Pulmonary Management

Authors

Affiliations

Nate Yomogida, B.S., SPT

Doctor of Physical Therapy

B.S. in Kinesiology

Chloë Kerstein, B.S., SPT

Doctor of Physical Therapy

B.A. in Neuroscience

Pharmacologic agents

• Adrenocortical steroids
• Antihistamines
• Bronchodilators
• Leukotriene modifiers
• Mast cell stabilizers

Note

PTs should time their treatment with the patient’s medications in mind

Surgical interventions

• Depending on pt and condition., common w cancer or lung pneumonia or fibrosis
• Wedge resection, segmental resection, lobectomy
• Pneumonectomy - whole lung removed

PT interventions

Goals

• Independence in mobility
• Maximize gas exchange (improve ventilation and airway clearance)
• Increase aerobic capacity
• Increase respiratory mm endurance

Patient education

Review the condition and offer advice on how to help patient maximize rehab or perform compensations to maximize current level of function

Bronchopulmonary Hygiene / Airway clearance techniques (ACT)

• Understand pathophysiology of condition
  • ACT not always indicated
• Assess before, during and after ACT
  • Vital signs before and after
  • Auscultation before and after
• Combine with O2 and meds as needed

Contraindications

• Blood in lungs
• Burns
• Recent incision sites
• Lung contusion, empyema– in pleural space so NO = pleural effusion or something, dont do it! , rib fx etc can be reasons to not do airway clearance

Cough effectiveness

Medications

• Pain meds (if pain is limiting issue to the cough)

Splinting

• Use splints if they have incisions
• can be w pillow (ie heart pillow for sternal precaution)
• Provide counterpressure w arms

Positioning

• Positioning

Hydration

• Especially important with older patients
• dehydration makes secretions harder to mobilize

Examples of ACT

• Percussion
• Vibration
• Autogenic drainage
• Active cycle of breathing
• Nasotracheal Suctioning (NT)
• Flutter valves: Flutter valves should be used in adjunct to manual ACT
• Postural drainage (see Ch22 of Paz¹)

Postural Drainage Positions¹

Choosing ACT based on disorder

Obstructive disorders

• Pursed lip breathing
• Rest breaks between coughs

Restrictive disorders

• Diaphragmatic breathing
• Chest wall stretching

Activity progression

• RPE better than HR - pulmonary usually more limiting that cardiac
• Shorter more frequent sessions
• Education on energy conservation– pacing
• Document need for rests and duration of rest during txt
• Bronchopulmonary hygiene prior to exercise may be beneficial

Precautions

• Table 22.3 - test question!!!!
• Consider head position (ICP monitor – no less than 30 deg on the bed, remember certain positions can be limited)
• ICP monitoring
• Chest wall complications
• Platelets <20k (risk of bleeding w percussion)
• Osteoporosis

Percussion, Postural Drainage, and Vibration/Shaking

Benefits

• Feasible for use with patients who are unable to follow commands¹
• Can individualize treatment to target specific lobes based on patient disease process¹

Considerations

• Most beneficial when used in conjunction with additional airway clearance techniques (ACTs)¹
• Patient cannot be independent with percussion or vibration/shaking; requires caregiver assistance¹
• Passive¹
• Time and effort intensive¹
• May be uncomfortable if pain is present¹
• Modification of postural drainage positions may be required with patients with increased intracranial pressure, decreased cardiac output, pulmonary hemorrhage, and severe dyspnea
• Postural drainage should be modified to remove head down positioning in infants and patients with gastroesophageal reflux disease¹

Contraindications

• High intracranial pressure (>20 mmHg)¹
• Uncontrolled hypertension¹
• Uncontrolled or unprotected airway with risk of aspiration
• Recent esophageal surgery¹
• Significantly distended abdomen¹
• Pulmonary edema and/or orthopnea¹
• Integumentary abnormalities over the area to be percussed or vibrated, such as burns, skin grafts, or open wounds¹
• Rib fractures, flail chest, rib metastases¹
• Acute hemorrhage and/or hemodynamic instability¹
• Unstable head or neck injury¹

References

1.

Paz JC, West MP, Panasci K, Greenwood KC, eds. Acute Care Handbook for Physical Therapists. 5th ed. Elsevier; 2020.