders, this
followed, but the pressure dial is not turned form of inspiratory muscle rest can provide
up gradually because the aim is not to relief from symptoms of hypoventilation,
increase lung volume. IPPB is indicated only such as insomnia, morning headaches, dys-
for people with acute disease because super- pnoea, poor concentration and low exercise
vision is needed. tolerance. Sustained normalization of blood
gases enhances respiratory muscle perform-
CPAP ance and can reverse pulmonary hyper-
In hyperinflation conditions, CPAP takes tension (Fernandez 1991). NIPPV can
over the work of sustained inspiratory increase vital capacity (Pehrsson 1994) and
muscle activity during inspiration. On expira- prolong life (Muir 1993). Patients are encour-
tion, CPAP keeps the airways open and aged to use the ventilator regularly, some-
allows greater gas emptying (Greenwald times just at night, until symptoms and blood
1993). To reduce breathlessness, pressures of gases are optimal. Improvements have been
4-5 cmH2 0 may be adequate (O'Donnell found with periods of rest from eight hours a
1994). In acute asthma, the pressure should week to 4-10 hours a day (Axen 1991).
be carefully titrated to the individual's re- Complications include discomfort and leaks
sponse to ensure that hyperinflation is main- from the mask, any of which may disturb
tained but not increased. sleep. Gastric distension can occur with
CPAP has been advocated for patients with volume-control machines, but becomes less
exacerbation of COPD (Mezzanotte 1994), but of a problem with time.
if poorly tolerated can cause desaturation For patients needing long-term respiratory
(Elliott et al1994), so is best attempted only if support, NIPPV facilitates discharge home
126 Physiotherapy management
and can show cost savings of 200% a year for people who are exhausted, hypercapnic
(Bach 1994). With rehabilitation and educa- or have type II respiratory failure.
tion, many patients can provide much of
their own care, so long as a comprehensive Bilevel positive airways pressure (BiPAP)
maintenance service is available.
The BiPAP machine delivers continuous
pressure with independent control of inspir-
Technique As with IPPB and CPAP, the atory and expiratory pressures. With bilevel
variables on a nasal ventilator are adjusted positive pressures, a lower pressure on ex-
according to comfort and Sa02. If patients do piration is often more comfortable than the
not want a chin strap or collar, mask leaks unrelenting pressure of CPAP.
can be compensated for by large minute The machine delivers not just BiPAP itself,
volumes (Elliott et al 1992). Success rates are but can be adjusted to deliver CPAP or
high if patients are acclimatized and carefully NIPPV. It can be set to provide the following:
educated.
• a spontaneous mode, which superimposes
inspiratory and expiratory pressures on
Machinery A volume- or pressure-
the patient's own breathing, i.e. BiPAP,
controlled machine can be used (p. 220). The
• a spontaneous/timed mode, which delivers
advantages of pressure control are the com- breaths if the patient does not breathe
fort of a limited peak pressure and compensa- after a set time interval,
tion for leaks. The advantage of volume • a timed mode, which is fully controlled
control is that ventilation can be maintained ventilation.
in patients who have restrictive disorders.
However, individual patients have their own Inspiratory positive airway pressure, set
preferences. with the IPAP button, is usually started at
It is best that patients trigger the inspirat- about 8 cmH20 and increased in increments
ory cycle to prevent inspiratory muscle atro- of about 2 cmH20 until there is minimum
phy. Machines should have a sensitive active inspiration and optimum gas ex-
trigger, short response time, variable flow change. Expiratory positive airway pressure,
rate, be capable of delivering large tidal set with the EPAP button, is usually started
at about 3 cmH20 and increased in
volumes and be quiet and portable. Oxygen
increments of about 2 cmH20 for optimum
can be entrained, and some have a PEEP
comfort. With IPAP and EPAP set at the same
option. Patients with CF or bronchiectasis
pressures, CPAP is delivered. Adjuncts
need a humidifier or heat-moisture
include a heat-moisture exchanger, entrained
exchanger. oxygen, PEEP and a stand-by button if the
Mouthpieces are used for those needing patient needs to talk or cough.
pressures above 25 cmH20 because high pres- The effects of BiPAP include improved
sures make nasal masks uncomfortable and sleep, reduced breathlessness and increased
allow unacceptable leaks. Some ventilator- exercise capacity (Renston 1994). The
dependent patients prefer mouthpieces in machine is flow-triggered, pressure-
the daytime while using a mask at night. controlled and flow-cycled (p. 220). It adjusts
Some prefer them throughout the 24 hours, spontaneously for leaks, which do not have
using a lip seal device. to be eliminated by ruthless tightening of the
CPAP is especially useful for people with mask. Some machines are unable to generate
hyperinflated chests or type I respiratory sufficiently high pressures to cope with
failure. NIPPV or IPPB are especially useful poorly compliant chests.
Methods to decrease the work of breathing 127
over and is unsafe unless the patient is for drug delivery, but are larger and used
protected by a plastic sheet and is under continuously. Sterile liquid is converted into
supervision. an aerosol, whose droplets are small enough
A hot water humidifier produces a vapour to navigate the nose and mouth and thus
by passing gas over heated sterile liquid. The reach the airways.
gas can also be bubbled through the liquid, The jet nebulizer commonly uses a cold
but this increases resistance. Some equip- liquid because heat is not necessary for
ment incorporates a heater in the tube to the this mechanism, but heated nebulizers are
patient in order to prevent condensation. available which combine the advantages of
When used with non-intubated patients, vapour and aerosol. A venturi device allows
the convoluted passages of the nose and different percentages of oxygen to be deliv-
mouth condense the vapour into large drops ered.
which cannot easily reach the lungs. The The ultrasonic nebulizer transmits vibra-
main use of hot water humidifiers, therefore, tions through a liquid to produce a 2-10-fold
is to provide humidification for patients with greater output than a jet nebulizer (Phillips
endotracheal or tracheostomy tubes, or to aid and Millard 1994). Advantages are its
expectoration for patients with a dry mouth. efficiency and silence, while disadvantages
To ensure safety, the humidifier should: are expense and, for patients with excess
work of breathing, increased airflow resist-
• be kept below the patient to prevent
ance due to the dense aerosol. Oxygen can be
condensed water tipping into the air-
added with a nasal cannula. Other staff
way,
should be advised that a physiotherapist
• be kept heated continuously in order to
should be available when it is used in certain
maintain an unfriendly environment for
patients in case they cannot clear the
bacteria,
increased volume of secretions .
• incorporate an over-heating safety device.
A cold water humidifier bubbles cold gas Heat-moisture exchange A filter can be
through cold water. This is unable to achieve fitted over a tracheal tube to act as an artificial
relative humidity greater than 50% at body nose. This is known as a heat-moisture
temperature (Darin 1982), is insufficient even exchanger (HME), a condenser humidifier or
to prevent insensible water loss (Hodgkin a Swedish nose. It functions by recycling
1993, p. 207) and was condemned as 'danger- exhaled heat and moisture. It is inadequate
ously inadequate' over two decades ago for patients needing more active humidifica-
(Graff and Benson 1969). Its only indication is tion, but convenient for many mobile
for the few patients on dry oxygen who feel patients and, for limited periods, for mech-
that it makes their mouth more comfortable. anically ventilated patients. Hygroscopic
Otherwise it simply increases airflow resis- HMEs increase moisture output more than
tance and grows bacteria, although the conventional HMEs by conserving moisture
patient is rarely infected because of the in the expired air chemically (Branson et al
inefficiency of the device. Cold water humidi- 1993).
fiers are still used, marketed in craftily- Tents and head boxes are discussed on
designed devices that mimic a nebulizer, due p.93.
to the untiring enthusiasm of the sales
representatives. Effects
The superficial gel layer of the mucus blanket
Nebulization Nebulizers to moisten air- acts as a protective barrier between the body
ways use the same mechanism as those used and the atmosphere, but is not totally water-
Methods to clear secretions 131
proof and can absorb some inhaled moisture • people on oxygen therapy who have
(Conway 1992b). hyperreactive airways (a heated system
is necessary) or some who use a simple
Complications mask for prolonged periods with flow
1. Ubiquitous hospital bacteria enjoy rates above 41!min (Fulmer 1984),
nothing more than stagnant humidifier • patients using non-invasive mechanical
water, especially if it is lukewarm, so aids, such as CPAP, which deliver high-
heated humidifiers should not be allowed flow dry gases (Conway 1992b),
to cool and reheat, and equipment • people with thick secretions, especially if
should be changed every 24 hours infected,
(AARC 1993b). Prefilled sterile bottles • people who are mouth breathing, nil-by-
reduce infection risk (Castel 1991). The mouth or have a dry mouth and find
more efficient the humidifier, the more expectoration difficult.
easily can bacteria penetrate deep into
the lung. Periodic administration of saline before
2. Bronchospasm can be caused in suscept- physiotherapy, using a small jet nebulizer,
ible patients by: only helps by wetting the mouth and aiding
(a) dense ultrasonic mist, expectoration, but for some people with
(b) an unheated nebulizer, cystic fibrosis, 30 minutes of ultrasonic nebu-
(c) use of fluid other than isotonic saline lization may deposit sufficient fluid in the
(Church 1991). airways to help shift secretions (Hodgkin
3. For babies or people in acute renal 1993, p. 206).
failure, fluid overload can occur with the Humidification is not necessary for the
ultrasonic nebulizer, leading to inactiva- following:
tion of surfactant, airway blockage, cil- • people using nasal cannulae because at low
iary damage and overwhelming of the flow rates the patient's nose provides
mucociliary escalator (Shelly et al1988). adequate humidification, and the mois-
4. Thermal injury can occur with heated ture is lost by condensation in the
humidifiers that are inadequately ser- narrow tubing (Campbell et al 1988),
viced. • people with permanent tracheostomies
5. Hypercapnic COPD patients may suffer because adaptation occurs (Shelly et al
loss of respiratory drive if uncontrolled 1988),
oxygen is used as the driving gas. Most • people using venturi masks because the
large nebulizers can be set up to run on entrained ambient air is not as dry as
24% oxygen, but this often reduces the piped oxygen, water may condense in
effectiveness of the mechanism. the entrainment ports and alter the F1 0 2 ,
Indications and attempts to humidify the oxygen
and/or entrained air with a humidity
A person's upper airway is his or her most
adaptor are rarely effective (Gribbin
efficient humidifying system. Humidification
1993); it is better to set up a nebulizer to
or nebulization is therefore necessary for
run on controlled oxygen.
people whose own humidifying system has
been bypassed with a tracheal tube. Others Method
who often benefit are:
A mask or mouthpiece can be used. A mask
• babies with respiratory problems whose is convenient for continuous treatment, and a
small airways easily block with secre- mouthpiece is best for intermittent use or for
tions, people who feel smothered by a mask.
132 Physiotherapy management
changed several hours after treatment. This modified positions are usually required so
suggests that it might be less useful for that the work of breathing is not excessive.
affecting a disease process, e.g. interrupting For people with chronic conditions, poor
the vicious cycle of CF, but appropriate for compliance with this antisocial procedure is
symptomatic management so that going to renowned (Currie et al1986). A week's trial of
school is more amenable or going to the PO should therefore include motivating
dentist more comfortable. patients to fit a programme into their daily
The direct effect of gravity on secretions routine, preferably with a home visit, so that
may not be the only mechanism involved. results can be assessed accurately and
Lannefors (1992) demonstrated how the decisions made on whether this and/or other
lower lung showed the most clearance, the measures are most suitable.
greater ventilation in dependent regions
encouraging movement of secretions by high Precautions
flows and mechanical squeezing. This argu- It is unwise to tip a patient head down in the
ment is reinforced by the limited effective- presence of:
ness of gravity with thick secretions as can be
seen if a sputum pot containing a mucus plug • cerebral oedema, e.g. acute head injury or
is left upside down and the following morn- recent stroke,
ing the plug is still clinging to the side of the • hypertension,
pot. • subcutaneous emphysema,
The head-down position increases the • trauma, bums or recent surgery to the
work of breathing (Marini et al1984), tends to head or neck,
reduce tidal volume (Olseni 1994) and • recent pneumonectomy or surgery to the
decreases FRC in people with normal lungs aorta, oesophagus or cardiac sphincter of
Genkins et al1988). Before embarking on PO the stomach,
it is therefore advisable to balance the risks • headache,
and benefits. • breathlessness,
• symptomatic hiatus hernia,
Indications • history of seizures,
• epistaxis or recent haemoptysis,
PO may be beneficial for people who show all • abdominal distension, pregnancy, obesity,
three of the following criteria: • acute spinal cord lesion,
• production of more than 30 ml of sputum a • pulmonary oedema, arrhythmias or cardio-
vascular instability,
day (Woodhead and Tattersfield 1987),
• difficulty in clearing it, • undrained pneumothorax,
• patient preference, and greater effective- • bronchopleural fistula,
ness than other methods. • risk of aspiration.
judged by sputum volume and the patient's Percussion or vibrations are performed in a
subjective report. postural drainage position. They aim to jar
Those who benefit are people with lung loose secretions from the airway walls.
abscess usually, bronchiectasis often and CF
Method
sometimes. PO is also beneficial for some
patients with acute problems if they are too Percussion consists of rhythmic clapping on
weak or tired for more active measures, but the chest with loose wrist and cupped hand,
134 Physiotherapy management
• abdominal breathing,
• one or two huffs from mid- to low lung
volume,
• abdominal breathing.
During huffing or forced expiration, the
pleural pressure becomes positive and equals
the alveolar pressure at a point along the
airway called the equal pressure point
(usually in the segmental bronchi). Towards
the mouth from this point, the transmural
pressure gradient is reversed so that pressure
inside the airway is lower than outside. This
squeezes the airways by a process known as I em
dynamic compression, which limits airflow, Figure 5.7 A section of the bronchial tree, (A) at
but the squeezing of airways mouthwards of FRC, (B) at full inspiration, (C) at full expiration,
this point mobilizes secretions. The equal and (D) during coughing. (From Marshall, R.
pressure point moves distally at low and Holden, W.S. (1963) Changes in calibre of
volumes, and it has been suggested that the the airways in man. Thorax, 18, 54--8, with
lower the lung volume, the deeper the region permission. )
from which secretions are cleared.
• end with relaxed abdominal breathing.
Effects
Avoidance of high lung volumes is easier if
The depth of the mucus clearance has not yet patients take in only a half-breath before the
been validated (AARC 1993c), and the effect huff. Higher lung volumes are used once
is still thought to be in the larger airways secretions are mobilized. Teaching the huff is
(Conway 1992b), but ACBT may be working sometime helped by blowing through a peak
quietly in the small airways by 'milking' the flow mouthpiece, and for children by incor-
mucus mouthwards. ACBT and coughing are porating blowing games.
equally effective (Hasani et al 1994) but Treatment continues until the chest is
correctly performed ACBT is less likely to subjectively or objectively clear, or until the
cause bronchospasm or desaturation in at- patient tires. Technique must be checked
risk patients. ACBT incorporates several regularly because patients tend to take in too
components, and may include PD, so it is deep a breath or skip the relaxed part of the
unclear which is the most effective element. cycle. ACBT gives patients independence
and is usefully incorporated into the chest
Method clearance routine of people with CF.
Correct teaching is essential because huffing
alone causes more airways obstruction than 5.4.7 Autogenic drainage (AD)
coughing (Fig. 5.7), mucus clearance can
AD is designed to produce the highest
actually be impaired (David 1991), and in-
possible airflow in different generations of
correct technique can cause bronchospasm,
bronchi by a three-phase controlled breathing
paroxysms of coughing and de saturation
regime, clearing secretions from the small to
(Steven et al 1992). Points to note are:
large airways by gradually increasing lung
• avoid too forceful a huff, volumes. It gives patients independence
• complete the full cycle, from ages four to five, but requires 30--45
136 Physiotherapy management
Phase 2 3
UNSTICK COLLECT EVALUATE
Low lung volume Mid-lung volume High lung volume
Mobilize peripheral Collect in middle Expec~ten
secretions airways
IRV
,.....,
,.......,
,.....,
~
11 ,.......,
,......., VT
r l r i '---'
ERV
------------ - - - - - - - - - - - - - - - - - - - - - - t-
RV
minutes to complete, and for people with CF crackles are felt, deep breathing clears the
is usually necessary twice a day. It can be mucus (Fig. 5.8). Coughing is inhibited until
incorporated into certain activities such as secretions are accessible. Flow is controlled to
driving. achieve highest flows without airway col-
lapse, aiming at a mucus rattle rather than a
Effects wheeze. Patients who find it difficult to
breathe at low lung volumes can breathe at
AD improves airflOW in the small airways, varying tidal volumes (Prasad 1993). Schoni
clearing secretions that are not accessible (1989) describes details of the technique, but
with 'conventional physiotherapy' (usually physiotherapists wanting to use AD require
defined as postural drainage, percussion and specialist training.
vibrations) (Hardy 1993). It improves Sa02
(McIlwaine 1991) and shows greater mucus
clearance than ACBT (Miller et al1995). 5.4.8 Mechanical aids
Positive expiratory pressure (PEP)
Method
PEP is the application of positive pressure at
The patient sits upright and inhales slowly the mouth via a face mask, one-way valve
through the nose, pauses at end-inspiration, and expiratory resistance.
then exhales through the mouth. Breaths
start from residual volume to un stick the Effects PEP incorporates the principle of
mucus, then when when the patient feels the maintaining lung volume so that secretion
secretions moving, tidal volume breaths are clearance is not hampered by collapsing
taken to collect the mucus, then when airways. Breathing out against resistance
Methods to clear secretions 137
opens up airways, evens the distribution of lungs feel subjectively clear. During stable
ventilation, forces air through collateral chan- disease, most patients find that two IS-minute
nels and pushes secretions from the lung or three 10-minute sessions a day are adequate.
periphery to the central airways, from where High pressure PEP creates pressures of
they can be coughed up (Fig. 5.9). PEP has 60 cmH2 0 (Hardy 1993), using flow volume
the added advantage of counteracting airway curves to gauge the correct pressure. This
closure caused by coughing. Its effects are shows added benefits of reduced hyper-
more long-lasting than PO (Mortensen et al inflation and improved lung function (Prasad
1991). 1993).
Method A resistance is chosen so that the Indications PEP is mostly used by people
patient is able to breathe comfortably for with CF, especially adolescents and those
two minutes into the mask and achieve a pres- seeking freedom from PO, but COPD
sure of 10-20 cmH2 0 during mid-expiration, patients who have difficulty clearing secre-
using a manometer between the valve and tions also find it helpful (Christensen, Simon-
resistance (Andersen and Falk 1991). The sen and Lange 1990). It is suited to people
patient sits leaning forwards to protect the with moderate amounts of sputum and can
lungs from overdistension. With the PEP be used by children as young as four years.
mask firmly over the nose and mouth, the Those with large amounts of ~putum need
patient inhales to tidal volume and then the addition of other techniques, but PEP
exhales actively, but not fully or forcefully, alone can be used as a stopgap, for example
giving way to the resistance (Fig. 5.10). Ten to enable a child with CF to go on a school
PEP breaths are followed by ACBT and outing. It is not advisable for people who
coughing, each session continuing until the wheeze.
138 Physiotherapy management
Perforated
Mechanical percussors, vibrators and
oscillators
Various substitutes for manual techniques
have been developed. They allow independ- Exhaled air
ence, but are expensive and need to be
accompanied by other techniques such as
deep breathing to discourage airway closure.
The following are available:
• taking slow shallow breaths, cardia and unstable BP. Stress can cause
• breathing through pursed lips, tachycardia.
• sucking lozenges, 6. Laryngospasm is a rare but dangerous
• drugs as described on p. 102. complication. If the patient stops breath-
ing and the catheter feels stuck, the crash
team should be called and oxygen
5.4.10 Nasopharyngeal suction applied.
The worst part is the initial introduction of the
Indications
catheter into the nostrils. Once past the turn at
the back of the nose, it was not too unpleasant, Suction is performed only if all of the
until a cough is stimulated; then it feels like following criteria are met:
hours as the catheter is brought back up ... it
• secretions are detrimental to the patient,
felt as if I was choking.
• secretions are accessible to the catheter, as
Ludwig 1984
indicated by crackles in the upper airway
These remarks come from a physiotherapist on auscultation,
who found herself at the wrong end of a • the patient is unable to clear the secretions
suction catheter, and they illustrate why by other means.
most clinicians are, rightly, reluctant to put
Weakness and semiconsciousness may be
their patients through the ordeal of naso-
indications. Fatigue is not, because unless
pharyngeal suction, which is usually distress-
fatigue is extreme enough for the patient to
ing and often painful. It is also dirty, risky
need mechanical ventilation, coughing is still
and limited in effectiveness, but there are
possible. Risks are increased in a combative
occasions when it is necessary.
patient, and those who need physical
restraint for suction rarely need to undergo
Complications
the procedure because they are usually
Untoward effects of suction may be subclin- strong enough to cough effectively, even
ical and go unrecognized. Common problems though they may choose not to. Forcible
are the following: suction is unethical, usually illegal and
acceptable only in life-threatening situations.
1. Airway mucosa is exquisitely sensitive
and can be damaged by passage of the
Catheters
catheter, poor technique or pull from the
vacuum (Kleiber et aI1988). Damage can Catheters have an end-hole through which
be tantamount to a crude biopsy, leading the mucus is suctioned, and side eyes to
to bleeding and up to 50% reduction in relieve vacuum if the end-hole touches the
mucociliary transport (Landa et aI1980). mucosa, because contact with the mucosa
2. Infective organisms find an easy target if causes invagination. Both end-hole and side
the protective mucosa is damaged by eyes are best slightly depressed to keep them
repeated suction. at a distance from the mucosa (Lomholt
3. Suction vacuum can cause atelectasis. 1982a). The side eyes should not be too large
4. Sustained hypoxia can be caused by (Fig. 5.12(c» or they reduce suction
atelectasis, sucking out oxygen, enforced efficiency. The total size of the side eyes
apnoea (Petersen et al 1979) and should be less than that of the end-hole so
increased oxygen demand due to stress. that they do not become the main suction
5. Hypoxaemia or irritation of the vagus channels and themselves damage mucosa.
nerve can cause arrhythmias, brady- Catheters with multiple side eyes show
Methods to clear secretions 141
(c)
RJ 2.
vomiting.
Pre oxygenate for two minutes if this is
not contraindicated. The oxygen mask
should then be kept close to the patient's
~
face throughout.
3. Explain to the patient how it will feel,
(d)
how long it will last and that he or she
may ask for a pause at any time, a request
:J) that must be responded to. Unconscious
patients also need an explanation.
(e)
4. Connect the catheter to the apparatus
and put gloves on both hands. The
iii
765 :J) dominant hand needs a sterile glove, and
both gloves should be non-powdered in
(f)
case the powder finds its way into the
Figure 5.12 Different catheter tips. lungs. Remove the catheter from the
package and lubricate the tip with water-
reduced suction efficiency (Lomholt 1982b), soluble or lignocaine jelly. Maintain the
but cause less invagination than those with sterility of the catheter and gloves.
one or two eyes (Link et al 1976). Catheters 5. With the suction port open, slide the
with one side eye (Fig. 5. 12(a» cause catheter gently into the nostril, aiming
unnecessary trauma (Lomholt 1982b) and towards the occiput. If resistance is felt at
although cheap should not be used. the back of the pharynx, rotate the
A beaded tip is designed to keep the eyes catheter slowly between the fingers and
away from grabbing the mucosa, but does ease very gently forwards.
not always fulfil this objective (Jung and 6. To reduce the risk of entering the oeso-
Gottleib 1976), and the bead makes it phagus, ask the patient to tilt the head
unsuited to nasal suction because of the back, stick the tongue out and cough. If
enlarged tip (Fig. 5.12(d». The ideal catheter coughing is not possible, slide the cath-
is flexible, has a smooth, rounded tip and eter down during speech or inhalation,
small, multiple, countersunk side eyes. when the glottis is open. If the patient
swallows, the catheter has slipped into
Method the oesophagus, so slightly withdraw the
A size 10 FG catheter is preferable, but some catheter, reposition the head and pro-
patients may need size 12. High suction ceed. The catheter is in the trachea if the
pressures can be damaging, but low pres- patient coughs or expired air can be felt
sures can be less effective and cause pro- through the end of the catheter.
142 Physiotherapy management
Precautions
Nasopharyngeal suction should be avoided
in patients with stridor because of the danger
of total airway obstruction. It should be
avoided if there is acute face, neck or head Figure 5.14 Minitracheostomy.
injury. If there is cerebrospinal fluid leak after
basal skull fracture, an oral airway should be itself can be sent to the laboratory or the
used because of the risk of infection. Bleeding catheter swilled with a few drops of sterile
may occur in patients who have dotting saline to draw secretions into the mucus trap.
disorders (see Glossary) or who are receiving It is possible to obtain a deeper specimen
heparin or thrombolytic drugs. If the patient that is less contaminated by pathogens lurk-
has pulmonary oedema, suction does not ing in the proximal airways. After preoxy-
help the condition and will remove surfactant genation, a catheter is inserted, 20 ml of
if performed repeatedly. Suction aggravates saline is injected by syringe through the
bronchospasm, but so too does excess catheter over 10 seconds, the saline is with-
mucus. Following recent pneumonectomy or drawn by the syringe (without suction), then
lung transplant, the catheter should not be the catheter is withdrawn.
taken beyond the pharynx in case it impinges
on the bronchial stump. Following recent Nasopharyngeal airway
oesophagectomy, the catheter should not be A nasopharyngeal airway may be preferred
taken beyond the pharynx in case it misses by some patients who need frequent suction
the trachea and damages the oesophageal (Fig. 5.13). It is lubricated with lignocaine
anastomosis. gel, inserted gently into the nose and left
It is advisable to wear a mask, goggles and for 24 hours, with a safety pin across the
gloves for self-protection. It is unlikely that top to prevent it disappearing into the
blood-streaked sputum can find its way patient.
through any non-intact skin or mucous mem-
branes, but it is theoretically possible.
5.4.11 Minitracheostomy
6.1 DOES PULMONARY helpless when faced with someone who has
REHABILITATION WORK? uncontrolled breathlessness, lungs like tissue
paper, a pessimistic outlook, an unglamorous
No patient is 'too sick' or 'too well' to benefit disease, and no nice straightforward problem
from a pulmonary rehabilitation program. such as excess sputum which can be dealt
Menier 1994 with by time-honoured techniques.
Rehabilitation has become widely accepted
Rehabilitation for people disabled by breath- for people with neurological, musculoskeletal
lessness is one of the most rewarding aspects and cardiac conditions, but does it work for
of physiotherapy, yet it is one of the most people with lung disease? Pulmonary re-
neglected. It is rewarding because it can habilitation does not reverse lung damage,
provide real improvement in the lives of but it modifies the disability that derives from
people who have become entangled in a web it. Participants report a sense of well-being
of inactivity, low self-esteem and helpless- which is due to gaining control over symp-
ness. It is neglected because of a widespread toms, especially the fear of breathlessness.
attitude that patients have reached a dead Other outcomes that have been demon-
end. Physiotherapists themselves may feel strated are (Brannon et a11993; Murray 1993):
146 Management of breathlessness and pulmonary rehabilitation
20
0L-~____~__~~__~~__~~__~L-__~~__~~__~~__
1 yr 1st yr 2nd yr 3rd yr 4th yr 7th yr 8th yr
Before
Years before and during pulmonary rehabilitation programme
Figure 6.1 Analysis of hospital admissions after initiation of pulmonary rehabilitation. (From
Hodgkin, J.E. (1993) Pulmonary Rehabilitation: Guidelines to Success, Butterworth, London, with
permission. )
lessness that is laboured, distressing and • i drive to breathe, e.g. interstitial lung
usually, but not always, associated with disorders such as pulmonary oedema,
effort (Demediuk et al 1992). In practice, the fibrosing alveolitis or pneumonia (which
terms breathlessness and dyspnoea tend to stimulate nerve impulses from inter-
be used interchangeably. They should be stitial receptors), acidosis, anaemia,
distinguished from the objective terms: thyrotoxicosis,
• ~ alveolar surface tension, e.g. pulmonary
• tachypnoea: rapid breathing,
oedema, acute respiratory distress syn-
• hyperpnoea: increased ventilation in re-
drome.
sponse to increased metabolism,
• hyperventilation: ventilation in excess of These mechanisms are often interlinked,
metabolic requirements. e.g. i airflow resistance causes i drive to
breathe (Duranti 1995).
6.2.1 Mechanism The result is an effort to breathe that is not
satisfied by the breathing that results, creat-
A respiratory physiologist offering a unitary
ing a deluge of impulses from the respiratory
explanation for breathlessness should arouse the
centre. This is perceived as the sensation of
same suspicion as a tattooed archbishop offering
breathlessness. Inspiratory muscle fatigue
a free ticket to heaven.
magnifies the perception of effort in the same
Campbell and Howell 1963
way that a suitcase feels heavier the longer it
The mechanism of breathlessness is obscure is carried. The perception of breathlessness is
and fascinating. There is little relationship heightened by uncertainty, distress, anxiety
between blood gases and breathlessness, (Muers 1993), past life experiences, frustra-
which makes sense of the limited effective- tion and lack of social support (Reardon
ness of oxygen therapy for breathlessness 1994). Hence the variation between breath-
(p. 90). Although hypercapnia and hypox- lessness and the effect on a person's lifestyle.
aemia may force people to breathe more Acute asthma shows typically how a com-
deeply, they are not directly related to the bination of factors may cause breathlessness:
subjective experience of breathlessness. A
• bronchial irritant receptors stimulate an
patient can be severely hypoxaemic without
abnormal drive to breathe,
feeling short of breath, and vice versa.
• airway obstruction and inefficient breathing
Breathlessness relates to mechanical abnor-
at high lung volumes increase the work-
malities and work of breathing. It correlates
load,
with motor output as reflected in the pressure
• anxiety triggers and sustains breathless-
generated by the respiratory muscles, which
ness.
can be consciously perceived as a sense of
effort (O'Donnell 1994). It is caused by one or
6.2.2 Effects on the patient
a combination of the following:
It's the worst feeling in the world, the worst way
• i airflow resistance, e.g. obstructive lung
to die, it's like smothering to death . .. to lose
disease,
control of your breathing.
• i elastic load, e.g. rigid chest, distended DeVito 1990
abdomen, fibrotic lungs,
• ~ energy supply, e.g. malnutrition, shock The experience of breathlessness can vary
states in which perfusion to the dia- from feeling that breathing is no longer
phragm is impaired, automatic, to total preoccupation and un-
• ~ power, e.g. neuromuscular deficiency, remitting fear. Fear itself makes breathing
fatigue, weakness, more difficult, and patients often find it
Assessment for rehabilitation 149
difficult to communicate their feelings. It can pulse rate > 120 bpm, and resting systolic
be frightening just to watch a breathless pressure > 200 mmHg or diastolic >
patient. 110 mmHg (AARC 1992). Steroid-induced
A degree of imaginative skill is needed by osteoporosis is not a contraindication, indeed
those working with people who are breath- this condition benefits from exercise. A
less. Lung disease is not blessed with high PaC02 above 8 kPa (60 mmHg) requires liai-
social standing. Other conditions may elicit son with the physician. The drug history is
more empathetic responses: for example, relevant:
paraplegics are seen as brave, heart attacks
• certain drugs render the BP and pulse
are assumed to afflict high achievers, and a
unreliable for monitoring purposes
white cane elicits instant sympathy. People
(p. 159),
labelled as 'only bronchitic', however, are
• if prescribed, bronchodilators and anti-
often elderly and depressed, they spit and
angina drugs should be taken before
wheeze, and anyway 'have they not brought
exercise,
it on themselves?'. This attitude is shared by
• steroids should be at the lowest effective
some health workers. Not everyone can
dose to minimize the risk of muscle
identify with the experience of spending
weakness.
night after night in a chair unable to sleep, or
dreading the effort of going to the toilet, or Patients with heart failure take longer to
anticipating the cruel slowness of death. recover from activity. Right heart failure is
compatible with reasonable exercise, but left
heart failure requires a limited programme.
6.3 ASSESSMENT FOR
Oximetry (p. 233) is advisable because the
REHABILITATION
response to exercise is unpredictable. The
Assessment needs to take account of: oximeter should be validated under exercise
conditions, and an ear sensor used in prefer-
• respiratory impairment: ~ lung function,
ence to a finger probe which is less accurate
• respiratory disability: the effect of this
on exercise. Small oximeters can be clipped to
impairment, e.g. ~ exercise capacity or
a belt. Transient de saturation is acceptable,
anxiety,
but if the Sa02 stays below 85%, oxygen is
• respiratory handicap: social and other dis-
required (Brannon et al 1993, p. 295).
advantages resulting from the environ-
If oximetry is not available, it is worth
mental effects of the disability.
checking the respiratory function tests
In other words, one breathless person may because a value for TLCO (p. 49) above 55%
be handicapped while another with a similar predicted indicates that de saturation is un-
degree of disability is not handicapped. likely during exercise (Mak et al 1993). This
Patients are assessed as described in suggests that diffusion characteristics play a
Chapter 2, with extra attention to the factors role in exercise-induced desaturation.
described below. Changes in breathlessness for an indi-
The case notes should be scrutinized for vidual can be measured (Fig. 6.2). Function
evidence that exercise training is safe. Contra- can be measured by a quality of life scale
indications include unstable angina, recent (Curtis 1994), rating scale (Hodgkin 1993,
embolism or myocardial infarct, 2nd or 3rd p. 481) or home-made questionnaire (Table
degree heart block and deep vein thrombosis. 6.1). These are more relevant to the patient's
Relative contraindications include disabling needs than physiological change, but some
stroke or arthritis, intermittent claudication, scales may be influenced by patients stopping
metastatic cancer, unstable asthma, resting 'wanting' to do what they cannot do. Scales
150 Management of breathlessness and pulmonary rehabilitation
Greatest
breathlessness
No breathlessness
Breathlessness scale
2. Breathlessness on stairs.
are most useful when they distinguish Education is the most cost-effective aspect of
breathless and distress (Wilson and Jones a rehabilitation programme (Tougaard et al
1991). Causes of distress include breathless- 1992), and its importance is underlined by
ness itself, anxiety, fear, fatigue, weakness, current policies of early discharge from
embarrassment, frustration, dependency and hospital. Education increases patients' confi-
loss of the capacity to be spontaneous. dence and reduces the uncertainty and fear
It is helpful to ask patients how breathless- that affects their quality of life (Small and
ness affects their lives, and why they think Graydon 1992).
they are breathless. Many patients are Education is not achieved by feeding infor-
relieved when asked if their breathlessness is mation into an empty vessel and pressing the
frightening, because they may not have right buttons. It should encourage participa-
heard this acknowledged before. tion throughout. Age does not hinder intel-
lectual ability, but elderly participants may
need time for processing information.
6.4 EDUCATION Hypoxaemia does not hinder mental speed
Real education must entail emancipation: liber- but may impair memory. Retention of infor-
ating people to make their own decisions on their mation is optimal if:
own terms. • the room is free of distractions,
Fahrenfort 1987 • teaching sessions are brief,
Education 151
natural for breathless people to feel or poor self-image. Drugs such as some
depressed and anxious, and that it is an antihypertensives, antiulcer and cardiac drugs
expression of humanity, not weakness. can affect sexual function, in which case a
Topics to discuss include: change in dose or type of drug may be
• identification of stressors, indicated.
• recognition and management of depression Many physiotherapists are comfortable to
(without taking comfort in smoking!) listen to patients talking about feelings, but
• living with limitations, patients can be referred for specialist help
• how to deal with panic during breathless when appropriate.
attacks,
• the importance of activity and maintaining 6.4.4 Nutrition, fluids, drugs and oxygen
a social life,
• relationship with a partner, including con- The role of the dietician is to identify indi-
cepts of guilt, dependence and resent- vidual nutrition problems, suggest six-meal-
ment, a-day menus, advise on healthy eating and
• relationships with others, coping with explain which foods are mucus-forming, gas-
embarrassment or perceived stigma, e.g. forming, constipating or hard to digest.
how to explain about using oxygen or Patients need to understand the effects and
walking slowly, how to cope when the
side-effects of drugs and oxygen therapy, the
legitimacy of their 'invisible' condition if
practicalities of equipment and the conse-
challenged.
quences of non-compliance. Further infor-
Relationships may be affected by lack of mation is in Chapter 4.
spontaneity because breathless people often
feel that they cannot waste breath in express-
ing anxiety, anger or happiness. Education 6.4.5 Smoking withdrawal
and counselling for both partners can help
There's nothing to giving up smoking. I've done
prevent this emotional straight-jacket isolat-
ing them from those they need most. it hundreds of times.
The relevance of this topic is shown by Mark Twain
evidence that attitudes and beliefs bear more Smoking cessation is the most important step
relation to exercise tolerance than ventilatory in treating people with COPD, and 70% of
capacity (Morgan et al 1983), and that denial
smokers want to give up (Venables 1994). But
reduces compliance (Borak et al 1991).
their endeavours are hampered by the tena-
ciously addictive properties of nicotine, as
6.4.3 Sexuality well as less specific obstacles such as the
Sexuality and self-esteem are closely linked, comradeship enjoyed by smokers. Discussion
and loss of sexual expression reinforces lack is the most effective method (Clarke 1991),
of confidence. Education can help discrimin- and physiotherapists are in an ideal position
ate between the effects of myth, illness and to contribute to the team effort, especially
drugs on sexual activity. Myths perpetuated when hospitalization presents a 'teachable
by society include the expectation that elderly moment'.
people cannot have, do not want, or should Multiple reinforcements are more success-
not want sexual relations, and that disabled ful than relying on a single intervention, and
people are sexually neutered. Illness may every strategy for encouragement should be
cause deconditioning, breathlessness, fatigue employed because failure drains the will. A
154 Management of breathlessness and pulmonary rehabilitation
quit date can be mutually decided, along with that it is never too late to stop, and then to
strategies in case of relapse. support patients after they have made their
Specific information can be given, such as decision.
the effects of tobacco on the smoker's family,
and the fact that while smoking appears to
help clear the chest, it only does so by 6.5 BREATHLESSNESS MANAGEMENT
causing irritation and producing extra secre-
tions. Participants need to understand the Clare is a physiotherapist whose description
physical and psychological difficulties of of the breathlessness that she experienced
withdrawal, but also the pleasures of during pneumonia indicates why some
improved appetite and bank balance, sweeter patients are not always pleased to see us:
breath, reduced cough and even some re-
At every breath I felt; was it going to be enough?
covery of lung function (Hodgkin 1993,
I thought life was over, even though I knew that
p. 91). Smokers often feel guilty for their own
was irrational. I didn't want to have to be polite,
contribution to their disease, but discussion
I didn't want the effort of please and thank you.
will help put this in perspective.
I didn't mind how much phlegm was there, it
Nicotine patches can double the rate of
could just stay there. The thought of a physio
cessation (Fiore et al 1994). Two patches or
coming near me made me feel even more ill.
half a patch can be used, worn in the daytime
(for less sleep disturbance) or over 24 hours Breathless people need reminding that
(for reduced early morning cravings). Side- they are in control of the pace of their
effects include skin irritation, which is treatment, that they can take their time and
managed by changing the site daily, and the not be expected to talk unless they want to.
normal but milder effects of quitting, which Questions should require only a 'yes' or 'no'
are managed by reassurance that they will answer. Patients need acknowledgement of
disappear in about 10 days of patch-wearing. the reality of their experience, not empty
Nicotine gum can be used in tandem with phrases like 'Don't be frightened' or 'Try to
patches, delivering rapid boluses in time of get control'.
need.
Extra sources of help are biofeedback by
carbon-monoxide monitoring Oarvis 1986), 6.5.1 Tips on reducing breathlessness
acupuncture, hypnotherapy, group counsel-
ling and role play to strengthen patients' Patients can be helped to understand how
resolve in asking friends not to smoke around breathlessness is affected by interactions
them. Participants themselves provide tips such as talking, eating, muscle tension,
and ideas for each other, and can set up a walking and posture. Awareness is rein-
'buddy system' by swapping phone num- forced by regularly bringing the patient's
bers. Positive support helps counteract attention to these, especially how breath-
patients' previous experience of being treated holding can interfere with function.
as if they should be punished for smoking Desensitization to breathlessness is a way
(maybe some of this punitive energy could be of reducing the fear that inhibits activity. First
directed at the tobacco companies). and foremost, patients are told that breath-
But would it not be preferable for a person lessness itself is not harmful. This can be a
who is disabled and housebound to continue revelation to them, but they are then free to
with one of life's few remaining pleasures? attempt activities that increase breathless-
That is the patient's decision. The job of the ness, in a way that they control, and then
rehabilitation team is to educate, to explain gently regain their own breath. Patient and
Breathlessness management 155
their own rhythm. No more than two deep awareness of tense areas, e.g. jaw or
breaths should be taken at a time, then hands, and advising on localized relaxa-
patients are advised to get their breath back tion. Patients may not be able to relax the
and breathe comfortably. Breathing rate and shoulder girdle because they need their
pattern are observed while they get their accessory muscles to breathe. A demon-
breath back. stration of a relaxed posture is helpful,
If a breathless person has a problem of and the physiotherapist's own calm voice
sputum retention, vibrations may be detri- and breathing pattern will help reduce
mental because they tend to disturb the the patient's tension. Other relaxation
breathing pattern. Percussion is better toler- techniques are on p. 210.
ated and can even be relaxing if a slow 4. Comfortable, relaxed breathing can be
rhythmic technique is used. The head-down facilitated by a modified yoga technique
postural drainage position is usually contra- in which patients sit with their feet flat on
indicated for breathless people, but is occasion- the floor and imagine that they are
ally beneficial for emphysematous patients breathing the air 'in through the head
because their flat diaphragm is pushed into a and out through the feet into the floor'.
more functional dome shape. However, this This is not exactly anatomical, but almost
manoeuvre must be done slowly and only if invariably generates relaxation.
comfortable for the patient. Oximetry can be 5. Patients may then be able gently to
reassuring. develop an abdominal pattern of breath-
ing, and/or raise the resting lung volume,
6.6 BREATHING RE-EDUCATION as described separately below.
6. Relaxation is rechecked, if appropriate.
The aims of breathing re-education are to
7. Praise is given liberally!
reduce the work of breathing and give
patients confidence in their ability to control During this sequence, breathing usually
breathless attacks. When intervening in a becomes slower and deeper naturally. Shal-
person's pattern of breathing, a minimal low breathing wastes energy because of
approach is needed. Compensatory mechan- ventilating dead space, and rapid breathing
isms, such as dynamic hyperinflation, should wastes energy because of turbulence. How-
not be interfered with mindlessly. Each of ever, breaths that are too deep are working
the following steps should be taken one at a against elastic recoil and can also increase the
time; close observation will then determine work of breathing, a twice-normal tidal
whether this has been helpful, and/or if the volume quadrupling the elastic workload
next step should be initiated: (Haas and Axen 1991, p. 17). Most people
have already achieved optimal efficiency
1. The position is chosen by the patient, but
themselves, but tense patients who have
the physiotherapist might suggest sitting
adopted a counterproductive breathing pat-
upright in a chair or forward-lean sitting
tern may benefit from intervention.
(p. 123).
Suggested guidelines are the following:
2. Awareness of breathing is encouraged by
bringing patients' attention to their brea- • rapid shallow breathing benefits people
thing pattern. Are they breathing api- with restrictive lung disease who have
cally, abdominally, with pursed lips and high elastic recoil and low lung com-
forced expiration, are they using their pliance (Mador 1991), i.e. they do not
nose or mouth? need to change their breathing pattern,
3. Relaxation is then encouraged. This may • hypercapnic patients with rapid shallow
be full-body relaxation, or simply raising breathing are conserving energy wisely
Breathing re-education 157
and their breathing pattern should not Patients should not change the rate or
be disturbed (Pitcher 1993) . depth of breathing. They simply start inhala-
• slow, deep breathing often benefits people tion just before the point at which visible
with moderate obstructive lung disease, recruitment of abdominal muscles begins,
but this is usually best encouraged in- i.e. when active expiration takes over from
directly, by the methods described passive expiration. The following steps are
above, because if imposed directly it can suggested:
disrupt the breathing pattern (Faling
1986) and tire the inspiratory muscles • positioning, relaxation and rhythmic breath-
(Begin 1991), ing as described above,
• observation of the patient's breathing pat-
Pursed lip breathing is often adopted tern,
voluntarily by breathless people because it • at each breath, instruction to the patient to
relieves breathlessness by acting as a form of inhale just before abdominal muscle
expiratory CPAP to prevent airway closure. recruitment, with a smooth transition
However, it has significant disadvantages from inspiration to expiration,
including increased work of breathing (p. 27).
• practice in this, at first with the physiother-
It should be neither encouraged nor discour-
apist's voice, then without.
aged, but breathing re-education may render
it unnecessary.
Patients should avoid holding their breath
or disturbing their breathing pattern. On-
6.6.1 Abdominal breathing going reinforcement is needed for some days,
Relaxed abdominal breathing (p. 114) can but the technique is simple, and it is a
facilitate relaxation, reduce BP (Fried 1993, pleasure to see the relief that it brings.
p. 177), diminish breathlessness (Breslin et al Once breathing is controlled, it can be
1990), and increase inspiratory muscle incorporated progressively into daily activities
strength (McConnochie and Chatham 1991). such as watching TV, standing, eating,
However, some severely impaired patients talking and sometimes walking and stair-
achieve none of these benefits because their climbing. Recreating and managing situ-
delicately balanced breathing can be upset ations that typically increase breathlessness
(Gosselink 1995). for the individual patient will improve con-
fidence.
Much encouragement is needed to change
6.6.2 Raising the resting lung volume a familiar breathing pattern, but the earlier in
Forced expiration does not improve expir- the disease process that these techniques are
atory airflow and consumes excess energy learnt, the more easily patients can incorpor-
(Tobin 1988). If patients continue to use ate them into their lifestyle. In the later stages
forced expiration despite the previous of disease, there is no evidence that a
manoeuvres, they can be helped by a simple voluntary act can become automatic, but if
technique that raises the FRC above the level repeated regularly, some learning may occur
at which forced expiration occurs (Innocenti by a change in the process underpinning
1966). This technique acts like CPAP to hold its control (Gallego and Perruchet 1991).
airways open and prevent the need for forced Most importantly, the new pattern can be
expiration, but consumes less energy than used consciously to bring relief at difficult
pursed lip breathing. times.
158 Management of breathlessness and pulmonary rehabilitation
\
Mr Smith becomes short of breath when he
exerts himself. Mr Smith has lung disease and I
know that lung disease causes shortness of
breath. Therefore Mr Smith's exercise limitation
is due to his lung disease.
quoted by Schwartzstein 1992 t Exercise
\
tolerance
Dubious logic has restricted the quality of life
for many breathless people. It has reinforced
the myth that they cannot benefit from
exercise training. It has prevented a therapy
which has proved effective from becoming an t Efficiency and Muscle
co-ordination weakness
integral part of respiratory care. There is an
assumption that respiratory patients cannot
~
Figure 6.3 Vicious cycle that augments
reach a training threshold because exercise is
breathlessness in patients with chronic lung
limited by breathlessness, but this does not disease.
take account of the following:
1. Killian (1992) has shown that a third of their age (Fiatarone 1994) or the severity of
COPD patients stop exercising because of their disease (Niederman et al 1991).
fatigue rather than breathlessness, and
Donner and Howard (1992) have shown
that cardiovascular or peripheral muscle 6.7.1 Effects
limitations are the main factors for people
with moderate disease. Non-ventilatory 1. Patients show improved cardiovascular
working muscles can also be impaired by fitness and raised anaerobic threshold
tissue hypoxia in patients with chronic (Schwartzstein 1992). Maximum oxygen
hypoxaemia (Wuyam et aI1992). consumption (V0 2max ) is increased in
2. A significant limiting factor is the people with less severe disease, and
patient's fear of breathlessness rather improvement in muscle strength can be
than breathlessness itself. Success relies comparable to that in healthy young
on desensitization to breathlessness and people (Simpson et al 1992). Poor prior
breaking out of a vicious cycle of breath- conditioning means that exercise is more
lessness and physical deconditioning likely to induce a physiological training
(Fig. 6.3). Exercise itself acts as a form of effect, even in elderly people (Casaburi
desensitization to breathlessness (Bel- 1992).
man et al 1991). 2. A sense of well-being and confidence,
along with reduced anxiety and de-
Long-term commitment is needed because pression, is consistently reported and is
detraining occurs faster than training. The greater than any objective change (Hodg-
programme must be individually planned, kin 1993, p. 286).
acceptable to the patient, accessible, safe, 3. Activity provides mechanical input that
show tangible benefits and be able to be eases the perception of breathlessness.
maintained unsupervised at home. The 4. Improved posture and rhythmic co-
effects of training are unrelated to lung ordination leads to a more efficient walk-
function and patients can benefit regardless of ing pattern.
Exercise training 159
5. Exercise reduces smoking (Russell et al • steady exercise with no rushing at the start,
1988), BP (Brannon et al 1993, p. 69) • adequate rest, including placement of chairs
and risk of chest infection (Karper and at intervals,
Boschen 1993). It promotes relaxation and • termination of exercise if there is angina,
sleep, regulates blood sugar and reduces cyanosis, pallor, fatigue, confusion, head-
gut problems (Hodgkin 1993, p. 109). ache, dizziness or nausea,
• termination of exercise if systolic pressure
6.7.2 Mechanism of training rises > 250 or diastolic > 120 (AARC
1992).
Successful training depends on the overload • for patients with coronary heart disease,
principle, which stipulates that the intensity of termination of exercise if there is failure to
training is greater than the load normally increase heart rate (HR) or failure to raise
encountered by the muscles. Endurance train- systolic pressure at least 10 mmHg above
ing, comprising low-resistance high-repetition the resting level, suggesting cardiac insuf-
exercise, is more suitable for respiratory ficiency.
patients than strength training, which entails
high-resistance low-repetition exercise. Endur- Resting BP should not be used as a predictor
ance training forestalls the onset of inefficient of BP during exercise for patients on beta-
anaerobic metabolism, i.e. it enhances the use blockers such as propranolol (Potempa et al
of oxygen. 1991). The pulse is an umeliable monitoring
tool for patients on beta-blockers, digoxin or
salbutamol,
6.7.3 Safety
People with stable diabetes benefit from
Oximetry is advisable during assessment and exercise so long as they maintain hydration,
is useful as biofeedback and reassurance for look after their feet and, when necessary, alter
the patient. Patients with restrictive disease, in their insulin and carbohydrates to avoid
particular, may find their performance hypoglycaemic events.
impaired by rapid desaturation. Training
should be terminated if saturation drops below
80% (AARC 1992). 6.7.4 Method
Fifty per cent of people with COPD aged Goal setting
over 50 have cardiovascular disease (Haas and
Haas 1990, p. 133). Breathlessness often Patients set their own goals, such as being able
prevents stress to the cardiovascular system, to walk to the pub, and then choose whether to
but the boundaries of safety should be defined train by walking, stair-climbing or other mea-
clearly. Practical safeguards are: surable activities. Elderly patients can be reas-
sured that training need not be rigorous.
• comprehensive medical screening, Inpatients should be dressed in their normal
• optimum nutrition to prevent depletion of clothes.
muscle proteins on exercise,
• appropriate fluid and drug therapy, Warm up
• treatment of any anaemia,
• detailed explanations and education on self- Participants C•.m warm up individually, but an
monitoring, exercise class allows them to enjoy movement
• isotonic rather than isometric exercise to for its own sake, distracts them from preoccu-
reduce the risks of hypertension, im- pation with breathlessness and reduces the
paired blood flow or fatigue, seriousness associated with a therapeutic
• discouragement of competition, environment.
160 Management of breathlessness and pulmonary rehabilitation
Stretching exercises are encouraged, e.g. They help reduce the breathlessness associated
trunk rotation, or pectoral stretch with the with upper limb activities and have a carry-
patient's hands on his or her lower back or over effect on the respiratory muscles that can
standing in a doorway holding the door frame be equivalent to inspiratory muscle training
and leaning forwards. Other muscles that need (Hodgkin 1993, p. 275). Typically, patients lift
stretching include the neck muscles, psoas, a weight to shoulder level and down again
hamstrings and calf muscles. for two minutes, in time with their breathing,
Participants should be reminded of the followed by two minutes rest, the load being
following: increased weekly.
• avoid straining, pain or discomfort, A circuit of exercises, incorporating both
• keep movements relaxed and fluid, and mobility and strength, can be enjoyable and
allow the arms and legs to move indepen- beneficial, including quadriceps and calf exer-
dently of the body, cises, step-ups and wall press-ups.
• be aware of the breathing pattern. Some patients enjoy exercising at the local
Music may be used for pleasure but not as a leisure centre or swimming pool where the
metronome. Participants should feel free to environment enhances compliance. Medical
move at their own pace, or not join in if they cover should be checked.
wish. For severely breathless patients, the Three methods of prescribing intensity are
warm-up period is brief and may simply mean used:
starting their modified exercise training slowly.
1. The predicted maximum HR can be
Exercise prescription estimated as either 220 minus age or as
measured during an incremental stress
During activity, patients are discouraged from test. Exercise is traditionally maintained
talking, rushing or breath-holding, which can at 70% of maximum HR, but this is often
disturb the breathing pattern and increase BP uncomfortable for respiratory patients,
(Linsenbardt et al 1992). They are encouraged and a training effect can be achieved at
to take long comfortable strides and maintain a 30--40% of maximum (Hellman 1994). HR
rhythmic quality of movement.
is linearly related to V0 2rnax (p. 34),
Four components make up the exercise
which can also be used to grade inten-
prescription: mode, intensity, duration and
sity. Multiples of V02rnax are sometimes
frequency.
The mode of exercise should relate to the expressed as METs (see Glossary), in
participants' lifestyles and be aerobic. Many which case prescription starts at 40% of
choose walking or stair-climbing. Some prefer maximal METs (Brannon et al 1993).
the stationary cycle or treadmill because they These complicated methods are widely
feel in control, have support for their shoulder described, but are often considered in-
girdle and can use oxygen easily. For treadmill valid because:
walking, the speed is set at a minimum (a) many respiratory patients are too
0.9 mph and is increased by increments of breathless to reach true maximal HR
0.3 mph until participants feel they have or V02rnax,
reached their normal walking speed, then (b) HR is affected by cardiovascular
progression is by increasing treadmill elevation drugs such as beta-blockers or
or speed. Others enjoy gym activities such as digoxin,
chair and floor exercises. (c) even people with normal lungs
Arm exercises should be included in the show a wide variation in HR (Bel-
programme for all participants (Celli 1994). man et al 1991).
Exercise training 161
Table 6.2 Perceived shortness of breath scale People who tend to rush at their exercise,
1 Not breathless
in a fruitless attempt to get it over with, may
2 Minimally breathless find that counting with their steps helps them
3 Slightly breathless to pace themselves in the early stages, e.g. in/
4 Mildly breathless one, out/one, or in/one, out/one/two. For
5 Mildly to moderately breathless others this disturbs their rhythm and dis-
6 Moderately breathless tracts them from focusing on awareness of
7 Moderately to severely breathless their breathing, level of effort and avoidance
8 Severely breathless of fatigue.
9 Breathing not in control Stair-climbing may be more efficient if
10 Maximally breathless
performed by inhaling as the leg is raised,
As patients become familiar with the feelings associated exhaling as the body is raised and interspers-
with exercising at the appropriate target level, ratings ing every few steps with a rest. This may be
from 4 (60% HR range) to 6 (85% HR range) define the
slower than the patient's normal speed, but
appropriate level of exercise. Whichever of these the
patient chooses, this is maintained while the level of causes less distress and is compatible with
exercise is gradually increased. (From Borg, G.A.V. exercise training if there is progression. Most
(1982) Psychophysical bases of perceived exertion. Med. patients find it best to exhale during the
Sci. Sport. Ex., 14, 377--81, with permission.) strenuous part of an activity.
Cool down
2. Exercise can be increased gradually by
maintaining breathlessness at a constant Patients are asked to slow down their activity
tolerable level using a perceived short- for the cool-down period to prevent sudden
ness of breath scale (Table 6.2), while pooling of blood in the lower extremities.
power output gradually increases. This They then rest, recheck their breathing pat-
is highly reproducible, correlates with tern and fill out their exercise diary with a
physiological measures of exercise triumphant flourish. The diary includes the
intensity, and even in people with number of sessions per day, time taken per
normal lungs has been shown to result in session, distance or number of steps and
greater improvement in endurance than columns for suggested and actual pro-
using HR (Koltyn and Morgan 1992). grammes.
3. Patients can achieve a moderate training
response if they are able simply to exercise Progression
briskly enough to increase breathlessness,
Patients progress by first increasing duration
again at a constant tolerable level, but
and then intensity (Brannon et al 1993,
avoid distress or desaturation.
p. 291), usually in weekly increments. Daily
The duration and frequency of training practice sessions are preferable, e.g. a 20--30
relate to the total amount of work done. minute walk, but success has been achieved
Supervised training sessions usually last for with three low-intensity sessions a week
30 minutes, but for home practice sessions, lasting one to two hours each (Belman 1993).
respiratory patients find it more acceptable to Improvement usually continues for four to
exercise for one or more short sessions a day six months, and when a plateau is reached,
with brief warm up and cool down periods. moderate exercise should be maintained for
Severely breathless people may prefer 'inter- the rest of the patient's life at a minimum 15
val training', i.e. alternating periods of brief minutes a day. An indoor programme is
work and rest. necessary when it is windy, rainy or smoggy.
162 Management of breathlessness and pulmonary rehabilitation
Once a week, participants should put A diaphragm that becomes less susceptible
themselves back on the same programme as to fatigue after training is in a fit state to adapt
that of the final day of their training. If this is to the training stimulus and has achieved an
difficult, they have lost fitness and will need optimum balance of supply and demand.
to increase their maintenance exercise. If
training is interrupted by illness or holiday,
the programme is restarted at a lower level. 6.8.2 Effects
The difficult task of maintaining fitness needs Having identified possible candidates for
follow-up from the rehabilitation team. inspiratory muscle training (IMT), does this
technique actually help them? There has been
6.8 INSPIRATORY MUSCLE TRAINING some debate over whether there is a purpose
in improving inspiratory muscle endurance
6.8.1 Rationale (Goldstein 1993), and there is limited evi-
dence of clinically important benefit (Smith et
There is conflicting evidence that respiratory
aI1992). However, with rested and nourished
disease can make inspiratory muscles either
patients, Weiner (1992) claims that IMT may
weaker or stronger than normal (Heidjra
improve exercise tolerance when combined
1994), and that training can make the dia-
phragm either more or less susceptible to with exercise training. With unsuitable
fatigue (Braun et aI1983). patients, Jederlinic et al (1984) claim that
Strong inspiratory muscles in respiratory IMT overrides the protective mechanism of
disease are due to hypertrophy caused by fatigue and may cause exhaustion and de-
working against the resistance of obstructed saturation.
airways. Why therefore impose a further
load? 6.8.3 Indications and contraindications
Weak inspiratory muscles are due to:
How can we select those patients with weak
• poor nutrition, which would respond muscles for whom training might provide
better to dietary management, an inter-
protection against chronic fatigue, and avoid
vention that can improve inspiratory
overburdening those with fatigued muscles?
muscle strength by 40% (Donahoe and
The clinical symptoms of fatigue and weak-
Rogers 1990),
ness are similar, but the two states are
• inadequate oxygen delivery to the muscles
distinguishable (p. 6). Fatigued muscles are
due to heart failure and blood gas
unsuited to training, and overuse may split
abnormalities, which respond better to
fluid, drug and oxygen therapy. fibres, create 'use atrophy' (Braun et a11983)
• steroid induced weakness, which would and cause muscle damage (Anzueto 1992).
respond better to drug review, Weak muscles may benefit from training,
• mechanical disadvantage, which might be regardless of how breathless the patient is.
improved by breathing re-education Suitable candidates are:
(Martinez et aI1991). • people who are fearful of any activity,
A diaphragm that becomes more suscept- because IMT can be used to desensitize
ible to fatigue after training is thought to have them to breathlessness prior to ventur-
reached maximum adaptability and can ing into exercise training,
improve performance no further. It is already • people who find breathing re-education
chronically fatigued and is more likely to difficult, in which case using the device
benefit from rest. might help to improve their breathing
Energy conservation 163
2. Take up your preferred position (if this is comfortable. A few minutes at any time of
sitting upright, it is advisable to supinate day can be taken to check body tension. An
the forearms to discourage clinging to the illuminated aquarium is a blissful way of
chair arms). reducing stress at night.
3. Imagine that you are in a place that you
find peaceful, such as a beach or sunny Yoga
meadow.
Yoga incorporates breathing techniques,
4. Breathe abdominally (p. 114), if this is
meditation and postures that consume min-
comfortable. imal energy. These induce physiological
5. Feel where your body presses against the effects characteristic of deep relaxation, and
chair, allow the chair to do the work of one study shows them to improve lung
your back muscles. As you breathe out, function tests (Beck et al1992).
feel the tension leave your body. Feel Yogic breathing promotes breathing aware-
your body melt into the chair as if you are ness, nose breathing and 'complete breathing',
meat without bone. Feel warm energy which begins with abdominal breathing, then
spreading through your body. expands the lower chest and finally the upper
6. To help focus on your breathing and chest (Fried 1993, p. 239). Meditation reduces
prevent your attention wandering, count the respiratory rate, heart rate and BP (Fried
silently as you follow your breath in: 1993, p. 235).
'1,2,3', and the same as you breathe out.
7. Check through your body for tension. Other therapies
Allow your mouth to fall slightly open.
Re-check your breathing. It is useful to gain some knowledge of
complementary therapies and local resources
Rhythmic breathing and an adequate brea- because patients sometimes request this
thing rate should continue throughout. information.
Patients should be reassured that relaxa- The Alexander technique uses inhibition of
tion is not difficult to learn, that there is no muscle tension to reduce the work of brea-
right or wrong way of doing it, and that they thing and improve objective measures, such
can follow what feels right for them. as peak flow and respiratory muscle strength
Although it does not matter if they fall (Austin and Ausubel 1992). Biofeedback
asleep, it is preferable to stay awake to enjoy gives auditory or visual feedback on, for
the experience of alert tranquillity so that example, muscle tension, so that participants
they can re-create it as desired. can recognize the sensation and gain control
The effects of this hypometabolic conscious over it (Hodgkin 1993, p. 404). Imagery uses
state are decreased respiratory rate, oxygen visualization of peaceful scenes, which has
consumption, heart rate and BP (Hodgkin been claimed to achieve the deeply relaxed
and Petty 1987). Many find that it improves alpha brain-wave state (Haas and Axen 1991,
their breathing pattern without formal breath- p. 285). Hypnotherapy reduces the metabolic
ing re-education. rate through deep levels of relaxation (Sato et
Daily practice is needed until the sensation al 1986). Acupuncture works directly on
is appreciated and the skill mastered, where- reducing the perception of breathlessness
upon it is integrated into everyday life by and has been shown to increase exercise
identifying stressful situations and practising tolerance Oobst et al1986). According to Roth
in different positions. In standing, patients (1990) 'the best way to still the mind is to
can be asked to feel as if they have roots into move the body', and activities such as circle
the ground. Walking can become relaxed and dancing or t' ai Chi provide gentle exercise
166 Management of breathlessness and pulmonary rehabilitation
6.11 EVALUATION
Celli, B.R (1994) Physical reconditioning of Mellins, RB., Zimmerman, B. and Clark, N.M.
patients with respiratory diseases: legs, arms (1992) Patient compliance. Am. Rev. Resp. Dis.,
and breathing retraining. Respir. Care, 39, 481- 146, 1376--7.
99. Nisell, O. (1992) Causes and mechanisms of
Chatham, K. (1995) Respiratory muscle training. breathlessness. Clin. Physioi., 12, 1-17.
Br. J. Ther. Rehab., 2(1), 31-6. O'Donell (1994) Breathlessness in patients with
Clark, c.J. (1994) Setting up a pulmonary rehabilita- chronic airflow limitation. Chest, 106, 904-12.
tion programme. Thorax, 49, 270--8. Peel, C. and Mossberg, K.A. (1995) Effects of
DeVito, A.J. (1990) Dyspnea during hospitaliza- cardiovascular medications on exercise res-
tion for acute phase of illness as recalled by ponses. Phys. Ther., 75, 387-96.
patients with COPD. Heart Lung, 19, 186--91. Royal College of Physicians (1981) Disabling chest
Gaskin, L. and Thomas, J. (1995) Pulse oximetry disease: prevention and care. J. R. Coli.
and exercise. Physiotherapy, 81, 254-61. Physicians, 15, 69-86.
7. Physiotherapy for specific groups
of people
People undergoing surgery Elderly people
respiratory complications of People who are dying
surgery reactions of patients
other complications of surgery reactions of relatives
preoperative management reactions of staff
pain management communicating with dying people
postoperative care management of symptoms
abdominal surgery on dying well
lung surgery dying children
pleural surgery Recommended reading
heart surgery
overview of cardiac rehabilitation
heart and lung transplantation
repair of coarctation of the aorta
oesophagectomy
chest drains
head and neck surgery
mastectomy
During surgery
Recumbency
ImmOb;IOy~
After surgery
~ J, FRC - - - Airway closure - Atelectasis
pain~
J, Cough
~ Sputum retention
Dry mouth .. J, Expectoration
The respiratory system bears the brunt of the tuate breathing and stimulate surfactant
after-effects of surgery, the cause being production.
mechanical rather than infective. Postoperative
complications are described below. Mucus plugs are usually caused by atelecta-
Atelectasis is the commonest respiratory sis rather than the other way round, so their
complication and is caused largely by pain removal rarely leads to recruitment of col-
(Simpson et al 1992). Following chest or lapsed alveoli (Susini et aI1992).
abdominal surgery, pain leads to guarding Atelectasis creates a restrictive lung defect
and reduces lung compliance. A degree of
spasm of the trunk muscles, inhibition of
atelectasis occurs in 95% of postoperative
breathing; tidal breathing falling into the
patients (Westbrook and Sykes 1992) and is
closing volume range, airway closure and
clinically significant when there are X-ray
atelectasis (Fig. 7.1).
changes and reduced breath sounds. It can be
Other causes of atelectasis are:
prevented by measures to increase lung
volume. Greater efforts are needed to inflate
• prolonged recumbency, which affects the collapsed alveoli than to inflate those that are
amount and distribution of ventilation partially open. Prevention is therefore better
and causes intrathoracic pooling of blood than cure.
which further displaces air from the Hypoxaemia is caused by the shunting of
lung, blood through airless lung. When present for
• loss of oscillations in tidal volume and a few hours it is related to the anaesthetic.
occasional sighs which normally punc- When present for several days, it is related to
People undergoing surgery 171
the operation and the patient (Hudes 1989). width above the distal crease on the inner
High-risk patients may suffer nocturnal wrist in line with the middle finger (McMillan
hypoxaemia for up to five nights after surgery 1994).
due to rebound intense REM sleep to make Anxiety increases diaphragmatic splinting
up for earlier disrupted sleep (Roberts et al and stimulates metabolic and hormonal
1993). Patients who have had major surgery, stress responses which delay healing and
or those with respiratory or cardiovascular promote infection (Salmon 1992). Anxiety is
disease, should be monitored for nocturnal reduced by giving preoperative information
oxygen desaturation to prevent premature and granting postoperative autonomy.
cessation of oxygen therapy. Postoperative Depression may occur if surgery causes
hypoxaemia impairs healing, promotes infec- mutilation or altered body image, e.g. colos-
tion and contributes to postoperative confu- tomy, head and neck surgery or mastectomy.
sion (Hanning 1992). An understanding ear or referral to a self-
Chest infection may occur several days after help group (Appendix C) may prevent a
surgery. Atelectasis can predispose to chest sense of loss degenerating into long-term
infection, but has different risk factors and the depression.
two are distinct (Dilworth and White 1992). Paralytic ileus is loss of gut activity and
Fever indicates infection but is not associated bowel sounds. It is normal for the first day or
with atelectasis (Brooks-Brunn 1995). two, but may last longer after abdominal
Respiratory depression can be caused by surgery, leading to restricted diaphragmatic
toxic levels of opioids (p. 175). movement, a nasogastric tube and nil-by-
Postoperative deterioration in lung func- mouth requirements.
tion reaches a maximum within 48 hours of Fluid imbalance can lead to hypovolaemia
surgery. However, it may not be significant or fluid overload. Hypovolaemia is due to
and many patients leave hospital happily pre- and postoperative fluid restriction, the
ignorant that they still have a degree of drying effect of premedication and unhumidi-
hypoxaemia. fied anaesthetic gases. It can cause desatura-
tion even if gas exchange is not impaired
(Westbrook and Sykes 1992). Fluid overload
7.1.2 Other complications of surgery
is due to overenthusiastic fluid replacement.
Fatigue, usually related to the degree of Postural hypotension may be a sign of
trauma, is more severe and prolonged than unrecognized hypovolaemia. Such patients
expected by most patients. It can be min- should avoid sudden motion or position
imized by encouraging frequent short walks change.
rather than infrequent long ones, and by Urine retention, flatulence or constipation
negotiating with patients rather than impos- impair excursion of the diaphragm. Urine
ing a programme on them. retention can be helped by acupressure to
Some drugs contribute to the 'big little Ki.l in the hollow proximal to the mid-
problem' of postoperative nausea. This is transverse arch of each foot. Flatulence can
experienced by 30% of patients and is most be relieved by pelvic tilting and knee rolling
common after lengthy surgery, if there is in crook-lying.
pain or dizziness and for patients who are Hypoxaemia increases the risk of wound
anxious or obese or female. Nausea inhibits infection (Whitney 1989), which is sus-
deep breathing. It can be relieved by drug pected if there is increased pain, pyrexia and
review (Watcha and White 1992), powdered erythema.
ginger (Phillips 1993), hydration, pain relief, Incessant hiccups, due to irritation of the
or acupressure to P.6 located two thumbs' diaphragm, cause sharp pain at the wound
172 Physiotherapy for specific groups of people
site. They may be inhibited by metoclopra- for children and those expecting to wake up
mide, chlorpromazine, sugar, acupressure to in the intensive care unit, where they will feel
CV.17 (on the sternum at mid-nipple level), relieved at the sight of a familiar face. For
an array of techniques to raise PaC02 (breath- anxious patients facing major surgery, it
holding, rebreathing, drinking a glass of should be carried out early because anxiety at
water from the wrong side), dropping a piece impending surgery inhibits receptivity
of ice down the back to hyperextend the (Cupples 1991).
neck, or prayers to St Jude, the patron saint Some patients find it beneficial to have
of lost causes. relatives present for the preoperative visit.
Deep vein thrombosis (DVT) is a blood clot The visit is mainly educational and can be
that develops surreptitiously in the lower brief. It includes:
limb, often during surgery, due to calf
1. Patient assessment.
compression, immobility and impaired blood
2. Explanations, i.e:
flow. It complicates one-fifth of major opera-
(a) inactivity leads to inadequate lung
tions (Ashby 1995), but is notoriously under-
expansion, so that mobilization and
diagnosed, being clinically silent in 50% of
sometimes deep breathing are
patients (Forbes 1994). It may become evident
needed after the operation,
as tenderness, swelling and warmth of the
(b) if there is extra sputum, coughing
calf, generalized fever and sometimes pain
may be necessary,
on dorsiflexion (Homan's sign). Diagnosis
(c) prevention forms the basis of man-
can be confirmed by ultrasound or Doppler
agement.
imaging (Goldhaber and Morpurgo 1992).
3. Advice to ask for adequate pain relief.
The clot may break free and cause pulmonary
4. Information specific to the operation.
embolism by lodging in the pulmonary
Most patients like to know everything
vascular bed (p. 86).
about the wound, drips, drains and what
Postoperative haemorrhage leads to any of
it will feel like, while a few make it clear
the following signs: that they want to know little. People
• obvious bleeding, undergoing complex procedures may
• rapid filling of drainage bottles, benefit from visits by patients who have
• signs of hypovolaemic shock, which sug- had similar surgery.
gest internal bleeding. 5. Advice to keep active before surgery and,
if applicable, to stop smoking. Just 24
7.1.3 Preoperative management hours' abstinence from smoking im-
proves the patient's cardiovascular status
Stress increases postoperative complications,
(Munday et a11993), and this includes no
lengthens hospital stay (Liu 1994) and is
passive smoking in the ward day room
thought to contribute to muscle breakdown,
(Dennis 1994).
delayed healing and immunosuppression
6. For high-risk or anxious patients, practice
(Salmon 1992). Preoperative instruction is
in how to roll, deep breathe, use the
aimed at reducing this stress and enhancing
incentive spirometer, sit up and cough
co-operation for postoperative care. Instruc-
with minimum pain.
tion has been shown to lessen postoperative
7. Any questions?
complications (Cupples 1991), increase ability
to deep breathe and cough (Lindeman 1971), People with lung disease may need atten-
reduce analgesic requirements by half and tion to sputum clearance and an exercise
lead to discharge nearly three days earlier regime to compensate for the inactivity of
(Egbert et al 1964). It is especially important hospitalization.
People undergoing surgery 173
Anxious people benefit from relaxation ible reasons for this 'deplorable state of
(Mogan et aI1985), but mindless reassurance affairs' are the following:
does not engender trust, and can impair the
'work of worry', which is a natural and 1. Inexperience, tradition and overwork
necessary part of adjusting to the operation ijustins and Richardson 1991).
and its outcome. Postoperative distress is 2. Ignorance of the fact that addiction
related to lack of accurate anticipation and occurs in less than 1 in 3000 people who
knowledge (Salmon 1992). take analgesic drugs (Lavies 1992).
The tradition of prolonged preoperative 3. Wide and unpredictable variations in
fluid restriction is now considered unjusti- patients' perception of pain and response
fied. Clear oral fluids up to two hours before to drugs.
surgery improves comfort, reduces de- 4. An attitude that pain is unimportant,
hydration and makes it easier to expectorate inevitable and to be borne with fortitude,
postoperatively without compromising safety especially in cultures which see stoicism
(Phillips et al 1993). as a virtue and distress as a weakness.
Before surgery, pre-emptive analgesia Patients' own low expectations have
reduces postoperative pain by preventing allowed this situation to continue with-
noxious impulses gaining entry into the out an outcry (Lavies 1992).
central nervous system, where they 'wind 5. Rudimentary pain assessment.
up' the response to subsequent afferent Pain is what the patient says hurts, but
inputs. This memory of pain can be pre- some staff have a limited understanding of
vented by adding, for example, anti- the subjective nature of pain and may dis-
inflammatory drugs to the premedication or believe patients. McCaffery and Ferrell (1992)
using preoperative nerve blocks. Drug found that 50% of nurses doubted patients'
dosage to prevent pain is significantly less reports, and it is common to hear criticism of
than that required to abolish pain after it has patients for having a 'low pain threshold' or
occurred (Katz et al 1994). A notable illus- being 'naughty' for complaining of pain. Pain
tration of this is the elimination of postampu- is more than a sensation, it is the reaction to
tation pain syndromes by epidural analgesia that sensation. It is a personal experience. It
up to three days preoperatively (Cousins may be difficult for us to accept the reality of a
1989).
patient's distress because it is frustrating to
Postoperative recovery can be facilitated feel helpless and easier to deny it by assum-
by factors as diverse as a leafy view through ing that patients are making a fuss. But we do
the window (Ulrich 1984) and positive not serve our patients well if we allow
suggestions under anaesthesia (Williams et al ourselves to lose our sensitivity and become
1994).
part of a system that can actually shame
patients who express pain.
7.1.4 Pain management
What is so surprising is that this deplorable Whose pain should the physician control? The
state of affairs has persisted and continues to patient's? That of the relatives? Or his own,
persist in many hospitals, despite considerable generated by his inability to help the patient?
advances in the pharmacology of analgesic Szasz 1968
drugs.
Smith 1991 Pain and breathing
P~stoperative pain is notorious for being The relationship between pain and atelectasis
WIdespread and unnecessarily severe. Poss- (Fig. 7.2) can be understood readily by
174 Physiotherapy for specific groups of people
60 o Atelectasis
If pain cannot be assessed by the patient,
objective signs are pallor, sweating, shallow
breathing, breath-holding and t pulse, BP
50
C/)
and respiratory rate. Severe pain causes
C nausea, vomiting and ~ pulse and BP.
Q) 40
~ Pain assessment is also a right for people
0..
'0 30 who are cognitively impaired or do not speak
CD
..Q English, not just those who can complain in a
E 20
::l
Z
way that is easy to understand. Family
members can be involved in assessment if
10
appropriate. Elderly people tend to be stoic
0 about reporting pain and are at risk of
Pain
k~ ~n ~n
undertreatment. Pain assessment for chil-
dren and infants is on p. 291.
Figure 7.2 Relationship between postoperative
pain and atelectasis. (From Embling, S.A. (1985)
Incidence, aetiology and implications of Reduction in the perception of pain
atelectasis following cardiopulmonary bypass
surgery, MSc dissertation, University of There are many things that make pain worse,
Southampton, with permission.) such as the spirit in which it is inflicted. You are
indeed acutely vulnerable to the attitude of
people surrounding you.
Donald 1977
anyone trying to take a deep breath when in
the dentist's chair. Pain not only inhibits Perception of pain varies with some factors
breathing, it also increases oxygen consump- that physiotherapists cannot modify, such as
tion and risk of infection, delays healing and type of incision, operative technique, discom-
postpones mobilization and hospital dis- forts such as drainage tubes and nasogastric
charge (Carron 1989). tubes, and the patient's upbringing and
previous experiences. Perception of pain also
Assessment varies with factors that physiotherapists can
Accurate assessment of patients in relation to modify, such as:
both pain and respiration allows logical
decisions to be made about management, • anxiety or fear,
with the help of the patient who will have his • discomfort,
or her preferences. It also prevents unnecess- • physical tension,
ary interventions, such as asking a patient • lack of autonomy or privacy,
with no secretions to cough. • depression,
Postoperative pain should be assessed and • sleep fragmentation (McIntosh 1989).
recorded on the patient's chart like any other
vital sign in consultation with the nursing This is fertile ground for the physiotherap-
team. A visual analogue scale or flow chart ist. Physical tension can be eased by simple
(Gould et aI1992) can be used to assess pain relaxation (Miller and Perry 1990). Anxiety
at rest and, more importantly, during can be reduced by keeping patients in-
activity. Interactive computer animation formed. Autonomy can be enhanced by in-
(Swanston 1993) assesses pain for computer cluding them in decisions. Above all, patients
buffs. need reassurance in words and actions that
People undergoing surgery 175
they will be heard and responded to. 'Tell me patients push back hard enough to elimi-
if it hurts and I'll stop' is music to their ears. nate eccentric abdominal muscle work.
Physiotherapists need the support of their
Handling patients in pain knee and fist on the bed to protect their
own back. This principle can also be used
. .. pain works subversively, undermining
for helping a long-sitting patient to lie back
one's self-confidence and self-control, worn dis-
on to the pillow after he or she has leant
mayingly fragile. The sense of anticipation is
forwards for auscultation.
honed, to hysteria almost, and one quickly
learns to be thoroughly suspicious of the well- Rolling (Fig. 7.4). Patients are asked first to
meant: 'this won't hurt'. bend their knees, then remain in supine
Brooks 1990 but shift away from the physiotherapist to
make room to roll. They then hold on to
Physiotherapists should be seen as experts in
the physiotherapist's arm or a bed rail,
the relief of pain rather than its perpetrators.
push with their knees and roll towards the
The essence of physiotherapy is skilful hand-
physiotherapist in one piece. They are
ling, and there are few rewards greater than
encouraged to emphasize pushing with
relief on the face of a patient whose pain we
their legs rather than pulling with their
have alleviated. Guidelines are the following:
arms in order to inhibit abdominal muscle
1. Most importantly, patients must be work. Again the physiotherapist uses a fist
assured that they are in control. on the bed for support.
2. Analgesia should be given automatically
before physiotherapy, instead of first Medication
'checking' to see if treatment causes pain, It is an ethical obligation at the core of
a strategy known as shutting the stable
a health professional's commitment to ensure
door after the horse has bolted.
that patients have access to the best level of pain
3. Unnecessary handling should be avoided.
relief that can safely be provided.
4. The patient should be informed of why,
Carson 1994
how and when each movement will take
place. Words to avoid are 'just relax', Physiotherapists must be active team mem-
which signals to any seasoned patient bers to ensure that analgesics are based on
that they are about to be hurt, or 'sorry' the principle that prevention is better than
after an unexpected movement instead of cure. Lack of teamwork and understanding
clear explanations before the movement. have led to patients receiving one-quarter of
The 'wince-sorry' scenario is familiar to the dose prescribed (Rosenberg 1992), male
those who have witnessed patients being doctors assuming that patients feel less pain
hurt and then routinely apologized to. than female doctors, and senior nursing staff
allowing patients less medication than
The principles of handling patients in pain juniors (Pitts and Healey 1989). An acute pain
are to offer them advice and support, but team is invaluable (Gould et al 1992).
allow them to move themselves as much as Morphine remains the favourite opioid
possible, for example: analgesic. Side-effects include nausea, con-
Long-sitting to lying (Fig. 7.3). Patients are stipation, hypotension and elimination of
asked to push back against the physio- spontaneous sighs. An exaggerated fear of
therapist's hand and forearm so that they the side-effects of respiratory depression and
are actively using their back extensors and dependence often leads to inadequate
therefore reciprocally relaxing their abdom- dosage. Large doses of morphine depress
inal muscles. Reassurance is needed so that respiration, but sedation is not synonymous
176 Physiotherapy for specific groups of people
with respiratory depression (pasero 1994), Intramuscular route Use of the time-
and hypoventilation is an unreliable and late honoured 'p.r.n.' intramuscular injection is
sign. However, if breathing is shallow, ir- widespread despite being the least effective
regular or less than 10 breaths/minute, the mode of pain relief. This 'as required' analge-
doctor should be infonned. Oximetry is help- sia has no rational basis, is usually inter-
ful. Depression of respiration is reversible by preted as 'give as little as possible', produces
the opiate antagonist naloxone without loss wide fluctuations in serum levels, leaves pain
of analgesia. Opioid dependence is rare unless unrelieved in half the recipients (Jacox et al
administration is continuous in a patient who 1992) and augments a vicious cycle of anxiety
has no pain (Aitkenhead 1989). Well-managed and pain, especially in patients who do not
narcotic drugs improve ventilation and gas ex- want to appear demanding. P.r.n. analgesia is
change when breathing is made easier by relief berated in the literature, but popular because
of pain (Harcus 1977). Vickers (1992) claims it is considered, mistakenly, to be the safest
that the opioid tramadol does not depress regime. Uncomfortable patients also use
respiration. Non-steroidal anti-inflammatory more staff time.
drugs engage the peripheral as well as the Regular, intennittent dosage is more effect-
central nervous system and can reduce opioid ive than the p.r.n. regime because it takes
requirements by over 20% (Cashman 1993). less drug to prevent pain than to subdue it,
People undergoing surgery 177
but dosage may still be inadequate and lead dose is released. Respiratory depression is
to 'spectacularly ineffective' outcomes be- rare, although oximetry is advisable if the
cause of wide variations in uptake, distribu- patient has limited understanding and staff-
tion and elimination of an intramuscular drug ing levels are low. peA does not reduce the
(Hull 1988). Blood concentration varies by at incidence of nausea, which can be avoided by
least a factor of five, and even if this variable is adding antiemetics to the peA (Barrow et al
overcome, the concentration at which each 1994). Relatives should be warned not to
individual becomes pain free varies by a factor press the button.
of three or four (lustins and Richardson, 1991).
Regional analgesia Transmission within the
Intravenous route The intravenous route
peripheral nervous system can be blocked by
gives superior pain relief, works immediately
and provides either a continuous infusion or regional techniques. These act locally, do not
bolus doses. Patient-controlled analgesia befuddle the entire central nervous system
(peA) delivers a preset dose of drug by a and cause less nausea.
syringe pump when the patient presses a Intercostal nerve blocks are used after
button. This accommodates to individual unilateral abdominal incisions, thoracotomy
need, reduces anxiety, encourages mobility, or rib fractures. They are administered by
reduces sleep disturbance, is preferred by repeated injections into multiple nerves or,
patients for the autonomy it allows, requires more comfortably, by continuous infusion or
less drug to achieve the same pain control extrapleural infusion (Majid 1992). Respira-
and leads to earlier discharge (Thomas, 1995). tion is not depressed, but pneumothorax is a
A programmed lock-out interval ensures that risk and the X-ray should be scrutinized if any
each dose achieves peak effect before the next positive pressure techniques are anticipated.
178 Physiotherapy for specific groups of people
The epidural route alters spinal processing Oral drugs can be used several days after
by delivering drugs to the epidural space, the surgery if acute pain has subsided, but the
catheter being left in situ. Opiates, local effect is variable.
anaesthetic or both work directly on the The transdermal route uses skin patches
opiate receptors along the spinal cord, and for trauma-free, safe, but slow-acting analgesia
can control pain originating anywhere below (Arts 1994) or antiemesis (Biddle 1992).
the cranial nerves. In increasing order of EMLA (eutetic mixture of local anaesthetics)
efficacy, administration is by intermittent cream causes skin anaesthesia when applied
blockade, continuous infusion or PCA (Owen to the skin an hour before a painful pro-
et al1993). cedure, and no child or baby should now be
Advantages of epidurals are legion: pro- submitted to venepuncture, lumbar puncture
longed pain relief, improved lung function, or any injection without prior application of
t oxygen consumption, t incidence of DVT this 'magic cream'. Needle-phobic adults also
and infection, hospital stay shortened by an benefit.
average of a week (Smedstad 1992), and an Non-invasive sophistication is taken further
increase in graft blood flow after vascular by iontophoresis of local anaesthetics, which
surgery (Cousins 1989). Disadvantages are penetrates deeper than EMLA cream and
partial sensory or motor loss, and blockade of is effective within 10 minutes (Irsfeld et al
sympathetic outflow which is especially notice- 1993).
able in hypovolaemic patients. Patients The transmucosal route uses the mucous
should, therefore, lie flat for 30 minutes after membranes, which impose less of a barrier
a top-up to avoid hypotension. High blocks than skin and allow speedy drug absorption
are mainly associated with hypotension, (StriebeI1993), as cocaine abusers have disco-
while blocks further down the spinal cord vered. Sublingual administration has meant
may cause urine retention. Respiratory that children now delightedly anticipate their
depression is found in fewer than 1% of postoperative fentanyl 'lollipops' (Yaster
cases, usually occuring within %-1 hour of a 1995).
top-up or 6-12 hours later (Jacques 1994), and
is reversible with naloxone. Other epidural Cryoanalgesia
side-effects are nausea and paralytic ileus.
Pain after thoracotomy or rib fracture can be
The intrathecal route delivers opioids to
eliminated by cryoanalgesia, an open pro-
the subarachnoid space (Grace and Orr 1993),
cedure which freezes the intercostal nerves
producing profound analgesia without
and then allows them to thaw, creating total
motor, sensory or sympathetic block. Com-
pain relief by rendering the area anaesthetic.
plications include 'spinal headache' due to
The nerve regenerates and sensation returns
CSF leakage through a punctured dura and
after a period of between two weeks and
loss of the intracranial CSF 'cushion'. If this
several months, but 20% of patients develop
occurs during mobilization, the patient
neuralgias (Kavanagh 1994).
should be returned to bed.
Further measures for one-sided surgery
Entonox
include the paravertebral route, which
combines the effects of epidural and inter- Short-lived analgesia can be achieved within
costal analgesia, intrapleural, which pro- 60 seconds of inhaling a 50% mix of nitrous
vides a continuous intrapleural infusion of oxide and oxygen (Entonox), delivered from
local anaesthetic (Kavanagh 1994), extra- a cylinder via face mask and demand valve.
pleural or extradural routes. Pneumothorax It is not metabolized and is eliminated
is a risk. unchanged by the lungs. Side-effects on the
People undergoing surgery 179
cardiovascular and respiratory systems are prevention rather than as a last resort, and
minimal (Sacchetti 1994), but the patient may high-risk patients should be identified early.
feel light-headed, drowsy or nauseous. A
gratifying side-effect is the maintenance of a Effects Effectiveness varies between patients,
normal FRC, which would otherwise be and TNS is normally used as an adjunct to
reduced by an average of 22% in narcotic- analgesic drugs, but one study has reported
treated patients (Kripke et al 1983). It is 95% of postoperative patients needing no
suitable for children as well as adults (Lawler narcotics when using TNS (Bayindir 1991).
1995). Agreeable side-effects include reduction in
1£ used continuously for over 12 hours, nausea and paralytic ileus (Akyiiz 1993).
minor bone marrow changes occur (Austin
1993), but this is not a problem with physio- Mechanism TNS is thought to reduce pain
therapy because only a few minutes' inhalation by:
is necessary. Despite its 175-year history,
Entonox is still not utilized for the many • at high frequencies, closure of the pain
minor but distressing hospital procedures for gate by stimulating large nerve fibres to
which it is ideal. Depending on local policy, it override pain input from small fibres,
mayor may not need medical prescription, • at low frequencies, the release of endor-
but medical staff must sanction its use phins (Han et al 1991).
(Lawler 1995). The initiative usually comes Other theories are that peripheral nerves
from the physiotherapist. Contraindications are fatigued by repeated stimulation or that
are: sympathetic overactivity is suppressed (Mar-
1. Acute head injury or low cardiac output, shall 1991).
because of peripheral vasodilation.
2. Sealed pockets of air (e.g. subcutaneous Method The skin is washed to minimize
emphysema, bullae, pneumothorax, bowel irritation. It is then checked for sensation
obstruction, ear surgery or balloon-tipped because anaesthetic areas do not respond to
catheters), because nitrous oxide is 32 TNS, while stimulating areas of hyperaesthesia
times more soluble than air and readily worsens pain. Gel is applied evenly and
diffuses into gas-collecting areas. The x- electrodes fixed securely. Two or four elec-
ray of a patient with fractured ribs should trodes are applied, close to each corner of the
be checked before using Entonox in case incision, as soon as possible after surgery.
of pneumothorax. Acupuncture points can be stimulated
instead of local areas. 1£ sterile electrodes are
Other precautions relate to the 50% oxygen used, two long electrodes are applied in
content, so that Entonox is unsuited to theatre alongside the wound and under the
patients who need more than 50% oxygen, or dressing, with the controls set at a level that
hypercapnic COPD patients dependent on a has been determined before surgery.
hypoxic drive to breathe. They require a When adjusting the controls, individual
different mix, to be re-prescribed. needs vary, but most patients find the follow-
ing sequence successful:
Transcutaneous nerve stimulation (TNS)
1. Increase output (amplitude) slowly until
TNS is underused in postoperative care. It a mild thumping is felt.
does not depress the respiratory system, is 2. Move the rate (frequency) dial around its
non-invasive, non-toxic, cheap and produces full extent to find the most comfortable
mobile and happy patients. It is best used as adjustment. 1£ more than half the full
180 Physiotherapy for specific groups of people
extent is achieved without any sensation, treatment other than a reminder to keep
a pulse width adjustment is needed. mobile. As well as the assessment described
3. Readjust output for maximum relief of in Chapter 2, a few other points should be
pain and optimum comfort of the sensa- noted.
tion. The temperature chart will normally show
No motor contraction should be felt, and a slight pyrexia following surgery as a reac-
patients need a reminder that a stronger tion to tissue trauma, but fever beyond 48
stimulus does not mean stronger pain relief. hours raises suspicions of a chest infection.
Readjustment is necessary as the patient Is oxygen titrated to the patient's needs?
adapts to the sensation or becomes more Does the mask stay on and, if not, does the
awake. Some machines provide a pulsed or patient need explanations, adjustment for
boost mode to reduce accomodation, and the comfort or replacement with a nasal cannula?
patient can use this when moving or cough- Nasogastric tubes are often present for
ing, or the connector pins on the machine can feeding or to prevent vomiting and gastric
be changed at intervals to reverse polarity. distension, and although necessary, they
Patients can adjust their own controls, decide indicate that coughing will be more difficult
how many days to continue using the and the protective oesophagogastric sphincter
machine, and whether to use it at night. will be disabled so that the lung may be
Liaison with nursing staff and daily skin colonized with bacteria from the stomach.
washes are needed.
Mobilization
Problems
Bed mobility and independence are encour-
1. Gel or adhesive tape can irritate the skin.
aged by a rope attached to the end of the bed,
This is dealt with by using self-adherent
by which patients pull themselves up. As
electrodes, a stockinette-type bandage
instead of tape, changing the electrode soon as possible they can be encouraged to
position frequently or using different sit with legs dangling over the edge of the
gel. . bed.
2. TNS near the chest is contraindicated for If early mobilization is surgically or medic-
people using a demand or synchronous ally acceptable, this should be on the first
pacemaker. postoperative day. Extra care is needed
3. Stimulation should not be applied over a during the first walk because of postural
pregnant uterus or damaged skin. hypotension associated with fluid shift to the
4. TNS electrodes should be placed as far as thorax during recumbency. For catheterized
possible from ECG electrodes to minim- patients, leg bags are more convenient and
ize interference. dignified than loose catheter bags. Posture
correction is incorporated as soon as dis-
7.1.5 Postoperative care comfort has eased.
Details of techniques to increase lung volume
Positioning
are covered in Chapter 5, but points specific
to surgery are discussed below. If pain, surgical procedure or instability delay
mobilization, emphasis should be on accurate
Aspects of assessment and comfortable positioning, alternating from
Assessment is particularly relevant in this side to side and, if possible, sitting out of bed.
area because many patients will need no Positioning itself can re-expand atelectatic
People undergoing surgery 181
Breathing exercises
Breathing exercises are not usually necessary
even after major surgery (Stiller et al 1994),
but if mobilization is delayed, positioning
limited, or respiratory complications deve-
lop, deep breathing may be required. This
should be done in a position that achieves a
balance between comfort and optimal ventil-
ation. For patients who can neither mobilize
nor lie well forwards on their side, incentive
spirometry in upright sitting is advisable. A
transmural pressure close to 20 cmH2 0 is
needed to open atelectatic areas, which cor-
responds to inspiration near TLC (Andersen
et al1979).
Cilia are immobilized by general anaesthe-
sia, but accumulated secretions are usually
cleared by mucoci1iary transport in the imme-
diate postoperative period. Superficial secre-
tions in the throat may be the only problem,
which are easily removed by throat-clearing. Figure 7.5 Manual support for postoperative
Stronger expiratory manoeuvres should not coughing after laparotomy. Gentle firm pressure
be routine, because expiration beyond FRC is directed at holding the wound edges together.
causes airway closure, which is not easily
reversible in patients who are weak and in
pain (Craig 1981). Forced expiration, un- If patients are too weak, fatigued or
necessary coughing, percussion and vibra- drowsy to co-operate, mechanical aids may
tions cause pain and splinting, and may be indicated.
simply produce the lesion that they are
supposed to cure. Prevention of deep vein thrombosis (DVT)
If there is subjective or objective evidence Patients most at risk of DVT are the follow-
of accessible secretions and coughing is ing:
necessary, patients may prefer to remain in
side-lying, but if they are willing, sitting over • those who are elderly or obese, or have
the edge of the bed is mechanically efficient malignancy, blood clotting or vascular
and allows for maximum support (Fig. 7.5). disorders,
Pressing on the incision with a pillow is less • those undergoing lengthy surgery, espe-
effective than sensitive and accurately-timed cially of the hip or knee,
manual support, but when patients are • those with a previous history of DVT.
alone, they may find a pillow, towel or cough Half the deaths from pulmonary embolism
belt helpful. could be avoided by following prophylactic
182 Physiotherapy for specific groups of people
Limited thoracotomy
Sternotomy -------t--
- - - - + - - Thoracolaparotomy
Cholecystectomy
Paramedian ------ir----
Appendicectomy - - - - - - \ -_\.
Hernia repair
I
Transverse
Figure 7.6 Surgical incisions.
Poor nutrition delays wound healing and experiences of my life. It took a long time to be
causes weakness of inspiratory and expir- able to talk about it.
atory muscles, leading to impaired cough and Katie, a nursing sister,
increased incidence of pneumonia (Windsor following thoracotomy
and Hill 1988). To facilitate rehabilitation,
A full thoracotomy involves rib resection and
preoperative fasting in excess of six hours
transection of major chest wall muscles,
should be avoided (Thomas 1987). For
leading to restricted shoulder movement and
patients who are malnourished or who are
'one of the most intense postoperative pain
not expected to eat orally in the days follow-
experiences known' (Kavanagh 1994). Pain
ing surgery, especially if they undergo major
should be controlled by local anaesthetic
surgery, enteral feeding should start as soon
infiltration of intercostal nerves before clos-
as the gut is functioning (Mainous and Deitch
ure, epidural or other potent technique. A
1994).
degree of atelectasis is inevitable after thor-
acotomy because of loss of lung tissue, pain
7.1.7 Lung surgery and interference with pleural function.
A full thoracotomy or limited thoracotomy
Incisions
(Fig. 7.6) may be needed to resect part of all
The pain was everywhere. I couldn't get across of a lung, but video thoracoscopy has led to
what I felt. I wanted to move myself but they reduced pain and disability, shorter hospital
were insistent on moving me. I lost the ability stays and return to work within one to two
to control the situation. I felt very alone. The weeks (Wood 1993a). Thoracoscopy leaves
whole thing was one of the most personal only 1.5 em scars, spares muscles and can now
184 Physiotherapy for specific groups of people
Some surgeons fill the pericardial sac with sleep deprivation and impaired cerebral
crushed ice or chilled saline to reduce the perfusion during bypass. It is common in
metabolic rate and protect the brain, myocar- elderly people. Permanent neurological
dium and other vital organs from hypoxia. defects occur in 11-S7% of patients and
This is no longer considered essential, but stroke in 2% (Harris et al1993).
moderate cooling to 30° may be retained to 6. Retraction of the sternum and ribs may
provide a safety margin. After surgery, the cause diaphragm dysfunction (Dickey
pericardium is either closed, using pericardial 1989), and 1st rib fractures have been
chest tubes for drainage, or left open and found in SO% of patients following
drainage allowed through mediastical chest sternal retraction (Weiner 1992).
tubes. 7. Impaired renal perfusion during bypass
For coronary artery bypass grafting (CABG), may cause acute kidney failure Oindani
the saphenous veins and/or internal mam- 1993).
mary artery (IMA) are used to replace diseased 8. In the following years, gradual occlusion
coronary arteries. The IMA shows improved of the grafted vessels limits the life of the
patency rates and survival times, but has to operation.
be harvested from the chest wall, puncturing
the pleura and leading to postoperative Physiotherapy
shoulder girdle pain and greater impair-
ment in lung function than when using the After CABG, blood pressure should be
saphenous veins (Rolla 1994). observed before, during and after treatment
because hypertension exerts pressure on
grafted vessels. A raised diastolic pressure is
Complications
more relevant than raised systolic pressure
1. Postoperative cardiovascular instability because coronary artery perfusion is highest
may restrict turning or other physiother- during diastole. The operation notes may
apy techniques. indicate the limits within which the BP
2. Lower lobe atelectasis, mainly of the left, should be maintained.
occurs in 30--88% of patients Oindani Patients are ventilated until haemodynamic-
1993), due to compression of the left ally stable. If hypoxaemia persists after ex-
lower lobe and/or trauma or cold injury tubation, CPAP may be helpful (Thomas et al
to the phrenic nerve. This is so common 1992). Until the patient can mobilize, regular
as to be hardly considered a complication positioning on alternate sides reduces post-
unless it progresses and, indeed, many operative complications (Tidwell 1990), so
patients leave hospital with radiological long as this can be achieved with comfort and
changes not yet resolved. safety. Right-side-Iying tends to cause less BP
3. Phrenic nerve injury may lead to dia- instability and better gas exchange than left-
phragmatic paralysis, occasionally bi- side-lying (Tidwell 1990).
laterally. A proportion of patients will appear
4. Aggressive fluid replacement may cause euphoric on the first day on realizing that
pulmonary oedema (Lowell 1990), and they have survived, then sink into de-
excess fluids or pericardial inflammation pression for some days afterwards. They
may cause pleural effusion Oindani should be encouraged to take things gently
1993). Pleural effusion is usually left- on the first day to avoid debilitating mood
sided and not significant. swings which interfere with rehabilitation.
S. Disorientation is due to the alien environ- If breathing exercises or incentive spiro-
ment in which the patient wakes up, metry are necessary for respiratory complica-
People undergoing surgery 187
tions, manual support of the wound on Table 7.1 Home advice for people following
inspiration improves comfort and allows heart surgery
greater excursion in some patients. 1. Take some form of enjoyable exercise for
Bed exercises provide the opportunity to about half-an-hour daily, increasing the
check for neurological damage and, for those level gradually so that you aim to produce
confined to bed because of complications, a rise in pulse rate to over 100 per minute
are necessary for joint range and muscle (unless you are on beta-blockers). Find
strength. some regular exercise that you enjoy and
can maintain indefinitely, e.g. a daily two-
When pain permits shoulder joint eleva-
mile brisk walk. Very strenuous activities
tion, it should be performed bilaterally to such as squash are not recommended.
avoid a shearing stress on the sternum. After Avoid fatigue.
IMA grafting, many surgeons ask for left 2. Take a rest in the afternoon for the next six
shoulder elevation to be limited to 90° for weeks.
the first 24 hours, and some request that 3. Do not lift, push or pull anything heavy for
the patient not be turned immediately after two to three months. This allows the breast
surgery. bone to heal.
Within the limits of fatigue, patients 4. Sexual activity can be started when you feel
should aim at: well enough.
5. Avoid driving for six weeks. Check your
• gentle walking on the 2nd postoperative insurance policy.
day, and stair-climbing on the 4th or 5th
6. Work can be resumed from between 6-12
day, gradually increasing thereafter,
weeks, depending on the level of exertion.
• postural correction in front of a mirror,
7. Expect a degree of breathlessness,
• immediate embarkation on a comprehensive
tiredness, poor concentration, memory loss
exercise programme such as that de- and aches and pains across the shoulders
scribed by Ungeman-deMent et al (1986). and chest. These are normal and should
improve over the next six weeks.
If the sternum is heard or felt to click on
8. Make a list of questions to ask the doctor at
movement, a cough belt is needed for sup-
your follow-up appointment.
port. One handle is passed through the other
9. No smoking.
and both are pulled on coughing.
Patients with continuing chest wall pain 10. Keep happy!
benefit from joint mobilizations (Dickey
1989). Patients are often ready for discharge vidually to each patient, but a cardiac re-
in a week, and it is useful to check the habilitation programme is advisable.
breathing pattern and posture to make sure
that there are no lingering signs of tension
which could become a habit. 7.1.10 Overview of cardiac rehabilitation
CABG is effective in reducing angina, but An integrated rehabilition programme is
functional impairment often continues after necessary to gain optimum benefit from heart
surgery (Allen 1990), and coronary artery surgery. Cardiac rehabilitation after surgery
disease is not eliminated. The patient and or myocardial infarct (MI) has led to reduced
family are well advised to cultivate a lifestyle BP, medication and smoking (Hedback et al
that retards the disease process in the grafted 1990), earlier return to work, and decreased
vessels. Table 7.1 gives basic information to angina, depression and anxiety (Hertanu
take home, which should be tailored indi- 1986). Carson (1989) claims a 20% reduction
188 Physiotherapy for specific groups of people
vascular disease for both lungs. Relative graphy is required to identify this. Treatment
contraindications are the side-effects of heavy is only by retransplantation.
steroid use and sometimes previous thoracic Transplanting the lung has proved more
surgery. Recipients are matched with donors difficult than other organs. It is the only
for factors such as blood type and organ size, organ in contact with the atmosphere and
but a smaller donor organ is usually accept- has evolved a strong immunity to anything
able. Rigid criteria are applied to donor and foreign. Complications following lung trans-
recipient (Corley 1994). plant are the following:
1. Infection is caused by denervation of the
Procedures
lung, which impairs mucociliary trans-
The operations are no longer technically port and the patient's awareness of the
awesome, and now that immunosuppressive presence of secretions, an awareness that
therapy is better able to prevent organ people with CF have developed to a fine
rejection, the main limiting factor is lack of art. Patients are reminded to expect some
donor organs. A quarter of CF patients die secretions in the immediate postopera-
while waiting (Piper et al 1992). tive period because it takes a few days
Cardiopulmonary bypass is used for heart for the debris to clear. Some secretions
transplants and some lung transplants. For continue to be produced from the native
single lung transplants, a thoracotomy incision airway above the anastomosis. A further
is used. For bilateral lung transplants, a hindrance in the short term is post-
massive trans-sternal bilateral thoracotomy operative oedema around the anastom-
(clamshell incision) allows sequential single- osis.
lung procedures, which create two separate 2. Pulmonary oedema may be caused by the
bronchial anastomoses and preserve the ischaemic insult of surgery followed by
coronary-to-bronchial collateral circulation. A reperfusion. Diuretics may thicken secre-
sternotomy is used for other procedures. tions.
A heart-lung transplant (HLT) transplants 3. People with preoperative CO2 retention
heart and lungs en bloc and retains the find that the new normal oxygenation
collateral circulation. HLT may incorporate a may suppress their hypoxic respiratory
domino procedure, in which the recipient's drive. The resulting hypercapnia usually
healthy heart is used as a donor for a second normalizes within a week.
recipient. 4. Acute or chronic lung rejection can occur
from a few days to several years post-
Complications operatively. FVC and FEV1 should reach
a plateau several months after surgery
All transplants are complicated by the side- and then remain stable, but a reduction
effects of long-term immunosuppressive of 10-15% is a warning of possible
drugs. Cyclosporin can cause renal damage, rejection, and suspicions are confirmed if
and steroids can cause opportunist infection there is fever, breathlessness, hypoxaemia
and altered body image due to extra body and fine crackles on auscultation. X-ray
hair or a cushinoid appearance. signs are similar for both rejection and
Some transplants are complicated by rejec- opportunistic infection, and gentle bron-
tion. Acute heart rejection is suspected if choscopy or biopsy is needed to dis-
there are temperature or ECG changes, con- tinguish the two. Patients are given a
firmed by biopsy. Chronic heart rejection diary in which to record spirometry
narrows coronary arteries, and annual angio- readings, weight and medication. Treat-
People undergoing surgery 191
condition having been picked up on routine • (for some surgeons) avoid neck move-
X-ray, but surgery is advisable before hyper- ments that might stretch the anastomosis.
tension wreaks damage in later life. Repair is
Discharge advice is detailed by Savage
by resection of the narrowed segment and
(1992).
anastomosis or insertion of a dacron graft.
The following precautions are needed post-
operatively to avoid any sudden rise in BP 7.1.14 Chest drains
that might strain the anastomosis: Simple wound drains are adequate to remove
1. The head-down tip should be avoided. blood from the affected site after most forms
Some surgeons prefer the patient not to of surgery, but if the operation has interfered
lie flat. with pleural pressures, underwater seal chest
2. Mobilization should be slow and fatigue drains are needed. This airtight system
avoided. Extra care is needed during the allows air and blood to escape from the
2nd postoperative week when patients pleural space while preventing their re-entry.
are beginning to feel well enough to exert It also restores normal negative pleural pres-
themselves. sures and allows lung re-expansion. Chest
3. Vigorous exercise should be discouraged drains are also used after heart surgery,
for several months. although some cardiac surgeons find that
simple wound drains are sufficient.
valve. Fluid drains by gravity and air is tents being sucked back into the patient.
expelled through the water into the atmos- If the bottle needs to be lifted above the
phere. Fluid cannot return so long as the patient for turning, the tubing should be
bottle is below the level of the patient's chest. clamped near its exit from the chest for
Air cannot be sucked back because the water the duration of the manoeuvre.
acts as a seal while offering minimal resist- 3. Except when lifting the bottle above the
ance to drainage. The length of tube under patient, it is preferable to avoid clamping
the liquid determines the pressure required during moving, deep breathing, cough-
to expel the unwanted contents in the chest, ing or mobilization, because drainage is
so is kept short without breaking the under- encouraged by these manoeuvres. Care
water seal. The underwater seal also produces should be taken to avoid disconnection
a siphon effect which enhances drainage. during any activity.
Drainage depends on gravity or suction. 4. When handling patients, the tubing
Free drainage occurs when the exit tube is should be held against and in alignment
open to the atmosphere. This allows the with the patient's chest, to minimize
water level in the underwater seal tube to discomfort.
swing (if it is a pleural drain), reflecting the
5. The tubing should be kept exposed
change in pleural pressure with breathing. If
throughout treatment to avoid accidental
gravity is inadequate for drainage, for ex-
kinking.
ample, with excess fluid drainage or air leak,
6. The bottle should be observed before and
suction is applied, typically at pressures of
minus 10-20 cmH2 0, with more negative after physiotherapy to check for any
pressures for large air leaks (Kam et aI1993). change in drainage, air leak or swing in
One bottle is used if little drainage is the water level. Extra drainage is
expected. This acts as both underwater seal expected after treatment, but excessive
chamber and collection chamber. Two bottles loss suggests haemorrhage and should
may be used individually or in series (Fig. be reported.
7.7). There is sometimes a third chamber in 7. If the system is on suction but the patient
series to regulate the negative pressure at a needs to mobilize, the surgeon's per-
preset value. Integrated devices with several mission is first obtained to temporarily
chambers avoid the floor becoming littered disconnect the suction, then the suction
with bottles and tubing. tube is disconnected from the exit tube so
that the patient can walk while connected
Management to an open system. If the suction appara-
tus is simply unplugged from the wall
Any patient with a chest drain needs to be
socket, the system would then be closed
seen by a physiotherapist for advice on
and allow no exit of air, so that a
mobility, posture correction and shoulder
movement. Some also need respiratory care. pneumothorax could develop.
The principles of safe handling of chest If air is bubbling through the water, there is
drains are the following: a hole in the visceral pleura, allowing air to
1. Before treating any patient who has a escape from the lung at each breath. This
chest drain, the location of the clamps hole should seal in time, but positive pres-
should be checked so that they can be sure techniques would hinder this process
found instantly if required. and are to be avoided unless essential. An air
2. Bottles should be kept below the level of leak is also a sign to avoid clamping because
the patient's chest to prevent their con- this would allow a pneumothorax to develop.
194 Physiotherapy for specific groups of people
Apical drain
(a)
(b)
If clamping is essential, this should be air leak after treatment, this should be
momentary only, and if both drainage bottles reported.
show bubbling, they should not be clamped If there is no pressure swing, this means
at the same time. If there is any change in the that:
People undergoing surgery 195
• the tube is kinked or blocked (sudden), • observe breathing rate and chest symmetry,
• the lung has successfully re-expanded, • if the patient is distressed, give reassur-
thereby occluding the pleural end of the ance and oxygen.
tube (gradual),
• the system contains a collection bottle, 7.1.15 Head and neck surgery
which tends to obliterate the swing, or is
Major head and neck surgery can lead to
on suction, which overrides pleural pres-
respiratory dysfunction that is equal to upper
sure changes.
abdominal surgery (Campbell et al 1987).
The procedure of 'milking' chest drains to Partial or total laryngectomy is undertaken to
dislodge clots and maintain patency can remove a tumour of the larynx. Partial or
cause pulmonary trauma. Gentle hand radical neck dissection is required for malig-
squeezing is now recommended (Kam et al nant invasion of other tissues. A more
1993). extensive commando procedure resects part
Chest drains are removed by nursing staff of the mandible, tongue, neck structures or
after the lung has fully expanded and floor of the mouth. The combination of
drainage is complete. The distress of the mutilation, loss of speech and limited ability
procedure is often unrecognized, despite to express feelings can be a devastating
being described as their worst memory by experience for the patient. Speech therapy is
nearly half the patients in one survey (Carson essential and comprehensive multidisciplin-
1994). Entonox analgesia is an essential ary support helps to limit the frustration and
requirement, unless surgeons have preplaced grief that can lead to isolation and hinder
minicatheters for local anaesthetic infusion rehabilitation.
(Carson 1994). The patient is asked to take
and hold a deep breath during removal to Tracheostomy
avoid air being drawn into the chest.
A tracheostomy is formed temporarily during
Problems some operations in order to protect the
airway from aspiration or swelling. It is
If any junction in the system becomes discon- permanent if a laryngectomy is performed.
nected, or the bottle breaks, the following For the first few days the tube has an inflated
steps should be taken: cuff, which encircles the tube within the
• immediately clamp the tubing close to the trachea to prevent aspiration.
patient's chest, For non-laryngectomy patients, the cuff is
• clean and reconnect the tubing, deflated as soon as there is a cough reflex. For
• unclamp to restore drainage, those who have had a laryngectomy, the
• report the incident. cuffed tube is removed after about 48 hours,
when haemorrhage is no longer a risk, and
If the tubing becomes disconnected from replaced with a permanent uncuffed tube.
the patient, the following steps should 'be This incorporates an inner cannula to prevent
taken: trauma from repeated tube changes. The
• ask the patient to exhale and, at the same inner cannula is removed and cleaned twice a
time, press gauze, sheeting or a hand day to prevent obstruction by secretions.
against the wound at end-exhalation, Some people without laryngectomies re-
speed taking precedence over sterility, quire a long-term tracheostomy, in which
• ask the patient to breathe normally, case speech is possible with a fenestrated
• notify the doctor, but stay with the patient tube. This has inner and outer cannulae with
and maintain pressure on the wound, matching openings in their outer curves
196 Physiotherapy for specific groups of people
allowing air to pass through the larynx. It the stoma regularly using sterile saline. People
may be cuffed or cuffless. Another device has with chronic lung disease may need on-going
an inner cannula with a flange that closes on intermittent humidification.
expiration, thus forcing air through the vocal If the sternomastoid muscle has been
cords for speech. excised, the patient's head will need manual
support during postoperative movement. If
Complications of tracheostomy the spinal accessory nerve has been tran-
Complications of tracheostomy include the sected, there might be shoulder pain and
following: limited abduction, and patients should
adhere scrupulously to an exercise regime,
1. Obstruction due to thick secretions or postural correction and advice such as avoid-
blood clot. ing traction to the brachial plexus. Connect-
2. Displacement of the tracheostomy tube, ing tubes need to be supported during
especially if there is excessive movement movement so that they do not drag on the
in the immediate postoperative period. wound. Swallowing may be problematic.
3. Haemorrhage. This may be obvious or Mouthwashes should be offered liberally.
indicated by pulsation of the trache- The greatest fear of tracheostomy patients
ostomy tube synchronously with the during their early postoperative days is the
patient's pulse. If suspected, the airway inability to summon help, and a bell must
should be suctioned and the cuff inflated. always be within reach. They will need time
This will temporarily inhibit aspiration for lip-reading and deciphering written
until medical attention arrives. The head- requests in order to reduce frustration. They
down position inhibits aspiration of may need questions that require only a yes or
blood into the lungs. no answer. They do not need a raised voice.
4. Fistula formation, which is suspected if For disfiguring surgery, a mirror should be
suctioned secretions contain swallowed given to patients only if someone is available
food and drink. to be with them for their first view. Visitors
5. Infection, partly because the oral pharynx need preparation before their first visit. Self-
is teeming with bacteria, and partly esteem often improves when patients are
because poor suction technique is wide- encouraged in activities ranging from clean-
spread. ing their own inner tube to helping other
6. Erosion of the trachea due to excessive patients. With a long-term tracheostomy,
movement of the tracheostomy tube, and patients or carers will need to be taught to do
late onset stricture due to granulation their own suction, although many patients
tissue as eroded areas heal. can huff out their secretions.
Major head and neck surgery requires a
Management
comprehensive exercise programme such as
It takes about a week for a tract to be estab- that described by Herring et al (1987). Advice
lished following tracheostomy, so tracheal includes protecting the stoma from water and
dilators are on hand in case the tube becomes dust, instructions to carers on mouth-to-
dislodged. Continuous humidification is stoma resuscitation, and who to contact if
needed, but if the tracheostomy is perm- there are problems. Assistance with swallow-
anent, this is discontinued when the airway ing difficulties will be given by the speech
has adapted to its new exposure to the and language therapist. Self-care is emphas-
environment. Patients will then need to ized throughout rehabilitation.
maintain adequate fluid intake, and are sup- Voice restoration is by laryngeal devices
plied with a spray with which to moisten held at the neck, oesophageal speech or the
Elderly people 197
11. Reversible respiratory disease is often Physiotherapists are suited to working with
missed, or may not be treated even if people who are dying because of their use
the diagnosis is made (Sherman et al of physical contact, which can often
1992). communicate what words cannot, and their
12. Misery is not an inevitable accompani- experience with disabled people, who have
ment to old age. similar needs to people who are dying
Practical ways to help maintain orientation (Purtilo, 1976). An area as subjective as death
in elderly people are to: requires more of us as humans than as
'experts', and working with dying people
• encourage dressing whenever possible, can be both enriching and painful. End-
• avoid using patients' first names uninvited stage disease is not a time to withdraw
(Gordon 1994), physiotherapy, because there is much that
• ensure that patients are kept fully in- can be done to ease the passage towards a
formed, good death.
• encourage them to bring to hospital their
budgerigars and as much clutter of
personal possessions as practical and 7.3.1 Reactions of patients
allowable.
Now and then the whole thing becomes unreal.
Autonomy can be maintained by respect- Out of the middle of the night's darkness, or
ing patients' senior status, experience and bringing me to a sudden, chilling halt during
wishes regarding management. This means, the day, the thought comes: this can't be
for example, allowing them to return to bed happening to me. Me with only a few months to
when they request, rather than enforcing live? Nonsense. And I stare up at the darkness,
unhappy hours slumped in uncomfortable or out at the sunlit street, and try to encompass
hospital chairs. Discomfort reduces the depth it, to feel it. But it stays unreal.
of breathing, and the zeal with which Bell 1961
patients are hauled out of bed has led to
'chairsores' becoming more prevalent than When told that they are dying, most people
bedsores in some hospitals (Mulley 1993). feel overwhelmed and experience a variety of
Respiratory health is best maintained by a reactions. Fear of dying is often greater than
personally tailored programme of mobility the fear of death. There is fear of isolation,
and a return to a home environment as soon fear of an agonizing disintegration, fear of the
as possible. unknown. 'Will it hurt? Will I suffocate? Will
I drown in phlegm? Will it be disgusting?' If
7.3 PEOPLE WHO ARE DYING fears remain unspoken, they become dis-
It begins with an easy voice saying, torted or concealed by anger.
Just a routine examination; Guilt is an extra burden that is common in
as October sunlight people dying from smoking-related dis-
pierces the heavy velvet curtains. orders. Anger is another ever-ready emotion
Later it is the friends who write but do not that may arise from feelings of helplessness,
visit . .. or act as a defence against experiencing grief.
it is boiled fish . . . Grief is a normal response to an abnormal
it is doctors who no longer stop by your situation, but if suppressed it can develop
bed ... into a psychiatric disorder. Patients should
it is terror every minute of conscious night and not be treated with antidepressants for their
day to a background of pop music. grief (Stewart and Shields 1985), but allowed
Wilkes 1983 to express sorrow, anger, guilt, unusual
People who are dying 199
humour or any natural feeling, for which The health problems suffered by bereaved
they should not have to apologize. people are reduced if talking is encouraged
Many patients deny reality in order to (Timmons and Ley 1994, p. 246). Children
avoid the pain of grief or fear, and they act also benefit from open communication and
and talk as if they expect to get better. These need the opportunity to be close to their
defence mechanisms are natural and to be dying relative. They know their own limita-
respected. When and if patients are ready to tions and may simply want to pop in and out
confront the truth, they may sink into a of the sick room. Children often fantasize
depression that can paradoxically be a creative that they are to blame for the death of a
process by which they begin to take respons- parent or sibling, or they may feel they must
ibility for the way they respond to change. avoid distressing their parent and therefore
Only then can they accept their loss and avoid talking about it. Siblings of dying
allow fear to dissolve. children are often the forgotten mourners,
These reactions are not stages that occur in and McGowan (1994) found that 50% develop
logical order and with defined boundaries, fears of getting cancer themselves. Free
but they weave in and out of a patient's discussion should be allowed and, as appro-
awareness, so that a moment of anger may priate, encouraged.
open into acceptance, followed by the mind
curling back into the darkness of fear. These 7.3.3 Reactions of staff
mechanisms take time to work. Cancer and
emphysema give patients time, which with The sister was very cross with me and told me to
support can be used wisely. pull myself together because the consultant was
coming.
Blanckenhagen (cancer patient) 1986
7.3.2 Reactions of relatives
Once a patient's condition is known to
When someone you love dies, you pay for the sin preclude recovery, this is sometimes inter-
of outliving them with a thousand piercing preted as failure by health staff. Reactions
regrets. may manifest as avoidance, heroic measures
Simone de Beauvoir 1966 to prolong life, dishonest reassurance,
unsuitable bonhomie or the use of drugs to
Bereavement carries its own burden of mor- suppress patients' expression of emotion.
bidity and mortality (Timmons and Ley 1994, Health staff working with people at the end
p. 244), and living near to death arouses a of their life need support themselves in order
kaleidoscope of emotions. Relatives may to support patients appropriately. They need
experience similar reactions to the patient, as access to their own feelings because expres-
well as feeling impotence and a variety of sion of feelings by staff, when appropriate,
responses, including relief or remorse. They, has been found to be therapeutic for patients,
too, need the opportunity to express their who find professional detachment unhelpful
feelings, and this includes sharing the truth and even offensive (Fallowfield 1993).
with the person who is dying. Unfortunately,
patients and their relatives are sometimes out
7.3.4 Communicating with dying people
of step, either because the patient is given a
falsely optimistic forecast, or because one or His yellow eyes watched us being taught at the
both parties try to 'protect' the other, some- bedside of each patient and when we came to his
times with the collusion of health staff. Just bed we all walked directly past him to the patient
when they need each other the most, they are on his other side. Not a word was said. Not a
separated by a conspiracy of silence. greeting. Not even a nod . .. Dismay turned
200 Physiotherapy for specific groups of people
to guilt with the thought that I, too, had no idea avoid giving information is unethical and
how to approach or comfort a dying patient. keeps patients in a subordinate position.
Carmichael 1981 Lying to patients may be due to a false
assumption that distress equals harm, or un-
It is not easy to find the right words to say to
certainty about who should take the initiative,
people who are facing death. The key is to but physiotherapists have as much right and
listen. Patients find relief if they feel that it is responsibility to inform patients as other
acceptable to talk, and the astute listener can health staff (Sim 1986), and can act to bridge
pick up indirect questions. Patients may drop the gap that sometimes exists between
hints that they would like to talk by ploys patients and their physicians. Honesty
such as mentioning other people who have should be tempered by sensitivity, with an
died, joking about their future or asking how emphasis on what medical science has to
long their illness will last. We can indicate a offer, and a check that patients do not
willingness to listen by asking if we can sit on associate emotive words such as 'cancer' with
the bed, maintaining eye contact and asking misconceptions about an inevitable and dis-
non-threatening questions such as 'how do tressing death.
you feel in yourself?' While patients are Important exchanges with the patient
talking, they can be encouraged by prompts should be communicated to the doctor and
such as, 'go on' or simply 'mm?'. head nurse. If it is difficult to talk with the
During and after talking, patients need patient, an appropriate member of the health
time to process their thoughts, and we team should be asked.
should develop the art of using silence To reveal the diagnosis to the family
constructively. It is not helpful to rationalize without the patient's knowledge creates ten-
patients out of their feelings, tell them what sion and mistrust between all involved and
to do, or say that we know how they feel (we is unethical. Family requests should be
do not). It is, however, helpful to provide respected, but have no legal standing and
information that reduces anxiety, and discus- should not take precedence over the rights of
sion itself helps to divest death of its power. the patient (Snider 1995).
Uncertainty is one of the hardest things to Reaction to bad news is varied and some-
bear (Bortoluzzi 1994), and patients who are times irrational, including regression to child-
left in ignorance feel a loss of control that like behaviour, projection of hostility, relief,
shackles their coping strategies. or despair at the loss of fulfilment. Patients
We might also find it useful to ponder may choose to face in a different direction
our own reactions: 'Am I feeling uncom- from that which we intend, but no defence
fortable? Am I helping or hindering her mechanism is maladaptive unless continued
flow of thought? Am I responding to his use causes undue distress. Patients should be
needs or mine? Am I frightened of death left with some realistic hope, even if this is
myself?' directed towards a minor everyday achieve-
Honesty is essential in this form of ment. And it is always worth casting a
communication. The overwhelming majority backward glance when leaving the bedside,
of patients want to be told their diagnosis because it is sometimes necessary to return
(Sell et al 1993). Fear of the unknown is a and pick up the pieces.
heavier burden than the truth. Most realize
eventually that they are dying, and are then
7.3.5 Management of symptoms
alone to face the truth from which they were
being sheltered. When patients ask questions As soon as it is known that patients are in
about their prognosis, however indirect, to need of care rather than cure, the emphasis is
People who are dying 201
on allowing them to choose both the method worth it. Nebulized lignocaine (Trochtenberg
and timing of treatment. 1994) is useful for a terminal cough caused by
pooling of saliva; it can be given several times
Breathlessness a day but is especially useful at night. Physical
management depends on whether the cough is
Breathlessness is the most dreaded accom-
productive or not (see Chapter 5).
paniment to advanced lung disease and is
present in 60% of people with any advanced
Death rattle
cancer (Clarke 1993). The pharmacological
and physical management of breathlessness People who are too weak to expectorate may
is discussed in Chapters 4 and 6, but further collect excessive secretions in their throat.
measures can be taken for people who are The resulting 'death rattle' is distressing for
dying. visitors and neighbouring patients. Reposit-
Specific causes of breathlessness should be ioning the patient may reduce the noise, but
identified and treated, e.g. pleural effusion, secretion formation can be prevented by
ascites, anxiety or anaemia. Steroids relieve administration of hyoscine using a patch or
breathlessness associated with diffuse malig- syringe pump at the first indication of moist
nant lung involvement, and increase appetite breath sounds (Ahmedzai 1988). Suction is
and well-being. The normal constraints on not indicated.
using these drugs are unnecessary at the end
of life. Nebulized morphine with lignocaine Difficulty in swallowing
can relieve breathlessness, and the canna-
binoids can be used for their bronchodilator Hyoscine is also useful for patients who
and tranquillizing effects (Ahmedzai 1988). cannot swallow easily. A speech therapist
Patients being managed at home often feel provides valuable support.
relieved if they can self-administer nebulized
morphine because of its many symptom- Dehydration
relieving properties. Its reassuring presence When it comes to dying, arms are for hugging
may reduce the incidence of respiratory not for intravenous infusions.
panic. Potts 1994
Patients vary in their response to oxygen. It
is usually of no value and simply sets up a People who are dying often escape symp-
barrier between patient and family (Burford toms associated with dehydration, such as
and Barton 1993), but it is worth a trial in headache, nausea and cramps. The trouble-
those with hypoxaemia (Bruera et al 1993), some symptoms of dry mouth and halitosis
so long as care is taken to prevent a dry can usually be relieved by sucking crushed
mouth. ice or lemon slices (Main 1993).
Cough Pain
Cough occurs in 30% of people with all Seventy per cent of patients with advanced
cancers and 80% of people with lung cancer malignancy experience pain, and fear of pain
(Twycross and Lack 1984). Pulmonary often exceeds fear of death (Main 1993). If
oedema, infection or bronchospasm can con- pain is allowed to fill the patient's field of
tribute to a cough, and these can be dealt consciousness, it can lead not only to dis-
with pharmacologically. Smoking cessation tress, but also to withdrawal, indifference to
will ease the cough, but not for two to four personal appearance or degeneration of per-
weeks, so the patient may decide that it is not sonality.
202 Physiotherapy for specific groups of people
Drug management for palliation of pain in afraid. Death may be routine to you, but it is
general hospitals is often characterized by . new to me . .. I've never died before.
underestimation of symptoms and over- Gallagher and Trenchar 1986
estimation of side-effects. Twycross and Lack
This message from a dying student nurse
(1990) is a useful reference to demonstrate
advises her colleagues how they can best
that this is inappropriate. Physical depen-
help her towards a good death. When
dence on opioids is rare and not an issue
patients are free from fears, they can live
unless medication is withheld.
their remaining life to the full. Conscious
Other pain-relieving strategies are TNS for
dying is possible when a pain-free state
localized pain, pain meditations (Levine 1988)
without undue sedation has been achieved,
and massage. The patient's own strategies
so that patients are not trapped between
should be encouraged, such as ointments
perpetual pain and perpetual somnolence.
and hot-water bottles.
Death can be a positive achievement when
patients are not consumed by anxiety about
Discomfort symptoms and have stopped fighting for life.
Through the many little deaths of dying, they
Regular turning and positioning to suit each have plumbed the depths of their being, but
individual eases the discomfort of immob- fear has dissolved, there is peace without
ility. Some patients like to be propped up defeatism and they are free to look for some
with their head well supported, while others meaning in the experience.
like to be curled up on their sides with
generous quantities of pillows. Constipation
is common and can be reduced by activity if 7.3.7 Dying children
possible, and abdominal massage if there is
Children have a right to grieve. They have
no malignant obstruction. Restless or sleep-
the capacity to do so, but may be prevented
less patients need attention firstly to physical from this necessary process because of a
discomfort and anxiety, because instant
natural desire by others to protect them from
recourse to sedation may lead to confusion.
suffering. Children understand more than
Extra care should be taken of the skin, and
they can articulate, and Purssel (1994) has
patients can be lifted out of bed comfortably
shown how children usually know if they are
on a sheet. going to die. Evasion can leave them with a
Exercise usually eases the discomfort of
sense of bewilderment, even betrayal, and
immobility. Simple brief exercises will tempt
fantasies that are more frightening than
patients who feel that exercises are unneces-
the facts. Many children are able to take
sary or worry that they will be unable to
decisions about treatment, including whether
perform. to have active or supportive therapy (Purssel,
For advanced malignancy, there is a risk of
1994).
bony deposits and the clinician should be
As well as experiencing the adult re-
alert to any new pain. Chest percussion is
sponses to dying, children carry the extra
rarely indicated and unsafe because of the
burden of their parents' grief. Parents may
risk of fracture. also carry an extra burden of being avoided
by their friends. Comprehensive support for
7.3.6 On dying well the family, including contact after the death,
helps reduce the high incidence of distress,
All I want to know is that there will be someone divorce and sibling neglect that tends to
there to hold my hand when I need it. I am accompany the death of a child.
Recommended reading 203
,
,
Origin
Trigger
~HYPerventilation
Anxiety~
Catecholamines
(stress hormones)
)
Symptoms
bereavement or other loss. Either immedi- • conditions that cause overbreathing and
ately or at a later stage, a vicious cycle becomes may predispose to HVS by reprogram-
established in which hyperventilation, symp- ming the respiratory centre, including
toms and anxiety reinforce each other (Fig. asthma, heart failure, pain and long-
8.1). The original event that initiated this term low-grade fever,
pattern may be unrelated to on-going factors • in children, family discord or anxieties
that maintain it, which could be, for example, about school.
stress or simply habit. Why do some people respond to stress by
Once the cycle is established, cause and chronic hyperventilation while others develop,
effect are indistinguishable. The question say, backache or hypertension? The reason is
that continues to tease researchers is whether elusive but may be related to past events
hyperventilation or anxiety come first, but in around fear and breathing, such as hypox-
clinical practice they both augment each aemic birth, a ducking in the school swim-
other. Either way, the syndrome is associated ming pool, an insensitively applied anaes-
with: thetic mask in childhood or a history of
abuse. Personality plays a part because people
• emotional factors such as fear, suppressed
who respond to stress in this way tend to
anger, depression, laughter and orgasm,
suppress their emotions and are often con-
• conditions such as agoraphobia and other
scientious, perfectionist and enthusiastic. It is
panic attacks, sleep disorders, hyper-
these qualities, along with the high motiva-
tension, chronic fatigue syndrome, Ray-
tion that accompanies their relief at finding
naud's disease, hypermobile joints and
constructive help, that make people with
migraine,
HVS a delight to treat.
• factors such as food allergy, premenstrua-
tion (progesterone being a respiratory
8.3 EFFECTS
stimulant), drugs (caffeine, nicotine,
aspirin) or restrictive clothes (hence the Overbreathing and unstable breathing cause
alternative name Designer Jeans Syn- low and/or fluctuating PaC02 1evels, t pH of
drome), the CSF and blood, t plasma calcium and
206 Physiotherapy for people with hyperventilation syndrome
Table 8.1 A selection of the signs and in fact be unaware of any breathing abnor-
symptoms associated with hyperventilation mality. If symptoms have worsened while
syndrome they are on a waiting list, this may be because
System Manifestation a common response to receiving a diagnosis
of a breathing disorder is to practise deep
Neurological Tingling and numbness breathing exercises.
(especially extremities/around Patients are often puzzled at why symp-
mouth)
toms affecting so many parts of the body can
Faintness
be caused by a breathing disorder, and may
Blurred vision, migraine
Poor memory and not report 'irrelevant' symptoms. Acceptance
concentration of the diagnosis is easier when they are asked
Tremor and tetany specific questions about symptoms that are
likely to correspond to their experience. We
Psychiatric Panic attacks also need to find out the patient's opinion of
Phobias (especially the cause of their problem.
claustrophobia/agoraphobia)
Patients should say all they want at this
Anxiety, clammy hands,
flushed face stage because it relieves tension and reduces
Suppression of emotion their need to talk during treatment, which
Depression upsets the breathing pattern.
Mood swings
Depersonalization
8.4.2 Observation
Gastrointestinal Oesophageal reflux
It is normal to sigh when sad, breath-hold
Difficulty swallowing
Nausea when frightened, say 'phew' when relieved
Abdominal pain, indigestion, and breathe fast when stressed, but people
wind who chronically hyperventilate often have a
Irritable bowel habitually labile breathing pattern, with dis-
turbance continuing long after the stress is
Musculoskeletal Myalgia
withdrawn. The breathing rate may be
Stiffness, cramps
Tetany in severe cases
excessive, and the breathing rhythm erratic
with a variety of patterns:
General Difficulty in breathing, talking,
swallowing • shallow, fast and apical,
Air hunger • sighing and yawning,
Weakness • irregular, with numerous hesitations,
Insomnia • prolonged inspiration and curtailed expira-
Hypoglycaemia tion,
Blurred body awareness • excessive thoracic movement, sometimes
Difficulty concentrating with abdominal paradox,
• 'cogwheel' breathing, as if the patient dare
not let the air out,
• 'statue' breathing, as if the patient has
momentarily forgotten to breathe,
Feelings vary from anxiety to fears of
• audible hissing in florid cases.
impending madness. Medical phobias and
fear of dying are common (Timmons and Ley Conversely, changes in breathing may be
1994, p. 142). Patients may complain of an subtle and hardly evident on observation
inability to take a satisfying breath, or may because the breathing required to maintain
208 Physiotherapy for people with hyperventilation syndrome
hypocapnia is less than that required to ECG monitoring because there is a danger of
induce it. arrhythmias or ischaemia if overbreathing is
Other signs are a stiff posture and gait, prolonged. Cerebral vascular disease and
excessive hand movements or other indica- epilepsy are contraindications.
tion of tension, speech uncoordinated with Voluntary overbreathing is an established
breathing, rapid speech, as if the patient is technique in psychotherapy to enable people
trying to cram several sentences into one, to gain access to their feelings, and the
and strategies to sneak in more air such as a provocation test sometimes brings out emo-
dry cough, throat clearing or chest heaving tions. Some patients need the opportunity to
before answering questions. Belching may be discuss these, and proffering a box of tissues
caused by air swallowing, cold hands by lets them know that tears are acceptable.
vasoconstriction and licking of the lips by a A low PaC02 is not itself diagnostic, because
dry mouth. the syndrome is intermittent, but a value
below 4.3 kPa (32 mmHg) would raise suspi-
cions. A more specific test is to use cap-
8.4.3 Questionnaire
nography to measure expired CO2 at the
Any person who demonstrates an unusual mouth. End-tidal CO2 is close to the arterial
mix of clinical features which include some of value when lung function is normal. If the
the above should raise suspicions of HVS. resting level is erratic, or if after a provocation
The diagnosis can be confirmed by the test of voluntary hyperventilation it has not
Nijmejen questionnaire (Fig. 8.2), which has normalized within five minutes, HVS is implic-
been validated by Vansteenkiste et al (1991). ated (Timmons and Ley 1994, p. 109). Cap-
nography is not distressing and can be used to
provide feedback for patients and outcome
8.4.4 Tests
measures for physiotherapists (Fig. 8.3).
Objective tests can be distressing and are
limited in accuracy because of the absence of 8.S EDUCATION
normal precipitating factors, but the follow-
Before launching into explanations, it is
ing are available:
worth checking the patient's expectations.
The provocation test entails rapid breathing
Goals can then be agreed, e.g. in the short
for one minute, which in patients with a
term to cope with panic attacks and in the
chronically low PaC02 brings on familiar
long term to integrate a normal breathing
symptoms speedily (not just dizziness which
pattern into everyday life. The mechanism of
is normal). It consists of the following:
HVS can be explained using the vicious cycle
• advice that the test may bring on a dry (Fig. 8.1) and this by itself often improves
mouth and be tiring (but patients are not symptoms. The explanation should include
told to anticipate their symptoms), reassurance that HVS is a normal response to
• advice to report any feelings that occur, stress, not a psychiatric illness, and stems
• instruction to take fast deep breaths for one from chemical reactions to certain events that
minute 'as if you're climbing a hill'. have become a habit. Bradley (1994) provides
a book full of patient-friendly education.
The test reassures patients of the validity of
Patients should gain an understanding of
their symptoms and shows them that they
the following:
have some control, but it is also considered
hazardous (Fried 1993, p. 42), and for • physiotherapy will not eliminate the cause
patients with chest pain it should be per- nor remove precipitating factors, but the
formed under medical guidance and with aim is for a collaborative approach so
Education 209
Chest pain
Feeling tense
Blurred vision
Dizzy spells
Feeling confused
Short of breath
Tingling fingers
Palpitations
Feelings of anxiety
Total: /64
Tense people often find relaxation an alien concept, but may need a reminder that slow
concept, and it may be easier after back or breathing does not mean deep breathing.
neck massage, during which they are advised 'Low and slow' is the key. Some need only a
to focus on the experience and not feel that pause at end-exhalation.
they have to talk or 'do' anything. Even the If patients tense up, the emphasis should
old infra-red lamp has been found helpful for be on smooth, gentle, rhythmic breathing. To
relaxation, usually to the back with the help patients maintain their rhythm, it is best
patient prone. Some patients find that lying not to ask for verbal feedback during the
prone for relaxation makes them feel less practice, but rather to observe the patient's
vulnerable. breathing pattern. When a session of breathing
Focusing on the breath itself helps relaxa- practice is finished, it is best for the patient to
tion, especially if patients are encouraged to stop smoothly and avoid gasping.
gently 'breathe in the good air' and 'breathe If patients still find this difficult, more
out the tension', as if freeing the breath. A structured support can be given by pacing
relaxed state should be maintained by bring- the patient's breathing to the physiotherap-
ing the patient's attention to areas of tension ist's voice. The patient's breathing pattern is
throughout treatment, especially the jaw and first observed closely, then he or she is asked
throat. Physiotherapists should ensure that to breathe in time with the physiotherapist's
they themselves are relaxed. words, the rate of which is slightly slower
It is not unusual for symptoms to appear in than the patient's breathing. Suggestions for
the early stages of treatment because of a instructions are:
paradoxical, but transient, increase in hyper-
ventilation. Relaxation lets down a wall of 'In-and-out, in-and-out ... '
tension and may release buried feelings, and 'In-and-out-two-three, in-and-out-two-
breathing re-education may feel subcon- three ... '
sciously threatening because of interference 'In-and-relax-out, in-and-relax-out ... '
with such a basic need. If this occurs, an 'In-and-Iet-it-out, in-and-Iet-it-out ... '
explanation is all that is required. Words and timing should be flexible to suit
the patient, but they need to be repeated
8.6.3 Abdominal breathing rhythmically. Some patients find that pacing
brings a sense of security in the early stages,
Patients are then taught abdominal breathing the words acting as a 'breathing pacemaker'.
(p. 114), taking care to maintain small gentle Progression is aimed at independent control
breaths. In lying, abdominal breathing may be without the physiotherapist's voice.
facilitated with the hands behind the head. Patients should experience a modicum of
discomfort from air hunger, but not enough
8.6.4 Slowing the breath to develop tension. If they feel an irresistible
need, they can take a conscious and
The combination of education, relaxation and controlled deeper breath, then get back
abdominal breathing has shown improve- gently into rhythm again, sometimes with a
ment in 94% of patients (Pinney et al1987). If preliminary breath-hold as compensation
further treatment is required, patients should (but not if this causes tension).
practise 'breathing less' - but gently, gently- Advice can be given at appropriate intervals:
avoiding tension and exacerbation of abnor-
mal breathing patterns. 'Breathing less' • keep it smooth, shallow and abdominal,
means reducing the rate or depth of breathing, • swallow if you need to suppress a deep
or both. Patients usually understand this breath,
212 Physiotherapy for people with hyperventilation syndrome
• have a stretch if you find yourself tensing 7. Patients can 'breathe in' to areas of
up (but do not use this as a way of muscle tension, then 'breathe out' the
sneaking in a surreptitious breath!), tension.
• keep the rhythm going, you don't need to 8. Abdominal breathing is sometimes facil-
hold your breath, itated by an object on the abdomen,
• maintain relaxation, avoid trying too hard, such as the patient's or physiotherap-
• don't fight your breathing, befriend it, ist's hand or a box of tissues.
• be assured that you are in control and can 9. Gentle alternate-nostril breathing is a
stop at any time. yoga technique that increases breathing
awareness and reduces the tendency to
The concept of control is important for
hyperventilate (Fried 1993, p. 238).
people who hyperventilate, because it re-
10. Putting the tip of the tongue between
duces anxiety and helplessness. They have
the lips encourages nose breathing.
felt out of control of their most fundamental
11. Humming slows breathing and eases
physiological function.
tension.
For some patients, anxiety or depression is
12. Patients can experiment with their own
the primary problem and slowing the breath-
ideas as they increase awareness of their
ing by itself can increase anxiety, in which
individual way of breathing, speaking
case referral is advisable.
and moving.
8.6.5 Variations
8.6.6 Monitoring
A process as individual as breathing re-
If the patient reports air hunger, reassurance
education needs a flexible approach. Sug-
is given that this means success. Throughout
gested variations are the following.
the session, the physiotherapist observes the
1. A demonstration can be given of what is patient closely in order to guard against:
seen as the patient's breathing pattern,
• any renewal of upper chest breathing or
followed by a demonstration of the
physical tension,
corrected breathing pattern. A mirror
• a tendency to breathe in steps or breath-
may also be helpful.
hold,
2. Patients sometimes achieve their
• abdominal movement without breathing.
rhythm by being asked to observe or put
• all sorts of manoeuvres to slip in a covert
their hand on the physiotherapist's
deep breath, e.g. a subtle change in
abdomen and 'breathe with me'.
breathing pattern, shoulder movement,
3. The simple yoga technique described on
shift in position or just extra conversation
p. 156 will often relax the most har-
(the physiotherapist and patient can
dened workaholic.
compete as to who notices these first!).
4. Patients can visualize their inhalation as
if going up a hill and exhalation as if Some physiotherapists count the respir-
coming down the other side. atory rate as a method of evaluation. If this
5. Some patients slow down more easily if method is chosen, a rate of 10-12 breaths per
the physiotherapist moves physically minute is a typical target. However, symp-
away and asks them to 'breathe from toms should take priority over numbers.
where I am'. By the nature of the syndrome, it is
6. Focusing is encouraged if the patient is essential that patients are not hurried, and an
asked to 'listen to the sound of your undisturbed hour should be set aside for each
breathing' . session.
Progression and home management 213
without food for more than three hours. This set aside 20 minutes a day for relaxation.
should be emphasized for patients who eat Others find individual ways of relaxing, such
heavily at night, which can produce night- as a rocking chair or personal stereo. A hot
time or early-morning symptoms. Meals bath is often unhelpful because excessive
should be slow and enjoyable, and patients heat stimulates the respiratory centre. Many
should avoid excessive coffee, cola or choc- people need reassurance to overcome guilt at
olate. If they must smoke, deep drags are to allowing themselves time to relax.
be avoided. Despite the plethora of potential advice, it is
Much encouragement is needed to help important not to burden patients with excess-
patients integrate their new breathing pattern ive homework because they tend to become
and attitude into the distractions of everyday preoccupied with their daily programme. It is
life. If progress is slow, more attention often best to use education as the basis for
should be given to identifying individual individuals to make their own decisions.
fears and precipitating factors. Reassessment Physiotherapy is needed weekly until self-
of the abnormally high demands to which management is stabilized, then sometimes
patients often subject themselves may be monthly for adjustment and encouragement,
fruitful. Family and friends can be enlisted as followed by occasional top-up visits. Three to
extra sources of encouragement. 14 weeks of treatment have shown positive
A handout helps to correlate this mass of outcomes, i.e. improvement in questionnaire
information. A tape can be made of each scores, capnography, anxiety and depression
physiotherapy session and be given to the (Tweeddale et al 1994). Once learned and
patient; the educational component of the reinforced, the new breathing pattern can be
session acts as a reminder, which may be maintained automatically because there is no
useful because poor concentration is a fre- structural damage. Self-awareness and stress
quent symptom, and the relaxation compon- management, however, must last a lifetime.
ent can assist practice at home. Some patients Patients often report that HVS has given them
ask for a tape of the physiotherapist's voice the opportunity to rethink their lifestyle.
counting at three levels of fast, medium and
The physiotherapist's most useful assets
slow. They can use this to pace themselves at
are warmth, humour and acute observational
the correct level, to the point of feeling air
skills. Patience and commitment are needed,
hunger but not distress. Relaxation tapes are
but the reward can be a dramatic restoration
also available commercially, but patients
of enjoyment to a life that has sometimes
must be reminded to ignore instructions to
become a shambles.
breathe deeply.
Practice in breathing re-education should
take place if possible little and often, usually RECOMMENDED READING
about two to three times a day for 15 minutes.
Grossman, P. (1985) A controlled study of a
In addition, spot checks throughout the day breathing therapy treatment of HVS. J. Psycho-
can be integrated so that they fit in with som. Res., 29, 49-58.
regular events, such as coffee breaks, queues, Howell, J.B.L. (1990) Behavioural breathlessness.
coming home from work, or television adver- Thorax, 45, 287-92.
tisements. Timers jog the memory, as will Innocenti, D.M. (1993) Hyperventilation, Physio-
stickers on toothbrushes, telephones and therapy for Respiratory and Cardiac Problems, (eds
B.A. Webber and J.A. Pryor), Churchill Living-
other strategic locations. Breathing should be stone, Edinburgh, pp. 377-97.
checked every day before getting out of bed. Rowbottom, I. (1992) The physiotherapy manage-
Although disruption to daily life should be ment of chronic hyperventilation. ACPRC J., 21,
minimal, many patients find it worthwhile to 9-12.
9. Intensive care
Introduction Monitoring
The environment gas exchange
effects on the patient haemodynamic monitoring
effects on relatives tissue oxygenation
effects on staff cardiac output (CO)
patients' rights overview of electrocardiography (ECG)
teamwork Support
infection control pacing
Mechanical ventilation nutrition
indications fluids
airway drugs
principles advanced cardiac support
effects and complications advanced pulmonary support
waveforms advanced cardiopulmonary support
modes Recommended reading
settings
positive end-expiratory pressure
(PEEP)
high-frequency ventilation
weaning
9.1 INTRODUCTION ... he will get a dozen people around the clock,
all busily preoccupied with his heart rate, pulse,
Patients are admitted to an intensive care unit secretions or excretions, but not with him as a
(leU) if they require intensive therapy, inten- human being.
sive monitoring or both. They are not neces- Kubler-Ross 1973
sarily critically ill, but are at risk of failure of
one or more major organs. Their needs range It is ironic that seriously ill people find
from observation of vital signs after major themselves in an environment that itself
surgery, to total support of physiological causes stress and fatigue, factors which are
systems. Admission usually depends on major contributors to hindering a patient's
expectation of recovery, and the majority of recovery (Swann 1989). It is not an optional
patients return to their previous health status extra to give attention to this aspect of patient
(Rustom 1993). management, but an integral part of physio-
therapy. The effects of stress are the follow-
9.2 THE ENVIRONMENT ing (Brannon et aI1993):
9.2.1 Effects on the patient • i respiratory rate, heart rate and BP,
• perceptual distortion and impairment of
He may cry out for rest, peace, dignity, but he judgement, causing poor response to
will get infusions, transfusions, a heart machine advice and education,
216 Intensive care
• i metabolic rate and protein breakdown in rarely achieved in the ICU (Wood 1993b).
patients who are already catabolic and The more ill the patient, the more sleep
nutritionally depleted, thus consuming he or she needs and the less is got.
energy that should be used for healing, Disruption is due to noise, interruptions,
• release of thyroid hormones (which increase anxiety, pain, difficulty finding a com-
oxygen consumption), and ADH (which fortable position and the fear of some
retains fluid), patients that falling asleep means not
• sleep disruption, which augments stress, waking up again.
• tendency to infection, gastric ulceration, 3. Fear. Patients face unknown and pre-
muscle tension and blood clotting ab- viously unmet fears which may com-
normalities, promise their coping mechanisms. Fear is
• depression, compounded if patients are unable to
• exhaustion. communicate.
4. Sensory deprivation. Despite being out-
lawed by the International Court of
Human Rights, sensory deprivation is
found in the ICU, albeit unintentionally,
due to social isolation, loss of touch,
immobilization, certain drugs, taped eye-
lids, sometimes no windows and often
removal of hearing aid or glasses. This
leads to a form of emotional solitary
confinement that can leave patients feel-
ing intense loneliness despite constant
attention.
5. Sensory overload. Patients find them-
selves lost in a sea of electronic wizardry
and bombarded by unfamiliar beeping,
constant overhead lights, telephones,
confining equipment, painful procedures,
tubes in every orifice and incomprehens-
ible conversations over their heads. Most
conversations are between staff, not with
the patient (Wood 1993b). ICU noise is
consistently above internationally recom-
The severity of the stress response varies
mended levels and leads to adverse
with patients' ability to control their situation.
physiological effects (Kam 1994). The
The causes of stress are the following:
combination of sensory deprivation and
1. Communication. Inability to communic- overload causes disorientation and some-
ate has been found to be the most times delusions.
stressful experience in the ICU (Pennock 6. Helplessness, dependency and depres-
1994; Villaire 1995). sion. The less patients are able to do for
2. Sleep fragmentation. It is claimed that themselves, the more frustrated they
lack of sleep leads to death faster than feel, and this may deteriorate into de-
lack of food (Wood 1993b). A full 90- pression, especially for long-stay patients.
minute cycle is needed to achieve the Depression can become internalized as
restorative benefits of sleep, yet this is anger, which is difficult for patients to
The environment 217
9.3.3 Principles
consistent minute volume regardless of lung reduces renal, hepatic and splanchnic
compliance. Pressure control is safer for blood flow (Beale et aI1993).
patients with stiff lungs (peak airway pres- 4. While spontaneous breathing draws
sure > 60 cmH2 0) and babies because it ventilation down to dependent lung
limits alveolar distension. regions (p. 7), IPPV reverses this gradient
Inspiration cycles into expiration according because:
to a preset time, pressure, volume or flow. (a) the diaphragm is passive,
Pressure cycling means that if the lungs are (b) positive pressure gas takes the path
stiff or airway resistance high, the machine of least resistance, which is the more
cycles prematurely. open upper region,
Pressure control is different from pressure (c) the lower region is compressed by
cycling. A pressure-controlled breath will not the increased perfusion.
necessarily cycle at a preset pressure, for Dependent areas receive the least
example inspiration might continue until a ventilation and are vulnerable to pro-
preset time. gressive atelectasis.
Alveolar pressure is not equal to that 5. Disturbed ventilation and perfusion
measured at the airway opening, unless there gradients result in VAIQ mismatch,
is zero flow, because of resistance to gas flow which would lead to hypoxaemia if not
in the airways. Alveolar pressure is more offset by the inspiratory pause, supple-
negative during patient triggering and more mental oxygen at a minimum 35% and a
positive during a positive pressure breath. generous minute volume.
6. Dead space increases because of re-
duced overall perfusion, and to a lesser
9.3.4 Effects and complications
extent because of positive pressure dis-
1. An advantage of IPPV is rest for tending tubing and the patient's air-
the inspiratory muscles. This rest is ways.
hindered by, e.g. a narrow ETT, 7. IPPV with overinflation depletes sur-
obstructed airways, stiff lungs, poor factant (Heulitt 1995).
trigger sensitivity or inappropriate set- 8. Positive pressure in the chest impedes
tings so that patient and machine are venous return to the heart, leading to a
not synchronous. Excess workload drop in cardiac output of typically 25%
becomes evident by accessory muscle (Ponte 1990). Compensation is by peri-
activity. The disadvantage of resting the pheral vasoconstriction, which main-
muscles is atrophy, one study showing tains filling pressures to the heart. This
a 50% loss of strength in only 11 days of mechanism may not be viable in
controlled ventilation (Anzueto et al patients who are elderly, hypovolaemic
1987). (either absolutely or implied by peri-
2. Mechanical ventilation allows complete pheral dilatation, e.g. in septic shock),
control of inspired gas and can deliver suffer autonomic neuropathy such as
up to 100% oxygen. Gas exchange also in Guillain-Barre syndrome, or who
depends on mean airway pressure, already have a raised right atrial pres-
which includes the effects of PEEP. sure from capo. These patients may
3. Positive pressure accentuates the perfu- drop their BP, especially when first put
sion gradient from upper to lower on the ventilator. The haemodynamic
regions, leaving the top virtually with- effects can be reduced by a low I:E ratio
out blood flow (Fig. 9.2). It also dis- so that the heart has time to fill on the
places blood away from the thorax and expiratory phase. Patients with stiff
222 Intensive care
Perfusion
gradient
_:::'Alveoli
Ventilation
gradient
Perfusion o o
0
gradient
o
Pressure
from
I abdominal
Ventilation contents
gradient
..
o .......1 - - - - -
lungs suffer less haemodynamic com- pressures, therefore high peak pres-
promise because less of the alveolar sures cause barotrauma'. But because
pressure is transmitted to the pleural the two occur together does not mean
space. that the one causes the other. Alveolar
9. Fluid retention can occur due to stress- overdistension and high FI0 2 levels are
mediated ADH secretion and redistribu- usually present when pressures are
tion of blood flow within the kidneys, high, and it is now thought that excess
leading to an average 40% decrease in oxygen and excess volume cause the
urine output (Pilbeam 1992, p. 223). damage rather than excess pressure
10. Barotrauma is extra-alveolar air which (Heulitt 1995). Most attention has been
occurs in 0.5-20% of patients (Schnapp, given to the excess volume because high
1994). In the past this was thought to be FI 0 2 levels are often unavoidable. The
due to excess pressure, which carne excess volume versus excess pressure
from the reasoning that 'patients with argument is explained by the fact that
barotrauma tend to have high peak coughing (in which pressure increases
Mechanical ventilation 223
60
Before After 9.3.6 Modes
IPPV can do all the work of breathing (WOB)
by controlled mandatory ventilation, or the
O+-~-r--~~ --~-r--~---
work can be shared between ventilator and
patient using a wide variety of ventilatory
60 modes. These modes allow ventilatory sup-
port to be adjusted to the needs of indi-
Figure 9.3 Flow curves representing different viduals, leaving them more comfortable, less
conditions: (a) normal, (b) intrinsic PEEP, sedated and with fewer complications.
showing positive flow at end-exhalation, (c) Ventilatory modes have to be matched
before and after bronchodilator, showing skilfully to the patient because all are less
prolonged and normal expiratory flow. efficient than spontaneous breathing (Shel-
ledy 1995), and while too much support leads
to muscle atrophy, too little overworks the
patient. Most modes allow or require patients
minute ventilation, decreasing I:E ratio or
to trigger breaths. Activating the demand
maintaining patent airways with a pressure
valve to trigger a breath requires effort
support mode of ventilation (Tokioga 1992) or
because valves must have some inbuilt
low levels of extrinsic PEEP. It may seem
insensitivity to prevent artifacts triggering
paradoxical to apply extrinsic PEEP, which inspiration.
conventionally increases lung volume, to a
condition characterized by hyperinflation, but
Controlled mandatory ventilation (CMV)
extrinsic PEEP counterbalances intrinsic
PEEP provided it is comfortable and below Fully controlled ventilation is usually only
the level of intrinsic PEEP (Slutsky 1993). needed for patients who are unable to
Mechanical ventilation 225
(a)
~O Peak airway pressure
:::I N
~I / Plateau pressure
~ E /
0.. 0
0
/
CD
en Time
:::I
Ventilator Insp. ~ Exp. Mean airway pressure
trigger (area under curve)
(b)
l l
SIMV period Spontaneous period SIMV period Spontaneous period
~
:::I
en
en ,I
~
0..
0
I'
Time
~ Ventilator
"" Patient
trigger trigger
(c)
Time
(d)
Spontaneous period Spontaneous period
Time
Figure 9.4 Pressure curves delivered by the ventilator:
(a) controlled mandatory ventilation, (b) SIMV, (c) pressure
support, (d) SIMV with pressure support. A negative deflection
indicates a patient-triggered breath. If PEEP is used, the baseline
would be raised above zero.
breathe at all or for whom complete control is tions is significant. Minute volume is set high
necessary, e.g. to allow a patient to be enough to maintain a mild respiratory alkalosis
paralysed. It is an unforgiving mode which so that spontaneous breathing is inhibited.
dictates the depth and frequency of each
Intermittent mandatory ventilation (IMV)
breath and time-cycles into expiration. If
patients try to breathe, they only receive gas The IMV mode allows patients to breathe
from a relief valve, and sedation is required. spontaneously between a preset number of
Risk of intrinsic PEEP and other complica- mechanical breaths, but without regard for
226 Intensive care
the patient's breathing pattern. This can lead triggered by the patient (Fig.9.4(d». This is
to the stacking of machine breaths on top of less synchronous and less comfortable than
spontaneous breaths, intrinsic PEEP and up pressure support, and if not carefully set can
to double the WOB of a spontaneous breath cause excess WOB (Shelledy 1995) and may
(Tobin 1991). overventilate patients who get a full preset
breath every time they breathe or even
Synchronized intennittent mandatory hiccup.
ventilation (SIMV)
In SIMV mode, the ventilator delivers either a Mandatory minute ventilation (MMV)
patient-triggered spontaneous breath or a
time-triggered mandatory breath. If the patient MMV is a little-used mode in which the vent-
has not taken a spontaneous breath after a set ilator provides a guaranteed preset minute
interval, the mandatory breath is delivered ventilation if the patient's spontaneous breath-
(Fig. 9.4(b». Synchrony with inspiratory ing drops below a preset level. Unlike SIMV,
effort is more comfortable than IMV and assistance is not provided until the patient's
avoids breath stacking. minute ventilation falls below a preset level.
Pressure support is sometimes added to
Pressure support or assist mode ensure adequate tidal volume for patients
Pressure support (PS) is a pressure- with rapid shallow breathing.
controlled, flow-cycled mode which delivers
a preset pressure while allowing patients to Inverse ratio ventilation
determine their own flow, V T , RR and I:E
ratio (Fig. 9.4(c». The preset variables are the For patients with refractory hypoxaemia but
trigger sensitivity and pressure support level. for whom high peak airway pressures are to
PS reduces WOB in proportion to the be avoided, inspiratory time can be pro-
pressure delivered, the patient doing up to longed to the point of reversing the I:E ratio
50% of the work (Pilbeam 1992, p. In), up to 4:1 (Pilbeam 1992, p. 413). Long
which is less than with CPAP (Shelledy inspiration recruits collapsed alveoli, and
1995). Newer machines increase the pressure short expiration aims to prevent recollapse.
if the patient makes more effort. PS is Disadvantages are risk of intrinsic PEEP and
relatively comfortable and ensures synchrony the discomfort of an unnatural breathing
because patients have control of ventilatory pattern, for which extra sedation is required.
timing. It acts like IPPB, but inspiration stops Inverse ratio ventilation is usually used with
according to flow rather than pressure, thus pressure control to reduce the risk of baro-
discouraging the unhelpful expiratory effort trauma for people with ARDS (Armstrong
that can mar IPPB. 1995).
PS is used for patients who can reliably
trigger the ventilator. It is especially useful
Airway pressure release ventilation
for weaning, when 10 cmH2 0 pressure sup-
port counteracts the work imposed by the In this modified form of BiPAP, spontaneous
ventilator circuit. breaths are passively supported by a con-
tinuous flow, with intermittent one to two
SIMV with pressure support or assist-
second releases on expiration so that CO2 is
control
eliminated (Pilbeam 1992, p. 124). The aim is to
This mode provides some minimum mandat- improve oxygenation with lower peak airway
ory breaths, topped up with extra breaths pressures, especially for people with ARDS.
Mechanical ventilation 227
maintains a constant pressure in the lungs vascular volume, and fluid administra-
during the expiratory phase and expiratory tion can therefore compensate, although
pause so that airway pressure does not fall to this may incur pulmonary oedema when
atmospheric pressure at ~nd-expiration. Like PEEP is discontined. Haemodynamic
CPAP, it aims to recruit collapsed alveoli. monitoring is required and PEEP should
PEEP can be used with any mode of be applied in small increments, titrated
ventilation, pressures varying from 3 to over against the improved oxygenation.
20 cmH20. The pressure gauge on the ventil- 2. PEEP increases the risk of barotrauma in
ator shows the pressure returning to the patients who have lung disease, e.g.:
PEEP value instead of zero at end-expiration. (a) hyperinflation conditions such as
For triggered breaths, the machine is set to emphysema (unless carefully control-
cycle into inspiration a few cmH20 below the led PEEP is being used to reduce
PEEP level so that the patient does not have intrinsic PEEP),
to make an inspiratory effort all the way to (b) unilateral pathology, in which PEEP
zero. would cause hyperinflation of the
PEEP is termed 'extrinsic PEEP' when it normal more compliant lung, unless
needs to be distinguished from intrinsic selective ventilation using a double
PEEP. lumen ETT is used.
3. Increased pressure within the chest may
Effects and complications increase CVP and P AWP readings (p.
Extra positive pressure raises the resting lung 234) at the same time as the ventricular
volume out of the range of airway closure, filling pressure that they are supposed to
thus increasing the area available for gas represent is declining because of de-
exchange and improving itA/Q match. At creased venous return.
optimum pressures, surfactant is conserved, 4. High level PEEP may disrupt the
PA-a02 reduced and oxygen saturation alveolar-capillary barrier and redistribute
improved for the same Fr0 2. Pressures of alveolar fluid, leading to pulmonary
10 cmH20 can reduce lung densities, but oedema. Any apparent X-ray improve-
these will reappear within one minute of ment may be due to recruitment of
removing PEEP (Brooks-Brunn 1995). alveoli even though lung water may be
PEEP does not reverse the underlying rising. However, levels of PEEP at or
pathology, and high levels of PEEP are asso- below 10 cmH20 are thought safe and,
ciated with complications that are exaggera- by preventing alveolar collapse, may
tions of the complications of mechanical even protect against ventilator-induced
ventilation, especially the following: damage due to shear stresses generated
by the reopening of collapsed alveoli
1. PEEP impairs venous return to the heart (Parker and Hernandez 1993).
and reduces cardiac output. This can 5. When disconnecting the ventilator circuit
offset the beneficial effects of PEEP by for suction, pressure from PEEP increases
causing a net decrease in oxygen delivery, blow-back, with risks to staff and other
even with improved Sa02. Haemody- patients of cross-contamination from the
namic compromise occurs at > 15 cmH20 spray.
in normovolaemic patients, at lower
pressures in hypovolaemic patients and Best PEEP
at higher pressures in patients with stiff
lungs (Pilbeam 1992, p. 392). Stability of Optimum levels of PEEP normalize oxygen
cardiac output depends partly on intra delivery to the tissues, not just increase
Mechanical ventilation 229
Indications
PEEP promotes oxygenation without toxic
levels of inspired oxygen, and is often used if
more than 50% oxygen is required. Its main
use is for hypoxaemia caused by alveolar
instability. It may also be used to overcome
intrinsic PEEP. Occasionally, differential
ventilation with selective PEEP is used for
Figure 9.5 Effect of PEEP on the relationship atelectasis (Klingstedt et al 1991) and to re-
between regional pressure and volume. duce haemodynamic side-effects (Veddeng
Compliance is greater in the upper part of the 1992).
lung without PEEP. It is greater in the base of
the lung with PEEP. (Source: Nunn (1987), with
permission.) 9.3.9 High-frequency ventilation
How does the Himalayan mountain shrew
oxygen in the blood: normal cardiac output maintain oxygenation during copulation?
with a hypoxaemic patient may be better than With a respiratory rate up to 600/min, its V T is
half the normal cardiac output without less than its dead space, but it manages to
hypoxaemia. Best PEEP is achieved with the achieve the feat of gas exchange by a mechan-
highest value for oxygen delivery or, if tissue ism similar to the intriguing phenomenon of
oxygenation monitoring (p. 236) is not avail- high-frequency ventilation (HFV).
able, a combination of optimum Sa02 and There are three basic methods of this form
cardiac output. A high lung compliance, as of mechanical ventilation:
indicated by the least pressure swing on the
ventilator pressure gauge, is also an indicator 1. High-frequency positive pressure ventil-
because while effective PEEP increases lung ation uses conventional ventilation at
compliance, excessive PEEP decreases it by respiratory rates of 50-100/min.
overdistending alveoli. The effect on oxygen 2. High-frequency jet ventilation directs
delivery is measurable within 15 minutes of short rapid jets of gas from a high-
initiating PEEP (Patel 1993). Figure 9.5 shows pressure nozzle down an EIT or mini-
how best PEEP can improve ventilation to the tracheostomy tube, pulsating gas into the
lung bases. airways and entraining air by the venturi
principle. Expiration is by passive recoil
Precautions and rates of 100-600/min are achieved.
3. High-frequency oscillation (HFO) forces
High levels of PEEP should be avoided in minibursts of gas in and out of the airway
patients with an undrained pneumothorax, so that both inspiration and expiration
avoided if possible with subcutaneous em- are active, thus avoiding the gas trapping
physema, bulla, bronchopleural fistula or that often occurs with passive exhalation
recent pneumonectomy, and used with (Hardinge 1995). This can be super-
caution in patients with damaged or diseased imposed on spontaneous breathing
lungs. (p. 127) or can be the sole method of
Hypovolaemia is a relative contraindica- ventilation. Rates up to 4000/min are
tion, but if PEEP is necessary, measures can achieved.
230 Intensive care
plus several new medically-made ones, in spite anaemia. When the oxygen dissociation
of feeling thankful for all the life-sustaining help curve is shifted to the right, the oximeter
and healing ministrations. shows a slightly low Sa02, and when shifted
Brooks 1990 to the left, a slightly high Sa02' The accuracy
From the patient's point of view, monitors of finger and toe sensors is affected by
bring both anxiety and reassurance. From the movement, and finger sensors are further
staff's point of view, they are useful to record compromised by nicotine stains or varnished
sudden or subtle changes in a patient's nails.
status. They are complementary to clinical
observation and not a substitute. Monitoring Transcutaneous monitoring (Ptc02 and
differs from measuring; it implies regular PtcCO~
observation and a systematic response if a
Oxygen and CO2 diffuse across the skin and
variable falls out of a specified range.
can be measured by a sensor. This is heated
to arterialize capillary blood, but measure-
9.4.1 Gas exchange ments vary with skin metabolism and capil-
Arterial oxygen tension lary blood flow, and are thought to reflect
tissue oxygen tension rather than Pa02' In
Arterial blood samples are taken by intermit- haemodynamically stable patients they there-
tent puncture of the radial artery, using local fore relate to respiratory status, but with
anaesthesia (Gribbin 1993), or more comfort- cardiovascular problems they reflect cardiac
ably by an indwelling arterial catheter. Pa02 output. Skin bums are avoided by rotating
values are subject to spontaneous variability, sites every few hours and incorporating a
and patients should be undisturbed for 30 temperature alarm.
minutes beforehand, stay in the same In neonates, Ptc02 correlates with arterial
position for each measurement and receive oxygenation, but in adults it is hampered by
the same FI 0 2. Arterialized capillary blood varying skin thicknesses and invalid if there
from the earlobe is more comfortable (Dar is poor perfusion, critical illness or if the
1995). sensor is not applied for 20 minutes before
measurement (Durbin 1994). If ideal con-
Arterial oxygen saturation ditions are met, the adult Ptc02 is at least
Oximetry is the physiotherapist's friend. It 10% below Pa02, and PtcC02 is similarly
gives instant feedback on arterial oxygen higher than PaC02.
saturation without trauma to the patient. The
different absorption of light by saturated and Capnography
unsaturated haemoglobin is detected by
the oximeter, which produces a continuous A capnograph provides continuous non-
display of oxygen saturation. Sensors fit invasive assessment of ventilation by mon-
comfortably on the ear, finger, toe or nose. itoring the percentage of CO2 in expired air
Oximetry is acceptably accurate at values (Szaflarski et al 1989). It monitors end-tidal
above 75%. Desaturation is indicated by CO2, which approximates alveolar PC0 2 if
values below 95% in black people, 92% in ventilation and perfusion are well matched,
white people, or a drop of 4% (Durbin 1994). but for patients with lung disease it is not
Being dependent on perfusion, the oximeter dependable (Tobin 1991). Capnography can
is fooled by vasopressor drugs, hypotension, be combined with oximetry to produce a
hypovolaemia, peripheral vascular disease or continuous display of both measurements.
234 Intensive care
35
30
Water manometer
25 measured in centimetres
20
(a)
People with COPD show an increased PAP of misuse of a system whose complications
up to 40 mmHg, which rises during sleep and include thrombosis, sepsis, arrhythmias and
on exercise. (Average values are given in the trauma to the delicate pulmonary vessels
Glossary.) (resulting in blood-stained secretions). Its use
The catheter can then be carried further by is best reserved for haemodynamically un-
the flow of blood until it wedges in a stable patients who are refractory to medical
peripheral branch of the pulmonary vascular treatment after scrupulous clinical assessment.
bed. With the balloon inflated, the catheter Both CVP and PAWP measurements are
tip is isolated from fluctuations on the right limited as a guide to fluid volume because
side of the heart and therefore reflects pul- some vasoconstriction may maintain values
monary venous pressure. So long as there is a despite hypovolaemia, and chronic lung or
continuous column of blood between the heart disease can also invalidate measure-
catheter tip and left atrium, this is assumed to ments. However, the trend is worth observ-
reflect left atrial pressure, measured as pul- ing.
monary artery wedge pressure (PAWP). The An increase in intrathoracic pressure due
balloon acts as a form of pulmonary embol- to IPPV, especially with PEEP, will raise both
ism, so is deflated between measurements to RAP and LAP values, but the common
reduce ischaemic damage. practice of discontinuing ventilation for
A high P AWP implies fluid overload, measurement is unnecessary and can cause
20 mmHg marking the onset of pulmonary persistent hypoxaemia (Schwartz 1987).
congestion and 25 mmHg being associated Readings are best taken at end-expiration.
with radiological evidence of pulmonary
oedema. The continuous column of blood in
the pulmonary vasculature is tenuous if the 9.4.3 Tissue oxygenation
catheter is in the upper zone of the lungs or if Outcome measures for bus journeys are more
the patient is severely hypovolaemic, has relevant taken at their destination than when
COPO or requires high lung inflation pres- the bus leaves the garage. Similarly, oxygen
sures, especially with PEEP. Therefore, the in the tissues is more relevant than oxygen in
more ill the patient, the less accurate are the blood.
single measurements, but the trend is still
relevant. Mixed venous oxygenation
PAWP reflects pressures in the lung vascu-
lature, left atrium and left ventricle, and is Oxygen delivery to the tissues is affected by
used as a guide to left heart function and many factors, such as fever, sepsis, pain and
blood volume. It shows changes earlier than physiotherapy. Oxygen levels in the pulmon-
CVP and gives a more accurate indication of ary artery measure the extent to which
fluid status because it is affected by fewer oxygen supply meets demand, indicating
variables. This allows fine tuning when estab- both the haemodynamic and gas exchange
lishing optimum PEEP, helps to rationalize components of oxygenation.
fluid and drug therapy and distinguishes Mixed venous blood in the pulmonary
between hypovolaemia (t P AWP) and left artery comprises venous blood from all body
ventricular failure (i PAWP) because hypo- tissues which has been thoroughly mixed in
volaemia can coexist with peripheral oedema. the right heart. The oxygen and CO2 in this
PAWP is also known as pulmonary capil- pooled blood reflect events anywhere in the
lary wedge pressure (PCWP) or simply respiratory chain from lung to mitochondria.
wedge pressure. The glamour of this expens- This measurement is especially useful in
ive monitoring system has led at times to identifying problems at tissue perfusion and
Monitoring 237
extraction level, beyond the reach of arterial loon into the stomach to measure the muco-
blood gas measurements. sal pH. Acidosis indicates hypoperfusion and
Mixed venous blood provides information ischaemia, which if not corrected may lead to
on mixed venous oxygen saturation (SV02), multisystem failure (Chang 1994).
monitored continuously from the pulmonary
artery catheter, or mixed venous oxygen
9.4.4 Cardiac output (CO)
tension (PV02), measured intermittently in
blood drawn from the catheter. Accurate CO measurements require the
A low SV02 reflects decreased oxygen patient to be in a steady state. If a pulmonary
delivery or increased demand. It· drops with artery catheter is in situ, CO is measured by
hypoxaemia, anaemia, low cardiac output, the thermodilution technique, in which a
haemorrhage or when oxygen consumption bolus of cold liquid is injected into the
rises with activity, pain, fever, anxiety, agi- pulmonary artery catheter and escapes
tation, laboured breathing or hypermetabolic through a hole into the right atrium. The
states. Values below 40% are usually asso- speed of its dispersal is then measured and
ciated with anaerobic metabolism. SV02 rises CO calculated by computer. CO can also be
with a high Fr0 2 or if the patient is paralysed assessed non-invasively through measuring
or sedated. Excessively high values above aortic blood flow by Doppler and a host of
85% indicate that tissues are too damaged to other techniques (Harrington 1993).
extract sufficient oxygen, e.g. in severe Cardiac output usually reflects BP, but they
sepsis, ARDS, acute pancreatitis or extensive do not always change in the same direction.
bums. If the myocardium is poorly contractile,
An advantage of this measurement is that peripheral vasoconstriction may t BP and ~
it indicates changes before BP, heart rate or CO, and vasodilation may ~ BP and t CO.
PAWP. A disadvantage is that it does not
pinpoint which of the variables is responsible 9.4.5 Overview of electrocardiography
for the change. It acts more as an early (ECG)
warning system to advise on further investig-
ation. Cardiac output should be simul- Disturbances such as hypoxia, physiotherapy
taneously monitored so that it can be treatment, electrolyte imbalance, myocardial
distinguished from other variables. ischaemia or anXiety can cause disorders of
During physiotherapy, if SV02 varies by heart rate or rhythm; some are transient but
> 10% from the baseline for more than three others are significant because of their effect
minutes, or for more than 10 minutes follow- on cardiac output. These are picked up on the
ing position change, treatment should be ECG, which is a recording of electrical
stopped (Hayden 1993). If it has not re- activity in the heart (Fig. 9.7).
covered three minutes after suctioning, Sinus tachycardia is a heart rate (HR) over
increased oxygenation is required. 100 bpm with normal rhythm. Sinus brady-
cardia is an HR under 60 bpm with normal
Gastric tonometry rhythm.
Supraventricular arrhythmias originate
Hypoxia or 20% hypovolaemia causes a 60% from above or in the atrioventricular (AV)
reduction in gastric blood flow (Ricour 1989). node, and are known as atrial and nodal
The gut is one of the first organs to be arrhythmias respectively. Ventricular arrhyth-
affected by poor perfusion and provides early mias originate from the ventricle.
warning of whole-body tissue hypoxia. Gastric Supraventricular tachycardia is recognized
tonometry entails passing a saline-filled bal- by a rapid rate, regular rhythm and normal
238 Intensive care
~--.
absent P wave, a wide and wayward QRS
complex and inverted T wave. They occur
following heart surgery or myocardial
infarction, and in smokers, and are associ-
ated with hypoxia or low potassium.
I .
Bigeminy means that every other beat is
------~----- --·a+------+--~~~
ectopic and trigeminy means that every third
s ---" ..-1----+ - -------j beat is ectopic.
'. Atrial fibrillation (AF) is the commonest
Figure 9.7 Normal ECG trace of one heart beat. arrhythmia, affecting 5% of people over 60
P = atrial depolarization, PR = atrioventricular years (Rowland 1994). It occurs when ectopic
conduction time, Q = ventricular depolarization,
foci throughout the atria discharge too fast
R = first positive deflection during ventricular
depolarization, 5 = first negative deflection
for the atrial muscle to respond other than by
during ventricular depolarization, QRS interval disorganized twitching. It appears as a rapid
= total ventricular depolarization, T = rate of up to 200 bpm, irregular rhythm and
ventricular repolarization (recovery period). the replacing of P waves with a fibrilla tory
baseline. It has a variety of causes including
increased sympathetic tone, hypoxaemia,
QRS complex. It is caused by excess drugs or hypokalaemia, over- or underhydration,
sympathetic activity and can reduce cardiac myocardial ischaemia, heart failure or heart
output. Ventricular tachycardia is distin- surgery. It causes fatigue, predisposes to
guished from supraventricular tachycardia by thrombosis and may reduce cardiac output.
its irregularity, lost P wave, and broad and Atrial flutter is similar to AF but is less
bizarre QRS complex. It can reduce cardiac common, and fires at a lower rate of dis-
output, BP and tissue perfusion, and lead to charge, causing regular saw-tooth undula-
ventricular fibrillation. tions on the ECG.
Sinus rhythm is normal rhythm, activity Ventricular fibrillation (VF) is total break-
being controlled by the sinus node. Nodal down of ordered electrical activity, causing
rhythm is abnormal and occurs when the AV an ineffectual quivering of the ventricles and
node takes over from a non-functioning sinus appearing as a chaotic line. There is no
node, resulting in lost P waves and a variable cardiac output and cardiac arrest ensues. A
or absent PR interval. Cardiac output remains similar disorganized trace may also appear,
stable unless HR is severely affected. but harmlessly, during percussion and
Ectopic beats are premature beats followed vibrations to the chest or if the electrodes fall
by a compensatory pause, sometimes felt as off the patient. Asystole is ventricular stand-
missed heart beats by the patient. They are still and also leads to cardiac arrest. It shows
common and do not contraindicate physio- as a straight line with occasional minor
therapy unless they increase in number or fl uctua tions.
cause haemodynamic disturbance, but they Heart block is caused by delayed or
may signal the onset of serious arrhythmias. blocked conduction between P wave atria
Atrial ectopics manifest as occasional abnor- and ventricles, shown as a disrupted relation-
mal P waves or an early normal beat, and are ship between P wave and QRS complex.
Support 239
Causes are hypoxia, myocardial infarction, their stay (Lowell 1990). The causes of mal-
digoxin therapy, heart disease or complica- nutrition are:
tions after heart surgery. First or 2nd degree
• increased catabolism, as shown by a study
heart block is suspected if there is a long PR
on starvation in which septic, trauma-
interval or several P waves prior to each QRS
tized or burned patients lost up to 200%
complex. Third degree heart block is indi-
more protein daily than healthy people
cated by an absent PR interval and abnormal
(Schlichtig and Sargent 1990),
QRS complex. This may reduce cardiac out-
• pre-existing nutritional deficit,
put and lead to asystole.
• inadequate feeding in an attempt to limit
weight gain following fluid overload
9.5 SUPPORT during surgery (Lowell 1990),
• lack of recognition of a process as un-
9.5.1 Pacing dramatic as starvation,
• lack of hunger, ability to express hunger or
An artificial pacemaker is used to deliver an
capacity to eat normally.
electrical stimulus to the myocardium when
the conducting pathways are damaged. For The effects of malnutrition are muscle
temporary use, pacing wires connect the wasting, difficult weaning, impaired healing,
patient's myocardium to an external pacing atelectasis, pulmonary oedema (Pilbeam,
box. For permanent support, the energy 1992, p. 261), increased risk of oxygen toxicity
source is implanted under the skin. Indica- (Durbin 1993) and the effects described on
tions are 3rd degree heart block, arrhythmias p.98.
refractory to medication and prophylactic The key is to provide early nutritional
support in the first days after heart surgery. support in order to prevent rather than
External wires on a patient's chest post- correct tissue breakdown. If patients are able,
operatively are common and not a contra- they should sit out of bed and eat at normal
indication to mobilization, so long as the times. If patients cannot swallow, they
cardiovascular system is stable. should have nasogastric or enterostomy
An implantable cardioverter defibrillator feeds, and those with gut dysfunction should
may be implanted into patients at risk of VF be fed intravenously. Intravenous (IV) feeds
that cannot be suppressed with drugs (Col- are hypertonic in order to provide sufficient
lins 1994). calories, and central venous access is re-
quired to allow for its rapid dilution with
blood to avoid vessel damage.
9.5.2 Nutrition
Disadvantages of IV feeding are infection
The oft-quoted comparison between the risk (Koretz 1995) and loss of integrity of the
nutritional status of prisoners of war and leu gut lining. The gut has long been considered
patients is a myth that comes perilously close dormant in critical illness, but is now known
to the truth at times. Physiotherapists com- to be metabolically active and a protective
monly watch their patients waste away on barrier against gut pathogens. IV feeding or
the empty calories of a dextrose infusion starvation can worsen the damage caused by
while they are struggling uphill to maintain gut ischaemia, leading to breakdown of the
the physical condition of lungs and limbs. mucosal barrier and liberation of micro-
Critical illness can double or treble the organisms into the portal circulation to wreak
metabolic rate, while at the same time reduc- havoc in the rest of the body. The gut is now
ing the body's adaptive response, leading to thought to be the 'motor' of multisystem
some patients being malnourished for 85% of failure (Johnston 1993). It is recommended
240 Intensive care
that some postoperative patients start enteral circulating volume should be ensured before
feeding in the recovery room, using small other forms of support are considered (Arm-
bowel access if there is paralytic ileus strong et al 1991). The detrimental effects of
(Babineau 1994). physiotherapy, especially suctioning, are less
The ability to meet the nutritional require- marked in a well-filled patient (Schwartz
ments of critically ill patients may be hindered 1987).
by fluid restriction, impaired renal function, Intravascular fluids are relevant to circulat-
gut problems or glucose intolerance. Remed- ory function whereas interstitial and intra-
ial measures include diuresis or haemofiltra- cellular fluids are not. Colloids are thick
tion to prevent fluid overload and early fluids such as plasma and albumin. Trans-
dialysis for kidney problems. fused colloid stays in the intravascular com-
Rapid administration of high calorie (espe- partment and affects osmotic pressure and
cially high carbohydrate) feeds can increase circulatory function (Golster 1995). Crystal-
CO2 production by 40% due to oxidation of loids are thin fluids, such as dextrose and
glucose (Schlichtig and Sargent 1990). For saline. Seventy-five percent of transfused
patients with marginal respiratory reserve, crystalloid is rapidly lost from the plasma
this can precipitate respiratory failure (Armstrong et al 1991), so that crystalloid
(Liposky 1994). Slow administration of high- transfusion has less effect on intravascular
fat, low-glucose feeds is necessary for volume or circulation and excess transfusion
patients with hypercapnic COPD, especially may lead to pulmonary oedema from the
during weaning, and the omnipresent dex- escaping fluid.
trose infusion must be taken into account.
9.5.4 Drugs
9.5.3 Fluids Critically ill people often respond abnormally
Preload is the filling pressure in the ventricle to drugs because of liver hypoxia, stress and
at end-diastole, which stretches the myocar- circulatory or renal impairment (Park 1994).
dium and assists contraction. It is determined They are also subject to complex interactions
by venous return and blood volume. It is of multiple medication. Many intensive care
increased in heart failure or fluid overload, drugs have a narrow window between effect-
and decreased in hypovolaemic shock or ive and toxic doses, and infusion pumps help
dehydration. Left preload is monitored by the titration of dosage to patient response.
P AWP and right preload by CVP.
Cardiovascular drugs
Afterload is the amount of pressure against
which the ventricle must work during The intimate relationship between heart
systole, as if opening the door against function, vascular tone and fluid volume can
a wind. It is increased with systemid be manipulated by medication to achieve
pulmonary hypertension, peripheral vaso- optimum tissue oxygenation. Many patients
constriction or aortidpulmonary valve dis- need a combination of increased CO, reduced
ease, and decreased in septic or neurogenic myocardial oxygen demand and redistribu-
shock. Left afterload is monitored by systolic tion of flow to vital organs.
BP and right afterload by pulmonary artery Diuretics reduce blood volume and pre-
pressure. load, and are used to treat hypertension,
Fluids are closely associated with cardio- heart failure and pulmonary oedema. When
vascular function. Critically ill people need a mobilizing a patient who is taking diuretics,
greater than normal blood volume to main- a wary eye should be kept for signs of
tain circulatory function, and an adequate hypotension.
Support 241
Vasodilators, such as the nitrates, reduce pranolol may induce bronchospasm, but this
systemic vascular resistance and are pre- risk is reduced with the more cardioselective
scribed for hypertension, heart failure and drugs, such as atenolol. Other side-effects are
angina. Side-effects include postural hypo- fatigue and the blunting of cardiac exercise
tension. responses. Beta-blockers should never be
Inotropes assist a failing heart by augment- given to patients on betaTstimulants because
ing the force of cardiac contraction. Natural of their mutual antagonism.
inotropic influences include the patient's own
adrenaline and noradrenaline. Before giving Sedation
inotropic drugs, the fluid status of the patient
should be sufficient to ensure that the drugs Sedation is required for most patients on
do not stimulate an empty heart. Dopamine IPPV, but should not be used as the first line
is an inotropic drug which at low doses treatment of anxiety. Drugs that cloud con-
increases renal perfusion (possibly due to t sciousness cause delusions if anxiety stems
CO), at medium doses increases CO directly, from patients' realistic perceptions of their
and at high doses causes unwanted vasocon- situation, and they are no substitute for the
striction. Dobutamine has a greater effect on primary task of explanations and relief of
oxygen delivery and does not cause vasocon- discomfort. Commonly prescribed anxiolytics
striction. Dopexamine combines the renal are midazolam and propofol, which reduce
effects of dopamine with the haemodynamic oxygen consumption but cause the side-
effects of dobutamine. effects of respiratory depression, loss of time
These inotropic agents are used for circu- sense and misinterpretation of voices and
latory failure and to offset the depressant noises, which can paradoxically increase
effects of PEEP on cardiac and renal function. anxiety.
They do so at the expense of increasing
myocardial oxygen requirements, and in Analgesia
patients with tachycardia, may actually Treatment for pain, anxiety and insomnia is
decrease oxygen delivery and cause myo- often interwoven. The pain component
cardial ischaemia. They are therefore only should be easily managed in mechanically
used after regulation of fluid, diuretic and ventilated people because respiratory de-
vasodilator therapy. pression is not a problem. Prior to physio-
Digoxin is a cardiac glycoside with mild therapy treatment, a bolus of intravenous
inotropic effects that has been in and out of analgesia is often indicated, using a short-
fashion for two centuries. It helps control acting drug, such as fentanyl or alfentanyl.
arrhythmias by strengthening and slowing Entonox can be administered by a doctor or
the HR, but tends to cause arrhythmias if respiratory technician through the ventilator
there is hypoxia. before and during treatment, but the initi-
A combination of vasodilator and inotropic ative for this must come from the physio-
medication is often used. Inolators are com- therapiSt.
bined vasodilators and inotropes which are
still in the experimental stage. Paralysis
Beta-blockers are 'negative inotropes'
which inhibit sympathetic action, block the I couldn't turn or change position. And even
action of adrenaline and related hormones though it may have been only an hour, it seemed
and slow the HR, reduce cardiac work and like a week to me . . . someone would come near
relieve hypertension, angina and arrhythmias. me and would just be working and not saying
Non-selective beta-blockers such as pro- anything to me. That would be frightening
242 Intensive care
because I didn't know what they were going to aerosolized drugs is variable and should be
do next. monitored, e.g. by ~ wheeze on auscul-
Parker et al1984 tation, ~ peak airway pressure, a normalized
flow curve (Fig. 9.3) or ~ intrinsic PEEP
Muscle relaxants such as pancuronium, atra-
(Wollam 1994).
curium or vecuronium are given to patients
An MOl with spacer delivers a greater dose
on IPPV in order to induce paralysis and
than a nebulizer and is quicker and cheaper
prevent resistance to ventilation. These neuro-
(Hess 1994). Nebulizers interfere with patient-
muscular blocking agents are used when it is
triggered breaths and ventilator settings, so
detrimental to allow patients to move, e.g.
the ventilator should be put on a non-assisted
after acute head injury, or to reduce oxygen
mode (Pilbeam 1992, p. 311), with reduced
consumption in severely-hypoxic patients.
flow and respiratory rates to maximize inspir-
Paralysing agents should not be used to keep
atory time for aerosol deposition (Manthous
a patient quiet. They act as a form of chemical
1994). It is placed at the Y-connector (Hess
restraint, and this can feel frightening for
1994).
patients if they are not told that they are
The MDI is also placed at the Y-connector
being given a drug that will make them feel
and either fired immediately after the begin-
weak.
ning of a mechanical breath or manually
The induction of weakness, not paralysis,
ventilated through the spacer just before
is sufficient to prevent patient-ventilator
inspiration using slow deep breaths, a breath
asynchrony (Marino 1995). The drugs must
hold and a one minute gap between actu-
be accompanied by sedation and, if appropri-
ations if this is not contraindicated (Hess
ate, analgesia, because they obliterate the
1994). Dry powder inhalers cannot be used in
only means by which patients can indicate
ventilator circuits.
discomfort. Patients feel, hear and think
A humidifier increases particle size of
normally, but it is easy to forget that they are
either MOl or nebulizer, and decreases aero-
conscious and need regular explanations and
sol delivery by 40-50% (Hess 1994), so it
orientation. Extra care must also be taken to
should be removed during administration.
prevent ventilator disconnection. Prolonged
administration sometimes leads to persistant
9.5.5 Advanced cardiac support
myopathy after cessation of the drug (Bel-
lomo 1994), especially in patients taking For patients in profound heart failure,
steroids or in renal failure. mechanical assistance can be provided tem-
porarily by an intra-aortic balloon pump
Drugs for airflow obstruction (Underwood 1993). The pump, housed in a
console, is connected to a catheter with a
Airflow obstruction raises airway pressure
deflated balloon at its tip. This is threaded
and increases the risk of barotrauma and
through the patient's femoral artery and into
haemodynamic disturbance. Bronchodilators
the aorta (Fig. 9.8), where it is triggered by
or steroids may be required, especially
the patient's EeG into the following cycle:
during weaning, and can be delivered to
ventilated patients by metered dose inhaler 1. Diastole causes balloon inflation, which
or small-volume nebulizer. Half the drug is assists aortic valve closure and displaces
lost in the endotracheal tube (Kacmarek and blood to augment perfusion of the myo-
Hess, 1991), but a spacer compensates for cardium, brain and kidneys.
this, whether using an inhaler or nebulizer 2. Systole deflates the balloon, which de-
(Harvey 1995). The spacer is removed from creases afterload and allows the ventricle
the circuit when not in use. The effect of to empty more completely.
Support 243
!
support, assistance is reduced gradually from
every beat (1:1) to every 4th beat (1:4).
Implications for physiotherapy are the fol-
lowing:
1. The augmented BP should be watched
because this is what the patient receives.
2. Hip flexion should be avoided at the
insertion site.
3. Patients are often too unstable to turn,
but if turning is indicated, care is
required to avoid disconnection of the
catheter.
Systole
4. If bag-squeezing is necessary, it should
be performed with caution because pres-
sure may compromise the function of the
balloon and destabilize cardiac output.
5. Percussion is unwise because of interfer-
ence with the ECG, and mechanical
percussors and vibrators are contra-
indicated. If vibrations are needed, one
supporting hand under the patient min-
imizes unnecessary movement.
6. To reduce the risk of bleeding, coughing
should be avoided for some hours after
the device has been removed.
The ventricular assist device is a supple-
Figure 9.8 Intra-aortic balloon pump. An mentary pump that assists a failing heart,
external balloon indicates the inflation or and is mainly used as a bridge while awaiting
deflation of the intra-aortic balloon. (From heart transplantation (Seche 1992).
Collier, P.5. and Dohoo, P.J. (1980) The intra-
aortic balloon pump. Physiotherapy, 66, 156-7,
9.5.6 Advanced pulmonary support
with permission.)
IPPV rests the respiratory muscles but does
The effect is like a mechanical form of not rest the lung itself, which is still being
combined inotropic and vasodilator therapy, intermittently stretched and released. Ventil-
increasing myocardial perfusion and reduc- ator pressures can be reduced by augmenting
ing the workload of the heart. Complications gas exchange using intravascular oxygenation
244 Intensive care
I
I
perfused, for example they have low cardiac position a pleural effusion loses its clear
output or are in shock. boundary and the fluid line is replaced by a
Fluid status may be measured by the daily faint smooth density throughout the lung.
weight, any change of more than 250 g/day The boundary between air and lung may be
representating fluid gain or loss (Parker and lost when there is a pneumothorax, which
Middleton 1993). The fluid balance chart can shows up more clearly on a CT scan.
be affected by a multitude of factors such as The tracheal tube should reach to just
drug therapy, IPPV, PEEP or postoperative above the carina. If it is too long, the right
fluid changes. Electrolyte and haematocrit main bronchus will be intubated, leaving the
values are decreased with fluid excess and left lung unventilated. If it is too short, the
increased with fluid loss. The signs of hypo- patient's head should be moved as little as
volaemia are: possible so that the tube is not dislodged.
• pallor
• t HR
• t respiratory rate 10.2.3 Monitors
• ~ vascular pressures (CVP, PAWP)
Monitoring of oxygenation is particularly
• ~ systolic BP
• ~ pulse pressure important because physiotherapy can increase
• ~ urine output oxygen consumption by over 50% (Weiss-
man and Kemper 1991). 5a02 has extra
Urine output is also depressed by low
significance in patients with cardiac in-
cardiac output because of the kidneys' sensit-
stability because hypoxaemia can precipitate
ivity to hypoperfusion. Hypovolaemia
reduces pulse pressure (see Glossary) arrhythmias. If the 5a02 falls during treat-
because the body compensates by vasocon- ment, e.g. below 90%, the F10 2 should be
striction, which assists venous return and increased and/or treatment halted. 5,,02 can
helps maintain diastolic pressure, so that in be used to monitor the effect of procedures
the early stages, systolic pressure drops such as suction, which reduces oxygen sup-
faster than diastolic pressure. ply, or position change, which increases
Blood test results may indicate a low oxygen demand.
platelet count or long prothrombin time (see Changes in BP and HR can reflect factors as
Glossary), which act as a warning to use diverse as septicaemia, pain, drugs or fluid
suction with care because of the risk of status. Monitors should be observed during
bleeding. Low serum albumen is associated treatment in order to identify responses re-
with reduced surfactant and a drop in os- lating to physiotherapy. BP usually relates to
motic pressure, leading sometimes to peri- cardiac output, which is a major determinant
pheral and pulmonary oedema. Potassium of oxygen delivery. Systolic pressures as low
levels below 4 mmolll predispose patients to as 80 mmHg are adequate so long as the
arrhythmias, so most forms of treatment are patient is warm and passing sufficient urine.
contraindicated. However, overvigorous physiotherapy can
The overall trend in BP should be checked reduce cardiac output by 50% in critically ill
for any response to previous sessions of bag- patients (Laws and McIntyre 1969).
squeezing. Although 78% of patients exhibit arrhyth-
mias spontaneously (Artucio and Pereira
10.2.2 Chest X-ray
1990), the ECG should be watched during
Portable radiographs in the ICU are taken physiotherapy to check for changes related to
with the patient supine or slumped. In this treatment.
248 Physiotherapy in intensive care
oQ) o
Q)
~ ~
o o
~ ~
u::: u:::
0 0
Q) Q)
~ ~
0 0
~ ~
0 0
u::: u:::
-1 -1
+0.5 0 +0.6 0
Volume, I Volume, I
(b) 1-
0
0 0
Q) Q)
~ ~
0 0
~ ~
0 0
u::: u:::
-1 -1
+0.5 0 +0.5 0
Volume, I Volume, I
CJ CJ
0 0
Q) Q)
~ ~
0 0
~ ~
0 0
u::: u:::
-1 -1
+0.5 0 +0.5 0
Volume, I Volume, I
either can't or don't want to listen' like to regain their day/night rhythm by
(Holden 1980). Understanding and being woken in the day or having a
memory may be affected by anxiety or sleeping pill at night. Autonomy is par-
drugs, but patients who are unable to ticularly important in a situation of
speak are neither deaf nor mentally unequal power and knowledge.
impaired. They need: 3. ICU patients are extra sensitive to human
(a) clear and explicit explanations, re- physical contact as a contrast to the cold
peated as necessary, clinical procedures to which they are
(b) hearing aid or glasses if used, frequently subjected. One patient said,
(c) information on why physiotherapy 'the most important thing for me was
is necessary, what it will feel like, the human contact, the communication'
how long it will last and instructions (Villaire 1995). Another said, 'it surprised
on how to ask for it to stop, me how much I valued human touch'
(d) if unable to speak, and lip-reading (Redfern 1985). Foot massage is access-
proves inadequate, communication ible for the ICU patient and has been
aids, such as word or picture cards, shown to reduce tension and lower the
pencil and paper or, for greater respiratory rate (Stevensen 1994). The
privacy, a magic slate, benefits of even brief massage can be
(e) if unable to write, yes-or-no ques- confirmed by watching the monitors. As
tions asked one at a time: always, it should be remembered that
individuals vary and some dislike touch.
'Are you hot? cold? itchy? wor-
4. Measures to alleviate physical discomfort
ried? tired? sleepy? nauseous? in
include regular turning (before the allot-
pain? Is your ear twisted against
ted time if the patient requests), minimal
the pillow? your mouth dry? the
use of restraints, cream for dry lips,
tube bothering you? Do you want
double taping all tape to protect the skin,
to tum? raise/lower your head?
and smoothing out all creases from
Do you need more air? less light?
the sheet after treatment. For immobile
less noise? more information? bot-
patients, creases feel like a knife after a
tle or bedpan?'
brief period.
Vigilance ensures that communication 5. Orientation is helped by the presence of
is aimed at patients, not over them. personal belongings in an area that the
Chatting over patients has been shown to patient can control, a visible clock and
increase stress more than suction (Lynch calendar, family photographs, infor-
1978). One patient said, 'it didn't matter mation on progress, interpretation of
what they talked about, so long as they noises and voices, attendance to alarms
talked to me' (Villaire 1995). If a patient promptly, avoidance of disagreements
wishes not to communicate, this should over the patient, patient-controlled radio
also be respected. and TV, and trips outside the unit when
2. The more helpless patients are, the more possible.
important it is that they be given a 6. Expression of emotion is best accepted,
measure of control. They can choose even encouraged, and reduces the
which side to finish on, whether they depression that is common in ICU
would like treatment now or later (if patients.
possible), whether the bed head is the 7. Praise is a potent motivator and enhances
right height, and whether they would a patient's self-esteem.
Handling patients who are critically ill 251
• adequate vitamin C and protein intake ventilator support if the patient walks more
(Barratt 1989). than a few steps from the ventilator. Walk-
ing should be brief because fatigue drains
Pressure sores can be prevented by a
motivation.
fluidized (Clinitron) bed. This looks like
The patient needs to spend some time
boiling milk, and consists of a miriad of beads
sitting with the legs dangling over the edge
floating in a current of warm air which
of the bed before standing. Patient and
supports the patient happily like a semi-
monitors should be scrutinized when he or
submerged iceberg. Turning is done with a
she is upright. For patients unable to stand,
sheet. The air compressor is switched off
sitting out two or three times a day helps
when the patient is side-lying so that the
prevent hypovolaemia (Wenger 1982). A tilt
beads mould to the body like sand. Points to
table is useful.
note are that:
Long-term patients are excited at the pros-
• good teamwork is needed to ensure regular pect of their much-awaited first expedition
turning for preventive respiratory care, out of bed, and some are then disillusioned
because turning is no longer required for by the extent of their weakness and fatigue.
pressure area care, This is when they most need encouragement.
• the dry air current may contribute to A visit outside is rewarding, especially if the
dehydration, ICU has no windows; lack of outside
• the bed should be switched off and un- windows has been shown to double the
plugged for cardiopulmonary resuscita- incidence of delirium (MacKellaig 1990).
tion. Patients confined to bed need active or
passive exercises to maintain sensory input,
A sacral pressure sore that has developed
comfort, joint mobility and muscle strength.
in supine does not preclude sitting out
Special attention should be given to the
in a chair, so long as an upright position
Achilles tendon, hip joint, joints around the
is maintained to prevent pressure on the
shoulder, two-joint muscles and, for long-
sacrum.
term patients, the jaw and spine. The longer
a patient is immobilized, the more time is
10.5 TECHNIQUES TO INCREASE needed for exercise. An overhead bar
LUNG VOLUME provides some independence.
In spontaneously breathing patients, lung Passive movements should be performed
volume can be increased by the techniques with caution for paralysed people, whose
discussed in Chapter 5. For ventilated joints are unprotected by muscle tone. Vigor-
patients, the following can be used. ous active exercise should be avoided for
patients who are (I) on inotropic support
because they have limited cardiovascular
10.5.1 Exercise
reserve, and (2) on CMV because they are
Bed exercises, even when strenuous, are unable to increase their minute volume.
unable to prevent de conditioning (Sandler Patients with fractures, burns or altered
1988). An attempt should be made to stand muscle tone need input from specialist col-
and walk all patients for whom there is leagues.
no contraindication such as cardiovascular
instability, fracture or paralysis. Attachment
10.5.2 Positioning
to a ventilator does not preclude getting out
of bed, but solicitous attention to lines and There nuzy be a fine irony in the observation that
tubes is required. A rebreathing bag provides our advanced knowledge and technology by
Techniques to increase lung volume 253
themselves cannot save the patient. Instead, Manual hyperinflation (or bag-squeezing or
something so simple as turning the patient from bagging) is a technique that delivers extra
supine to lateral to prone to lateral, at least volume and oxygen to the patient via an
hourly, may make the difference between living anaesthetic bag. Compared with positioning,
and dying for the intensive care patient. which is accepted for the prophylactic respir-
Bendixen quoted by Ray 1974 atory care of most ICU patients, bag-
squeezing is not used routinely. Disadvant-
Positioning is the main treatment for patients ages are the following:
in intensive care, and may be the only
treatment for an unstable patient. By pre- • prophylactic effectiveness has not been
venting the abdominal contents encroaching substantiated,
on lung volume (p. 110), positioning restores • it can be uncomfortable and frightening if
ventilation to dependent lung regions more done incorrectly,
effectively than PEEP or large tidal volumes • haemodynamic and metabolic side-effects
(Froese and Bryan 1974). are common.
Supine is the least helpful position for lung However, bag-squeezing has been shown
function. For ventilated patients, the lateral to open up atelectatic lung (Nunn 1987,
position increases FRC (Ibanez et a11981) and p. 33) and reverse deterioration in gas ex-
enhances gas exchange (Lewandowski 1992) change and compliance (Novak et aI1987). It
compared with supine. The prone posi- also assists in mobilizing secretions.
tion is useful for some severely hypoxaemic
patients (see p. 284). Terminology
Studies using rotating beds show mixed
outcomes, which may reflect the limited side- • Manual inflation or manual ventilation
lying position they achieve, i.e. patients may refers to the squeezing of gas into the
not be positioned forwards enough to free lungs at tidal volume, e.g. when chang-
the diaphragm from abdominal compression. ing ventilator tubing,
During positioning, transient changes in • manual hyperventilation is when a high
HR and 5V02 are acceptable, but if HR flow rate of gas is used in order to supply
increases or decreases by over 10 bpm, or rapid breaths, e.g. if the patient is
5V02 drops more than 10% from baseline, breathless or hypoxaemic,
the patient should be returned gently to • manual hyperinflation is when the patient
supine (Winslow et al 1990). Factors which is given deep breaths, usually 50%
modify positioning are head trauma, abnor- greater than a ventilator breath, in order
mal muscle tone, pain, spinal cord injury, to increase lung volume, e.g. when
fractures, pressure sores and an unstable BP. treating atelectasis.
As with spontaneously-breathing patients,
ventilated patients with unilateral lung patho- Physiotherapy is usually related specifi-
cally to manual hyperinflation.
logy show optimum gas exchange when
lying with the affected lung uppermost
(Rivara 1984). Technique
100
this is less successful than using an angled
(coude-tipped) catheter with the tip directed
to the left. Some angled catheters have a
guideline to indicate the direction of the
tip. For physiotherapy purposes, a straight
catheter is usually sufficient because secre-
tions have already been brought proximally.
100
Technique
1s Time- Catheter size should be nO more than half the
internal diameter of the tracheal tube. A size
Figure 10.3 Airflow during manual 12 catheter is normally used, but size 14 is
hyperinflation and vibrations. (Source: MacLean, acceptable with large tubes. Aseptic tech-
D., Drummond, G., Macpherson, C. et al. (1989) nique should be pristine. Violations such as
Maximum expiratory airflow during chest
touching the edge of the tracheal tube open-
physiotherapy on ventilated patients before and
after the application of an abdominal binder. Int. ing with an ungloved hand or catheter are
Care Med., 15, 396-9, with permission from the taboo.
copyright holder, Springer-Verlag.) Vibrations are unnecessary during suction
because enforced coughing overrides outside
influences, unless the patient is paralysed.
et al 1990), decreases oxygen supply, causes
Bagging should be stopped before opening
haemodynamic disturbance and may re-
the system for suction in order to prevent
peatedly flood the lungs with bacteria which
blow-back of possibly infected aerosol from
adhere to the inside of the EIT (Sottile 1986).
Suction should be carried out when indi- the patient.
cated, not routinely (Judson 1994). If more than one suction pass is necessary,
Indications, contraindications and technique this should wait until 5a02 returns to base-
for nasopharyngeal suction are described in line levels. Returning the patient to the
Chapter 5. Modifications for tracheal tube ventilator at normal settings between suction
suction are described below. passes is not adequate to prevent de-
saturation (Baun 1984), and other measures
Preliminaries should be used to prevent hypoxaemia (see
below). The same catheter should not be
For patients with cardiovascular instability, used for repeated suction because of the
administration of a narcotic analgesic before bacteria-ridden inner surface of the EIT
suction can attenuate haemodynamic disturb- (Sottile 1986) The patient's mouth often needs
ance (Klein et al 1988). Patients are advised suction afterwards with the rinsed catheter or
that they will feel more in control if they let a yankauer sucker. Patients who are able to
the catheter go down and avoid coughing will prefer to do this themselves.
until it is irresistible. Self-ventilating intu-
bated patients find it helpful to hyperventil- To minimize hypoxaemia
ate voluntarily beforehand.
When suctioning beyond the end of the Suction causes hypoxaemia, and the discon-
tracheal tube, the catheter normally enters tinuation of ventilation that accompanies
the right main bronchus. If access to the left suction can cause sustained hypoxaemia for
main bronchus is required, Judson (1994) up to an hour (Schwartz 1987). The following
recommends turning the head to the left, but measures reduce suction-induced hypoxaemia:
258 Physiotherapy in intensive care
secretions or the patient biting the tube. When using a closed-circuit catheter with
Biting requires reassurance and sometimes an HME, caution is required to prevent influx
insertion of a bite block. If secretions are of saline into the device (Martinez 1994).
mixed with blood, this may be due to recent
tracheostomy change, trauma from a Swan- 10.7 END OF TREATMENT SESSION
Ganz catheter, clotting disorder, heparin-
ization or suction that is rough, frequent or After suction, patients should not be turned
used with dry airways. or moved immediately, so that they can
stabilize (Riegel 1985). After treatment, it is
Saline instillation advisable to check that all alarms are on, to
tell patients the time, and ensure that their
Normal saline is sometimes instilled into
bell and other requirements are within reach.
lungs with the intention of liquefying and
Patients need reassurance that they are not
mobilizing thick secretions. Disadvantages
being left alone, and that their lines are safe
are the risk of infection, bronchospasm and
so that they do not feel inhibited from
interference with gas exchange. There are
moving. Some patients may be frightened for
also doubts about its efficacy because one of
a variety of reasons, e.g. being left facing a
the functions of mucus is to prevent the lungs
wall, so it is worth eliciting a nod before
drying out, and therefore mucus does not
leaving to check that they feel secure.
incorporate water easily (Dulfano 1973). The
need for saline also suggests that humidifica-
tion has been inadequate. 10.8 RECOGNITION AND
However, saline may help dislodge en- MANAGEMENT OF EMERGENCIES
crusted secretions or encourage coughing The key to the successful management of
(Gray et aI1990); limited data suggest that it is emergencies is informed anticipation and
beneficial (Judson 1994) and continuous- recognition. Physiotherapists are not im-
irrigation catheters show improved clearance mersed in life-threatening events every day,
(I sea 1993). If saline is used, the following so it is advisable to review protocols regularly
points are suggested: in order to maintain confidence and avoid the
• warm the ampoule of saline first to minim- indecision that is often evident at the scene of
ize the risk of bronchospasm, an emergency.
• administer the liquid slowly to prevent
patients feeling as if they are drowning, 10.8.1 Cardiac arrest
• not a drop must touch the tracheostomy
dressing, Cardiac arrest is the sudden cessation of heart
• 5 rnl has been advised (Bostick and Wendel- function. It is the commonest mechanism of
gass 1987), but more can be used if the old-fashioned process of death, but is
trickled in slowly and interspersed with potentially reversible. It is followed within
bagging (or large tidal volumes on the seconds by loss of consciousness and within
ventilator if bagging is contraindicated) a minute by loss of respiration and dilatation
to prevent desaturation, of pupils.
If this does not clear secretions, the saline
Anticipation
can be delivered more distally by injecting it
through the suction catheter or the patient Before starting work in any new unit, the first
can be turned to the opposite side after task is to locate the crash trolley. It is
instillation, so that the instilled side is upper- also advisable to have prior knowledge of
most for treatment. patients' past medical and drug history.
260 Physiotherapy in intensive care
Patients with pre-existing ischaemic heart the chin forwards. Insert an airway from
disease, severe respiratory disorder or drug the crash trolley. Suction the mouth and
overdose are most at risk of cardiac arrest, throat if required. Ventilate with 100%
especially if compounded by metabolic dis- oxygen using the face mask, resuscitation
turbance, arrhythmias or shock. Warning bag and oxygen at lSI/min. For an air-
signs are a change in the patient's breathing, tight seal, pull the mask edges apart
colour, facial expression, mental function or before positioning over the face. Vent-
ECG. Hypoventilation with altered conscious- ilation is easier with two people. The first
ness is an ominous combination. two breaths should be slow to minimize
the risk of aspiration.
Recognition 4. Kneel on the bed and apply external
chest compression with short thrusts,
Loss of consciousness is the first obvious using a degree of body weight through
sign. The patient's colour may be pale, ashen straight arms. With the heels of both
or blue, depending on the cause. No carotid hands two finger-breadths above the
pulse can be felt in the groove between the xiphoid process, depress the lower part
larynx and sternomastoid muscle. Respira- of the sternum by 4-5 cms at 60 compres-
tion becomes gasping and then stops (unless sions a minute. Apply pressure smoothly
respiratory arrest has been the primary and evenly to minimize fracture risk, but
event). Monitored patients show ventricular if rib fracture occurs, adjust hand posi-
fibrillation (VF) or asystole on ECG. tion and continue. Most hospital beds are
firm enough to support effective CPR,
Management but if not a footboard or meal tray can be
The time between collapse and initiation of pushed under the chest. Pulling the
resuscitation is critical, and a false alarm is patient to the floor to achieve a firm sur-
better than a dead patient. Irreversible brain face takes time, sometimes loses precious
damage will occur unless circulation is re- intravenous lines, and creates an awkward
stored within three to four minutes, less if the position for intubation. Effectiveness of
patient is severely hypoxaemic before the chest compression is evaluated by return
arrest. If suspicions are raised by a change in of a healthy colour and, when a spare
consciousness and colour, do not waste time person is available, palpation for a spon-
fumbling for the pulse unless skilled in this. taneous pulse.
Call out to the patient, and if he or she is For in-hospital CPR, the above two stages
unresponsive, follow the basic life support are performed concurrently, with chest com-
stage of cardiopulmonary resuscitation pressions and ventilation at a ratio of 5:1.
(CPR): For one-person CPR, the compression-to-
1. For patients whose ECG shows VF, ventilation ratio is 15:2. For physiotherapists
thump the midsternum once. This may working in the community or out of reach of
reverse VF in the early stages. At the a crash trolley, a pocket mask is advisable for
same time, summon help by bellowing, mouth-to-mouth resuscitation, and a finger
'cardiac arrest!'. sweep across the back of the tongue may be
2. Position the patient supine and remove needed to remove any obstruction.
the pillows. Do not leave the patient. Check the pulse
3. Establish a patent airway. Use one hand after the first minute and every few minutes
to tilt the head back (unless cervical thereafter. If the patient regurgitates, tum
injury is suspected) and the other to lift the head to the side, suction or wipe out the
Recognition and management of emergencies 261
mouth, and continue with CPR. If recovery hypoxaemia), airway obstruction (e.g. for-
occurs, turn him or her into the semiprone eign body, swelling or bleeding from trauma,
recovery position so that the tongue falls regurgitation from the stomach or smoke
safely to the side of the mouth and any inhalation) or aspiration (especially following
unwanted material can drain out. Common drug overdose). Warning signs are inability
errors are: to speak, and violent respiratory efforts,
laboured breathing or drowsiness.
• not maintaining a patent airway through-
out, e.g. inadequate neck extension,
• not allowing chest deflation between
Recognition
breaths, Respiratory arrest is indicated by absence of
• not compressing the chest with sufficient movement of the chest, loss of airflow from
force, the mouth and nose and sometimes cyanosis.
• compressing one side of the sternum This progresses to loss of consciousness.
rather than the mid-sternum.
The addition of abdominal compressions Management
alternately with chest compressions appears
to improve outcome (O'Nunain 1993). Guidelines for dealing with a respiratory
Spare personnel should call the crash team. arrest are the following:
When the team arrives, they will instigate 1. Call for help.
advanced life support: 2. Establish a patent airway as described for
• intubation and continued hand-ventilation, CPR. If there is no airflow, continue as
• medication such as atropine and adren- below.
aline for asystole, lignocaine for VF, 3. If a foreign body is the likely culprit,
calcium antagonists and beta-blockers, attempt to dislodge it from the throat by
• ECG monitoring, suction or finger sweep manoeuvre. If
• defibrillation, which delivers direct current unsuccessful, attempt to dislodge any
to the heart through the chest wall in foreign body from the airway by admin-
an attempt to abolish arrhythmias and istering up to five piston-like Heimlich
allow the sinus node to regain control of manoeuvres, i.e. inward and upward
the heart beat. Staff should stand clear thrusts to the abdomen, below the rib
while the shock is being delivered. cage and above the navel. This can be
from behind a standing victim or kneel-
When no longer needed, the physiotherap- ing astride a supine victim. If unsuccess-
ist can give attention to other patients who ful, turn the victim and deliver several
may be distressed at witnessing the event. sharp blows between the shoulder
blades. If the patient is still not breathing,
10.8.2 Respiratory arrest continue as below.
As cardiac arrest leads to respiratory arrest, 4. Hand ventilate or perform mouth-to-
so too does respiratory arrest, if untreated, mouth resuscitation once every five
lead to cardiac arrest. seconds. Check the carotid pulse once a
minute.
Anticipation
If cardiac arrest ensues, instigate full CPR.
Predisposing factors include exacerbation of If the patient starts breathing, turn him or
COPD (which can lead to depression of her into the recovery position. Vomiting is
respiratory drive by inspiratory loading and common as consciousness lightens.
262 Physiotherapy in intensive care
If a patient with a tracheostomy suffers a 3. Protect the patient's head and body from
respiratory arrest due to obstruction, follow injury. Do not use restraints or hold the
these steps: victim down, but keep in side-lying if
1. Suction the airway. possible. Loosen tight clothing, espe-
2. Move the head, which may relieve the cially around the neck.
obstruction. 4. Afterwards, ensure the patient is in the
3. Summon help. recovery position. Reassure as conscious-
4. Insert the suction catheter (not attached ness returns.
to suction), deflate the cuff, cut the
securing tape, slide out the tracheostomy 10.8.4 Haemorrhage
tube over the catheter while keeping the Anticipation
catheter in position in order to maintain
the airway. Then follow one of two Uncontrolled bleeding can follow surgery or
choices, depending on availability of other trauma.
equipment and experience:
(a) insert a new tracheostomy tube over Recognition
the catheter, using the catheter as a External bleeding is not easily missed. In-
guide, ternal bleeding is suspected if there are signs
(b) maintain ventilation through the of severe hypovolaemia (p. 247). The BP and
catheter or via tracheal dilators, heart rate are the least reliable of these signs
either encouraging the patient to because BP may be maintained by vaso-
breathe spontaneously, or blowing constriction and high cardiac output until 20--
down the catheter or the stoma. 40% of blood volume is lost, and heart rate is
responsive to many other variables.
10.8.3 Seizure
Anticipation Management
The medical notes indicate whether a patient 1. Position the patient flat.
has a history of epilepsy. Other causes of 2. Apply pressure to the bleeding point if
fitting are fever in children, head injury or accessible.
alcohol intoxication. Some patients sense an 3. Elevate the affected part if possible.
aura that warns them of an imminent seizure. 4. Request assistance.
5. Explain to the patient what is being done
Recognition throughout.
Seizures vary from minor loss of conscious- Fluid resuscitation is required with acute
ness to major muscle activity, followed by blood loss < 30% of total blood volume in
drowsiness. order to maintain perfusion to vital organs.
Haemorrhage from a tracheostomy is des-
Management cribed on p. 196.
1. Patients subject to seizures should have
10.8.5 Massive haemoptysis
the bed kept low, side rails up and
padded, and oxygen and suction avail- Expectoration of > 200--600 ml blood over
able. 24--48 hr implies massive haemoptysis, which
2. If there is advance warning, insert air- is rare but carries 30--50% mortality, usually
way. Do not attempt this once the fit is from asphyxiation more than blood loss (Reid
underway. 1994).
Recognition and management of emergencies 263
Heightened -+_+--+-+___---,~.
sternomastoid
activity
Suprasternal and
--"...---¥\.-+>.-\-_ Rapid breathing
supraclavicular
recession
Intercostal recession
-t'...........~'"-T---\--Abdominal paradox
teaching sessions so that nursing staff are 3. Physiotherapists. Junior and non-
able to perform maintenance chest care respiratory physiotherapists need confi-
and know when it is appropriate to dence in making informed decisions.
suggest that the physiotherapist be Useful time can be spent working along-
called. side juniors, going through equipment,
268 Physiotherapy in intensive care
and ensuring that all staff are proficient advance that the physiotherapist can act as
in identifying respiratory problems. It is adviser and consultant over the phone and
easy to forget how frightening the first that it is not always necessary to give hands-
on-call experience is, and several steps on treatment. Unnecessary call-outs can be
can be taken to facilitate a sound night's followed up by diplomatic chats between the
sleep for those on duty: respective managers.
(a) set aside time on the preceding
afternoon for the on-call physiother-
apist to see any patient whose res- RECOMMENDED READING
piratory status is borderline, Bergbom-Engberg, 1. (1989) Assessment of
(b) talk through a handout such as that patients' experiences of discomfort during res-
set out in Table 10.1 (also to include pirator therapy. Crit. Care Med., 17, 1068-72.
location of equipment), to be kept Judson, M.A. (1994) Mobilization of secretions in
by the on-call physiotherapist's ICU patients. Respir. Care, 39, 213-25.
Odell, A., Allder, A., Bayne, R. et al. (1993)
phone,
Endotracheal suction for adult non-head-injured
(c) clarify departmental policy on who patients. A review of the literature. Int. Crit.
is authorized to call out the phy- Care Nurs., 9, 274-78.
siotherapist, e.g. junior or senior Selsby, D. and Jones, J.G. (1990) Some physiolo-
registrar, gical and clinical aspects of chest physiotherapy.
(d) give inexperienced on-call physio- Br. J. Anaesth., 64, 621-31.
therapists the phone number of a Singer, M., Vermaat, J. and Hall, G. (1994)
Hemodynamic effects of manual hyperinflation
respiratory physiotherapist who is
in critically ill mechanically ventilated patients.
willing to advise them over the Chest, 106, 1182-7.
phone. Snow, N., Bergin, K.T. and Horrigan, T.P. (1990)
Thoracic CT scanning in critically ill patients.
The interest of the patient and good re-
Chest, 97, 1467-70.
lations with other disciplines can be fostered Stone, K.S., Talaganis, S.A.T., Preusser, B. et al.
by the physiotherapist taking responsibility (1990) Effect of lung hyperinflation and endo-
for prearranging call-outs when appropriate. tracheal suctioning on heart rate and rhythm in
Communication is improved by explaining in patients after CABG. Heart Lung, 20, 443-50.
11. Conditions in intensive care
Lung disease Smoke inhalation
COPD Poisoning, pulmonary aspiration and
asthma near-drowning
Neuromuscular disorders Shock
Guillain-Barre syndrome Disseminated intravascular coagulation
acute quadriplegia (DIC)
Fractured ribs and lung Acute respiratory distress syndrome
contusion (ARDS)
Acute head injury causes
effect of head injury on gas pathophysiology
exchange clinical features
effect of head injury on the brain medical treatment
factors which increase ICP physiotherapy
general management Recommended reading
physiotherapy
self-help groups (Appendix C). Recovery and causing hypotension and bradycardia,
takes weeks or months, but 80% of patients especially during suction or exertion. Cardiac
recover fully (Hund 1993). monitoring is required for the first two
weeks, and oximetry is advisable to detect
nocturnal desaturation and monitor treat-
11.2.2 Acute quadriplegia
ment. DVT is a high risk, especially if there is
You can't appreciate what it is to be para- multiple trauma.
lysed unless you are. The big things you get
used to easier, like not getting up and walking Physiotherapy
around. The trivial things - like not being able
to scratch your nose or feed yourself- they hurt. If hypoxia is allowed to develop, the spinal
Patient quoted by cord may be further damaged. The 3rd to 5th
Stewart and Rossier 1978 crucial days after injury are when lung
complications are commonest. McMichan et
People whose lives have been devastated by al (1980) have shown how the need for IPPV
trauma or disease to the cervical spine are can be reduced by two-thirds with regular
overwhelmed at first and find it difficult to preventive measures in the form of frequent
comprehend how savagely their life has been position change and hourly incentive spiro-
reduced. metry to maintain lung volume, and percus-
Physiotherapists who care for people with sion and assisted coughing to clear secretions.
acute quadriplegia need to allow them to The head-down position is unwise, but if it
work through their grieving at their own is essential for postural drainage, care is
pace, while endeavouring to prevent the needed to ensure that tipping is done slowly,
respiratory complications that are the leading not fully, that traction is maintained, that
cause of death. patients are not left unsupervised in case of
sudden sputum mobilization, and that arterial
Pathophysiology and clinical features and venous pressures are monitored because
Lesions above T6 to L1 paralyse the abdom- of the loss of compensatory cardiovascular
inal muscles and impair coughing. Higher reflexes.
thoracic lesions paralyse the intercostals and Coughing is assisted with manual pressure
destabilize the rib cage, causing paradoxical upwards and inwards using the heel of the
inward motion on inspiration. The common- hand from below the xyphoid process, in
est picture is maintenance of accessory muscle synchrony with any expiratory force that the
and diaphragmatic action but loss of inter- patient can muster. Some patients require
costal and abdominal action, leading to a vital two helpers for this. Care should be taken to
capacity (VC) between 1250--2500 cc. If VC is avoid disturbing neck traction, jarring the
below this with a high thoracic lesion, further fracture site, exacerbating associated injuries,
pathology such as unilateral diaphragmatic or pushing towards the spine instead of the
paralysis is suspected. Lesions above C4 diaphragm. This form of assisted coughing
denervate the diaphragm, leaving only the should not be attempted if there is a paralytic
sternomastoid and trapezius muscles to shift ileus.
a trace of air into the lungs. Early minitracheostomy is advisable if
Paralysed abdominal muscles lead to re- there is a hint of sputum retention, especially
duced venous return and an exaggerated as the neck cannot be extended for effective
response to hypovolaemia. Sympathetic out- nasopharyngeal suction. If suction is re-
flow is impaired in traumatic lesions above quired, whether for an intubated or spon-
T6, leaving parasympathetic tone unopposed taneously breathing patient, it should be
272 Conditions in intensive care
..
Inspiration Expiration
the risks of IPPV (Bolliger and Van Eeden hypoxaemia, hypotension, anaemia (due to
1990). Contused lungs do not take kindly bleeding), infection and intracranial hyper-
to percussion and vibrations, and postural tension. These can be made worse or better
drainage can spread bloody secretions to by the quality of management.
other parts of the lung. Mechanical vibrators
may help to mobilize secretions, and an
oscillating bed has been found to reduce 11.4.1 Effect of head injury on gas
chest infections (Fink et al 1990). If frank exchange (Fig. 11.2)
bleeding is present, suction is contra- Chest infection is second only to intracranial
indicated. hypertension as the main cause of death
following head injury (Rudy et al 1991).
11.4 ACUTE HEAD INJURY Reasons for this and other respiratory com-
plications are legion:
Nowhere is accurate assessment and finely-
tuned clinical judgement more vital than in 1. Damage to the respiratory centre may
the management of a person with acute head cause abnormal breathing, leading to
trauma. Methods to control intracranial pres- either hypercapnia, which causes vaso-
sure and prevent lung complications are dilation and raised intracranial pressure, or
often in conflict, and this is further complic- hypocapnia, which causes tissue hypoxia
ated if other trauma is present. (Fig 11.3). Cheyne-Stokes or ataxic breath-
The effect of most injuries is maximal at ing are signs of severe damage.
onset, but head injury may precipitate a 2. Regurgitation and loss of protective
process that converts a mild injury to a life- pharyngeal reflexes in an unconscious
threatening condition. Primary damage sus- patient may cause acute aspiration.
tained at the time of impact is irreversible, 3. Associated injuries such as facial injury,
but secondary damage can double mortality fractured ribs, haemopneumothorax or
by reducing oxygen delivery to the brain lung contusion compromise the airway
(Wald 1993). Secondary damage includes or impair gas exchange.
274 Conditions in intensive care
Pulmonary oedema
Shallow breathing
IPPV
Pneumonia
DIC
Fat embolism
ARDS
Hypermetabolism . . i 1io2
----------------
Hypotension
} - - - - - - - -......-..t, 00 2
..t, Hb (if bleeding)
Disrupted cerebral regulation i ..t, 00 2 to brain
Hyperventilation
_____ - J, PaC02
l
i Work of breathing ~
i Oxygen consumption ,
____ _ _ - - - - J, Oxygen delivery
Hypoxia -
mechanisms have been exhausted, a small 11.4.3 Factors which increase ICP
increase in cerebral oedema within the rigid
container of the skull causes a disproportion- ICP is keenly sensitive to a multitude of
ate upsurge in ICP, as shown by Fig. 11.4. factors:
Raised ICP is implicated as the major cause 1. Head-down postural drainage increases
of secondary brain injury because it impairs arterial, venOUS and intracranial pres-
CPP. CPP must be kept above 60 mmHg in sures, impairs compensatory venOus out-
order to perfuse the brain. CPP needs an flow, and is contraindicated in the acute
adequate blood pressure but is compromised stage (Lee 1989). Beware of literature that
by a high ICP. MAP (related to BP) and ICP gives unreferenced reassurance about
are in effect competing for space in the this position or suggests that advice be
contused brain, i.e.: sought from doctors, who cannot be
CPP = MAP - ICP expected to know about the effect of
physiotherapy procedures.
The picture can be further complicated if 2. Turning the patient increases ICP (Chud-
pressure autoregulation is affected. Normally ley 1994), much of this being due to head
cerebral blood flow remains constant over a
CPP range of 50-150 mmHg due to com-
pensatory vasodilation as a response to
hypoxaemia or hypotension. If this mechan-
80
ism is damaged by brain injury, ICP follows
MAP passively rather than maintaining
independence. Medical intervention may be 60
needed to regulate cerebral vascular resistance
ICP
(Zhuang et al 1992). (mmHg) 40
Intracranial dynamics are reflected in a
vicious cycle that exacerbates the secondary
20
effects of head trauma (Fig. 11.5). Lung
complications cause hypoxia to which brain
tissue is particularly sensitive because of its o ~------------------------~
Intracranial Volume
high oxygen requirements and dependence
Figure 11.4 Intracranial pressure-volume curve,
On aerobic glucose metabolism. Hypoxia showing the steep rise in ICP once compensation
causes cerebral oedema, and disturbances in for increased volume has reached its limit.
PaC0 2 add to this woeful picture. It is no Reproduced with permission from J.M. Ooeheny
wonder that head injuries have a reputation et al., Critical Care Nursing; published by W.B.
for being treacherous. Saunders Company, 1993.
276 Conditions in intensive care
/
Cerebral oedema
Hypoxia t ICP
I
Cerebral
hypoperfusion
)
Capillary
compression
movement obstructing drainage from the general discussion (Mitchell and Mauss
brain. 1978). When relatives talk to them, a
3. Coughing, suction, bagging, vibrations reduction in ICP may be seen (Chudley
and percussion impede compensatory 1994).
outflow from the brain and raise ICP 6. ICP is increased by stress such as noise,
(Paratz 1993; Garradd and Bullock 1986). pain, restraints, movement of the tracheal
Outflow is also obstructed by extreme hip tube, arousal from sleep or emotional
flexion (Mitchell and Mauss 1978), PEEP, upset (Mitchell et al 1981).
tight tracheostomy tape and a cervical Most of these factors warn physiotherap-
collar that may be applied for some days ists to keep their distance, but the importance
after trauma until cervical injury has been of maintaining adequate gas exchange is a
ruled out (Raphael 1994). cogent reminder not to stray too far.
4. Hypertension increases ICP and hypo-
tension reduces CPP. If pressure auto- 11.4.4 General management
regulation is lost and cerebral perfusion
Monitoring
is related linearly to blood pressure, BP
can be monitored as a surrogate for ICP monitoring (Fig. 11.6) is needed because
cerebral blood flow. assessing neurological function by clinical
5. Even deeply comatosed patients show a examination means that secondary damage
surprising sensitivity to conversation has already occurred (Harrington 1993). The
over their beds, discussion about their intraventricular catheter has the capacity to
condition increasing ICP more than withdraw CSF for diagnosis or therapy.
Acute head injury 277
of venous outflow due to coughing, and cilia and ulceration. These 'heat sink' filtering
increased heart rate and BP. If suction is properties are overwhelmed by inhalation of
indicated, the patient should be rested from steam or crack cocaine, which penetrates to
previous activity, hyperventilated with 100% alveoli, bums lung and destroys surfactant
oxygen before and after, monitored and have (Haponik 1992).
the head strictly in alignment. Multiple suc- Respiratory complications are the major
tion passes without a rest in between are cause of death following fire entrapment,
dangerous (Rudy et aI1991). although X-ray changes may not appear for
Extreme hip flexion should be avoided in days. Upper airway obstruction is the most
the acute stage to prevent a rise in intra- treatable of respiratory complications, but
abdominal pressure. If flaccidity is present deaths still occur from delayed intubation.
with no pattern of activity, then it may be Oxygen delivery is impaired by shock and
best to avoid any movements in the first few inhaled carbon monoxide, which displaces
days. If postural tone indicates that spastic oxygen from haemoglobin and shifts the
patterning is developing, extra attention dissociation curve to the left. Infection can be
should be given to avoiding factors which transmitted to the lung from the hospital
exacerbate abnormal activity, e.g. poor posit- environment or infected bums. Epithelial
ioning, infection, pain, anxiety, pressure damage may lead to long-term small airway
under the feet and the weight of bedclothes. injury and hyperreactivity (Kinsella et al
Staff and carers should be taught positioning 1991). Lung expansion may be restricted by a
and handling to encourage inhibitory control tight armour of scarring around the chest.
over spasticity. If increased tone is identified, General treatment follows a fourfold ap-
serial splinting to maintain dorsiflexion is proach:
indicated immediately (Moseley 1993). • pain management, e.g. by PCA (Choiniere
Preplanning is needed to avoid a cumulat- 1992),
ive rise in ICP. Most teams work to space • judicious fluid administration with crystal-
physiotherapy, nursing and other interven- loids and colloids to replace lost water
tions as far apart as possible, although some and protein without incurring pulmon-
find it best to do everything at once and then ary oedema,
let the patient settle. Co-ordinated teamwork • supplementary feeding to compensate for
is a priority, especially in the first vulnerable hypermetabolism that can last for months
week. It is worth remembering that many (Milner 1994),
patients are better with no hands-on physio- • oxygen, CPAP (if the face is not burned) or
therapy at all in the very acute stage. IPPV as required to maintain gas ex-
It is also worth remembering that rehabilita- change.
tion is now expected to start in the ICU.
MacKay (1992) showed that length of coma Inhaled nitric oxide may also be given to
can be cut to a third by an early multi- assist gas exchange by va so dilating pulmon-
disciplinary programme of orientation, sensory ary vessels (Ogura 1994).
stimulation, exercise and family involvement. Respiratory physiotherapy is aimed at
maintaining lung volume and clearing the
thick and prolific secretions caused by airway
11.5 SMOKE INHALATION damage. Lavish humidification is needed.
Thermal damage by inhalation of hot gas is Precautions include the following:
inflicted on the airways, which filter heat 1. Treatment should be little and often
at the expense of bronchospasm, mucosal because of the importance of prophylaxis
swelling, pulmonary oedema, paralysis of and the inevitable fatigue.
280 Conditions in intensive care
vance to the physiotherapist is haemato- ARDS is also called leaky lung syndrome
logical insufficiency, which leads to clotting because of the seive-like characteristic of the
abnormalities, and the most common and alveolar-capillary membrane. It is also called
dramatic manifestation, acute respiratory dis- shock lung because it first came to light in
tress syndrome (ARDS). soldiers resuscitated from shock in the Viet-
Both alveolar and vascular functions of the nam war.
lung are ravaged by the inflammatory re-
sponse. Non-cardiogenic pulmonary oedema
floods the alveoli and makes the lungs four or 11.9.3 Clinical features
five times their normal weight, almost Following the provoking insult, there is a
drowning the patient from the inside. Invad- latent period of 24-72 hours before the
ing plasma proteins deplete surfactant, which syndrome develops. In the next 24 hours
exacerbates atelectasis, increases PA-a02 to there is rapid shallow breathing and respir-
250 mmHg or more, and leads to refractory
atory distress. The following one to two days
hypoxaemia. show reduced Pa02 and PaC02 and minor X-
Hypoxaemia is exacerbated by broncho- ray changes. Diagnosis is not usually made
spasm, and hypoxia is exacerbated by (1) until the third phase, when virulent hypoxae-
reduced gas diffusion at tissue level because mia develops, PaC02 rises as the patient
of interstitial oedema, (2) impaired oxygen tires, and the X-ray shows diffuse ground-
extraction due to damaged cells and (3) glass shadowing which characteristically
excess oxygen consumption due to a twice- spares the costophrenic angles. CT scanning
normal metabolic rate. shows opacities in dependent regions, repre-
The water-logged lungs suffer a restrictive senting lung areas compressed by the weight
defect, which worsens as fibrosis sets in. The of oedematous lung above, and will show up
lungs become progressively and irregularly any barotrauma (Fig. 11.7).
damaged, showing areas of hyperinflation, The incidence of pneumothorax varies
compression atelectasis and a small area of according to ventilator management and is
undamaged compliant lung. The capacity of demonstrated in 8-77% of patients (Heullit
this so-called 'baby lung' may be one-third of 1995). Breath sounds are surprisingly normal,
normal (Slutsky 1993). with just a harsh edge to them. Fibrosis sets
As demand exceeds supply, oxygen con-
sumption (V0 2 ) becomes dependent on oxy-
gen delivery (D0 2), even if delivery is well
above normal. If anaerobic metabolism
occurs, blood lactate levels rise, further
impairing the normal mechanisms of oxygen
extraction.
Vascular injury leads to pulmonary hyper-
tension, which exacerbates oedema forma-
tion and inhibits right ventricular function.
Circulating catecholamines may increase car-
diac output and total body blood flow, but
deranged autoregulation means loss of
control of capillary blood flow, increasing Figure 11.7 CT scan of a patient with ARDS,
perfusion to non vulnerable systems such as showing dense areas of atelectasis in dependent
skin and muscle, and further depriving regions, and pneumothorax in right non-
needy systems such as the gut and liver. dependent region.
Acute respiratory distress syndrome (ARDS) 283
in after the first week. Pulmonary artery Complications include the following:
catheterization shows a high PAP, reflecting
1. Barotrauma, which becomes more likely
increased pulmonary vascular resistance.
as lung damage progresses.
PAWP is < 18 mmHg because ARDS is not a
2. Intrinsic PEEP, because non-homogeneous
condition of generalized overhydration, in
loss of elasticity causes uneven distribu-
contrast to cardiogenic pulmonary oedema,
tion of expiratory time, leading to
which causes a high PAWP.
increased expiratory resistance (Pesenti
and Pelosi 1992, p. 328).
11.9.4 Medical treatment 3. Impaired cardiac output because of high-
pressure IPPV.
Gastric tonometry can detect gut ischaemia
before mucosal injury occurs. Then vigorous Various ventilatory manoeuvres help to
efforts are made to find and eradicate septic maintain D02 with minimal damage:
foci. Management is then aimed at restoration
1. To recruit alveoli and maintain D02 ,
of normal homeostasis rather than attempts
levels of PEEP up to 30 cmH2 0 are
to reverse individual components of the
imposed, even though this may over-
syndrome, because support of a single
distend some areas of lung.
system may place an intolerable burden on
2. To discourage barotrauma, low tidal
another. The principle is to sustain tissue
volumes may be used, sometimes to the
perfusion by supranormal D02 , using vent-
point of permissive hypercapnia (Hickling
ilatory and haemodynamic support. The
1994). High PaC02 is well tolerated if
balance between beneficial and damaging
established over several days, but VAle?
interventions is a fine one.
mismatch may be exacerbated.
Skilled fluid management is required
3. Pressure control ventilation limits peak
because transfused fluid tends to escape into
pressure and minimizes overdistension
the lung, while inadequate circulating
of the more compliant areas of lung. The
volume hinders D02 , Renal impairment may
decelerating inspiratory flow also allows
complicate the picture. PAWP is kept as low
a more equal distribution of gas to lung
as is consistent with optimum D02 and
units with varied filling speeds.
haemodynamic stability, and overload may
4. Techniques can be tried such as airway
require slow continuous ultrafiltration
pressure release ventilation, inverse-ratio
(Anderson 1994).
ventilation (p. 226) or high-frequency
D02 is promoted by inotropic support,
oscillation (Imai, 1994), which minimizes
packed red blood cell transfusion and vaso-
overdistension by using small tidal
dilators. V0 2 is reduced by sedation, paralysis
volumes.
and avoidance of stress and pyrexia. Added
5. Extracorporeal gas exchange allows
oxygen is limited to 60% if possible to
reduced ventilation pressures and lower
prevent oxygen toxicity, which resembles the
F10 2 , but causes bleeding in 75% of
effects of ARDS itself. Haemodynamic sup-
patients (Anderson 1994).
port is by manipulation of preload, heart rate,
myocardial contractility and afterload. Medical management is mainly supportive,
Paralysis and IPPV can reduce V0 2 by 20% but curative measures include haemofiltra-
(Manthous 1995). However, IPPV squeezes tion to wash out circulating mediators
the bulk of the ventilation into the 'baby (Lingnau 1995), inhaled surfactant (Spragg
lung', creating stretching forces that can 1994) or inhaled nitric oxide. Despite nitric
cause secondary lung injury (Parker and oxide's reputation as the car exhaust killer of
Hernandez 1993). rain forests, its ability to cause selective
284 Conditions in intensive care
pulmonary vasodilation and bronchodilation • care is needed to protect the eyes, secure
in ARDS led it to be elected the 'molecule of the tracheal tube and guard against
the year' in 1992 (Anggard 1994). shoulder joint damage,
• potential cardiac arrest must be planned
for and a procedure prepared in case
11.9.5 Physiotherapy rapid return to supine is necessary,
although CPR can be achieved in prone
Like medical management, physiotherapy with a fist under the sternum and com-
aims to maximize D0 2 while causing the least pression of the mid-thoracic spine (Sun
harm. Gratuitous increase in stress and 1992).
energy expenditure must be avoided.
Bagging is undertaken only if necessary.
In spontaneously breathing patients,
However, the literature on barotrauma
CPAP or BiPAP may delay or prevent IPPY
during extended periods of IPPY should not
(Martin 1995). For ventilated patients, the
main problem is loss of lung volume, secre- be extrapolated to the brief bagging used for
tions usually being of little note. Positioning physiotherapy. Enright (1992) has shown
is the first approach. Occasionally, patients how patients with atelectasis or sputum
who are well hydrated can sit up in bed. Side- retention show sustained improvement in
lying mayor may not be beneficial, as guided D02 after positioning, bagging, vibrations as
by the monitors, but regular position change necessary and suction. This caused no baro-
in a kinetic bed has been shown to reduce trauma (Enright, personal communication). If
atelectasis and improve gas exchange (Hor- bagging is anticipated, the X-ray should be
mann 1994). Barotrauma is less likely to occur examined for any precursors to a pneumo-
in the dependent lung (Stewart 1993). thorax such as thin-walled air cysts beneath
A more dramatic improvement in Sa02 the visceral pleura or linear streaking towards
may be found by gently turning the patient the hilum (Albelda 1983; Haake et al 1987).
into prone. This can reverse atelectasis in the Pneumomediastinum is suspected if there is
non-dependent lower lobes, which improves air outlining the mediastinum or aorta.
overall gas exchange because there is more Patients fare better if well filled before treat-
space in the lungs posteriorly due to the ment. Disconnection for suction should be
chest's triangular cross-section and the space avoided when possible (Schwartz 1987) by
taken up by the heart anteriorly. Lung using a closed circuit catheter.
expansion is also more uniform in prone than The observant physiotherapist is a useful
supine because the heart is supported by team member because treatment is more
the sternum and there is less parenchymal effective if the syndrome is recognized early.
distortion (Yang 1991). By opening pre- Suspicions are raised if a patient with the
viously deflated lung, oxygenation may relevant predisposing factors develops
improve to such an extent that PEEP and tachypnoea and hypoxaemia more severely
F10 2 can be reduced (Lamm 1994). The than would be expected from the clinical
benefits are reversed on returning to supine picture, or if a ventilated patient develops
and many patients are best left in prone for high airway pressures.
extended periods, most comfortably on a A concerted approach of regular position
fluidized bed. Not all patients benefit. change, permissive hypercapnia and inhaled
Problems of the prone position are: nitric oxide has shown that mortality can be
• it can be a frightening experience for the brought down to 16% (Lewandowski 1992) .
patient, However, the past 20 years have shown no
Recommended reading 285
general reduction in mortality from ARDS, Bone, R.C., Balk, R., Slotman, G. et al. (1992)
and 50-75% of patients still perish overall Adult respiratory distress syndrome. Chest, 101,
(Heulitt 1995), mostly because of superinfec- 320--6.
Bullock, R. and Teasdale, G. (1990) Head injuries.
tion and multiple organ failure, and rarely
Br. Med. J., 300, 1515-18, 1576-9.
because of lung injury (Pearl 1993). High-risk Johnson, J. and Silverberg, R. (1995) Serial casting
factors include infection as a cause, and lack of the lower extremity to correct contractures
of response to treatment in the first 24 hours. during the acute phase of burn care. Phys. Ther.,
Low-risk factors include trauma as a cause, 75,262-6.
and younger age groups (Beale et al 1993). Jones, B. (1994) The effects of patient repositioning
Survivors show a remarkable capacity to on intracranial pressure. Austr. J. Adv. Nurs., 12,
32-9.
regenerate lung tissue; most show abnormal
Keilty, S.E.J. (1993) Inhalation burn injured
gas transfer and many a mild restrictive patients and physiotherapy management. Physio-
defect, but rarely is there functional impair- therapy, 79, 87-90.
ment. Pinsky, M.R. (1994) Through the past darkly:
ventilatory management of patients with
COPD. Crit. Care Med., 22, 1714-17.
Senekal, M. and Eales, C. (1994) The optimal
RECOMMENDED READING physiotherapeutic approach to penetrating stab
wounds of the chest. S. Afr. J. Physiother., 50,
Bellomo, R. (1994) Asthma requiring mechanical 29-36.
ventilation - a low morbidity approach. Chest, Wake, D. (1995) Near drowning. Int. Crit. Care
105,891-6. Nurs., 1,40-3.
12. Physiotherapy for children and
infants
Physiotherapy for children Physiotherapy for infants
introduction indications
aspects of assessment precautions
physiotherapy management assessment
specific measures for children methods to decrease the work of
with medical conditions breathing
specific measures for children methods to increase lung volume
undergoing surgery methods to clear secretions
The neonatal unit Modifications for specific neonatal
introduction disorders
care of the parents respiratory distress syndrome (RDS)
management of pain and stress meconium aspiration
temperature and fluid intraventricular haemorrhage
regulation pneumonia
oxygen therapy chronic lung disease of prematurity
mechanical ventilation Emergencies in the neonatal unit
advanced life support sudden hypoxaemia
apnoeic attacks
pneumothorax
cardiorespiratory arrest
Recommended reading
and guilt. Parents need confidence in their Table 12.1 Vital signs in children (source:
own competence, and acknowledgement that Prasad and Hussey 1995)
they are the experts on their own children. Over
Their anxiety is otherwise contagious. Newborn 1-3 years 3-7 years 7 years
It is normal for adults to adopt the sick role
when hospitalized, and children may also act RR 40-60 20-30 20-30 15-20
as if younger than their years when finding Pa02 60-90 80-100 80-100 80-100
themselves in a dependent position, often HR 100-200 100-180 70-150 80-100
showing an exaggeration of the behaviour
patterns that they normally use to cope with BP 60-90 75-130 90-140 90-140
stress. 30 60 45 90 50 80 50 80
Young children tend to react more severely
to acute respiratory infection than older or a doll. The diaphragm or bell should be
people because of their narrow airways. The warmed before use.
incidence of infant infections is reduced by Normal respiratory rate, blood gas and
breast feeding (Wright 1989), and increased cardiovascular measurements during child-
by factors such as damp homes (Brunekreef hood are shown in Table 12.l.
1989) and parental smoking (Couriel 1994a). Laboured inspiration is represented by
Childhood respiratory infection tends to intercostal recession because of a compliant
leave a legacy of sensitized airways and a chest wall. Laboured expiration is repres-
higher incidence of COPD in adult life ented by grunting, which acts as a form of
(Shaheen et al 1994). PEP to splint open the narrow airways. Other
signs of respiratory distress are:
12.1.2 Aspects of assessment • tachypnoea,
• asynchronous or paradoxical breathing,
Parents should be welcomed during assess- shown by a see-saw motion between
ment and treatment. If this causes the child to chest wall and abdomen, with the over-
express anxiety more noisily than when compliant rib cage being sucked inwards
unaccompanied, this is healthier than with- during inspiration,
drawal. The younger the child, the greater • nasal flaring,
the need for a parent. • apnoea associated with bradycardia or
The presence of an intravenous needle can cyanosis.
inhibit children from moving, and they
should be reassured that it will be watched Breathlessness may hamper communica-
and supported during assessment and treat- tion, interfere with the child's sleep or that of
ment. The presence of a nil-by-mouth sign the parents, and affect eating or drinking.
may indicate considerable distress if the child Deterioration in gas exchange may be
cannot understand why he or she is so indicated by pallor, sweating, restlessness
thirsty, and parents can be enlisted to help agitation, glazed eyes and, in ventilated
with explanations and mouth care. Children young children, fighting the ventilator.
should be allowed oral fluids up to two hours Hypoxaemia must be excluded before sedat-
before surgery to reduce the risks of de- ing an unsettled child.
hydration, hypoglycaemia and misery (Phillips
et al1994). 12.1.3 Physiotherapy management
Before auscultation, children can be given Before treatment, clear and honest explana-
the opportunity to see and feel the stetho- tions should be given to the child, including
scope, and use it to listen to themselves descriptions of what the treatment will feel
288 Physiotherapy for children and infants
like, how long it will last and reassurance that 1991). This is due to the compliant chest wall
it can be stopped by request at any time. being unable to counteract fully the elastic
Resistance to treatment can often be over- recoil of the lungs, and lack of connective
come by giving the child a choice, such as tissue support for the small airways. This
either incentive spirometry or a walk outside. pattern predominates in the first 10 years
Requests to stop treatment must be re- (Davies et aI1990). In the presence of unila-
spected, and if further treatment is refused terallung pathology, gas exchange is optimal
despite cajoling, distraction, joking and with the diseased lung dependent, which is
enlisting the parent's help, serious thought opposite to the adult pattern.
should be given to whether the benefits of Many young children have gastro-
continuing treatment outweigh the effects of oesophageal reflux (GOR). Most improve
enforced intervention. In the UK, a child's spontaneously by 18 months, but up to 30%
consent to treatment is required if he or she is remain symptomatic until aged four (Phillips
of 'sufficient understanding to make an et aI1994). Persistent wheezing and vomiting
informed decision' (Children Act 1989). are the main manifestations, and GOR is
The parent is encouraged to take part in, as often underdiagnosed. Management is by
well as learn from, the treatment. Two-year- feeding little and often, and maintainance of
olds can do breathing exercises if taught 30° head elevation, although this should
imaginatively, and all but the youngest match the needs of the child because occasion-
appreciate explanation about their disease ally children aspirate in this position only.
and the purpose of physiotherapy. CPAP is particularly suited to children to
compensate for the floppy chest wall. Admin-
Methods to increase lung volume istration can be via the closed system of an
endotracheal tube, or by an open system
The use of paper mobiles, bubble-blowing, using face mask, nasal prongs or naso-
blowing through a straw or simply blowing a pharyngeal tube. The open system allows the
tissue utilizes the deep breath that is taken infant to generate more distending pressure
before blowing out. Paediatric incentive spiro- in moments of need by grunting. CPAP is
meters are enjoyable and encourage deep usually indicated for intubated children
breathing without a subsequent forced expira- under age six and for 24 hours after extuba-
tion. Abdominal breathing can be taught by tion Games 1991) because of the loss of the
placing a favourite toy on the abdomen. ability to grunt. For spontaneously breathing
Young children need particular attention to children, it is used if adequate oxygenation
maintenance of lung volume, because lack of cannot be maintained with high inspired
elastic tissue in immature lungs means that oxygen. A starting pressure of 5 cmH2 0 is
they share with elderly people a tendency used, which is gradually increased until
towards airway closure at low lung volumes. grunting stops or oxygenation is optimum.
Any suggestions that children should be Pressures above 10 cmH2 0 bring risks of
made to cry to encourage deep breathing gastric distension and pneumothorax. When
should be rejected. ready for discontinuation, CPAP should be
When positioning for gas exchange, the reduced slowly to prevent atelectasis.
distribution of ventilation is opposite to the
adult pattern (p. 7), which means that venti- Methods to clear secretions
lation is directed preferentially to upper Postural drainage can be enjoyable over a
regions. In side-lying, the lower lung is bean bag or on the helper's lap in a rocking
poorly ventilated because airway closure chair. In infants, who spend much time
occurs above FRC until age five or six Games supine, the sitting position is included to
Physiotherapy for children 289
drain the apical segments of the upper lobes. underdiagnosed, one study showing that
Percussion is often more soothing than vibra- children consulted a general practitioner an
tions. Huffing can be encouraged by blowing average of 16 times before asthma was
cotton wool or using the story of the big bad diagnosed (Levy and Bell 1984). Asthmatic
wolf who 'huffed and puffed and blew the children are sometimes given non-specific
house down'. Coughing can be motivated by diagnoses such as 'wheezy bronchitis' or
laughter and rewarded by earning a star on a simply 'chestiness', possibly because it is
cough score sheet. From age four, children thought that the word 'asthma' causes
can do the ACBT and are able to spit out and parents to worry. But explanation of a child's
blow their nose to prevent secretions spilling persistent symptoms relieves worry and
into the airways. In infants, coughing can be brings relief to both parents and child.
stimulated by gentle inward pressure against Recurrent cough or wheeze is sufficient to
the trachea in a circular pattern during suspect childhood asthma. Diagnosis is aided
exhalation. Nasotracheal suction is usually by a six-minute exercise test, a positive result
unnecessary if the child is coughing effect- being a drop of more than 15% in peak flow
ively, even if secretions are swallowed. When within 10 minutes after exercise (Jones and
suction is necessary, the child's saliva should Bowen 1994).
be used as lubricant, unless the nose is Parents, teachers and doctors may have
already clogged up with mucus. different perceptions of the needs and poten-
Although the level of suction pressure is tial of children with asthma. The child's view
related to mucosal damage, there is no of the disease is often based on fear, re-
original research examining at what level this inforced by continuing anxiety about future
occurs. Howard (1994) claims that greater attacks. Two-thirds of children outgrow their
negative pressure does not remove more asthma (Sears 1994), and it is thought to be
secretions, and Hazinski (1984) recommends more than coincidence that this is when they
the following pressures: outgrow their fears (Gillespie 1989). Educa-
• 60-90 cmH2 0 for infants tion is therefore the foundation of physio-
• 90-110 cmH2 0 for young children therapy. This is achieved most effectively
• 110-150 cmH2 0 for older children. through an asthma group because there is
little time for education during the brief
Minitracheostomy is indicated for children
hospitalization for an acute attack. The group
who need repeated suction (Allen and Hart
involves the family, whose attitude is crucial.
1988).
The programme could include:
A specimen of nasopharyngeal aspirate
may be requested in order to obtain epithelial • prevention (p. 62),
cells for diagnostic purposes. Nasal suction is • practice in using inhalers, preferably in
used to reach the post-nasal pathway, and front of the group to improve confidence
the procedure followed is described on p. 143. at school,
• for children over six years, practice in
12.1.4 Specific measures for children with monitoring their own peak flows,
medical conditions • voice work such as humming to control
Asthma expiration,
• hard, enjoyable, controlled physical activity
Most cases of asthma appear before the age of
(a warm swimming pool is particularly
two (Pinn 1992). The disease affects 10% of
suitable).
children (Deaves 1993), twice as many as any
other chronic illness, and mortality is increas- If bronchospasm following exercise is not
ing (Ryan-Wenger 1994). But it is widely prevented by the normal measures (p. 62),
290 Physiotherapy for children and infants
children have been known to mistake a bone • children's subjective complaints may not
marrow test for a 'bow-and-arrow test' or a be taken seriously, health staff tending
dye injection for a 'die injection'. Young to rely on assumptions and personal
children have a protracted sense of time and beliefs when assessing children's pain
will benefit from being told in advance that (Beyer and Byers 1985),
postoperative pain will go away after a few • children's analgesia needs meticulous pre-
days. Physical sensations should be de- scription, which is often not met and
scribed, and the reason for the sensations leaves children as 'therapeutic orphans'
explained. Without explanations, the bound- (Yaster 1995),
ary between reality and fantasy can be • children may minimize complaints because
blurred. Truth is essential because if the of fears of the dreaded needle,
child's trust is shaken co-operation is lost. • children may not express pain in terms that
Separating a screaming child from its are easily understood by adults, and an
parent at the door of the operating room is absence of crying does not indicate an
distressing for all concerned. It is now under- absence of pain,
stood that a parent should be present during • some health staff do not realize that chil-
induction of and emergence from anaesthesia dren are able to feel pain from birth, and
(Goresky 1994; Hall 1995). even before birth (Abu-Saad 1994).
• children are easily held down by force.
Pain management
For pain assessment of young children, the
If postoperative pain is poorly managed in parent gives a more accurate indication than
adults, this tendency is exaggerated in chil- health staff, but this information must be
dren and even more so in infants. One
actively requested because parents tend to
survey found that the majority of children
assume that everything is automatically done
who had had major surgery or burns received
to minimize pain. For older children, it is
no analgesia at all (Eland 1985). Similarly, it is
unfortunately fairly common for young chil- better to ask the child, especially as this gives
dren to undergo intubation and chest drain an indication of the associated fear (Manne et
insertion without analgesia; and older chil- aI1992). Children over seven years can use a
dren have described the pain of medical visual analogue scale, those over three years
procedures as the worst aspect of their can use colour intensity scores, scales with
condition (Yaster 1995). In animals, such happy-sad faces (Fig. 12.1) or comprehensive
treatment would bring prosecution, and the charts with body outlines (Qureshi 1994).
psychological impact on children can be long- Prelingual and non-verbal children can be
term and profound (Beyer and Byers 1985). observed for signs of withdrawal, face and
The causes of poor pain management in body reactions, irritability, pallor, momentary
children include the following: breath-holding, prolonged sleeping and, in
292 Physiotherapy for children and infants
older babies who have been subjected to must not be discouraged from crying or told
traumatic procedures over some time, an to be brave. If they are difficult, it is usually
expression of frozen watchfulness similar to because they are frightened.
the abused child. Further details are in Beyer
and Byers (1985) and Sparsholt (1989).
Physiological measures, such as changes in 12.2 THE NEONATAL UNIT
respiratory rate, heart rate, BP and 5a02 can
be used as adjuncts, but are not specific as 12.2.1 Introduction
indicators of pain and are not sustained with
continued pain. The emergence of the baby into the outside world
Any method used for adult pain relief can is perhaps the most cataclysmic event of its life.
be adapted for children (Rice 1989) using a West 1994
painless route. An exception is the rectal
route, which is not advisable because absorp- Normal babies have undergone the trauma
tion is slow and variable, it can be perceived of birth and the complex transition from
as abusive by children, and there has been respiration via the placenta to gas exchange
one known fatality (Gourlay and Boas 1992). through the lung. Premature babies, who are
Children benefit from TNS (Lander 1993), in effect displaced fetuses, have the added
and patient-controlled analgesia can be shock of being delivered into a world against
adapted for children from age four years. For which they have limited defence mechan-
younger children, 'parent-controlled' analgesia isms, and sometimes they are without a basic
provides similar benefits. Nausea is common capacity for respiration, feeding or tempera-
in children and may need treatment. Infants ture control. The lower the gestational age,
given opioids exhibit no more respiratory the more keenly sensitive they are to their
depression than older children (Nichols 1993). environment. A neonatal unit (NNU) pro-
For ventilated children, of course, respiratory vides the technology and skill to care for sick
depression is not a concern. babies, whether full term or premature. But it
Methods to reduce pain perception include: is not always the ideal emotional environ-
ment, with its bright lights, chorus of noises
• according to 99% of children, the presence
and frequent disturbances. Recognition of
of a parent (Broom 1990),
this has led to an acknowledgement that as
• information on what will occur and what it
well as the importance of saving life, there is
will feel like,
the need to prevent physical, intellectual and
• distraction with toys, stroking, stories,
emotional impairment.
games or television.
Central to the baby's universe is his or her
mother. Bonding between child and mother
Postoperative management
is hindered by the barrier of the incubator
After heart surgery, atelectasis may be more and the mother's reticence in disturbing
extensive than in adults. For optimum 5a02, equipment. Since the discovery that NNU
the atelectatic lung is theoretically better in 'graduates' run an above-average risk of
the dependent position, but oxygen satu- suffering abuse in later life (Anon 1985),
ration varies (Polacek et al 1992). attention now focuses on facilitating attach-
Children like to be touched as little as ment between parents and child in this
possible after surgery. If coughing is neces- vulnerable early period. Parents need to be
sary, they prefer to splint the incision them- involved in the care and comfort of their
selves by leaning forwards with their arms child, and the child needs to hear and feel his
crossed or hugging a teddy bear. Children or her mother. Handling by health staff can
The neonatal unit 293
1. The immature respiratory centre causes Two previous assumptions about infants
irregular breathing patterns and occasional have now been questioned. It had been
periods of apnoea. thought that they were obliged to breathe
through their nose because of their large
2. For the first year of life the intercostal
tongues occluding the oropharynx, but this
muscles are immature, the ribs cartilage-
has been discounted for most babies,
nous and horizontal, and the rib cage
although they are still preferential nose
nearly three times as compliant as the
breathers (Sporik 1994). It had also been
lung (Papastamelos 1995). The dia-
thought that infants were unable to respond
phragm does most of the work of breath- to bronchodilators, but these drugs have now
ing, despite containing fewer fatigue- been proved effective, although response is
resistant fibres and working at a dis- varied and should be monitored (Holt 1995),
advantage because of its horizontal and mucosal oedema may create more
rather than oblique angle of insertion. obstruction than bronchospasm.
Work of breathing is two to three times
that of adults (Hoffman 1995). By age two
12.2.2 Care of the parents
the rib cage and lung are equally com-
pliant (Papastamelos 1995) and by age I longed as I have never longed for anything so
three or four, when more time is spent badly, to hold her ... to put her face against
upright, rib cage configuration is oblique mine, whisper that I was here, that it was all
rather than horizontal. right. . . I stroked her hand with my finger. . .
3. The response to heavy work loads is an and feeling her minute pink fingers holding so
increased rate rather than increased hard to mine, I was hit sideways and bowled
depth of breathing. over by the purest, tenderest, most passionately
4. Hypoxaemia tends to cause bradycardia committed love I have ever felt . . .
rather than tachycardia. Immature myo- I couldn't bear to ... not be able to help her
cardium has less capacity to increase myself at all ... It hurt me so much, to see her
stroke volume, and bradycardia often weak, in distress and apparently struggling so
causes a fall in cardiac output. hard . . . I wanted to drag everything away
294 Physiotherapy for children and infants
from her, every bit of machinery, to pick her up child when attached to awesome equipment,
and hold her to my breast, even if it meant that advice on baby massage, and a rocking chair
she died in a few minutes. That would be better and other comforts for them and their child.
than having her suffer this, the pain, fear, noise, Rocking beds have also been advocated
bewilderment, being surrounded and handled by because of the beneficial effects on vent-
strangers . .. ilation, feeding, crying and length of stay
Every time I touched her, she relaxed and the (Sammon 1994). Neonatal oxygen consump-
monitors showed it, her heart rate settled, her tion is reduced by skin contact with the
limbs were calmer, her eyes searched less mother, hearing the mother's heartbeat and
frantically about . . . voice, and being held between the breasts
I had never held her to me and I ached to do (Ludington 1990). Visiting should be un-
so, she seemed so alone in there amongst all the restricted and include grandparents and
wires and drips and tubes and monitors. siblings Oohnstone 1994).
Hill 1989 A team approach to this form of stress
reduction results in a more stable cardio-
When working in a neonatal unit, we need pulmonary system, with benefits lasting for
some understanding of the powerful feelings months after discharge (Mann 1986).
between parent and infant.
hypoxia or hyperoxia. For babies on trans- ing chronic lung disease of prematurity (Cog-
cutaneous monitors, Ptc02 should be kept hill et al 1991). These complications can be
between 6.7-10.7 kPa (50-80 mmHg) and reduced by low tidal volume, high-frequency
PtcC02 between 5.3-7.3 kPa (40-55 mmHg). ventilation, negative pressure ventilation
(Samuels and Southall 1989), ECMO or liquid
ventilation (Chapter 9).
12.2.6 Mechanical ventilation
PEEP is generally used in all neonates at
If neither oxygen therapy nor CPAP maintain 2-5 cmH20, but is specifically required if
oxygenation, IPPV may be needed. Elaborate Pa02 is < 6.7 kPa (50 mmHg) with oxygen>
systems for endotracheal tube fixation are 60% (Pilbeam 1992, p. 554). Weaning from
required to prevent such a heavy contraption IPPV is by gradual reduction in peak pres-
becoming disconnected from such a tiny sure, PEEP, inspired oxygen and/or I:E ratio.
nose. Tracheal tubes are uncuffed, allowing a Secretions in the endotracheal tube can
slight air leak and less risk of mucosal double airflow resistance (Chatburn 1991),
damage, especially as the subglottic area is and shallow suction is indicated as required.
the narrowest part of the child's airway and Physiotherapy may be indicated after extuba-
babies tend to move more than adults. tion if airway irritation has created excess
Pressure-controlled ventilators are used for secretions.
infants up to one year old, so that flow can
increase automatically to compensate for the
12.2.7 Advanced life support
cuff leak, and high peak airway pressures can
be avoided. Prolonged extra corporeal gas exchange and
A quarter of ventilated babies develop other life support systems are being used
some form of barotrauma such as pneumo- with increasing success as a rescue therapy
thorax (suspected if there is rapid deterior- for full-term infants with severe but re-
ation without apparent cause) or pulmonary versible respiratory failure (Bower 1995).
interstitial emphysema (PIE), which is identi- Bleeding may occur during suction.
fiable as black-and-white streaks radiating
from the hila which do not branch or taper
12.3 PHYSIOTHERAPY FOR INFANTS
towards the periphery, unlike vascular mark-
ings. The high compliance of the chest wall The main role of the physiotherapist is to
and low collagen and elastic content of lung judge if and when intervention is appropri-
tissue affords little protection against lung ate. Treatment itself may be carried out by
overdistension (Parker and Hernandez 1993), the physiotherapist, specialist nurse or in
and the lungs are subjected to the alternating part by the parent.
effects of positive pressure, which repeatedly The maxim that routine treatment is taboo
stretches the more compliant regions, and is never more apt than in the NNU. Infants
lung deflation, which induces regional atelec- should not, for example, be treated just
tasis of less compliant regions. Babies with because they are on a ventilator. The
RDS (p. 300) are particularly at risk of PIE approach is to assess, identify the problem
because of their lack of surfactant, whereas and balance up the benefits and risks of
those with more compliant lungs are more at intervention.
risk of pneumothorax (Chatburn 1991). A
pneumothorax is treated by chest tube
12.3.1 Indications
drainage, but PIE is difficult to treat and often
leads to lung damage, up to a third of Physiotherapy may be needed if there are
ventilated low-birth-weight babies develop- excess secretions that cannot be cleared by
296 Physiotherapy for children and infants
suction alone, if there is poor gas exchange, Vigilance is needed to avoid dislodging
increased work of breathing or radiological drips, drains or the tracheal tube.
evidence of atelectasis. All babies need Good teamwork is required to ensure
assessment, although not necessarily hands- periods of undisturbed sleep. Sleep fragmen-
on assessment. Intubated babies need a tation brings risks of hypoxaemia, hyperten-
check on their humidifiers. Auscultation, sion and apnoea (Cole et aI1990).
oxygen saturation and liaison with their
nurse on the quality of secretions will indi- 12.3.3 Assessment
cate whether their tracheal tubes may have Notes, charts and reports give information on
become encrusted with secretions. Post- birth and other history, weight gain or loss
extubation physiotherapy may be indicated (indicating general health), response to hand-
in case of thick secretions. Babies need ling and suction, results of the last suction,
assessment after surgery, and all neonates mode and frequency of feeds and whether
who have aspirated meconium need treat- the baby has rested since the last inter-
ment unless contraindicated. vention. A recent history of self-limiting
bradycardia or periods of apnoea suggests
12.3.2 Precautions that suction might be needed. Much reliance
is placed on this information because of
Physiotherapy is contraindicated for babies the limitations of clinical and subjective
who are hypothermic, show cardiac instability examination.
(unless this is due to hypoxia), have an Monitors should be observed for baseline
undrained pneumothorax or are producing levels and for changes during treatment.
fresh blood-stained secretions. Physiological distress shows as bradycardia
Because of the poorly developed defences (HR < 90 bpm), tachypnoea or apnoea.
of neonates, all health workers should wash Worsening oxygenation may be a sign of
their hands meticulously and avoid the NNU accumulating secretions or infection.
if they have even a minor infection. Auscultation seems to pick up every sound
Treatment should be scheduled before in the unit except a baby's breath sounds.
feeds or at least one hour after feeds. If Rapid shallow breathing, or ventilator noise
physiotherapy is essential within these times, and other referred sounds, can thwart the
the gastric contents should be aspirated by listener. Wheezes and crackles may be picked
syringe before treatment and replaced after- up, but are often easier to feel than hear.
wards. X-ray findings may indicate atelectasis or
Both infant and monitors should be ob- consolidation, with the right upper lobe
served before, during and after treatment. needing special attention because of its
Casual handling should be avoided and tendency to collapse. Babies have a large
physiotherapy sessions structured so that the thymus that looks similar to right upper lobe
infant is rested before and after treatment. consolidation. The appearance of blebs
Cumulative procedures or major disturb- suggests pulmonary interstitial emphysema
ances such as suction can drop the Pa02 by as and contraindicates bag-squeezing.
much as 5.3 kPa (40 mmHg) (Speidel 1978).
12.3.4 Methods to decrease the work of
If the infant is receiving phototherapy for
treatment of jaundice, the light can be breathing
removed temporarily for physiotherapy, but Work of breathing is increased by stress
the baby's protective eye shields must be (Wessel 1993). Measures to reduce stress are
replaced afterwards. the following:
Physiotherapy for infants 297
• limit the total treatment time to between 10 must be reassured of this, but before dis-
seconds and 10 minutes, depending on charge there should be a gradual change to
the infant's response, spending more time in supine.
• talk to the infant as required (but not a The side-lying position allows greater
continuous chatter), diaphragmatic excursion than supine. If there
• keep other sounds to a minimum to avoid is a pneumothorax or unilateral interstitial
risk of hearing loss (Cole et aI1990), emphysema, side-lying with the affected
• minimize bright lights by keeping the lung dependent is preferable (Swingle et al
incubator partially covered, 1984). When babies are in side-lying, they
• avoid restraints unless essential (Sparsholt respond best when the trunk and limbs are
1989), supported in the flexed position.
• prevent unnecessary heat loss, especially Precautions to observe when positioning a
from the head, neonate are to monitor the effects of hand-
• avoid procedures that cause crying because ling, avoid dragging on the tracheal tube and
this leads to irregular breathing, apnoeic check for any air leak around the tracheal
episodes, increased pulmonary artery tube after position change.
pressure and hypoxaemia (Murphy 1991).
20
10
2 3
Minutes
the airways are clear so that secondary pulmonary interstitial oedema, pulmonary
infection is prevented. Nurses should be hypertension and radiological evidence of
taught this technique unless physiotherapy is cyst formation and ill-defined opacification.
available straight after birth. Prevention is by strict attention to vent-
ilator management in order to minimize
inflation pressures (Greenough 1990), or the
12.4.3 Intraventricular haemorrhage
use of CPAP to reduce Fr0 2 • Treatment is by
Bleeding into the cerebral ventricles may diuretics, bronchodilators and, ironically, in-
occur in the first week of premature life, creasing levels of oxygen and higher inflation
when swings in BP or blood gases can cause pressures as the disorder progresses. The child
the fragile capillaries in the ventricles to may need long-term hospitalization.
burst. Precipitating factors are suction, endo- Physiotherapy is indicated if secretions are
tracheal obstruction or intubation without present because pulmonary defence is dis-
sedation (Wren 1989). Small haemorrhages rupted and the lungs are prone to recurrent
are asymptomatic, but massive bleeding atelectasis and infection. However, it may be
causes cerebral damage. The head-down tip contraindicated if the child is wheezy or has
is contraindicated if this condition is dia- pulmonary hypertension. If necessary, it is
gnosed. best carried out after bronchodilators and
stopped if wheezing is precipitated. Percus-
sion in alternate side-lying and sometimes
12.4.4 Pneumonia
suction can be given, with extra attention to
Pneumonia is relatively uncommon in neo- the upper lobes. This may be needed after
nates. The pathology is similar to pneumonia discharge, either directly or through parent
in adults, but the clinical course is more acute education. After long hospitalization, parents
and ventilator assistance may be needed. need comprehensive preparation for dis-
Clinical features are a respiratory rate> 60, charge so that they build up confidence and
chest indrawing and an X-ray similar to RDS. do not feel that they have just 'borrowed'
Physiotherapy may be indicated in the later their baby from hospital to take home.
clearing-up stages. Domiciliary oxygen, BiPAP or nasal vent-
ilation may be required (Teague 1995).
About 30% of infants with BPD die, but if
12.4.5 Chronic lung disease of
infections are prevented, the lungs repair as
prematurity
they grow. Survivors may have neurological
Premature infants who receive prolonged problems, are at risk of cot death and are
mechanical ventilation may develop chronic thought to carry airways obstruction and
lung disease of prematurity, also known as bronchial hyperreactivity into adulthood
bronchopulmonary dysplasia (BPD). This is a (Hess 1991).
form of barotrauma resulting from high-
volume, high-oxygen ventilation, and is con- 12.5 EMERGENCIES IN THE
sidered to be present if there is oxygen NEONATAL UNIT
dependency for more than 28 days following
12.5.1 Sudden hypoxaemia
IPPV in the first weeks of life (Hess 1991).
Inflammation, opportunistic infection and If oximetry is not available, bradycardia may
exudation of fluids and protein flourish, be the first sign of hypoxaemia, especially if
leading to varying amounts of scarring and the infant is fighting the ventilator. Bagging
disordered growth. Signs are persistent res- with gentle pressure should be carried out
piratory distress, high oxygen requirements, until the cause is found. A sudden disturb-
302 Physiotherapy for children and infants
ance in blood gases could mean a displaced encircling the chest with both hands and
or blocked tracheal tube (no change in CVP), squeezing the mid-sternum to a depth of
or barotrauma (increased CVP). 2 em, with the thumbs one finger's breadth
below an imaginary line joining the nipples,
12.5.2 Apnoeic aHacks and ensuring that the chest fully re-expands
between compressions. The ratio of breaths
Neonates who stop breathing can usually be to compressions is 1:5 in infants and children,
revived by skin stimulation. If unsuccessful, repeated 20 times per minute. The easiest
intubation may be needed. pulse to locate is the brachial pulse on the
inside of the upper arm (Zideman 1994).
12.5.3 Pneumothorax
Any sudden deterioration in the condition of RECOMMENDED READING
a ventilated infant raises suspicions of baro- Downs, J. and Parker, A. (1991) Chest physiother-
trauma. A pneumothorax is evident on X-ray, apy for preterm infants. Paed. Nurs, 3(2), 14-17.
but clinical signs can be elusive. Breath Gillespie, D. (1989) Let's listen to the children.
sounds may still be present because sound is Respir. Dis. Pract., 6(5), 23.
easily transmitted through the small chest Howard, F. (1994) Endotracheal suctioning and
from the unaffected lung. A tension pneumo- the neonate. Paediatr. Nurs., 6(7), 14-17.
James, I. (1991) Respiratory management in
thorax causes bradycardia and a plunge in paediatrics. Care Crit. Ill., 7, 47-50.
cardiac output. Hall, S.J. (1995) Paediatric pain assessment in
intensive care units. Int. Crit. Care Nurs., 1, 20-
12.5.4 Cardiorespiratory arrest 5.
LaMontagne, L.L. and Pawlak, R. (1990) Stress
Most cardiorespiratory arrests in infants and and coping of parents of children in a pediatric
children are of respiratory origin. Establish- ICU. Heart Lung, 19, 416-21.
ing a patent airway by head positioning may Parker, A. (1993) Paediatrics, in Physiotherapy for
prevent progress of the event. Care should be Respiratory and Cardiac Problems (eds B.A. Web-
taken to avoid pressing on the soft tissues ber and J.A. Pryor), Churchill Livingstone,
Edinburgh.
under the chin or overextending the neck Ratcliffe, J.M. (1994) Sedation in the ICU. Curro
because this may occlude the trachea. Paeds., 4, 106-9.
If an oral airway is required, it is not turned Rau, J.L. (1991) Delivery of aerosolized drugs to
upside down for insertion, as in the adult. In neonatal and pediatric patients. Respir. Care, 36,
the NNU, oxygen by bag and mask is usually 514-40.
available, but if mouth-to-mouth breathing is Rees, J. and Price, J. (1995) Asthma in children:
treatment. Br. Med. ,., 310, 1522-4.
necessary, both mouth and nose should be
Russell, R.I.R. (1993) Complications of mechanical
covered with the rescuer's mouth and gentle ventilation in children. Paed. Resp. Med., 1, 17-
puffs given. 20.
If artificial ventilation does not restore the Shield, J.P.H. and Baum, J.D. (1994) Children's
heart beat, chest compression is started by consent to treatment. Br. Med. ,., 308, 1182-3.
13. Evaluation of chest physiotherapy
Introduction Outcome evaluation
Standards patientquestionnarre
personal standards outcome measures
departmental standards Literature criticism
Audit Research
Self-assessment Continuing education
Recommended reading
the outcome is attributable to what is Students and junior staff require the
being investigated. following:
6. Randomized controlled trials allocate • a balance of guidance and responsibility,
subjects randomly so that certain charac- • clarification of expectations on both sides,
teristics are unlikely to be over-represented • feedback,
in any group. • assistance in setting feasible objectives and
7. Blind trials keep subjects in the dark assessing whether these are met,
about which side of the study they are • praise when due,
participating in, so that the placebo effect • encouragement to work creatively and not
is minimized. become a clone of their seniors,
8. Double-blind trails prevent investigators • correction in a way that does not under-
knowing the subjects' allocation. mine their confidence or belittle them in
9. Meta-analysis combines results from front of patients,
different studies on the same question • space for reflection,
into 'master results' Oones 1994). • enjoyment in their work.
Commonly encountered obstacles are: Senior students expect to be asked how
closely they want to be supervised (Onuoha
• lack of defined categorization in physio-
1994).
therapy compared with medicine,
Seniors have the privilege and opportunity
• statistical significance not necessarily rep-
to inspire as well as educate, and indeed it is
resenting clinical significance,
their human qualities that are often con-
• unfamiliarity with the research process,
sidered of equal or more importance than
• shortage of time, money or support,
their clinical skills (Neville and French 1991).
• anxiety about ethics.
Learning through role modelling takes place
The ethical question 'What right do I have through:
to withhold treatment from some patients?' • enthusiasm, honesty and commitment,
is offset by 'What right do I have to give • willingness to say 'I don't know',
treatment that has not been proved effective?'. • self-evaluation,
There are no known facts, only the present • respect for juniors so that they in tum
theory of the day. respect their patients,
Howell quoted by Conway 1992a • setting priorities,
• toleration of a wide range of normality,
13.8 CONTINUING EDUCATION • use of language, e.g. 'this person with
COPD', rather than 'this chronny
Sometimes learning requires courage. To become bronny',
a learner is to become vulnerable. • avoidance of labelling patients as difficult
Berwick 1991 or not liked,
Updating knowledge requires structured • coaxing the nervous patient, soothing the
planning and the fostering of a non- fearful, encouraging the weary,
judgemental atmosphere in which staff feel • constructive relationships with medical
free to discuss uncertainties about their work. and other staff.
Lack of this freedom leads to routine treat- Communication skills and empathy are not
ment. Physiotherapists are now expected to incompatible with technical competence.
update themselves continually. As Alfred Both need to be learnt, not left for uncertain
North Whitehead said in 1933, 'knowledge assimilation. Sensitivity should be developed
keeps no better than fish'. rather then blunted, e.g. by discussing
Recommended reading 311
a ward round in which a patient's needs are selecting articles from respiratory journals
ignored, rather than accepting this behaviour and analysing their contents. A file of articles
as normal. written by patients can be compiled (e.g.
It is common to become inured to the Appendix D).
distress of patients by prolonged exposure, Continuing education lays the foundation
and easy to forget the reactions of young staff for lifelong self-evaluation. It incorporates
or students when fresh to the intensive care the opportunity to show that compassion is
unit: 'What can the patients be feeling? Why fundamental to effective respiratory care, not
are ICU staff not upset at working closely an old-fashioned, unscientific luxury reser-
with such ill people? Whence this light- ved for the naIve and uninitiated.
heartedness?' Seniors need to maintain
awareness of these reactions lest juniors feel RECOMMENDED READING
obliged to conform. Barnard, s. (1995) Models for intervention audit.
Case presentations and a journal club can Physiotherapy, 81, 202-7.
be enjoyable methods to update ideas and Hartigan, G. (1995) Choosing a method for clinical
evaluate practice. New staff may need help in audit. Physiotherapy, 81, 187-8.
Glossary of definitions, abbreviations,
symbols and normal values
See also index for definitions in the text. a useful measure of aerobic capacity for
Values in [square brackets] are from the USA monitoring endurance training, but of
(all values are approximate). limited value in severe COPD because peak
2,3-DPG Enzyme in red blood cells, t in exercise levels are often reached below the
chronic hypoxaemia, shifting O 2 dissociation anaerobic threshold. In normal subjects,
curve to right and allowing easier unload- anaerobic threshold can be increased by
ing of O 2 to hypoxic tissues. 25-40%.
A Alveolar, e.g. PA02. Angioplasty Invasive but non-surgical dila-
a Arterial, e.g. Pa02. tation of coronary artery stenosis, using
ACBT Active cycle of breathing techniques. catheter via femoral puncture, or laser.
ACE inhibiters Angiotensin-converting en- Anoxia Synonymous with hypoxia, although
zyme inhibiter drugs, for hypertension, implying a more complete oxygen lack.
e.g. captopril, enalapril. AP Anteroposterior.
ACPRC Association of Chartered Physio- APACHE Acute Physiology And Chronic
therapists in Respiratory Care. Health Evaluation (scoring system to meas-
ADL Activities of daily living. ure severity of illness).
Adult respiratory distress syndrome Alterna- Apgar score Combined measurement of heart
tive name for acute respiratory distress rate, respiratory effort, muscle tone, reflex
syndrome. irritability and colour (scoring system to
Aerosol Suspension of particles in a gas measure birth asphyxiation).
stream. Therapeutic aerosols are for Apneustic breathing Prolonged inspiration
humidification and drug delivery, other usually due to brain damage.
aerosols spread some lung infections and Apnoea Absence of breathing for > 10
allow damage from noxious agents. seconds.
AIDS Acquired immune deficiency syndrome. ARDS Acute respiratory distress syndrome.
Air trapping Retention of inspired gas in Arteriovenous oxygen difference Assess-
poorly ventilated areas of lung. ment of oxygen delivered to, and returning
Airway closure Closure of small airways, from, tissue, related to metabolic rate and
mostly in dependent lung regions during calculated from arterial and mixed venous
expiration. . blood samples.
Airway resistance Normal: 0.5-2.0 cmH20/llsec. Ascites Fluid in the abdominal cavity.
Albumin Plasma protein responsible for pro- Aspiration (1) Inhalation of unwanted sub-
viding most osmotic pressure in blood. stances (e.g. gastric acid, sea water) into
Normal: 40-60 gil, [4.0-6.0 g/100ml]. the lungs, or (2) therapeutic removal of
~ albumin suggests malnutrition, blood fluid or gas from a cavity such as the
loss, liver failure, nephrotic syndrome. pleural space.
Anaerobic threshold Highest oxygen con- Atelectasis Alveolar collapse due to poor
sumption during exercise, above which lung expansion or complete obstruction of
sustained lactic acidosis occurs. Normally an airway.
Glossary 313
Base deficit Negative base excess. tures outside lung that participate in breath-
Base excess (BE) Normal: from -2 to +2 ing movements.
mmolll. Closing capacity Volume at which airway
BB 'Blue bloater' patient. closure begins (as lung volume is reduced
Bicarbonate Normal 22-26 mmoUI. towards residual volume, dependent air-
Biot's respiration Irregular cycles of deep ways begin to close); rises with age until it
gasps and apnoea. equals FRC at about 66 years in standing,
BiPAP Bi-Ievel positive airways pressure. 44 years in supine.
Bleb Collection of air under visceral pleura, Closing volume Closing capacity minus
outside alveoli (see also bulla). residual volume.
Blood culture Blood taken from a pyrexial Normal: 10% of vital capacity in young
patient to identify responsible micro- people with normal lungs.
organism. Age 65: 40% of Vc.
bpm Beats per minute. Increases (i.e. becomes a greater propor-
Bradypnoea Slow breathing. tion of FRC) with small airways dis-
Bronchomalacia Degeneration of elastic and ease, smoking and extremes of age.
connective tissue of trachea and bronchi. Clotting studies
Bulla Collection of air inside distended Platelet count
alveoli, over 1 em in diameter, caused by Normal: 140000-400000 mm-3 •
alveolar destruction (see also bleb). Low enough to cause spontaneous bleed-
CABG Coronary artery bypass graft. ing: 20000-30000.
Cachectic Emaciated. Prothrombin time (PT)
CAL Chronic airflow limitation, i.e. COPD. Normal: 12-30 seconds.
Calcium Normal: 2.2-2.6 mmoUI. Expressed as internalized normalized ratio
CCF Congestive cardiac failure. (INR)
Ca02 Arterial oxygen content. Normal: < 1-1.3.
Normal: 17-20 mU100ml. If on warfarin: 4--4.5 (pulmonary em-
Cardiac enzymes Enzymes released from bolus), 2-4 (myocardial infarct), 1.8
damaged heart muscle after myocardial (postoperative ).
infarction. With DIC: up to 1.5-2.2.
Cardiac index Cardiac output divided by Expressed as activated partial thrombo-
body surface area. plastin time (PIT)
Normal 2.5-3.5 Uminlm2 • Normal: 25-35 seconds.
Cardiac output (0) Heart rate x stroke DIC: 50 seconds.
volume (stroke volume depends on pre- CMV Controlled mandatory ventilation.
load, afterload and contractility), i.e. CNS Central nervous system.
amount of blood ejected by left ventricle CO Cardiac output.
per minute. COAD Chronic obstructive airways disease
Normal; 4-6 Umin at rest, up to 25 Umin on (= COPD).
exercise. Collateral ventilation Exchange of inspired
Catecholamines Collective term for com- gas between adjacent lung units.
pounds having a sympathomimetic action, Colostomy Surgical creation of opening into
e.g. adrenaline. large bowel.
CF Cystic fibrosis. Compliance of lung Change in volume in
Chest wall Rib cage, diaphragm, abdominal response to change in pressure (aV/ap).
contents and abdominal wall, i.e. struc- Normal: 0.09-0.40 UcmH2 0.
314 Glossary
shift in dissociation curve (high value PCWP Pulmonary capillary wedge pressure
suggests slow affinity of Hb for oxygen). (= PAWP).
Normal: 27-28 mmHg. PD Postural drainage.
PA Posteroanterior. PE Pulmonary embolus.
P A-a02 (alveolar to arterial oxygen gradient) PEEP Positive end-expiratory pressure.
Difference in partial pressures of alveolar PEFR Peak expiratory flow rate (peak flow).
oxygen (PA02) and arterial oxygen (Pa02)' PEmax Maximum expiratory pressure at the
Normal on room air: < 10 mmHg (re- mouth.
flecting normal anatomical shunt). PEP Positive expiratory pressure.
i in respiratory disease (due to ~ VA/Q pH Hydrogen ion.
mismatch), Phlebotomy/venesection Therapeutic with-
i on exercise (up to 20-30 mmHg), i in drawal of blood.
the elderly (up to 30 mmHg), i on PImax Maximum inspiratory pressure at the
supplemental oxygen (up to 100 mmHg mouth (see MIP).
on 100% oxygen). PIP Peak inspiratory pressure.
Pack years Number of years of smoking Plasma osmolarity Normal: 280--300 m osmolll.
multiplied by number of packs smoked -plasty Reconstruction.
each day, e.g. smoking one pack a day for Platelet count See clotting studies.
30 years = 30 pack year history. Platypnoea Difficulty breathing while sitting
Packed cell volume See PCV. up.
Pancoast's tumour Tumour of upper lobe Plethoric Florid complexion due to excess red
affecting brachial plexus, sometimes indic- blood cells.
ated by wasting of small muscles of the Pneumonitis Inflammation of lung tissue due
hand. to chemical or physical insult.
Pa02 Partial pressure of oxygen in arterial Polysomnography Recording of physiological
blood. parameters during sleep.
PaC02 Partial pressure of CO2 in arterial Polyuria i urine output, i.e. > 100 mllh.
blood. POMR Problem oriented medical record.
PAP Peak airways pressure (= peak inspir- Potassium (K) Electrolyte in plasma or urine.
atory pressure). Normal in plasma: 3.5--5.0 mmolll.
PAP Pulmonary artery pressure. ~ K (hypokalaemia) predisposes to car-
Normal: 10-20 mmHg. diac arrhythmias, i K (hyperkalaemia)
Parenchyma Gas exchanging part of lung, suggests kidney failure.
largely alveolar tissue. Poudrage Pleurodesis.
Parenchymal lung disease Disease affecting PP 'Pink puffer' patient.
alveolar walls, e.g. interstitial lung disease, Prader-Willi syndrome Combination of
pneumonia, pulmonary TB, ARDS. obesity, hypotonia and impaired cognitive
PAWP Pulmonary artery wedge pressure. ability, associated with respiratory prob-
Normal: 5--12 mmHg. lems due to reduced diaphragmatic excur-
Paw Mean airway pressure. sion, upper airway soft-tissue collapse and
PCA Patient controlled analgesia. sleep apnoea.
PCP Pneumocystis carinii pneumonia. PT Prothrombin time (see clotting studies).
PCV Packed cell volume. Psittacosis Infectious disease of birds trans-
Normal: 0.40-0.50 (men), 0.36--0.47 mitted to humans as atypical pneumonia.
(women). PtC02 transcutaneous oxygen tension.
i in polycythaemia, ~ in anaemia. PtcC02 Transcutaneous carbon-dioxide ten-
Equivalent to haematocrit. sion.
318 Glossary
Adrenaline Epinephrine
Accident and Emergency (A & E) Emergency Room (ER)
ASAP (as soon as possible) Stat
Cardiac arrest Code
Chest drains Chest tubes
Chronic obstructive airways diseases Chronic obstructive pulmonary disease
Community care Home care
Consultant Staff person
Drip IV
Drugs Medication
Entonox Nitronox (USA)
ECG EKG
Frame Walker
General practice Primary care/family practice
Hospital Health Sciences CenteriFacility
Houseman/woman Intern
Lignocaine Lidocaine
mm of Hg (unit of pressure) torr
Nil by mouth NPO
Patient's notes Patient's chart
Passive or active movements Range of motion
Peak expiratory flow rate Maximum expiratory flow rate
Queue Line up
Referral Consult
Registrar Resident
Respiratory physiotherapist Part physical therapist, part respiratory therapist (USA)
RTA (road traffic accident) MYA (motor vehicle accident)
Salbutamol Albuterol (USA)
Sluice Utility room
Splint Cast
Stick Cane
Theatre Operating room or OR
Walk or mobilize Ambulate
Ward Floor
1st floor 2nd floor
Appendix B: Postural drainage positions
1. UPPER LOBES 4. LOWER LOBE
l(a) Apical segments of both upper lobes- 4(a) Apical segments of both lower lobes -
sitting upright prone, head turned to side
l(b) Posterior segment of right upper lobe- 4(b) Anterior basal segments of both lower
left-side-Iying, turned 45° towards lobes - supine, foot of bed raised 46 ern
prone (18 ins)
l(e) Posterior segment of left upper lobe - 4(e) Posterior basal segments of both lower
right-side-Iying, turned 45° towards lobes - prone, head turned to side, foot
prone, shoulders raised 30 ern (12 ins) of bed raised 46 em (18 ins)
l(d) Anterior segments of both upper lobes 4(d) Medial basal segment - right-side-
- supine lying, foot of bed raised 46 ern (18 ins)
4(e) Lateral basal segment - left-side-lying,
2. MIDDLE LOBE foot of bed raised 46 ern (18 ins)
Lateral and medial segments - supine,
quarter turned to left, foot of bed raised 35 ern From: Downie, P.A. (1987) (ed.) Cash's Text-
(14 ins) book of Chest Heart and Vascular Disorders for
Physiotherapists, Faber, London, with per-
3. LINGULA mission.
Superior and inferior segments - supine,
quarter turned to right, foot of bed raised
35 ern (14 ins)
Appendix B 323
l(a)
He)
1 (d)
4(b)
4(c)
4(e)
Appendix C: Resources and
organizations
Action for Sick Children, Argyle House, 29- Surrey, CR5 3LT. (01737) 557997, fax
31 Euston Rd, London NW1 2SD, UK. (01737) 556671.
(0171) 8332041. Booklets and references on Canadian Lung Association, Suite 908,
postoperative pain. 75 Albert St, Ottawa, Ontario, KIP 5E7. + 1
American Association for Respiratory Care, (613) 237 1208.
11030 Ables Ln, Dallas, Texas, 75229. +1 Carbon monoxide biofeedback for smoking
(214) 243 2272. cessation, contact ASH, above.
American Lung Association and American Carers National Association, 20 Glasshouse
Thoracic Society, 1740 Broadway, New Yard, London EC1A 4JS, UK. (0171) 490
York, NY 10019-4374. +1 (212) 315 8700. 8818, fax (0171) 490 8824.
Includes 'Superstuff' children's asthma CPAP and BiPAP equipment:
education programme. Medicaid, Hook Lane, Pagham, Sussex
ASH (Action on Smoking and Health), 109 P021 3PP, UK. (01243) 267321, fax (01243)
Gloucester Place, London W1H 3DA, UK. 262556.
(0171) 935 3519, fax (0171) 935 3463. ResCare, 68 Milton Park, Abingdon, Oxon
Association of Chartered Physiotherapists in OX144RX, UK. (01235) 862997, fax (01235)
Respiratory Care (ACPRC), c/o CSP, 14 831336.
Bedford Row, London WC1R 4ED, UK. Respironics, 530 Seco Rd, Monroeville, PA
(0171) 306 6666. 15146, USA.
Asthma and Allergy Foundation of America, Cystic Fibrosis Research Trust and Associ-
1717 Massachusetts, Washington, DC, ation of Cystic Fibrosis Adults, 5 Blyth Rd,
USA. + 1 (202) 265 0265. Bromley, Kent BR1 3RS, UK. (0181) 464
7211, fax (0181) 313 0472.
Asthma Society of Canada, PO Box 213,
Flutter: Clement Clarke, Airmed House,
Station K, Toronto, Ontario M4P 2G5. + 1
Edinburgh Way, Harlow, Essex CM20
(416) 9779684.
2ED. (01279) 414969, fax (01279) 635232.
BACUP (British Association of Cancer United Guillain-Barre Syndrome Support Group,
Patients), 3 Bath Place, London EC2A 3JR. Foxley, Holdingham, Sleaford, Lincs,
(0171) 613 2121. NG34 8NR, UK. (01529) 304615.
BiPAP equipment see CPAP. Headway (Head injuries association), 7 King
British Lung Foundation, 8 Peterborough Edward Court, King Edward Street,
Mews, London SW6 3BL, UK. (0171) 371 Nottingham NG1 lEW. (0115) 924 0800,
7704. Includes Breathe Easy Club (self-help support group (0115) 967 9669, fax (0115)
club for patients) and Lung and Asthma 9240432.
Information Agency (epidemiological data- Inspiratory muscle trainers:
base for health staff). Medix, Medix House, Catthorpe, Lutter-
British Snoring and Sleep Apnoea Associ- worth, Leics, L176DB, UK. (01788) 860366.
ation, The Steps, How Lane, Chipstead, Healthscan, Cedar Grove, NJ 07009, USA.
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Index
Page numbers appearing in bold represent figures, page numbers appearing in italic represent tables.
Posture 24, 158, 187 Quadriplegia 271 see also Oxygen, saturation
Potassium 247 Questionnaire Sarcoidosis 78
Prednisolone 100 for assessment 151 Scleroderma 78
Prednisone 100 for hyperventilation Secretions 2, 249
Preload 240 syndrome 208 to clear 128--44, 181, 256-9
Pre-operative management 172 for outcome evaluation 306 see also Mucus; Sputum
for children 290 Sedatives 241
Pressure Radiolabelling 128 Segmentectomy 184
alveolar 4 Radionuclide imaging 40 Seizure 262
central venous 234 Rebreathing bag 253, 254 Septic shock 281
intrathoracic 4 Rebreathing mask 93 Sexuality 153
left atrial 234 Recession, see lndrawing Shock 280
mean airway 224 Recurrent laryngeal nerve 184 Shortness of breath
mean arterial 234, 275 Rehabilitation scale 161
peak airway 224, 248 cardiac 187 see also Breathlessness
plateau 224, 227 pulmonary 146-68 Shunt, pulmonary 10, 11, 90
pleural 4 Relaxation 156, 164, 189, 210 Shuttle test 34
pulmonary artery 234 Renal, see Kidney disease Sickle cell anaemia 87
Research 309 Sigh 227, 256
right atrial 234
Residual volume 45, 46 Silent chest 30, 61
transdiaphragmatic 49
Resistance, airflow 5 Silhouette sign 37
transmural 4
Respiration 6 Sinus bradycardia 237
vascular 247
Respiratory arrest 261 Sinus rhythm 238
Pressure sores 251
Respiratory centre 3 Sinus tachycardia 237
Pressure support 225, 226
Respiratory distress syndrome Six minute distance 34
Pressure volume curve 5
300 Sleep 15, 19, 28, 122
Primary ciliary dyskinesia 74
Respiratory failure 13, 88 in leU 216, 245
Propanolol 159 Respiratory function tests 43-50 studies 49
Propofol 241, 246 Respiratory insufficiency 88 Sleep apnoea 83
Pseudomonas 24 Respiratory muscles 3 Sleeve resection 184
Pulmonary artery pressure 234, see also Diaphragm Small airways 47
235,240 Respiratory pump 3 Smoking 17-18, 153-4, 158
Pulmonary artery wedge Respiratory rate 25, 227 Smoke inhalation 279
pressure 235, 236 Retinopathy of immaturity 294 Sodium bicarbonate 132
Pulmonary capillary wedge Rheumatoid disease 78 Sodium cromoglycate 100
pressure 236 Rib fracture 4, 255, 272 Spacers 104, 105
Pulmonary embolism 12, 86, Rib springing 115 Spinal cord injury 271
264 Right atrial pressure 234 Spirogram 147
diagnosis 40 Right ventricular failure 86 Spirometry 147
postoperative 172, 181 see also Heart failure Sputum 128-9
Pulmonary hypertension 53, Rocking bed 127 assessment for 23-4
54, 103 Rotahalar 104, 105 drugs for 102
Pulmonary oedema 85-6 induced 76
assessment of 32, 33, 234, Salbutamol 100, 101, 159 specimen 143
236 Saline see also Secretions; Mucus
neurogenic 274 for humidification 132 Stair climbing
and suction 143 hypertonic 132 for exercise testing 34
on x-ray 38, 43 instillation 258, 299 for training 161
Pulse pressure 247 Salmeterol 100, 101, 102 Standards 304
Pulsus paradoxus 62 Sa02 Status asthmaticus 62
Pyrexia, see Fever in leU 247 Steam inhalation 129
364 Index