Patient's problems, PT management and outcome measures Flashcards
Most common pt problems
> Impaired airway clearance > Dyspnoea > ↓ exercise tolerance > Reduced lung vol > Impaired gas exchange > Airflow limitation > Respiratory muscle dysfunction > Dysfunctional breathing > Pain > MSK dysfunction (postural abnormalities, ↓ compliance or deformity of the chest wall)
Problem solving (Note)
Pt often present with more than one problem that is amenable to PT. In this situation, the intervention plan should focus on strategies that address as many pt problems as possible, using the best evidence and practice, and should be determined in collaboration with the individual and with a focus on self-management where appropriate.
Impaired Airway Clearance: problem
Normal airway clearance depends upon 2 mechanisms:
- Mucociliary clearance
- Effective cough
Normal volume of mucus in adult is up to 100 ml/day.
When the volume has increased so the individual becomes conscious of the presence of secretions on coughing or “clearing the throat” the mucus is defined as sputum. Its presence is abnormal.
Impaired Airway Clearance: clinical features
> Hx of usual daily sputum production
Altered breathing pattern due to ↑ work of breathing (WOB)
Infection (can produce fever and tachycardia)
Auscultatory findings: whezzing, diminished or absent breath sounds, bronchial breath sounds, crackles.
Chest Rx: sometimes show signs of lung collapse and/or consolidation
In the postoperative pt: ↑ volume of sputum; weak, ineffective moist cough; possible bacterial contamination of sputum; fever; and chest Rx changes consistent with atelectasis or pneumonia.
Impaired Airway Clearance: PT management
Factors to consider when choosing airway clearance TQ:
- Evidence supporting TQ
- pt age and ability to learn TQ
- pt motivation
- pt preference and confort
- PT’s skill in teaching TQ
Impaired Airway Clearance: outcome measures
► Short-term outcomes can be monitored by:
> Change in sputum expectorated (weight, vol or rate of expectoration)
> VAS for ease of expectoration
> In acute conditions, chest Rx and auscultatory findings
> Radio-aerosol clearance may be used in studies of clearance TQs
► Long-term outcomes can be monitored by:
> Number of exacerbations, courses of antibiotics, hospitalizations, etc.
> Quality of life scales (St George’s Respiratory Disease Questionaire)
> Spirometry (pulmonary fx)
Improved cough or huff TQ may be associated with a ↓ in associated problems such as fatigue, dyspnoea, syncope, airflow limitation, arterial O2 desaturation or stress incontinence.
Dyspnoea: problem
Sensations experienced by individuals complaining of unpleasant or uncomfortable respiration, AKA breathlessness.
Some pt with moderate or severe disease, especially those with COPD, report marked dyspnoea when performing ADLs that involve the use of the ULs, especially when the ULs are unsupported.
Dyspnoea: clinical features
Some pt seek medical care when they become breathless playing sports, but many don’t seek help until breathlessness occurs during ADLs.
Dyspnoea: PT management
> Bronchodilators may ↓ dyspnoea and ↑ exercise tolerance, so inhaler TQ and timing should be optimized.
Positioning, breathing control and relaxation TQs.
Symptomatic relief may be achieved by ↑ mvmt of cold air onto pt’s face.
Pursed-lip breathing may be very effective in ↓ discomfort associated with dyspnoea.
Encouraging exhalation during effort may be helpful.
For selected pt with severe dyspnoea, education on energy conservation TQs during ADL is important.
Exercise training is effective relieving dyspnoea in pt with stable chronic lung disease and those with cardiac failure.
Walking aids that facilitate the forward lean position and arm support may ↓ dyspnoea, ↑ exercise tolerance and limit the extent of O2 desaturation in pt with COPD.
Ambulatory O2 only indicated if shows to produce benefit in terms of ↑ exercise tolerance and ↓ breathlessness.
For pt with COPD, high-intensity inspiratory muscle training (IMT) has been shown to ↓ dyspnoea.
Dyspnoea: outcome measures
Ax of dyspnoea at rest, during ADL and when exercising:
> Intensity: Borg RPE
> Exercise tolerance: walking test
> Fx limitation: scales such as Medical Research Council (MRC), New York Hearth Association (NYHA), University of California San Diego Shortness of Breath Questionnaire, etc
Decreased Exercise Tolerance: problem
Exercise tolerance in pt with respiratory or cardiovascular disease is invariably limited by dyspnoea, pain (chest or legs) or fatigue (general or local).
Depression and anxiety often accompany chronic respiratory or cardiovascular disease and may ↓ an individual’s confidence or motivation to exercise.
Decreased Exercise Tolerance: clinical features
> ↓ ability to exercise or perform ADLs → breathlessness, fatigue or pain.
↓ Fx exercise capacity (measured with field walking test)
When Exercise-Induced Asthma (EIA) ↓ in FEV1 and peak expiratory flow rate measured right after exercise.
In some pt respiratory muscle strength may be ↓ compared to normal.
For pt with acute cardiopulmonary dysfunction an exercise test in inappropriate.
Decreased Exercise Tolerance: PT management
> Pt with known or suspected EIA should use inhaled short-acting beta-agonist or NSAIDs before ex’s.
> Strong evidence supports benefits of exercise training for these pt. Also effective in prevention.
> Group training is recommended.
> Program should have warm-up, stretches, aerobic component, resistive training (when appropriate), and cool-down.
Decreased Exercise Tolerance: outcome measurements
> Ax of anthropometric variables > Resting BP > Peripheral muscle strength > Fx ex capacity > QoL (questionnaires) > Ability to perform ADLs (questionnaires or self-report by pt)
Reduced Lung Volume: problem
Inability to expand the lung tissue. involves ↓ RV, Vt, ERV and/or IRV.
Main clinical consequences:
- ↓ TLC and VC: pt unable to ↑ inhaled vol sufficiently to expand lung tissue
- ↓ FRC: pt unable to sustain alveolar inflation
Reduced Lung Volume: main consequences
> Impaired oxygenation due to V/Q mismatch.
Ineffective cough
Increased WOB
Dyspnoea during physical activity
