PT Procedural Interventions Flashcards
Aerobic Exercise Prescription - Intensity
Percent of max HR:
- Lower target heart rate = HRmax x 55% - Upper target heart rate = HR max x 90%
HR reserve or Karvonen formula:
- Lower target heart rate = [(HRmax - HRrest) x 40%] + HRrest - Upper target heart rate = [(HRmax - HRrest) x 85%] + HRrest
Aerobic Exercise Prescription - Duration
20-60 min depending on intensity. Continuous or intermittent with at least 10 min bouts
Aerobic Exercise Prescription - Frequency
3-5 days per week
Aerobic Exercise Prescription - Acute response
SBP increases linearly 8-12 mmHg per MET
No change or moderate decrease in DBP
Aerobic Exercise Prescription - Chronic adaptations
VO2max increased at max exercise
HR and BP decreased at submax exercise
Arteriovenous oxygen increased at max exercise
Plasma increased
Improved body heat transfer due to larger plasma volume and more responsive thermoregulatory mechanisms
Airway Clearance Techniques - Active cycle of breathing
May be used for secretion clearance with asthma
3 Phases:
1) Breathing control - gentle, relaxed breathing at resting TV and RR
2) Thoracic expansion exercises - 3 to 4 deep, slow, relaxed inhalations to inspiratory reserve with passive exhalation. Chest percussion, vibration, or shaking may be combined with exhalation.
3) Forced expiratory technique - One or two huffs at mid to low lung volumes with the glottis open into the expiratory reserve volume. Brisk adduction of upper arms may be added to self-compress thorax.
Precautions/Contraindications:
- Splinting post-op incisions to achieve adequate expiratory force
- Bronchospasm or hyperactive airways
Airway Clearance Techniques - Autogenic drainage (AD)
Mobilizes secretions by varying expiratory airflow without postural drainage or coughing. Improves airflow in small airways to facilitate movement of mucus.
Pt sitting upright with back support.
Controlled breathing at 3 lung volumes:
-Unsticking phase: slow breath in through nose at low-lung volumes by 2-3 second breath hold then exhale into ERV.
-Collecting phase: breathe at tidal volume, interspersed by 2-3 second breath holds
-Evacuating phase: deeper inspirations from low to mid IRV, breath holding then huff
Treatment 30-45 min
Precautions/contraindications:
Requires motivation and concentration to learn.
Airway Clearance Techniques - Directed cough
Tries to compensate for pt’s physical limitations to elicit maximum forced exhalation.
Inhale maximally, close glottis and hold breath for 2-3 seconds
Contract expiratory mm to increase intra-thoracic pressure
Cough sharply 2-3 times through a slightly open mouth
Post-surgical pts may need to splint the chest or abdomen by applying pressure over incision with pillow
Airway Clearance Techniques - Huff
Forced expiratory maneuver performed with glottis open. Less airflow velocity as cough but less potential for airway collapse.
Inhale deep through open mouth.
Contract abdominal muscles during rapid exhalation with glottis open, saying “ha, ha, ha”
May perform quick adduction of arms to self-compress chest wall
Airway Clearance Techniques - High-frequency airway oscillation
Devices like Acapella and Flutter combine positive expiratory pressure and high frequency airway vibrations to mobilize mucus secretions.
Place device in mouth with lips firmly sealed.
Inhale slowly to 75% of full breath
Hold breath for 2-3 seconds
Exhale through device for 3-4 seconds
Repeat 10-20 breaths
Remove device and perform 2-3 coughs or huffs to raise secretions
Precautions/contraindications:
- Pt tolerance for increased work of breathing
- Intracranial pressure > 20 mmHg
- Hemodynamic instability
- Recent facial, oral, or skull surgery or trauma
- Acute sinusitis
- Nosebleed
- Esophageal surgery
- Active hemoptysis
- Nausea
- Middle ear pathology or tympanic rupture
- Untreated pneumothorax
Airway Clearance Techniques - Postural drainage
Assume position based on affected lung segment and stay in position for 2-3 minutes.
Precautions/Contraindications for all positions:
- Intracranial pressure > 20 mmHg
- Head and neck injury until stabilized
- Active hemorrhage with hemodynamic instability
- Recent spinal surgery or acute spinal injury
- Active hemoptysis
- Empyema (pus in pleural cavity)
- Bronchopleural fistula
- Pulmonary edema with CHF
- Large pleural effusion
- Pulmonary embolism
- Rib fracture
- Surgical wound or healing tissue
Precautions/Contraindications for trendelenburg position:
- Uncontrolled hypertension
- Distended abdomen
- Esophageal surgery
- Recent gross hemoptysis related to lung carcinoma treated surgically or with radiation therapy
- Uncontrolled airway at risk for aspiration
Airway Clearance Techniques - Percussion and Vibration
Place pt in appropriate postural drainage position
Cover skin over affected lung segment with thin material (towel or clothes)
PT rhythmically strikes chest with cupped hand for 2-3 min per lung segment
PT places one hand on top of the other or one hand on each side of rib cage
Vibrate chest wall during exhale by tensing muscles of hands and arms while applying moderate pressure. Movement performed in direction that ribs move on expiration
Encourage pt to cough or huff after 2-3 vibrations
Precautions/contraindications:
- All listed for postural drainage
- Subcutaneous emphysema
- Recent epidural spinal infusion or spinal anesthesia
- Recent skin grafts or flaps on thorax
- Burns, open wounds, skin infection of thorax
- Recently placed transvenous or subcutaneous pacemaker
- Suspected tuberculosis
- Lung contusion
- Bronchospasm
- Osteomyelitis of the ribs
- Osteoporosis
- Complaint of chest wall pain
Apical segments R and L upper lobes
Sitting leaning back 30-40 degrees. Percussion and vibration above clavicles.
Posterior segment R upper lobe
Turned 1/4 from prone on L side with head and shoulders on pillow. Percussion and vibration on medial border of R scapula.
Posterior segment of L upper lobe
Turned 1/4 from R side with HOB elevated 45 degrees and head and shoulders on pillow. Percussion and vibration around medial border of L scapula.
Lingula L upper lobe
Patient turned 1/4 from supine on R side with foot of bed elevated 12 inches. Percussion and vibration are performed over L chest between axilla and l nipple.
Anterior segments R and L upper lobes
Patient supine. Percussion and vibration below clavicles.
R middle lobe
Pt turned 1/4 from supine on L side with foot of bed elevated 12 inches. Percussion and vibration over R chest between axilla and R nipple.
Superior segments L and R lower lobes
Pt prone. Percussion and vibration below inferior border of L and R scapulae.
Anterior basal segments L and R lower lobes
Supine with foot of bed elevated 18 inches. Percussion and vibration over lower ribs.
Posterior basal segments lower lobes
Pt prone with foot of bed elevated 18 inches. Percussion and vibration over lower ribs.
Diaphragmatic breathing
Minimizes action of accessory muscles and motion of the upper rib cage during inspiration.
Precautions/Contraindications:
- Moderate to severe COPD and marked hyperinflation without diaphragmatic movement
- Pt with paradoxical breathing
Procedure:
- Semi-Fowler’s is a good starting position
- Sniffing to facilitate contraction of diaphragm
- One hand on chest, one just below rib cage
Inspiratory muscle training (IMT)
Attempts to strengthen diaphragm and intercostal muscles if weak or if ventilation is limiting exercise.
Devices can provide 2 training modes: flow resistive breathing and threshold breathing. Flow resistive breathing requires pt to inspire through a mouthpiece with adjustable diameter. Decreased diameter increases resistance to breathing. Threshold breathing requires buildup of negative pressure before flow occurs through a valve that opens at a critical pressure. It provides consistent pressure for IMT regardless of rate of breathing.
Threshold Inspiratory Muscle Trainer:
Measure maximum inspiratory pressure (MIP). Begin training with setting at 30-40% of MIP. With resting TV and RR, breath at this resistance for 5-15 minutes, 2-3x/day. Increase resistance in small increments until training load reaches 40-60% of MIP over a 4-6 week period.
PFLEX Inspiratory Muscle Trainer
Begin training at 30-40% of MIP for 10-15 minutes daily, gradually increasing to 20-30 minutes, 3-5 days/week. Once pt had easily tolerate 30 min, increase resistance to next setting.
Paced breathing and exhale with effort
To prevent pt from holding breathing during activity. Inhale during resting or less active part of exercise and exhale during movement or more active part of activity.
Pursed-lip breathing (PLB)
Helps reduce RR, dyspnea, and maintain small positive pressure in bronchioles to prevent airway collapse.
Semi-fowler’s is good position to start in.
Segmental breathing
Intended to improve regional ventilation and prevent and treat pulmonary complications after surgery. To prevent or decrease asymmetrical chest wall motion.
PT applies firm pressure at end of exhalation to chest wall overlying area to be expanded. Pt inhales deeply and slowly expands rip cage under PT’s hands. PT reduces pressure during inhalation.
Sustained maximal inhalation with incentive spirometer
Maintain max inspiration for 3 or more seconds. Often used in airway clearance.
Forward leaning with arm support
Can provide relief of dyspnea to patients with lung disease. Allows pec muscles to assist in elevating rib cage during inspiration.
Reverse Trendelenburg position
Supine with head above trunk and LEs. Decreases weight of abdominal contents on diaphragm.
Semi-Fowler’s position
Supine with HOB elevated to 45 degrees and pillows under knees. Often used for patients with congestive heart failure or other cardiac conditions.
Cardiac rehab indications
Medically stable post MI Stable angina pectoris Coronary artery bypass surgery Heart transplant Other cardiac surgery (like valve or pacemaker) Compensated heart failure Cardiomyopathy PAD High risk for coronary artery disease with diabetes, dyslipidemia, hypertension, or obesity End stage renal disease
Cardiac rehab contraindications
Unstable angina
Resting SBP > 200 mmHg or resting DBP > 110 mmHg
Orthostatic BP drop of > 20 mmHg with symptoms
Aortic stenosis
Acute systemic illness or fever
Uncontrolled arrhythmias
3rd degree AV block without pacemaker
Active pericarditis or myocarditis
Recent embolism
Thrombophlebitis
Resting ST segment depression or elevation > 2 mm
Uncompensated congestive heart failure
Orthopedic or metabolic conditions that would prohibit exercise
Inpatient Cardiac Rehab (Phase I) - Medical Evaluation
Can begin rehab when medically stable by the referring physician:
No new or recurrent chest pain in 8 hours
No new signs of uncompensated heart failure (dyspnea at rest with bilateral basilar crackles)
-No new significant, abnormal heart rhythm or ECG changes in 8 hours
-Stable creatine kinase and troponin levels
Inpatient Cardiac Rehab (Phase I) - Monitoring & safety
Ask pt to report any chest discomfort, dyspnea, or faintness
Discontinue exercise if:
-HR >130 bpm or >30 bpm above resting HR
-DBP > or equal to 110 mmHg
-Decrease in SBP > 10 mm Hg
-Significant ventricular or atrial dysrhythmias
-2nd or 3rd degree heart block
-Angina, marked dyspnea, and ECG changes suggesting ischemia
Inpatient Cardiac Rehab (Phase I) - Active exercise
Active UE and LE exercises may begin 24 hours after bypass graft surgery and 2 days after infarction
Active exercises progress from sitting to standing (1-4 METs)
UE exercises should not stress incisions of post-surgical pts
Inpatient Cardiac Rehab (Phase I) - Aerobic exercise
Mode: Progressive, supervised level walking (2-3 METs) to walking up/down steps or treadmill walking (3-4 METs)
Intensity:
- RPE < 13
- Post infarction: HR < 120 bpm or < 20 above resting HR
- Post surgery: < 30 bpm above resting HR
Duration: 3-5 min bouts, progressing to 10-15 min of continuous activity
Frequency:
- First 3 days: 3-4x/day
- After 3 days: 2x/day with increased duration
Progression:
Activity can progress if…
-Adequate increase in HR
-Adequate rise in SBP (10-40 mmHg)
-No new dysrhythmias or ST changes on ECG
-No cardiac symptom (palpitations, dyspnea, angina, excessive fatigue)
Total inpatient treatment usually lasts 3-5 days
Inpatient Cardiac Rehab (Phase I) - Expected outcomes
Walks 5-10 min continuously or 1000 feet 4x/day
Walk up and down one flight of stairs indep
Know safe HR and RPE limits for exercise
Recognize abnormal signs and symptoms suggesting intolerance to activity
Inpatient Cardiac Rehab (Phase II) - Medical evaluation
ECG when starting a phase II program.
Physical examination should include medical history, cardiovascular disease risk, BMI or wast-hip ratio, resting ECG and BP, auscultation of lung sounds, palpation and inspection of extremities for arterial pulses, edema, and skin integrity. Examination of chest and leg wounds in patients after CABG or PTCA. Orthopedic and neuromuscular status.
Inpatient Cardiac Rehab (Phase II) - Monitoring & safety
For low risk pts with known stable coronary artery disease, 6-12 sessions of ECG and BP monitoring and medical supervision recommended to ascertain desirable exercise levels.
For pts at moderate to high risk and/or unable to self-regulate or understand recommended activity levels, continuous ECG and BP monitoring and medical supervision recommended until safety is established, usually more than 12 sessions.
Discontinue exercise for any of the following adverse responses:
- Plateau or decrease in HR with increase in work
- SBP plateaus or falls with increase in work or > 250 mmHg
- DBP >115 mmHg
- ST segment depression > 1 mm
- 2nd or 3rd degree heart block
- Ventricular dysrhythmias
- Angina or other symptoms of cardiovascular insufficiency
Inpatient Cardiac Rehab (Phase II) - Aerobic exercise
Mode: Rhythmic activities that use large muscle groups and can be performed continuously and safely.
Intensity:
HR - Can use target HR zones or resting HR + 20 bpm
METs - Must determine max MET during exercise test.
Lower METs = [(MaxMETs - Rest METs) x 40%] + RestMet
Upper METs = [(MaxMETs - Rest METs) x 85%] + RestMet
Duration:
15-20 min during first month (initial training phase)
25-30 min during next 3-4 months (improvement stage)
Interval training (bouts of 3-5 min duration followed by equal rest periods). May be appropriate for those who can’t exercise continuously.
Can continue to increase endurance as fitness and confidence improves
Frequency: 3-5 days/week
Inpatient Cardiac Rehab (Phase II) - RPE
RPE of 12-16 corresponds to 65% to 85% maximal capacity
RPE of 11-13 is an appropriate upper limit during the initial phases of outpatient cardiac rehab
RPE of 14-16 may be appropriate for higher intensity training later in rehab if no signs of ischemia or serious dysrhythmias
Pulmonary Rehab - Clinical Indications
Indicated if presence of respiratory impairments including dyspnea, hypoxemia, hypercapnia, reduced exercise tolerance or a decline in ability to perform ADLs due to: Chronic bronchitis Emphysema Asthma Interstitial lung disease Bronchiectasis Cystic fibrosis Lung cancer Chest wall disease Neuromuscular disease (Parkinson's, ALS, MS) Pro-op and post-op lung resection, transplant, or volume reduction Ventilatory dependency
Pulmonary Rehab - Clinical contraindications/precautions
Ischemic cardiac disease Congestive heart failure Acute cor pulmonale Severe pulmonary hypertension Significant hepatic dysfunction Metastatic cancer Renal failure Severe cognitive deficit that interferes with memory and compliance Visual, hearing, or orthopedic impairments may require exercise modification
Pulmonary Rehab - Medical Evaluation
Medical hx Nutritional assessment Spirometry Resting ABG Arterial O2 sat by pulse oximeter Chest xray Resting ECG Exercise test (6MWT or graded exercise test) Complete blood count Height and weight Resting BP, HR, and RR Temperature Breathing pattern Auscultation of lung sounds Auscultation of breath sounds Palpation and inspection of extremities for arterial pulses, edema, and skin integrity Orthopedic and neuromuscular status Functional status Anxiety and depression
Pulmonary Rehab - Monitoring & safety
Remind pt not to hold breath and to exhale during exertion phase of activity
Clinical monitoring includes:
-Signs and symptoms of exercise intolerance
-HR and BP
-ECG if pt has heart disease
-RPE and dyspnea
-O2 sat via pulse oximeter
Pulmonary Rehab - Aerobic Exercise
Mode: Rhythmic activities that use large muscle groups and can be performed continuously and safely
Intensity: Determined primarily by patient tolerance and safety.
Guidelines include:
> or equal to 50% peak oxygen consumption determined from exercise test
-Use dyspnea rating reported at submax exercise level during exercise test
-60-80% of peak work rate achieved determined from exercise test
-RPE of 4-6 on 0-10 scale or 12-16 on 6-20 scale
-Maintain O2 sat > 90%
Duration:
- Minimum of 30 min of accumulated exercise per session
- Interval training (bouts of 30 sec to 3 min followed by rest) for those who cannot exercise continuously
Frequency: 3-5 days/week
