Cardiovascular & pulmonary physiotherapy

Cardiopulmonary physical therapists offer therapy for a wide variety of cardiopulmonary disorders. They also offer therapy before and after cardiac surgery (like coronary artery bypass surgery) and pulmonary surgery. Primary goals of this specialty include increasing endurance and functional independence. Manual therapy is used in this field to assist in clearing lung secretions experienced with cystic fibrosis. Patients with various disorders, including heart attacks, chronic obstructive pulmonary disease, and pulmonary fibrosis, can benefit^[1] from specialized cardiovascular and pulmonary physical therapists.

Physiotherapists treating patients following uncomplicated coronary artery bypass surgery (also called coronary artery bypass graft surgery, or CABG) surgery continue to use interventions such as deep breathing exercises that are not supported by best available evidence. Standardised guidelines may be required to better match clinical practice with current literature.^[2]

Diseases and Conditions Treated

Cystic Fibrosis

Cystic fibrosis (CF), also known as mucoviscidosis, is a genetic disorder that affects mostly the lungs, but also the pancreas, liver, kidneys, and intestines.^[3] Major advances over the past few years in the management of cystic fibrosis (CF) have resulted in dramatic improvements in longevity and quality of life for many patients. However, respiratory dysfunction remains responsible for much of the morbidity and mortality associated with the disorder. Physiotherapy has long played an important role in the respiratory management of the disease, and has had to adapt to the changes in disease pattern from infancy to adulthood. The role of the physiotherapist is not limited to airway clearance, but also includes encouragement and advice regarding exercise, posture and mobility, inhalation therapy and, in the later stages of the disease process, non-invasive respiratory support. It is generally felt that the use of chest physiotherapy in CF has lacked good scientific basis, and the current call for evidence-based medicine requires physiotherapists to scrutinize their practice closely.^[4]

Chronic Obstructive Pulmonary Disorder (COPD)

Chronic obstructive pulmonary disease (COPD), also known as chronic obstructive lung disease (COLD), and chronic obstructive airway disease (COAD), among others, is a type of obstructive lung disease characterized by chronically poor airflow. It typically worsens over time. The main symptoms include shortness of breath, cough, and excess sputum production.^[5] As COPD gets worse, subject may be short of breath even when one does simple things like get dressed or fix a meal. It gets harder to eat or exercise, and breathing takes much more energy. People often lose weight and get weaker.^[6]

Techniques

Active cycle of breathing techniques

The active cycle of breathing techniques (ACBT) is a flexible regimen comprising breathing control, thoracic expansion exercises and the FET, frequently combined with gravity-assisted positioning. Increasing lung volumes during thoracic expansion allows air to get behind distal secretions via collateral ventilatory channels. During a forced expiratory manoeuvre, compression and narrowing occurs within the airways at a point dependent on lung volume (the equal pressure point). This is shifted distally as a forced expiration is continued to low lung volume, thereby mobilizing peripheral secretions.

This technique has been reported to be an effective and efficient means of airway clearance^[7][8] with documented improvements in lung function^[9] and no detrimental effect on oxygen saturation.^[10] In comparative studies the ACBT has been found to be advantageous when compared with CCPT,^[11] Flutter,^[12][13] and PEP.^[14] When compared with the technique of autogenic drainage (AD) Miller et al., reported no differences in efficacy, although ACBT was associated with oxygen desaturation in some cases.^[15] There was, however, no significant overall difference in saturation between the two techniques. A more recent comparison of the Flutter and forced expiration with the ACBT reported no significant differences between the treatments for sputum weight, lung function tests or oxygen saturation.^[16]
One method suggested to perform ACBT is as follows:

Deep Breathing

1. Breath in deeply feeling your lower chest expand as far as possible. Try to keep your neck and shoulders relaxed.
2. Hold the breath for up to three seconds.
3. Let the air out gently.
4. Repeat this step 4 - 5 times.
5. Your physiotherapist may advise you to use your Incentive Spirometry at this point.

Relaxed Breathing / Breathing Control

This is normal, gentle breathing using the lower chest.

1. Rest one hand on your abdomen so that you can feel it rise and fall with your breathing.
2. Breathe in gently feeling your hand rise and your lower chest expand.
3. Breathe out gently allowing your shoulders to relax down. The breath out should be slow, like a “sigh”.

Huff

This is a short sharp breath out through an open mouth that helps to force the secretions out. To perform this, imagine you are trying to fog up a glass or mirror. Remember the huff needs to be through an open mouth, using your abdominal muscles.

Cough

Only cough if you feel the secretions are ready to be cleared.^[17][18]

Autogenic Drainage

Autogenic drainage is a respiratory self-drainage technique that utilizes controlled expiratory airflow (tidal breathing) to mobilise secretions. It consists of three phases:

1. Loosening peripheral secretions by breathing at low lung volumes (slow, deep air movement)
2. Collecting secretions from central airways by breathing at low to middle lung volumes (slow, mid-range air movement)
3. Expelling secretions from the central airways by breathing at mid to high lung volumes (shallow air movements)

The velocity or force of the expiratory airflow must be adjusted at each level of inspiration so that the highest possible airflow is reached in that generation of bronchi, without being high enough to cause the airways to collapse during coughing. Autogenic drainage does not use Postural Drainage positions since it is performed while sitting upright.

Instruction

Posture

• Choose a breath-stimulating position like sitting or reclining. Relax, with the neck slightly extended.
• Clear your nose and throat by blowing your nose and huffing.

Breathing in

• Slowly breathe in through the nose to keep the upper airways open. Use the diaphragm and/or the abdomen if possible.
• First take a large breath in, hold it for a moment. Breathe all the way out for as long as you can. Now you are at low lung volume. The size of breath and level at which you breathe depends on where the mucus is located.
• Take a small to normal breath in, and pause. Hold your breath for about 3 seconds. All the upper airways should be kept open. This improves the even filling of all lung parts. The pause allows time for the air to get behind the mucus.

Breathing out

• Breathe out through the mouth. Keep the upper airways open. This is your glottis, throat and mouth. Breathing out is done in a sighing manner. When you force your breath out the airways can collapse. You will hear a wheeze.
• At low lung level breathing use your abdominal muscles. Squeeze all the air out until you can breathe out no more.
• You hear the mucus rattling in the airways when breathing the right way. Put a hand on your upper chest, and feel the mucus vibrating. High frequencies mean that the mucus is in the small airways. Low frequencies mean that the mucus is in the large airways. Using this feedback lets you easily adjust the technique.

Repeat the cycle

Inhale slowly to avoid sending the mucus back down. Keep breathing at the low level until the mucus collects and moves upward.

Signs of this are:

• Crackling of the mucus can be heard as you exhale.
• You feel the mucus moving up.
• You feel a strong urge to cough.

The level of breathing is raised when any of the above occurs. Moving the breathing from lower to higher lung area takes the mucus with it. Finally the collected mucus reaches the large airways where it can be cleared by a high lung volume huff. Don't cough until the mucus is in the larger airways. Cough only if a huff did not move the mucus to the mouth.

You have now finished one cycle. Take a break of one to two minutes. Relax and perform breathing control before you start on the next cycle. The cycles are repeated during the session. A session lasts between twenty to forty-five minutes or until you feel all the mucus has been cleared. Do sessions of AD more often if you still have mucus present at the end of a session.^[19]

Assessment Tests

6 Minute Walk Test (6MWT)

Pulmonary rehabilitation is an evidence-based intervention for the management of patients with chronic obstructive pulmonary disease (COPD). In clinical practice, the 6-minute walk test (6MWT) is commonly used to assess changes in functional exercise capacity in COPD patients following pulmonary rehabilitation with the primary outcome reported being the distance walked during the test (i.e. 6MWD). The 6MWD has demonstrated validity and reliability after one familiarisation test and the capacity to detect changes following pulmonary rehabilitation. In addition to assessing the outcomes of pulmonary rehabilitation, 6MWD may be used to quantify the magnitude of a patient's disability, prescribe a walking programme, identify patients likely to benefit from a rollator and to identify the presence of exercise-induced hypoxemia.

Method of Use

Equipment Required

• Stopwatch
• Measuring/trundle wheel to measure distance covered
• 30-metre stretch of unimpeded walkway
• Pulse oximeter for measuring heart rate and oxygen saturation
• Borg Breathlessness Scale

Set-Up

• Place cones at either end of the 30 metre stretch as turning points
• Have chairs set up either side and halfway along the walking stretch

Patient Instructions

"The object of this test is to walk as far as possible for 6 minutes. You will walk back and forth in this hallway. Six minutes is a long time to walk, so you will be exerting yourself. You will probably get out of breath or become exhausted. You are permitted to slow down, to stop, and to rest as necessary. You may lean against the wall while resting, but resume walking as soon as you are able. You will be walking back and forth around the cones. You should pivot briskly around the cones and continue back the other way without hesitation. Now I’m going to show you. Please watch the way I turn without hesitation.”

Read this standardised encouragement during the test:

• After the 1st minute: "You are doing well. You have 5 minutes to go."
• When the timer shows 4 minutes remaining: "Keep up the good work. You have 4 minutes to go."
• When the timer shows 3 minutes remaining: "You are doing well. You are halfway done."
• When the timer shows 2 minutes remaining: "Keep up the good work. You have only 2 minutes left."
• When the timer shows 1 minute remaining: "You are doing well. You only have 1 minute to go."
• With 15 seconds to go: "In a moment I’m going to tell you to stop. When I do, just stop right where you are and I will come to you."
• At 6 minutes: "Stop."

If the participant stops at any time prior, you can say: "You can lean against the wall if you would like; then continue walking whenever you feel able." Do not use other words of encouragement (or body language) to influence the patient’s walking speed. Accompany the participant along the walking course, but keep just behind them. Do not lead them.

If available, record the distance at which the oxygen saturation drops below 88%.^[20]

Modified Borg Scale for Perceived Dyspnea (Shortness of Breath)

The "Rating of Perceived Dyspnea (RPD) Scale" is used during exercise or tasks to decide the amount of shortness of breath the subject is having. Patient is asked to say how hard one is breathing on a scale of 0 to 10. On the scale, 0 is "no shortness of breath." A 10 represents "so much shortness of breath that you have to stop the activity." Using the RPD scale will help patient to be aware of how short of breath one is during a specific activity.

Modified Borg Rating Scale for Perceived Dyspnea

• 0: Nothing at all
• 0.5: Very, very slight shortness of breath
• 1: Very mild shortness of breath
• 2: Mild shortness of breath
• 3: Moderate shortness of breath or breathing difficulty
• 4: Somewhat severe
• 5: Strong or hard breathing
• 6: -
• 7: Severe shortness of breath or very hard breathing
• 8: -
• 9: Extremely severe
• 10: Shortness of breath so severe you need to stop.^[21]

Current Concepts

Randomized trials have demonstrated that pulmonary rehabilitation (PR) can improve dyspnea, exercise tolerance, and health-related quality of life. Rehabilitation has traditionally been provided in secondary care to patients with moderate to severe disease. However, current concepts are recommending that it should be delivered in a primary and community care setting for patients with milder disease.

There are several opportunities for spreading the word for PR in primary care. One of these is to improve access to PR for all those disabled by their disease by the increase of community schemes. One such scheme being utilised in Canada is reviewed. The essential components of PR include behavior change, patient self-management and prescriptive exercise. In the last decade new strategies have been developed to enhance the effects of exercise training. An overview of these new approaches being an adjunct to exercise training is reviewed. Although the role of exercise training is well established, we are only just beginning to appreciate the importance of behavior change and patient self-management in contributing to improved health and diminished healthcare resource utilisation.^[22]

References