Therapeutic Exercise Foundations and Techniques

00Kisner (F)-FM 3/9/07 1:28 PM Page i

FIFTH EDITION 00Kisner (F)-FM 3/9/07 1:28 PM Page ii 00Kisner (F)-FM 3/9/07 1:28 PM Page iii

Therapeutic Exercise Foundations and Techniques

FIFTH EDITION

CAROLYN KISNER, PT, MS Assistant Professor Emeritus The Ohio State University School of Allied Medical Professions Physical Therapy Division Columbus, Ohio

LYNN ALLEN COLBY, PT, MS Assistant Professor Emeritus The Ohio State University School of Allied Medical Professions Physical Therapy Division Columbus, Ohio 00Kisner (F)-FM 3/9/07 1:28 PM Page iv

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Library of Congress Cataloging-in-Publication Data

Kisner, Carolyn. Therapeutic exercise : foundations and techniques / Carolyn Kisner, Lynn Allen Colby. — 5th ed. p. ; cm. Includes bibliographical references and index. ISBN-13: 978-0-8036-1584-7 ISBN-10: 0-8036-1584-1 1. Exercise therapy—Handbooks, manuals, etc. I. Colby, Lynn Allen. II. Title. [DNLM: 1. Exercise Therapy—methods. WB 541 K61t 2007] RM725.K53 2007 615.8′2—dc22 2007007512

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Management of Pulmonary Conditions 25 CHAPTER

REVIEW OF RESPIRATORY STRUCTURE Teaching an Effective Cough 868 AND FUNCTION 852 Additional Techniques to Facilitate a Cough and Thorax and Chest Wall: Structure Improve Airway Clearance 869 and Function 852 Suctioning: Alternative to Coughing 870 Muscles of Ventilation 852 POSTURAL DRAINAGE 870 Mechanics of Ventilation 853 Manual Techniques Used with Postural Anatomy and Function of the Drainage Therapy 870 Respiratory Tracts 854 Postural Drainage Positions 872 The Lungs and Pleurae 855 Guidelines for Implementing Postural Lung Volumes and Capacities 856 Drainage 874 EXAMINATION 856 Modified Postural Drainage 874 Components of the Examination 857 Home Program of Postural Drainage 875 BREATHING EXERCISES AND VENTILATORY MANAGEMENT OF PATIENTS WITH CHRONIC TRAINING 861 OBSTRUCTIVE PULMONARY DISEASE 875 Guidelines for Teaching Breathing Exercises 861 Types of Obstructive Pulmonary Disorders 875 Diaphragmatic Breathing 862 Pathological Changes in the Pulmonary Segmental Breathing 863 System 875 Pursed-Lip Breathing 864 Impairments and Impact on Function 875 Preventing and Relieving Episodes Management Guidelines: COPD 876 of Dyspnea 865 MANAGEMENT OF PATIENTS WITH Positive Expiratory Pressure Breathing 865 RESTRICTIVE PULMONARY DISORDERS 876 Respiratory Resistance Training 866 Acute and Chronic Causes of Restrictive Glossopharyngeal Breathing 866 Pulmonary Disorders 876 EXERCISES TO MOBILIZE THE CHEST 867 Pathological Changes in the Pulmonary Specific Techniques 867 System 876 Management Guidelines: Post-Thoracic COUGHING 868 Surgery 876 The Normal Cough Pump 868 Factors that Decrease the Effectiveness of the INDEPENDENT LEARNING ACTIVITIES 880 Cough Mechanism and Cough Pump 868

Cardiovascular and pulmonary physical therapy is a mul- Prevent airway obstruction and accumulation of secre- tifaceted area of professional practice that deals with the tions that interfere with normal respiration/oxygen management of patients of all ages with acute or chronic, transport. primary or secondary cardiovascular and pulmonary disor- Improve airway clearance, cough effectiveness, and ders. Although the cardiovascular and pulmonary systems ventilation through mobilization and drainage of are inherently linked as they interface with all other body secretions. systems, the focus of this chapter is on examination proce- Improve endurance, general exercise tolerance, and dures and therapeutic interventions used for the manage- overall well-being. ment of patients with pulmonary dysfunction. In particular, Reduce energy costs during respiration through exercise interventions and manual techniques that enhance breathing retraining. ventilation and airway clearance are presented. Prevent or correct postural deformities associated with The goals of cardiovascular and pulmonary physical pulmonary or extrapulmonary disorders. therapy for patients with respiratory dysfunction are to: Maintain or improve chest mobility.

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852 REVIEW OF RESPIRATORY STRUCTURE AND FUNCTION

All of these goals are aimed at improving a patient’s overall ability to meet necessary and desired functional demands. Treatment settings vary widely, from intensive care or postsurgical care units and extended care/subacute rehabilitation facilities to outpatient pulmonary centers and the home setting.

REVIEW OF RESPIRATORY STRUCTURE AND FUNCTION

Respiration is a general term used to describe gas exchange within the body and can be categorized as either external respiration or internal respiration. Basic terms are described here but an in-depth discussion of respiratory physiology,

including diffusion and perfusion, goes well beyond the FIGURE 25.1 Anterior view of the rib cage. (From Starr, J, Dalton, D: The thorax scope or purpose of this chapter. The reader is referred to and chest wall. In Levangie, PK, Norkin, CC [eds] Joint Structure and Function: A Compre- several references for further study.11,22,34,59,61 hensive Analysis, ed 4. FA Davis, Philadelphia, 2005, p 197, with permission.) External respiration describes the exchange of gas at the alveolar-capillary membrane and the pulmonary capillaries. When a person inhales and oxygen is delivered to articulate directly with the sternum via the costal cartilage. the alveoli via the tracheobronchial tree, oxygen diffuses The eighth to tenth ribs have cartilaginous attachments to through the alveolar wall and interstitial space and into the the rib above, whereas the eleventh and twelfth are floating bloodstream through the pulmonary capillary walls. The ribs (Fig. 25.1).68 opposite occurs with carbon dioxide transport. Internal respiration describes the exchange of gas between the Muscles of Ventilation pulmonary capillaries and the cells of the surrounding tissues. Internal respiration occurs when oxygen in arterial Multiple muscles attaching to the thoracic cage have an blood diffuses from red blood cells into tissues requiring impact on the movement of air in and out of the lungs during either the inspiratory or expiratory phases of oxygen for function. The reverse occurs with carbon 8,11,68 9 dioxide transport. breathing. Box 25.1 lists the muscles of ventilation. Ventilatory muscles, also referred to as respiratory Ventilation, as it refers to the respiratory system, is the 56,68 mass exchange of air to and from the body during inspira- muscles, are classified as primary or accessory. The tion and expiration. This cyclic process requires coordinat- primary muscles of ventilation are recruited during quiet ed ventilatory muscle activity, rib cage movements, and (tidal) breathing, whereas the accessory muscles of ventila- appropriate structure and function of the upper and lower tion are only recruited during deep, forced, or labored respiratory tracts.8,22,34,59,61 breathing. During quiet inspiration the diaphragm, scalenes, and parasternals are activated.56,68 In contrast, no primary ventilatory muscles contract during resting expiration. Dur- Thorax and Chest Wall: ing deep or forced breathing different accessory muscles of Structure and Function ventilation are recruited, depending on whether inspiration or expiration is occurring, as noted in Box 25.1. The main functions of the thoracic cage, also referred to as the chest wall, are to protect the internal organs of respira- Inspiration tion, circulation, and digestion and to participate in ventila- Diaphragm. The diaphragm, the major muscle of inspira- 58 tion of the lungs. The thoracic cage provides the site of tion, is innervated by the phrenic nerve (C3, C4, C5). Dur- attachment for the muscles of ventilation to mechanically ing relaxed inspiration it is the primary muscle responsible enlarge the thorax for inspiration or to compress the thorax for movement of air, and under these quiet conditions it 68 for expiration. It is also the site of attachment of upper performs about 70% to 80% of the work of breathing.56 extremity muscles, which function during lifting, pulling, As the diaphragm contracts, it moves caudally from its or pushing activities. These activities usually are carried dome-shaped position at rest to increase the capacity of out in conjunction with inspiratory effort. the thoracic cage. Along the posterior aspect of the thorax, the dorsal portions of the ribs articulate with the 12 thoracic vertebrae Scalenes. The scalenes, which insert proximally on the at the costotransverse and costovertebral joints. Along the transverse processes of the lower five cervical vertebrae anterior aspect of the thoracic cage, the first to seventh ribs and distally on the upper surface of the first two ribs, also 25Kisner (F)-25 3/9/07 12:54 PM Page 853

CHAPTER 25 Management of Pulmonary Conditions 853

Expiration BOX 25.1 Primary and Accessory Expiration is a passive process when a person is at rest. Ventilatory Muscles When the diaphragm relaxes after a contraction, the diaphragm rises and the ribs drop. The elastic recoil of Inspiration tissues decreases the intrathoracic area and increases • Primary muscles: diaphragm, scalenes, parasternals intrathoracic pressure, which causes exhalation. Dur- • Accessory muscles: sternocleidomastoids, upper trapezius, ing active expiration, which can be controlled, forced, pectoralis major and minor, subclavius, and possibly the or prolonged, several accessory muscles groups are external intercostals active.9,56,68 Expiration Abdominals. The rectus abdominis, the internal and exter- • Primary muscles: none active during tidal (resting) expi- nal obliques, and the transversus abdominis contract to ration • Accessory muscles: abdominals including the rectus force down the thoracic cage and force the abdominal abdominis, transversus abdominis, and internal and contents superiorly into the diaphragm. When the abdomi- external obliques; pectoralis major; and possibly the nals contract, the intrathoracic pressure increases and air is internal intercostals forced out of the lungs. A strong contraction of the abdominals also is necessary for a strong cough. The abdominals are innervated by spinal cord levels T10 to T12. Other accessory muscles of expiration include the pec- are active during quiet inspiration.56,68 They begin to con- toralis major muscles (when the distal insertion is inferior tract at the onset of inspiration and generate an even to the clavicle and the arm is fixed in position), the quad- greater amount of tension late into the inspiratory cycle ratus lumborum, because of its attachment to the twelfth as the tension-producing capacity of the diaphragm is rib, which enables it to act to stabilize the diaphragm dur- decreasing. The scalenes lift the sternum and the first two ing phonation, and possibly the internal intercostals, which ribs in a “pump handle” action, which causes an upward may act to depress the rib cage.56,68 and outward action of the upper portion of the rib cage. Parasternal intercostals. The parasternals, a portion of the Mechanics of Ventilation internal intercostals, are active during resting inspiration. They function to stabilize the rib cage and prevent inward Movements of the Thorax During Ventilation movement of the superior aspect of the chest wall.56,68 Each rib has its own pattern of movement, but generaliza- tions can be made. The ribs attach anteriorly to the sternum Accessory muscles of inspiration. The sternocleidomastoid (except ribs 11 and 12) and posteriorly to the vertebral (SCM), upper trapezius, pectoralis major and minor, and bodies, disks, and transverse processes, making a closed subclavius muscles are all active during deep or labored kinematic chain. The thorax enlarges in all three planes of inspiration.9,56,68 These muscles become increasingly active movement during inspiration.8,11,56,68 with greater inspiratory effort, which occurs frequently during strenuous physical activity. Increase in the AP dimension. There is a forward and The accessory muscles of inspiration may become the upward movement of the sternum and upper ribs, described primary muscles of inspiration and may become active dur- as a pump-handle motion. The thoracic spine extends ing resting inspiration when the diaphragm is ineffective or (straightens), enabling greater excursion of the sternum. weak as the result of pathology. For example, paralysis of the abdominals as the result of a spinal cord injury reduces Increase in the transverse (lateral) dimension. There is an the support to the viscera (when the patient is in an upright elevation and outward turning of the lateral (midshaft) por- position) which, in turn, allows the diaphragm to assume a tions of the ribs, described as a bucket handle motion. The flattened rather than a normal dome-shaped position. Thus, lower ribs (8–10), which are not attached directly to the diaphragmatic excursion is reduced, and breathing is less sternum, also flare or open outward, increasing the sub- efficient, which necessitates recruitment of the accessory costal angle. This is described as caliper motion. The angle muscles of inspiration. at the costochondral junction also increases, making the rib The SCM muscles elevate the sternum to increase the segments longer during inspiration. anteroposterior (AP) diameter of the thorax. In patients with weakness of the diaphragm, the SCM muscles are Increase in vertical dimension. The central tendon of required to act as primary muscles of inspiration. The the diaphragm descends as the muscle contracts. This is upper trapezius muscles elevate the shoulders and, indirect- described as a piston action. Elevation of the ribs increases ly, the rib cage during labored inspiration. They also fixate the vertical dimension of the thorax and improves the the neck so the scalenes have a stable attachment. The pec- effectiveness of the diaphragm. At the end of inspiration, toralis major muscles can act to elevate the rib cage and the muscles relax and elastic recoil causes the diaphragm contribute to inspiration when the arms are overhead. to move superiorly. The ribs return to their resting position. 25Kisner (F)-25 3/9/07 12:54 PM Page 854

854 REVIEW OF RESPIRATORY STRUCTURE AND FUNCTION

Movement of Air Anatomy and Function of As noted previously, ventilation is the mass exchange of the Respiratory Tracts gases to and from the body. During inspiration, as the thorax enlarges, the pressure inside the lungs (alveolar pres- Upper Respiratory Tract sure) becomes lower than the atmospheric pressure, and air The structures of the upper respiratory tract are the nasal 11,58,66,69 rushes into the lungs. At the end of inspiration, the muscles cavity, pharynx, and larynx. As air is brought into relax, and the elastic recoil of the lungs pushes the air out, the body, the nasal cavity and pharynx filter and remove resulting in expiration. particles in the air and begin to humidify and warm it to body temperature. The mucosal lining of these structures NOTE: Breathing exercises, a common intervention for has cells that secrete mucus and cells that are ciliated. the management of patients with cardiopulmonary, neuro- Cilia and mucus trap particles; a sneeze removes large muscular, and musculoskeletal conditions, are designed to particles. affect the movement of air to and from the lungs.11,28,48,56 With illness and elevated body temperature, the mucous membrane tends to dry out, so the body secretes Compliance more mucus. This mucus dries out, and a cycle begins. Compliance refers to the distensibility of tissue or how eas- The action of the cilia is inhibited by drying of mucus. ily the lungs inflate during inspiration. With regard to ven- The patient tends to breathe by mouth, which decreases tilation, it relates to how easily the lungs inflate or the the humidification of mucus and increases its viscosity. chest wall expands during inspiration.22,59,61 Normal lungs The larynx, which extends from C3 to C6, controls are highly distensible (compliant), but compliance changes airflow; and when it contracts rapidly, the epiglottis pre- with age and the presence of disease. During the normal vents food, liquids, or foreign objects from entering the aging process lung tissue becomes more compliant. Dis- airway.47 eases of the pulmonary system that, for example, cause fibrosis of tissues (alveolar or pleural) make the lungs Lower Respiratory Tract rigid (i.e., less compliant), whereas emphysema, one of The lower respiratory tract is composed of conducting air- the chronic obstructive diseases, makes lung tissue more ways of the tracheobronchial tree and the terminal respira- compliant to pressures.22,59,61 tory units. There are approximately 23 generations (branchings) of the structures within the tracheobronchial Airway Resistance tree, which extends from the trachea to the terminal respi- The amount of resistance to the flow of air through the ratory units of the lungs. The structures and branchings airways depends on a number of factors.22,59,61 The bifurca- of the lower respiratory tract are summarized in Box 11,58,66,69 tion and branching of airways is a source of airway resist- 25.2. ance. The size (diameter) of the lumen of each airway also The initial branchings of the tracheobronchial tree are influences resistance. The diameter of the lumen can be depicted in Figure 25.2. The first 16 airway branchings of decreased by mucus or edema in the airways, contraction the lower respiratory tract primarily conduct air, whereas of smooth muscles, and the degree of elasticity or distensi- the last 6 are respiratory airways that end (in the mature 69 bility of the lung parenchyma. lung) in approximately 300 million alveoli. The diameter Normally, the airways widen during inspiration and of the airways becomes increasingly smaller with each suc- narrow during expiration. As the diameter of the airway cessive generation of the tracheobronchial tree. decreases, the resistance to airflow increases. With diseases Trachea. The trachea is an oval, flexible tube supported that cause bronchospasm (asthma) or increased mucus pro- by semicircular rings of cartilage. It extends from C6 in duction (chronic bronchitis), airway resistance is even an oblique, downward direction to the sternal angle level greater than normal, particularly during expiration. of rib 2 and T6, at which point it bifurcates. The posterior wall is smooth muscle, and it contains an equal number of Flow Rates ciliated epithelial cells and mucus-containing goblet cells. Flow rates indicate measurements of the amount of air moved in or out of the airways over a period of time. Flow rates, which are related to airflow resistance, reflect the 22,59,61 ease with which ventilation occurs. Expiratory flow BOX 25.2 Structures and Branchings rate is determined by the volume of air exhaled divided of the Lower Respiratory Tract by the amount of time it takes for the volume of gas to be 27 exhaled. • Trachea Flow rates are altered as the result of diseases that • Mainstem bronchi: 2 affect the respiratory tree and chest wall. For example, • Lobar bronchi: 5 with chronic obstructive pulmonary disease, the expiratory • Segmental bronchi: 18 flow rate is decreased in comparison to normal. That is, it • Bronchioles: subsegmental, terminal, and respiratory takes a longer than the normal amount of time to exhale a • Alveolar ducts and sacs specific volume of air. 25Kisner (F)-25 3/9/07 12:54 PM Page 855

CHAPTER 25 Management of Pulmonary Conditions 855

Terminal Bronchiole Respiratory Trachea Bronchiole Left Apical Right Posterior Posterior Anterior Apical Apical posterior Aveolus Anterior Lingula Aveolar Sac Carina Right middle Apical superior lobe Apical superior Lateral Cardiac (medial Posterior Posterior Anterior Lateral Aveolar Ducts Anterior FIGURE 25.3 Bronchopulmonary segment. FIGURE 25.2 Lower respiratory tract—tracheobronchial tree. (From Frownfelter, DL: Chest Physical Therapy and Pulmonary Rehabilitation. Year-Book Medical Publishers, Chicago, 1987, p 26, with permission.) Conduct air to and from the alveolar system for gas exchange Mainstem bronchi. The trachea branches into two main- Assist with humidification and trap small particles to stream bronchi: the right, which is directed almost vertical- clean the air with the mucosal lining ly, and the left, which is directed more obliquely. Warm the air by the vascular supply Lobar bronchi. The two mainstem bronchi then divide into Move mucus upward with the cilia five lobar bronchi: three on the right and two on the left. Elicit the cough reflex to clear the larger airways Mainstem and lobar bronchi have a great amount of cartilage, which helps maintain airway patency. The Lungs and Pleurae Segmental bronchi. Each of the lobar bronchi divide into The lungs and pleurae are made up of the following com- two or more segmental bronchi: 10 on the right and 8 on ponents. The right lung has three lobes—the upper, middle, the left. Segmental bronchi have scattered cartilage, and lower—and 10 bronchopulmonary segments. The left smooth muscle, elastic fibers, and a capillary network. The lung has two true lobes—the upper and lower—and a slip mainstem, lobar, and segmental bronchi have a mucous of lung called the lingula, which is not considered a “true” membrane essentially the same as the trachea. lobe of the lungs. The left lung has eight bronchopul- Bronchioles. Segmental bronchi divide into subsegmental monary segments. The lobes of the lungs are depicted in bronchi and bronchioles, which have less and less cartilage Figure 25.4. and ciliated epithelial cells. These bronchioles divide into the terminal bronchioles, which are distal to the last cartilage of the tracheobronchial tree. Terminal bronchioles contain no ciliated cells. Terminal bronchioles divide into Trachea respiratory bronchioles and provide a transitional zone between the bronchioles and alveoli. Upper Upper Alveoli. The respiratory bronchioles divide into alveolar Lobe Lobe ducts and alveolar sacs (Fig. 25.3). One duct may supply Right Left Right Left several sacs. The ducts contain smooth muscle, which nar- Bronchus Bronchus rows the lumen of the duct with contraction. The alveoli Lung Lung are located in the periphery of the alveolar ducts and sacs Middle and are in contact with capillaries (alveolar-arterial mem- Lower Lobe Lower brane). Gas exchange occurs here. Lobe Lobe Summary of Function of the Upper Diaphragm and Lower Respiratory Tracts The upper and lower respiratory tracts, as a unit, serve the FIGURE 25.4 Structure of the right and left lungs. following functions. They: 25Kisner (F)-25 3/9/07 12:54 PM Page 856

856 EXAMINATION

Each lung is covered in pleura, a serous membrane Expiratory Reserve Volume known as the visceral pleura. This membrane adheres to Expiratory reserve volume (ERV) is the amount of air a all surfaces of each lung. The parietal pleura lines the person can exhale after a normal resting expiration inside of the thoracic wall. The parietal pleura is sensitive (approximately 1000 mL). to pain, but the visceral pleura appears to be insensi- 30,31 Residual Volume tive. A negative pressure in the minute space between Residual volume (RV) is the amount of air left in the lungs the pleurae serves to keep the lungs inflated. Pleural fluid after a maximum expiration (approximately 1500 mL). RV is found between the pleurae and lubricates the pleurae as increases with age and with restrictive and obstructive pul- they slide on each other during ventilation. monary diseases. Inspiratory Capacity Lung Volumes and Capacities Inspiratory capacity (IC) is the maximum amount of air a Pulmonary function tests that measure lung volumes and person can breathe in after a resting expiration (approxi- capacities are performed to evaluate the mechanical func- mately 3500 mL). tion of the lungs (Fig. 25.5). Lung volumes and capacities Functional Residual Capacity are related to a person’s age, weight, sex, and body posi- Functional residual capacity (FRC) is the amount of air tion and are altered by disease.27,59,61 Two or more lung remaining in the lungs after a resting (tidal) expiration volumes, when combined, are described as a capacity. A (approximately 2500 mL). It is the sum of the ERV and basic understanding of these measurements and what the RV. FRC represents the point during ventilation at which values reflect is useful for a therapist treating patients with the forces that expand the thoracic wall are in balance with pulmonary dysfunction. the forces that tend to collapse the lungs.59 Vital Capacity Vital capacity (VC) is the sum of the TV, IRV, and ERV. It is measured by a maximum inspiration followed by a maximum expiration (approximately 4500 mL). Vital capacity decreases with age and is less in the supine position than in an erect posture (sitting or standing). VC decreases in the presence of restrictive and obstructive diseases.

EXAMINATION

Evaluation of the patient with pulmonary dysfunction and determination of a diagnosis, prognosis, and intervention plan are based on the findings derived from a comprehen- FIGURE 25.5 Normal lung values and capacities. sive examination, including a history, systems review, and specific tests and measures.31 The multiple purposes of this examination are summarized in Box 25.3. Total Lung Capacity Total lung capacity (TLC) is the total amount of air con- tained in the lungs after a maximum inspiration. TLC can BOX 25.3 Purpose of the Examination be subdivided into four volumes: tidal volume, inspiratory reserve volume, expiratory reserve volume, and residual • Determine a patient’s primary and secondary respiratory volume. The vital capacity plus the residual volume equal and ventilatory impairments and how they limit physical the TLC, which is approximately 6000 mL in a healthy, function. young adult. • Determine the adequacy of the ventilatory pump and the oxygen uptake/carbon dioxide elimination mechanisms Tidal Volume to meet the oxygen demands at rest and during function- The amount of air exchanged during a relaxed inspiration al activities. followed by a relaxed expiration is called the tidal volume • Ascertain a patient’s suitability for participation in a pul- (TV). In a healthy, young adult, TV is approximately 500 monary rehabilitation program. mL per inspiration. Approximately 350 mL of the tidal vol- • Develop an appropriate level intervention plan for the ume reaches the alveoli and participates in gas exchange patient. (respiration). • Establish a baseline to measure a patient’s progress and the effectiveness of the treatment. Inspiratory Reserve Volume • Determine when to discontinue specific interventions Inspiratory reserve volume (IRV) is the amount of air a and implement a home program as a basis for self- person can breathe in after a resting inspiration (approxi- management. mately 3000 mL). 25Kisner (F)-25 3/9/07 12:54 PM Page 857

CHAPTER 25 Management of Pulmonary Conditions 857

Components of the Examination ties, the housing situation, and available family support systems. A brief systems review should follow the history. A comprehensive examination of a patient with known or suspected dysfunction related to primary and secondary General Appearance of the Patient pulmonary or chest disorders has many elements. The Table 25.1 describes the type of information that can be examination procedures described in this section are those obtained by visual inspection of a patient and the possible often used by a therapist during an initial evaluation to implications of these observations. Many of these findings establish a therapy-related diagnosis or during subsequent can be noted during the course of the history or during the assessments for modification of therapeutic interven- systems review. 11,31,35,38,52,67 tions. Additional examination procedures not Analysis of Chest Shape and Dimensions described in this section but integral to the management of a patient with pulmonary dysfunction are radiography, Symmetry of the chest and trunk. Observe anteriorly, evaluation of blood gases, tomography, bronchoscopy, and posteriorly, and laterally; the thoracic cage should be hematological tests. symmetrical. History and Systems Review Mobility of the trunk. Check active movements in all The examination process begins with a patient’s history directions and identify any restricted spinal motions, par- including an interview with the patient and sometimes fam- ticularly in the thoracic spine. ily members if they are available. During the interview a therapist can identify a patient’s and/or family members’ Shape and dimensions of the chest. The anteroposterior perception of any functional limitations or disabilities and (AP) and lateral dimensions are usually 1:2. Common determine a patient’s chief complaints and why he or she is chest deformities include: seeking treatment. In preparation for the interview, the med- Barrel chest. The circumference of the upper chest ical history and any medical diagnoses are obtained from appears larger than that of the lower chest. The sternum the patient’s medical record, if available, or more generally, appears prominent, and the AP diameter of the chest is from the patient or family. Relevant occupational and social greater than normal. Many patients with chronic obstruc- history are obtained; particularly important are on-the-job tive pulmonary disorders, who are usually upper chest physical demands, the environment of the workplace, and breathers, develop a barrel chest. social habits that affect a person’s well-being, such as Pectus excavatum (funnel breast). The lower part of tobacco or alcohol use. Assessment of the home or family the sternum is depressed and the lower ribs flare out. environment might include a patient’s family responsibili- Patients with this deformity are diaphragmatic breathers;

TABLE 25.1 General Appearance of the Patient and Implications

General Appearance Implications

¥ Level of awareness (level of consciousness): alert, ¥ Respiratory acidosis, hypercarbia (increased Pco2 level), responsive, or cooperative versus lethargic, disoriented, or hypoxia (decreased Po2 level) can alter level of or inattentive consciousness ¥ Body type: normal, obese, or cachectic ¥ May reflect intolerance to exercise ¥ Color: cyanosis (bluish appearance) peripherally ¥ Peripheral cyanosis may indicate low cardiac output; (nailbeds) or centrally (lips) central cyanosis may indicate inadequate gas exchange in the lungs ¥ Facial signs or expressions: focused or dilated pupils, ¥ Signs of respiratory distress, fatigue, or pulmonary or nasal flaring, sweating, or distressed appearance musculoskeletal pain ¥ Jugular vein engorgement: visualization of the jugular ¥ Bilateral distention associated with congestive heart venous pulse with the patient supine and the head and failure/right-sided heart failure neck on pillows at a 45 angle ¥ Hypertrophy of or use at rest of accessory muscles of ¥ Seen in patients with early chronic lung disease or ventilation: SCM, upper trapezius weakness of the diaphragm ¥ Supraclavicular or intercostal retractions occurring with ¥ Seen in patients with labored breathing inspiration ¥ Use of pursed lip breathing (usually with expiration) ¥ Indicates difficulty with expiration; often seen in patients with COPD ¥ Clubbing of digits: loss of angle between the nail bed ¥ May be linked to perfusion and DIP joint ¥ Peripheral edema ¥ Sign of right ventricular failure or lymphatic dysfunction 25Kisner (F)-25 3/9/07 12:54 PM Page 858

858 EXAMINATION

excessive abdominal protrusion and little upper chest The normal sequence of inspiration at rest is (1) the movement occur during breathing. diaphragm contracts and descends and the abdomen (epi- Pectus carinatum (pigeon breast). The sternum is gastric area) rises; (2) this is followed by lateral costal prominent and protrudes anteriorly. expansion as the ribs move up and out; and finally (3) the Posture or Preferred Positioning upper chest rises. The neck muscles that act as accessory Identify a patient’s preferred sitting or standing posture. A muscles of inspiration should be inactive during relaxed patient who has difficulty breathing as the result of chronic inspiration. lung disease often leans forward on hands or forearms to To assess the breathing sequence, have the patient stabilize and elevate the shoulder girdle to assist with assume a comfortable position (semireclining or supine). inspiration (Fig. 25.6). This position increases the effec- Place your hands on the patient’s epigastric region and tiveness of the pectoralis and serratus anterior muscles to sternum to observe movements in these two areas. act as accessory muscles of inspiration by reverse action. It A number of terms are used to describe abnormal 11,35,38,52 is also important to identify a patient’s preferred sleeping breathing patterns and are defined in Box 25.4. position. A patient with cardiopulmonary dysfunction often Chest Mobility prefers to sleep in a head-up rather than a fully recumbent position. Assuming a horizontal position may result in Symmetry of chest movement. Analysis of the symmetry shortness of breath. of the moving chest during breathing gives the therapist information about the mobility of the thorax and indicates indirectly what areas of the lungs may or may not be responding. Procedure: Place your hands on the patient’s chest and assess the excursion of each side of the thorax during inspiration and expiration. Each of the three lobar areas can be checked.11,35,38,52 To check upper lobe expansion, face the patient; place the tips of your thumbs at the midsternal line at the sternal notch. Extend your fingers above the clavicles. Have the patient fully exhale and then inhale deeply. To check middle lobe expansion, continue to face the patient; place the tips of your thumbs at the xiphoid process and extend your fingers laterally around the ribs. Again, ask the patient to breathe in deeply (Fig. 25.7A). To check lower lobe expansion, place the tips of your thumbs along the patient’s back at the spinous processes (lower thoracic level) and extend your fingers around the ribs. Ask the patient to breathe in deeply (Fig. 25.7B).

FIGURE 25.6 A patient who is short of breath at rest or after activity often assumes a forward-bent position with hands or elbows resting on the thighs to reduce or relieve symptoms. BOX 25.4 Abnormal Breathing Patterns

• Dyspnea. Distressed, labored breathing as the result of shortness of breath. In addition, note any postural deformities such as • Tachypnea. Rapid, shallow breathing; decreased tidal vol- kyphosis and scoliosis and postural asymmetry from tho- ume but increased rate; associated with restrictive or racic surgery, which could restrict chest movements and obstructive lung disease and use of accessory muscles of ventilation. inspiration. Breathing Pattern • Bradypnea. Slow rate with shallow or normal depth and Assess the rate, regularity, and location of ventilation at regular rhythm; may be associated with drug overdose. rest and with activity. A normal respiratory rate for a • Hyperventilation. Deep, rapid respiration; increased tidal volume and increased rate of respiration; regular rhythm. healthy adult is 12 to 20 breaths per minute. This is most • Orthopnea. Difficulty breathing in the supine position. accurately determined when a patient is unaware that his or • Apnea. Cessation of breathing in the expiratory phase. her respiratory rate is being measured, as when taking the • Apneusis. Cessation of breathing in the inspiratory phase. pulse rate. The normal ratio of inspiration to expiration at • Cheyne-Stokes. Cycles of gradually increasing tidal vol- rest is 1:2 and with activity 1:1. A patient with chronic umes followed by a series of gradually decreasing tidal obstructive pulmonary disease (COPD) may have a ratio of volumes and then a period of apnea. This is sometimes 1:4 at rest, which reflects difficulty with the expiratory seen in the patient with a severe head injury. phase of breathing. 25Kisner (F)-25 3/9/07 12:54 PM Page 859

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can mimic musculoskeletal pain, such as pulmonary embolism, pleurisy, pneumonia, pneumothorax, and pulmonary artery hypertension.31 Mediastinal shift. The position of the trachea normally is oriented centrally in relation to the suprasternal notch indi- cating symmetry of the mediastinum. The position of the trachea shifts as the result of asymmetrical intrathoracic pressures or lung volumes. For example, if the patient has had a pneumonectomy (removal of a lung), the lung volume on the operated side decreases, and the trachea shifts toward that side. Conversely, if the patient has a hemothorax (blood in the thorax), intrathoracic pressure on the side FIGURE 25.7 (A) Anterior and (B) posterior placement of a therapist’s hands of the hemothorax increases, and the mediastinum shifts on a patient’s thorax to assess the symmetry of movement during breathing. away from the affected side of the chest.11,35,38,52 (From Brannon, FJ, et al: Cardiopulmonary Rehabilitation—Basic Theory and Application, ed 3, FA Davis, Philadelphia, 1998, p. 288. Adapted from Rothstein, JH, Roy, SH, Wolf, SL: Procedure: To identify a mediastinal shift, have the The Rehabilitation Specialist’s Handbook, FA Davis, Philadelphia, 2005, p 416–417, with patient sit facing you with the head in midline and the neck permission.) slightly flexed to relax the sternocleidomastoid muscles. With your index finger, gently palpate the soft tissue space on either side of the trachea at the suprasternal notch. Extent of excursion. The extent of chest mobility can be Determine whether the trachea is palpable at the midline or measured by two methods.35,38 has shifted to the left or right. Measure the girth of the chest with a tape measure at Mediate Percussion three levels (axilla, xiphoid, lower costal). Document Mediate percussion is an examination technique designed change in girth after a maximum inspiration and a maxi- to assess lung density, specifically, the air-to-solid ratio in 11,35,38,52 mum expiration. the lungs. Place both hands on the patient’s chest or back as previ- Procedure: Place the middle finger of the nondomi- ously described. Note the distance between your thumbs nant hand flat against the chest wall along an intercostal after a maximum inspiration. space. With the tip of the middle finger of the opposite hand, firmly tap on the finger positioned on the chest wall. Palpation Repeat the procedure at several points on the right and left Palpation of the thorax provides evidence of dysfunction of and anterior and posterior aspects of the chest wall. This the underlying tissues including the lungs, chest wall, and maneuver produces a resonance; the pitch varies with the mediastinum.11,35,38,52 density of the underlying tissue. The subjective determina- Tactile (vocal) fremitus. Tactile fremitus is the vibration tion of pitch indicates the following. felt while palpating over the chest wall as a patient speaks. The sound is dull and flat if there is a greater than nor- Procedure: Place the palms of your hands lightly on mal amount of solid matter (tumor, consolidation) in the the chest wall and ask the patient to speak a few words or lungs in comparison with the amount of air. repeat “99” several times. Normally, fremitus is felt uni- The sound is hyperresonant (tympanic) if there is a formly on the chest wall. Fremitus is increased in the pres- greater than normal amount of air in the area (as in ence of secretions in the airways and decreased or absent patients with emphysema). when air is trapped as the result of obstructed airways. If asymmetrical or abnormal findings are noted, the patient should be referred to the physician for addi- Chest wall pain. Specific areas or points of pain over ante- tional objective tests such as a chest radiograph. rior, posterior, or lateral aspects of the chest wall can be identified with palpation. Auscultation of Breath Sounds Procedure: Firmly press against the chest wall with Auscultation is a general term that refers to the process your hands to identify any specific areas of pain potentially of listening to sounds within the body, specifically to of musculoskeletal origin. Ask the patient to take a deep breath sounds during an examination of the lungs.11,35,38,52 breath and identify any painful areas of the chest wall. Breath sounds occur because of movement of air in the Chest wall pain of musculoskeletal origin often increases airways during inspiration and expiration. A stethoscope with direct point pressure during palpation and during a is used to magnify these sounds. Breath sounds should be deep inspiration.35,38 assessed to: NOTE: Pain in the anterior, posterior, or lateral region of Identify the areas of the lungs in which congestion exists the chest can be of musculoskeletal, pulmonary, or cardiac and in which airway clearance techniques should be per- origin.31 Pain of pulmonary origin is usually localized to a formed. region of the chest but also may be felt in the neck or Determine the effectiveness of any airway clearance shoulder region. Several pulmonary or cardiac conditions intervention. 25Kisner (F)-25 3/9/07 12:54 PM Page 860

860 EXAMINATION

Determine whether the lungs are clear and whether inter- after several deep breaths to prevent dizziness from hyper- ventions should be discontinued. ventilation. Guard the patient closely to prevent loss of balance if lightheadedness occurs. Procedure: When assessing breath sounds, be sure the setting is quiet. Have the patient assume a comfortable, Classification of Breath Sounds relaxed, sitting position to allow access to the chest wall. Breath sounds are classified by location, pitch, and intensi- Place the diaphragm of the stethoscope directly against the ty as well as the ratio of sounds heard on inspiration versus patient’s skin along the anterior or posterior chest wall. Be those heard on expiration. Breath sounds also are identified sure that the tubing does not rub together or come in con- as normal or adventitious (extra).5,50,52,77 tact with clothing during auscultation, as this contact pro- Normal breath sounds occur in the absence of patholo- duces extraneous sounds. gy and are heard predominantly during inspiration. Normal Follow a systematic pattern (Fig. 25.8A&B) and place breath sounds are categorized as vesicular, bronchial, or the stethoscope against specific thoracic landmarks (T2, T6, bronchovesicular based on the location and quality of the T10) along the right and left sides of the chest wall. Ask sound. They are described in Box 25.5.5,77 Adventitious the patient to breathe in deeply and out quickly through the breath sounds are abnormal sounds in the lungs that are mouth as you move the stethoscope from point to point. heard with a stethoscope. Although terminology in the lit- Note the quality, intensity, and pitch of the breath sounds. erature is inconsistent, the nomenclature used most often PRECAUTION: Auscultate slowly from one area to was proposed by a joint committee of the American Col- another. Allow the patient to breathe in a relaxed manner lege of Chest Physicians and the American Thoracic Soci- ety.5,77 Adventitious breath sounds are categorized as crackles or wheezes. Box 25.5 describes the location and quality of these breath sounds.

BOX 25.5 Normal and Adventitious Breath Sounds

Normal Breath Sounds • Vesicular. Soft, low-pitched, breezy but faint sounds heard over most of the chest except near the trachea and mainstem bronchi and between the scapulae. Vesicular sounds are audible considerably longer on inspiration than expiration (about a 3:1 ratio). • Bronchial. Loud, hollow, or tubular high-pitched sounds heard over the mainstem bronchi and trachea. Bronchial sounds are heard equally during inspiration and expiration; a slight pause in the sound occurs between inspiration and expiration. • Bronchovesicular. Softer than bronchial breath sounds; also heard equally during inspiration and expiration but without a pause in the sound between the cycles. The sounds are heard in the supraclavicular, suprascapular, and parasternal regions anteriorly and between the scapulae posteriorly. Adventitious Breath Sounds • Crackles. Fine, discontinuous sounds (similar to the sound of bubbles popping or the sound of hairs being rubbed between your fingers next to your ear). Crackles, which can be fine or coarse, are heard primarily during inspiration as the result of secretions moving in the airways or in closed airways that are rapidly reopening. The former term for crackles was rales. • Wheezes. Continuous high- or low-pitched sounds or sometimes musical tones heard during exhalation but FIGURE 25.8 Pattern of specific thoracic landmarks for auscultation. The occasionally audible during inspiration. Bronchospasm diaphragm of the stethoscope is placed along the right and left (A) anterior or secretions that narrow the lumen of the airways cause chest wall and the (B) posterior chest wall at T2, T6, and T10. (From Frownfelter, wheezes. The term previously used for wheezes was DL: Chest Physical Therapy and Pulmonary Rehabilitation. Year-Book Medical Publishers, Chicago, 1987, p 135, with permission.) rhonchi. 25Kisner (F)-25 3/9/07 12:54 PM Page 861

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Breath sounds may be totally absent or substantially BOX 25.6 Goals of Breathing Exercises and diminished over a portion of the lungs. This indicates total Ventilatory Muscle Training or partial obstruction and lack of aeration of lung tissue. The absence of air and collapse of an area of lung tissue is known as atelectasis. Obstruction of airways may be • Improve or redistribute ventilation. caused by fluids, mucus, bronchospasm, or compression • Increase the effectiveness of the cough mechanism and by tumor. promote airway clearance. • Prevent postoperative pulmonary complications. Cough and Cough Production • Improve the strength, endurance, and coordination of the The strength, depth, length, and frequency of a patient’s muscles of ventilation. cough must be assessed. An effective cough is sharp and • Maintain or improve chest and thoracic spine mobility. deep. In the patient with current or potential pulmonary • Correct inefficient or abnormal breathing patterns and dysfunction a cough can be described as weak, shallow, decrease the work of breathing. soft, or throaty. A patient may have a weak, shallow cough • Promote relaxation and relieve stress. as the result of pain or paralysis. A sudden onset of a • Teach the patient how to deal with episodes of dyspnea. • Improve a patient’s overall functional capacity for daily cough or a sustained cough often is described as paroxys- living, occupational, and recreational activities. mal or spasmodic. If a cough is substantially weak or ineffective, suctioning may be required to clear the airways.11,35,52 A cough may be productive or nonproductive in the COPD (chronic bronchitis, emphysema, asthma) or cystic presence of pathology. The productivity of the cough and fibrosis, for patients with a high spinal cord lesion, for secretions produced by the cough should be assessed. patients who have undergone thoracic or abdominal sur- Secretions are checked for: gery and are at high risk for acute pulmonary complica- Color (clear, yellow, green, blood-stained) tions, or for patients who must remain in bed for an * Consistency (viscous, thin, frothy) extended period of time. Amount (minimal to copious) Breathing exercises and ventilatory training can take Odor (no odor to foul-smelling) on many forms including diaphragmatic breathing, segmental breathing, inspiratory resistance training, incentive Production of a small amount of clear or white secre- spirometry, and breathing techniques for the relief of dysp- tions on a daily basis is normal. Copious but clear secre- nea during exertion. The goals of these interventions are tions are common with chronic bronchitis. Yellow, green, listed in Box 25.6. and purulent secretions with a strong odor are indicative of Research studies indicate that although breathing exer- some type of infection. Blood-streaked secretions, known cises or ventilatory muscle training may affect and possibly as hemoptysis, is indicative of some degree of hemorrhage alter a patient’s rate and depth of ventilation these interven- in the lungs. Frothy, white secretions are associated with tions may not necessarily have any impact on gas exchange pulmonary edema and heart failure. at the alveolar level or on oxygenation.11,28,48,60 Therefore, When secretions are produced during the course of breathing exercises or ventilatory training should be only interventions, such as exercise or airway clearance, it is the one aspect of management to improve pulmonary status responsibility of the therapist to document the characteris- and to increase a patient’s overall endurance and function tics of the secretions. during daily living activities. Depending on a patient’s Additional Areas of Examination underlying pathology and impairments, exercises to The examination procedures described in this section are improve ventilation often are combined with medication, complemented with other areas of examination, which may airway clearance, the use of respiratory therapy devices, include a patient’s use of assistive respiratory equipment, and a graded exercise (aerobic conditioning) program. ROM particularly of the shoulders, neck, and trunk, muscle strength, general endurance and graded exercise testing, Guidelines for Teaching Breathing Exercises and a patient’s identification of functional abilities or limitations and perceived disability and quality of life. If possible, choose a quiet area for instruction in which you can interact with the patient with minimal distrac- tions. BREATHING EXERCISES AND Explain to the patient the aims and rationale of breathing exercises or ventilatory training specific to his or her VENTILATORY TRAINING particular impairments and functional limitations. Have the patient assume a comfortable, relaxed position Breathing exercises and ventilatory training are fundamen- and loosen restrictive clothing. Initially, a semi-Fowler’s tal interventions for the prevention or comprehensive man- position with the head and trunk elevated approximately agement of impairments related to acute or chronic pulmonary disorders. For example, these interventions * See references 3, 7, 11, 14, 15, 28, 36, 40, 44, 45, 48, 57, 60, 63, 66, are frequently advocated in the literature for patients with 76. 25Kisner (F)-25 3/9/07 12:54 PM Page 862

862 BREATHING EXERCISES AND VENTILATORY TRAINING

45, is desirable. By supporting the head and trunk, Controlled breathing techniques, which emphasize flexing the hips and knees, and supporting the legs diaphragmatic breathing, are designed to improve the effi- with a pillow, the abdominal muscles remain relaxed. ciency of ventilation, decrease the work of breathing, Other positions, such as supine, sitting, or standing, increase the excursion (descent or ascent) of the diaphragm, may be used initially or as the patient progresses during and improve gas exchange and oxygenation.11,28,44,48,60 treatment. Diaphragmatic breathing exercises also are used during Observe and assess the patient’s spontaneous breathing postural drainage to mobilize lung secretions.25,51 pattern while at rest and later with activity. Determine whether ventilatory training is indicated. Procedure Establish a baseline for assessing changes, progress, and Prepare the patient in a relaxed and comfortable position outcomes of intervention. in which gravity assists the diaphragm, such as a semi- If necessary, teach the patient relaxation techniques. This Fowler’s position. relaxes the muscles of the upper thorax, neck, and shoul- If your examination revealed that the patient initiates the ders to minimize the use of the accessory muscles of breathing pattern with the accessory muscles of inspira- ventilation. Pay particular attention to relaxation of the tion (shoulder and neck musclulature), start instruction by sternocleidomastoids, upper trapezius, and levator scapu- teaching the patient how to relax those muscles (shoulder lae muscles. rolls or shoulder shrugs coupled with relaxation). Depending on the patient’s underlying pathology and Place your hand(s) on the rectus abdominis just below impairments, determine whether to emphasize the inspi- the anterior costal margin (Fig. 25.9). Ask the patient to ratory or expiratory phase of ventilation. breathe in slowly and deeply through the nose. Have the Demonstrate the desired breathing pattern to the patient. patient keep the shoulders relaxed and upper chest quiet, Have the patient practice the correct breathing pattern in allowing the abdomen to rise slightly. Then tell the a variety of positions at rest and with activity. patient to relax and exhale slowly through the mouth.

PRECAUTIONS: When teaching breathing exercises, be aware of the following precautions11,28,48,60:

Never allow a patient to force expiration. Expiration should be relaxed or lightly controlled. Forced expiration only increases turbulence in the airways, leading to bronchospasm and increased airway restriction. Do not allow a patient to take a highly prolonged expiration. This causes the patient to gasp with the next inspiration. The patient’s breathing pattern then becomes irregular and inefficient. Do not allow the patient to initiate inspiration with the accessory muscles and the upper chest. Advise the patient that the upper chest should be relatively quiet during breathing. Allow the patient to perform deep breathing for only three or four inspirations and expirations at a time to avoid hyperventilation. FIGURE 25.9 The semireclining (as shown) and semi-Fowler’s positions are comfortable, relaxed positions in which to teach diaphragmatic breathing. Diaphragmatic Breathing When the diaphragm is functioning effectively in its role as the primary muscle of inspiration, ventilation is efficient Have the patient practice this three or four times and and the oxygen consumption of the muscles of ventilation then rest. Do not allow the patient to hyperventilate. is low during relaxed (tidal) breathing.7,28 When a patient If the patient is having difficulty using the diaphragm relies substantially on the accessory muscles of inspiration, during inspiration, have the patient inhale several times the mechanical work of breathing (oxygen consumption) in succession through the nose by using a sniffing increases and the efficiency of ventilation decreases. action.28,60 This action usually facilitates the diaphragm. Although the diaphragm controls breathing at an involun- To learn how to self-monitor this sequence, have the tary level, a patient with primary or secondary pulmonary patient place his or her own hand below the anterior dysfunction can be taught how to control breathing by opti- costal margin and feel the movement (Fig. 25.10). The mal use of the diaphragm and decreased use of accessory patient’s hand should rise slightly during inspiration and muscles. fall during expiration. 25Kisner (F)-25 3/9/07 12:55 PM Page 863

CHAPTER 25 Management of Pulmonary Conditions 863

Deep breathing while focusing on movement of the lower portion of the rib cage may facilitate diaphragmatic excursion.28 This technique is particularly important for the patient with a stiff lower rib cage, as is often seen with chronic bronchitis, emphysema, or asthma.7 Procedure Have the patient begin in a hook-lying position; later progress to a sitting position. Place your hands along the lateral aspect of the lower ribs to direct the patient’s attention to the areas where movement is to occur (Figs. 25.11 and 25.12).

FIGURE 25.10 The patient places his or her own hands on the abdomen to feel the movement of proper diaphragmatic breathing. By placing the hands on the abdomen, the patient can also feel the contraction of the abdominals, which occurs with controlled expiration or coughing.

After the patient understands and is able to control breathing using a diaphragmatic pattern, keeping the shoulders relaxed, practice diaphragmatic breathing in a variety of positions (sitting, standing) and during activity FIGURE 25.11 Bilateral lateral costal expansion—supine. (walking, climbing stairs). NOTE: Evidence concerning the effect of diaphragmatic breathing exercises on the rate of ventilation, the work of breathing and oxygen consumption, excursion of the diaphragm, and exercise capacity in normal subjects and in patients with pulmonary disorders is inconclusive, with some studies supporting and others refuting the benefits of diaphragmatic breathing.13,28,44,62 Segmental Breathing It is questionable whether a patient can be taught to expand localized areas of the lungs while keeping other areas quiet. It is known, however, that hypoventilation does occur in certain areas of the lungs because of chest wall fibrosis, pain, and muscle guarding after surgery, atelectasis, and pneumonia. Therefore, there are certain instances such as during postural drainage or following thoracic surgery when it is important to emphasize expansion of prob- lem areas of the lungs and chest wall. Two examples of segmental breathing that target the lateral and posterior segments of the lower lobes are FIGURE 25.12 Bilateral lateral costal expansion—sitting. described in this section. However, segmental breathing techniques also may need to be directed to the middle and upper lobes if there is accumulation of secretions or insuf- Ask the patient to breathe out, and feel the rib cage move ficient lung expansion in these areas. downward and inward. As the patient breathes out, place Lateral Costal Expansion pressure into the ribs with the palms of your hands. Lateral costal expansion, sometimes called lateral basal Just prior to inspiration, apply a quick downward expansion, can be carried out unilaterally or bilaterally. and inward stretch to the chest. This places a quick 25Kisner (F)-25 3/9/07 12:55 PM Page 864

864 BREATHING EXERCISES AND VENTILATORY TRAINING

stretch on the external intercostals to facilitate their the posterior aspect of the lower ribs, and follow the same contraction. procedure just described for lateral costal expansion. Apply light manual resistance to the lower ribs to increase sensory awareness as the patient breathes in deeply and the chest expands and ribs flare. Then, as Pursed-Lip Breathing the patient breathes out, assist by gently squeezing the Pursed-lip breathing is a strategy that involves lightly purs- rib cage in a downward and inward direction. ing the lips together during controlled exhalation. This Teach the patient how to perform the maneuver inde- breathing pattern often is adopted spontaneously by pendently by placing his or her hand(s) over the ribs patients with COPD to deal with episodes of dysp- (Fig. 25.13) or applying resistance with a towel or belt nea.7,10,28,43,48 Patients with COPD using pursed-lip breath- around the lower ribs (Fig. 25.14A&B). ing report a decrease in their perceived level of exertion during activity.10 However, whether it is beneficial to teach a patient pursed-lip breathing often is debated. Many therapists believe that gentle pursed-lip breathing and controlled expiration is a useful procedure, particularly to relieve dyspnea if it is performed appropriately. It is thought to keep airways open by creating back-pressure in the airways. Studies suggest that pursed-lip breathing decreases the respiratory rate and the work of breathing (oxygen consumption), increases the tidal volume, and improves exercise tolerance.15,28,43,48 PRECAUTION: The use of forceful expiration during FIGURE 25.13 The patient applies his or her own manual pressure during pursed-lip breathing must be avoided. Forceful expiration lateral costal expansion. while the lips are pursed can increase the turbulence in the airways and cause further restriction of the small bronchioles. Therefore, if a therapist elects to teach this breathing Posterior Basal Expansion strategy, it is important to emphasize with the patient that Deep breathing emphasizing posterior basal expansion is expiration should be performed in a controlled manner but important for the postsurgical patient who is confined to not forced. bed in a semireclining position for an extended period of Procedure time because secretions often accumulate in the posterior Have the patient assume a comfortable position and relax segments of the lower lobes. as much as possible. Have the patient breathe in slowly and Procedure deeply through the nose and then breathe out gently Have the patient sit and lean forward on a pillow, slightly through lightly pursed lips as if blowing on and bending bending the hips (see Fig. 25.15). Place your hands over the flame of a candle but not blowing it out.43 Explain to

FIGURE 25.14 Belt exercises reinforce lateral costal breathing (A) by applying resistance during inspiration and (B) by assisting with pressure along the rib cage during expiration. 25Kisner (F)-25 3/9/07 12:55 PM Page 865

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the patient that expiration must be relaxed and that contraction of the abdominals must be avoided. Place your hand over the patient’s abdominal muscles to detect any contraction of the abdominals.

Preventing and Relieving Episodes of Dyspnea Many patients with COPD (e.g., emphysema and asthma) may suffer from periodic episodes of dyspnea (shortness of breath), particularly with physical exertion or when in contact with allergens. Whenever a patient’s normal breathing pattern is interrupted, shortness of breath can occur. It is helpful to teach a patient how to monitor his or her level of shortness of breath and to prevent episodes of dyspnea by controlled breathing techniques, pacing activities, and becoming aware of what activity or situation precipitates a shortness of breath attack. Pacing is the performance of functional activities, such as walking, stair climbing, or work-related tasks, within the FIGURE 25.16 While standing, a patient can lean forward and place some limits of a patient’s ventilatory capacity.11 Although some weight on the hands to relieve dyspnea. patients may understand intuitively the limits to which functional activities can be pushed, others must be taught to recognize the early signs of dyspnea. If the patient After each pursed-lip expiration, teach the patient to use becomes slightly short of breath, he or she must learn to diaphragmatic breathing and minimize use of accessory stop an activity and use controlled, pursed-lip breathing muscles during each inspiration. until the dyspnea subsides. Have the patient remain in a forward-bent posture and Procedure continue to breathe in a slow, controlled manner until the episode of dyspnea subsides. Have the patient assume a relaxed, forward-bent posture (Figs. 25.15 and 25.16; also see Fig. 25.6). A forward- bent position stimulates diaphragmatic breathing (the Positive Expiratory Pressure Breathing viscera drop forward and the diaphragm descends more Positive expiratory pressure breathing is a technique easily). Use bronchodilators as prescribed. in which resistance to airflow is applied during exhala- Have the patient gain control of his or her breathing and tion, similar to what occurs during pursed-lip breathing, reduce the respiratory rate by using pursed-lip breathing except that the patient breathes through a specially during expiration. Have the patient focus on the expirato- designed mouthpiece or mask that controls resistance to ry phase of breathing while being sure to avoid forceful airflow.19,20,25 This breathing technique is used to hold expiration. airways open during exhalation to mobilize accumulated secretions and improve their clearance. Positive expiratory pressure breathing provides an alternative or adjunct to postural drainage which a patient can perform independ- ently.

Procedure Positive expiratory pressure breathing is performed in an upright position, preferably seated with the elbows resting on a table. The procedure can be performed against low or high pressure. A low pressure technique involves tidal inspiration and active, but not forced, expiration through a mouthpiece or mask. The patient inhales, holds the inspiration for 2 to 3 seconds, and then exhales, repeating the sequence for approximately 10 to 15 cycles.19,20,25 The patient removes the mouthpiece or mask, takes several “huffs” and then coughs to clear the mobilized secretions from the airways. The breathing sequence typically is FIGURE 25.15 A patient can sit and lean forward on a pillow to relax and repeated four to six times with a total treatment session relieve an episode of dyspnea. lasting about 15 minutes. 25Kisner (F)-25 3/9/07 12:55 PM Page 866

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Respiratory Resistance Training a decreased respiratory rate) in patients with cervical-level spinal cord lesions.24,49,57,74 The process of improving the strength or endurance of the muscles of ventilation is known as respiratory resistance Procedure training (RRT). Other descriptions used to denote this form The patient inhales through a resistive training device of breathing exercises are ventilatory muscle training, placed in the mouth. These devices are narrow tubes of inspiratory (or expiratory) muscle training, inspiratory varying diameters or a mouthpiece and adapter with an resistance training, and flow-controlled endurance train- adjustable aperture that provide resistance to airflow during. These techniques typically focus on training the mus- ing inspiration and therefore place resistance on inspira- cles of inspiration,14,26,32,33,54,65 although expiratory muscle tory muscles. The smaller the diameter of the aperture training also has been described.32,33 RRT is advocated to and the faster the rate of airflow, the greater is the resist- improve ventilation in patients with pulmonary dysfunction ance. associated with weakness, atrophy, or inefficiency of the The patient inhales through the device for a specified muscles of inspiration or to improve the effectiveness of period of time several times each day. The time is gradu- the cough mechanism in patients with weakness of the ally increased to 20 to 30 minutes at each training ses- abdominal muscles or other expiratory muscles. sion to increase inspiratory muscle endurance. With support from animal studies,46,62 it has been sug- Incentive Respiratory Spirometry gested that the principles of overload and specificity of Incentive spirometry is a form of ventilatory training that training apply to skeletal muscles throughout the body, emphasizes sustained maximum inspirations.18,48,60 The including the muscles of ventilation.* In humans, it is not patient inhales as deeply as possible through a small, hand- feasible to use invasive procedures to evaluate morphologi- held spirometer that provides visual or auditory feedback cal or histochemical changes in the diaphragm that may about whether a target maximum inspiration was reached. occur as the result of strength or endurance training. Typically, this breathing technique is performed while Instead, strength or endurance changes must be assessed using a spirometer, but it also may be performed without indirectly. Increases in respiratory muscle strength and the equipment. endurance are determined by ultrasonographic meaure- The purpose of incentive spirometry is to increase the ments of the thickness of the diaphragm, maximal volun- volume of air inspired. It is used primarily to prevent alve- tary ventilation, and decreased reliance on accessory olar collapse and atelectasis in postoperative patients. muscles of inspiration. Respiratory muscle strength (either Despite the widespread use of incentive spirometry for inspiratory or expiratory) also is evaluated indirectly with patients after surgery, the effectiveness of this technique measurements of inspiratory capacity, forced expiratory alone or in addition to general deep breathing and cough- volume, inspiratory mouth pressure using a spirometer, ing for the prevention of postoperative pulmonary compli- vital capacity, and increased cough effectiveness. cations is not clear.18,40,71 PRECAUTION: Avoid prolonged periods of any form of Procedure resistance training for inspiratory muscles. Unlike muscles of the extremities, the diaphragm cannot totally rest to recover Have the patient assume a comfortable position (semire- from a session of resistance exercises. Use of accessory mus- clining, if possible) and inhale and exhale three to four cles of inspiration (neck and shoulder muscles) is a sign that times and then exhale maximally with the fourth breath. the diaphragm is beginning to fatigue.3,76 Then have the patient place the spirometer in the mouth, inhale maximally through the mouthpiece to a target set- Inspiratory Resistance Training ting and hold the inspiration for several seconds. Inspiratory resistance training, using pressure- or flow- This sequence is repeated five to ten times several times based devices to provide resistance to airflow, is designed per day. to improve the strength and endurance of the muscles of inspiration and decrease the occurrence of inspiratory mus- Glossopharyngeal Breathing cle fatigue. This technique has been studied in patients with acute and chronic, primary and secondary pulmonary Glossopharyngeal breathing is a technique that became disorders, including COPD,1,15,54,64 cystic fibrosis,26 respi- known to therapists during the 1950s through patients ratory failure and ventilator dependence (weaning fail- with severe ventilatory impairment as the result of ure),2,65 chronic heart failure,14 and chronic neuromuscular poliomyelitis. It is a means of increasing the inspiratory disease.32 Although reviews of the literature have demon- capacity when there is severe weakness of the muscles of strated that outcomes of inspiratory muscle training pro- inspiration.28,39,53,75,76 Today, it is used primarily by patients grams in patients with pathologies are inconsistent,33,50 who are ventilator-dependent because of absent or incom- some positive changes reported after training are increased plete innervation of the diaphragm as the result of a high vital capacity, increased exercise capacity, and fewer cervical-level spinal cord lesion or other neuromuscular episodes of dyspnea.14,26,54 Inspiratory muscle training also disorders. Glossopharyngeal breathing combined with the has been studied and found to be effective (as evidenced by inspiratory action of the neck musculature can reduce ventilator dependence or can be used as an emergency proce- * See references 1–3, 15, 26, 32, 33, 44, 46, 54, 57, 62, 65, 71, 76. dure should a malfunction of a patient’s ventilator 25Kisner (F)-25 3/9/07 12:55 PM Page 867

CHAPTER 25 Management of Pulmonary Conditions 867

FIGURE 25.17 Chest mobilization during inspiration and expiration. To mobilize the lateral rib cage have the patient (A) bend away from the tight side during inspiration and (B) bend toward the tight side during expiration.

occur.3,39,53,75,76 It also can be used to improve the force Then, have the patient push the fisted hand into the later- (and therefore the effectiveness) of a cough or increase al aspect of the chest, bend toward the tight side, and the volume of the voice. breathe out (Fig. 25.17B). Progress by having the patient raise the arm overhead on Procedure the tight side of the chest and side-bend away from the Glossopharyngeal breathing involves taking several “gulps” tight side. This places an additional stretch on hypomo- of air, usually 6 to 10 gulps in series, to pull air into the bile tissues. lungs when action of the inspiratory muscles is inadequate. After the patient takes several gulps of air, the mouth is To Mobilize the Upper Chest and closed, and the tongue pushes the air back and traps it in Stretch the Pectoralis Muscles the pharynx. The air is then forced into the lungs when the While the patient is sitting in a chair with hands clasped glottis is opened. This increases the depth of the inspiration behind the head, have him or her horizontally abduct the 39,75 and the patient’s inspiratory and vital capacities. arms (elongating the pectoralis major) during a deep inspiration (Fig. 25.18A). XERCISES TO OBILIZE THE HEST Then instruct the patient to bring the elbows together E M C and bend forward during expiration (Fig. 25.18B).

Chest mobilization exercises are any exercises that com- To Mobilize the Upper Chest and Shoulders bine active movements of the trunk or extremities with While sitting in a chair, have the patient reach with both deep breathing.21,60 They are designed to maintain or arms overhead (180 bilateral shoulder flexion and slight improve mobility of the chest wall, trunk, and shoulder gir- abduction) during inspiration (Fig. 25.19A) and then bend dles when it affects ventilation or postural alignment. For forward at the hips and reach for the floor during expira- example, a patient with hypomobility of the trunk muscles tion (Fig. 25.19B). on one side of the body does not expand that part of the chest fully during inspiration. Exercises that combine stretching of these muscles with deep breathing improve ventilation on that side of the chest. Chest mobilization exercises also are used to reinforce or emphasize the depth of inspiration or controlled expiration. A patient can reinforce expiration, for example, by leaning forward at the hips or flexing the spine as he or she breathes out. This pushes the viscera superiorly into the diaphragm.

Specific Techniques To Mobilize One Side of the Chest While sitting, have the patient bend away from the tight side to lengthen hypomobile structures and expand that FIGURE 25.18 (A) A stretch is applied to the pectoralis muscles during inspiration, and (B) the patient brings the elbows together to facilitate expiration. side of the chest during inspiration (Fig. 25.17A). 25Kisner (F)-25 3/9/07 12:55 PM Page 868

868 COUGHING

Decreased inspiratory capacity. Inspiratory capacity can be reduced because of pain due to acute lung disease, rib fracture, trauma to the chest, or recent thoracic or abdominal surgery. Weakness of the diaphragm or accessory muscles of inspiration as a result of a high spinal cord injury or neuropathic or myopathic disease decrease a patient’s ability to take in a deep breath. Postoperative- ly, the respiratory center may be depressed as the result of general anesthesia, pain, or medication. Inability to forcibly expel air. A spinal cord injury above T12 and myopathic disease, such as muscular dystrophy, cause weakness of the abdominal muscles, which are vital for a strong cough. Excessive fatigue as the result of critical illness and a chest wall or abdominal incision causing pain all contribute to a weak cough. A patient who has had a tracheostomy also has difficulty producing a strong cough, even when the tracheostomy site is covered. FIGURE 25.19 (A) Chest expansion is increased with bilateral movement of the arms overhead during inspiration. (B) Expiration is then reinforced Decreased action of the cilia in the bronchial tree. by reaching the arms toward the floor. Action of the ciliated cells may be compromised because of physical interventions such as general anesthesia and intubation or pathologies such as COPD including chronic bronchitis, which is associated with a decreased COUGHING number of ciliated epithelial cells in the airway. Smoking also depresses the action of the cilia. An effective cough is necessary to eliminate respiratory Increase in the amount or thickness of mucus. Patholo- obstructions and keep the lungs clear. Airway clearance is gies (e.g., cystic fibrosis, chronic bronchitis) and pul- an important part of management of patients with acute or monary infections (e.g., pneumonia) are associated with chronic respiratory conditions.25,51,60 an increase in mucus production and the thickness of the mucus. Intubation irriates the lumen of the airways and causes increased mucus production, whereas dehydration The Normal Cough Pump thickens mucus. A cough may be reflexive or voluntary. When a person coughs, a series of actions occurs (Box 25.7).47 Under nor- Teaching an Effective Cough mal conditions, the cough pump is effective to the seventh Because an effective cough is an integral component of air- generation of bronchi. (There are a total of 23 generations way clearance, a patient must be taught the importance of of bronchi in the tracheobronchial tree.) Ciliated epithelial an effective cough, how to produce an efficient and con- cells are present up to the terminal bronchiole and raise trolled voluntary cough, and when to cough. The following secretions from the smaller to the larger airways in the sequence and procedures are used when teaching an effec- absence of pathology. tive cough.25,51,66 1. Assess the patient’s voluntary or reflexive cough. Factors that Decrease the Effectiveness 2. Have the patient assume a relaxed, comfortable position of the Cough Mechanism and Cough Pump for deep breathing and coughing. Sitting or leaning forward usually is the best position for coughing. The The effectiveness of the cough mechanism can be com- patient’s neck should be slightly flexed to make cough- promised for a number of reasons including the following more comfortable. ing.25,39,51,60,76 3. Teach the patient controlled diaphragmatic breathing, emphasizing deep inspirations. 4. Demonstrate a sharp, deep, double cough. BOX 25.7 The Cough Mechanism 5. Demonstrate the proper muscle action of coughing (contraction of the abdominals). Have the patient place the • Deep inspiration occurs. • Glottis closes, and vocal cords tighten. hands on the abdomen and make three huffs with expira- • Abdominal muscles contract and the diaphragm elevates, tion to feel the contraction of the abdominals (see Fig. causing an increase in intrathoracic and intra-abdominal 25.10). Have the patient practice making a “K” sound to pressures. experience tightening the vocal cords, closing the glottis, • Glottis opens. and contracting the abdominals. • Explosive expiration of air occurs. 6. When the patient has put these actions together, instruct the patient to take a deep but relaxed inspiration, fol- 25Kisner (F)-25 3/9/07 12:55 PM Page 869

CHAPTER 25 Management of Pulmonary Conditions 869

BOX 25.8 Precautions for Teaching an Effective Cough

• Never allow a patient to gasp in air, because this increases the work (energy expenditure) of breathing, causing the patient to fatigue more easily. It also increases turbulence and resistance in the airways, possibly leading to increased bronchospasm and further constriction of airways. A gasping action also may push mucus or a foreign object deep into air passages. • Avoid uncontrolled coughing spasms (paroxysmal coughing). • Avoid forceful coughing if a patient has a history of a cerebrovascular accident or an aneurysm. Have these FIGURE 25.20 Therapist-assisted manual cough technique. patients huff several times to clear the airways, rather than cough. • Be sure that the patient coughs while in a somewhat erect or side-lying posture.

lowed by a sharp double cough. The second cough during a single expiration is usually more productive. 7. Use an abdominal binder or glossopharyngeal breathing in selected patients with inspiratory or abdominal muscle weakness to enhance the cough, if necessary. Precautions that should be observed while teaching a patient an effective cough are noted in Box 25.8.

Additional Techniques to Facilitate a Cough and Improve Airway Clearance To maximize airway clearance, several techniques can be used to stimulate a stronger cough, make coughing more FIGURE 25.21 Therapist-assisted or self-assisted manual cough technique. comfortable or improve the clearance of secretions. Manual-Assisted Cough PRECAUTION: Avoid direct pressure on the xiphoid If a patient has abdominal weakness (e.g., as the result of a process during the maneuver. mid-thoracic or cervical spinal cord injury), manual pressure on the abdominal area assists in developing greater Self-Assisted Technique intra-abdominal pressure for a more forceful cough. Manu- While in a sitting position, the patient crosses the arms al pressure for cough assistance can be applied by the ther- across the abdomen or places the interlocked hands apist or the patient.3,25,39,51,66,76 below the xiphoid process (see Fig. 25.21). Therapist-Assisted Techniques After a deep inspiration, the patient pushes inward and With the patient in a supine or semireclining position, upward on the abdomen with the wrists or forearms and the therapist places the heel of one hand on the patient’s simultaneously leans forward while attempting to cough. abdomen at the epigastric area just distal to the xiphoid Splinting process. The other hand is placed on top of the first, If chest wall pain from recent surgery or trauma is restrict- keeping the fingers open or interlocking them (Fig. ing the cough, teach the patient to splint over the painful 25.20). After the patient inhales as deeply as possible, area during coughing.25,45,51 Have the patient press the the therapist manually assists the patient as he or she hands or a pillow firmly over the incision to support the attempts to cough. The abdomen is compressed with an painful area with each cough (Fig. 25.22). If the patient inward and upward force, which pushes the diaphragm cannot reach the painful area, the therapist should assist upward to cause a more forceful and effective cough. (Fig. 25.23). This same maneuver can be performed with the patient in a chair (Fig. 25.21). The therapist or family member Humidification can stand in back of the patient and apply manual pres- If secretions are very thick, work with the patient after sure during expiration. humidification therapy or ultrasonic nebulizer therapy, both 25Kisner (F)-25 3/9/07 12:55 PM Page 870

870 POSTURAL DRAINAGE

PRECAUTION: Only individuals who have been taught proper suctioning technique should use this alternative means of clearing the airways. Suctioning, if performed incorrectly, can introduce an infection into the airways or damage the delicate mucosal lining of the trachea and bronchi. Improper suctioning also can cause hypoxemia, an abnormal heart rate, and atelectasis. A complete description of the proper endotracheal suctioning technique may be found in other resources.29,60

POSTURAL DRAINAGE

Postural drainage (bronchial drainage), another intervention for airway clearance, is a means of mobilizing secretions in one or more lung segments to the central airways by placing the patient in various positions so gravity assists 4,11,25,51,60 FIGURE 25.22 Splinting over an anterior surgical incision. in the drainage process. When secretions are moved from the smaller to the larger airways, they are then cleared by coughing or endotracheal suctioning. Postural drainage therapy also includes the use of manual techniques, such as percussion, shaking, and vibration, coupled with voluntary coughing. Goals and indications for postural drainage are noted in Box 25.9, and relative contraindications are summarized in Box 25.10.4,11,25,51,60 Despite the risks, postural drainage may be necessary in the unstable patient. Modified positioning to avoid head-down or fully horizontal positions typically is necessary for most high-risk patients.

Manual Techniques Used with Postural Drainage Therapy In addition to the use of body positioning, deep breathing, and an effective cough to facilitate airway clearance, a variety of manual techniques are used in conjunction with postural drainage to maximize the effectiveness of the FIGURE 25.23 Splinting over a posterior lateral incision.

BOX 25.9 Goals and Indications of which enhance the mucociliary transport system and for Postural Drainage facilitate a productive cough.66 Tracheal Stimulation Prevent Accumulation of Secretions in Patients at Tracheal stimulation, sometimes called a tracheal tickle, Risk for Pulmonary Complications may be used with infants or disoriented patients who can- • Patients with pulmonary diseases that are associated with not cooperate during treatment.66 Tracheal stimulation is a increased production or viscosity of mucus, such as somewhat uncomfortable maneuver, performed to elicit a chronic bronchitis and cystic fibrosis reflexive cough. The therapist places two fingers at the • Patients who are on prolonged bed rest sternal notch and applies a circular motion with pressure • Patients who have received general anesthesia and who downward into the trachea to facilitate a reflexive cough. may have painful incisions that restrict deep breathing and coughing postoperatively Suctioning: Alternative to Coughing • Any patient who is on a ventilator if he or she is stable enough to tolerate the treatment Endotracheal suctioning may be the only means of clear- Remove Accumulated Secretions from the Lungs ing the airways in patients who are unable to cough or huff • Patients with acute or chronic lung disease, such as voluntarily or after reflex stimulation of the cough mecha- pneumonia, atelectasis, acute lung infections, COPD 29,60 nism. Suctioning is indicated in all patients with artifi- • Patients who are generally very weak or are elderly cial airways. The suctioning procedure clears only the • Patients with artificial airways trachea and the mainstem bronchi. 25Kisner (F)-25 3/9/07 12:55 PM Page 871

CHAPTER 25 Management of Pulmonary Conditions 871

25,67 BOX 25.10 Relative Contraindications drained. The therapist’s cupped hands strike the to Postural Drainage patient’s chest wall in an alternating, rhythmic manner (Fig. 25.24B). The therapist should try to keep shoulders, elbows, and wrists loose and mobile during the maneuver. • Severe hemoptysis Mechanical percussion is an alternative to manual percus- • Untreated acute conditions sion techniques. • Severe pulmonary edema Percussion is continued for several minutes or until the • Congestive heart failure • Large pleural effusion patient needs to alter position to cough. This procedure • Pulmonary embolism should not be painful or uncomfortable. • Pneumothorax PRECAUTIONS: To prevent irritation to sensitive skin, • Cardiovascular instability have the patient wear a lightweight gown or shirt. Avoid • Cardiac arrhythmia percussion over breast tissue in women and over bony • Severe hypertension or hypotension prominences. • Recent myocardial infarction • Unstable angina Relative Contraindications to Percussion • Recent neurosurgery Prior to using percussion in a postural drainage program, a • Head-down positioning may cause increased intracra- therapist must weigh the potential benefits versus potential nial pressure; if PD is required, modified positions can risks. In most instances, it is prudent to avoid the use of be used percussion.25,67

Over fractures, spinal fusion, or osteoporotic bone 11,25,51,60,66,72 mucociliary transport system. They include Over tumor area percussion, vibration, shaking, and rib springing. Findings If a patient has a pulmonary embolus from studies that have been implemented to evaluate the If the patient has a condition in which hemorrhage could efficacy of these manual techniques as adjuncts to postural easily occur, such as in the presence of a low platelet 66 drainage are inconclusive. count, or if the patient is receiving anticoagulation therapy Percussion If the patient has unstable angina Percussion is used to augment mobilization of secretions If the patient has chest wall pain, for example after tho- by mechanically dislodging viscous or adherent mucus racic surgery or trauma from the airways. Percussion is performed with cupped Vibration hands (Fig. 25.24A) over the lung segment being Vibration, another manual technique, often is used in conjunction with percussion to help move secretions to larger airways. It is applied only during the expiratory phase as the patient is deep-breathing.25,51,72 Vibration is applied by placing both hands directly on the skin and over the chest wall (or one hand on top of the other) and gently compressing and rapidly vibrating the chest wall as the patient breathes out (Fig. 25.25). Pressure is applied in the same direction as the chest is moving. The vibrating action is achieved by the therapist isometrically contracting (tens- ing) the muscles of the upper extremities from shoulders to hands.

FIGURE 25.24 (A) Hand position for applying percussion. (B) The therapist alternately percusses over the lung segment being drained. FIGURE 25.25 Hand placement for vibration during postural drainage. 25Kisner (F)-25 3/9/07 12:55 PM Page 872

872 POSTURAL DRAINAGE

Shaking Postural Drainage Positions Shaking is a more vigorous form of vibration applied during exhalation using an intermittent bouncing maneuver Positions for postural drainage are based on the anatomy of coupled with wide movements of the therapist’s hands. The the lungs and the tracheobronchial tree (see Figs. 25.2 and therapist’s thumbs are locked together, the open hands are 25.4). Each segment of each lobe is drained using the posi- placed directly on the patient’s skin, and fingers are tions depicted in Figures 25.26 through 25.37. The shaded wrapped around the chest wall. The therapist simultaneous- area in each illustration indicates the area of the chest wall ly compresses and shakes the chest wall.25,51,72 where percussion or vibration is applied.

RIGHT AND LEFT UPPER LOBES

Anterior apical segments

FIGURE 25.27 Percussion is applied above the scapulae. Your fingers curve FIGURE 25.26 Percussion is applied directly under the clavicle. over the top of the shoulders.

FIGURE 25.28 Percussion is applied bilaterally, directly over the nipple or just above the breast.

FIGURE 25.29 Patient lies one-quarter turn from prone and rests on the right side. Head and shoulders are elevated 45 or approximately 18 inches FIGURE 25.30 Patient lies flat and one-quarter turn from prone on the left if pillows are used. Percussion is applied directly over the left scapula. side. Percussion is applied directly over the right scapula. 25Kisner (F)-25 3/9/07 12:55 PM Page 873

CHAPTER 25 Management of Pulmonary Conditions 873

LINGULA MIDDLE LOBE

FIGURE 25.31 Patient lies one-quarter turn from supine on the right side, FIGURE 25.32 Patient lies one-quarter turn from supine on the left side, supported with pillows and in a 30 head-down position. Percussion is supported with pillows behind the back, and in a 30 head-down position. applied just under the left breast. Percussion is applied under the right breast.

RIGHT AND LEFT LOWER LOBES

FIGURE 25.34 Patient lies prone with a pillow under the abdomen in a 45 FIGURE 25.33 Patient lies supine, pillows under knees, in a 45 head-down head-down position. Percussion is applied bilaterally over the lower portion position. Percussion is applied bilaterally over the lower portion of the ribs. of the ribs.

FIGURE 25.35 Patient lies on the right side in a 45 head-down position. FIGURE 25.36 Patient lies on the left side in a 45 head-down position Percussion is applied over the lower lateral aspect of the left rib cage. Percussion is applied over the lower lateral aspect of the right rib cage.

FIGURE 25.37 Patient lies prone with a pillow under the abdomen to flatten the back. Percussion is applied bilaterally, directly below the scapulae. 25Kisner (F)-25 3/9/07 12:55 PM Page 874

874 MANAGEMENT OF PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE

The patient may be positioned on a postural drainage Check the patient’s vital signs and breath sounds. table that can be elevated at one end, a tilt table, a rein- Position the patient in the correct position for drainage. forced padded table with a lift, or a hospital bed. A small See that he or she is as comfortable and relaxed as pos- child can be positioned on a therapist’s or parent’s lap. sible. Stand in front of the patient, whenever possible, to Guidelines for Implementing observe his or her color. Maintain each position for 5 to 10 minutes if the patient Postural Drainage can tolerate it or as long as the position is productive. General Considerations Have the patient breathe deeply during drainage but do not allow the patient to hyperventilate or become short Time of day. Consider the following when scheduling pos- of breath. Pursed-lip breathing during expiration is tural drainage into a patient’s day. sometimes used. Never administer postural drainage directly after a meal. Apply percussion over the segment being drained while Coordinate treatment with aerosol therapy. Some thera- the patient is in the correct position. pists believe that aerosol therapy combined with humidi- Encourage the patient to take a deep, sharp, double fication prior to postural drainage helps loosen secretions cough whenever necessary. It may be more comfortable and increases the likelihood of productivity. Others for the patient to momentarily assume a semiupright believe that aerosol therapy is best after postural position (resting on one elbow) and then cough. drainage when the patient’s lungs are clearer and maxi- If the patient does not cough spontaneously during posi- mal benefit can be gained from medication administered tioning with percussion, instruct the patient to take sev- through aerosol therapy. eral deep breaths or huff several times in succession as Choose a time (or times) of day likely to be of most ben- you apply vibration during expiration. This may help efit to the patient. A patient’s cough tends to be highly elicit a cough. productive in the early morning because of accumulation If the patient’s cough is not productive after 5 to 10 min- of secretions from the night before. Postural drainage in utes of positioning, go on to the next position. Secretions the early evening clears the lungs prior to sleeping and that have been mobilized during a treatment may not be helps the patient rest more easily. coughed up by the patient until 30 minutes to 1 hour after treatment. Frequency of treatments. The frequency of postural The duration of any one treatment should not exceed 45 drainage each day or during the week depends on the type to 60 minutes, as the procedure is quite fatiguing for the and severity of a patient’s pathology. If secretions are thick patient. and copious, two to four times per day may be necessary until the lungs are clear. If a patient is on a maintenance Concluding a Treatment program, the frequency is less, perhaps once a day or only Have the patient sit up slowly and rest for a short while a few days a week. after the treatment. Watch for signs of postural hypotension when the patient rises from a supine position or Preparation for Postural Drainage from a head-down position to sitting. Loosen tight or bulky clothing. It is not necessary to Advise the patient that even if the cough was not produc- expose the skin. The patient may wear a lightweight tive during treatment it may be productive a short while shirt or gown. after treatment. Have a sputum cup or tissues available. Evaluate the effectiveness of the treatment by reassess- Have sufficient pillows for positioning and comfort. ing breath sounds. Explain the treatment procedure to the patient. Note the type, color, consistency, and amount of secre- Teach the patient deep breathing and an effective cough tions produced. prior to beginning postural drainage. Check the patient’s vital signs after treatment and note If the patient is producing copious amounts of sputum, how the patient tolerated the treatment. instruct the patient to cough a few times or have the Criteria for Discontinuing Postural Drainage patient suctioned prior to positioning. Make any adjustments of tubes and wires, such as chest If the chest radiograph is relatively clear tubes, electrocardiography wires, or catheters, so they If the patient is afebrile for 24 to 48 hours remain clear during positioning. If normal or near-normal breath sounds are heard with auscultation Postural Drainage Sequence If the patient is on a regular home program Determine which segments of the lungs should be drained. Some patients with chronic lung diseases, such Modified Postural Drainage as cystic fibrosis, need to be drained in all positions. Other patients may require drainage of only a few seg- Some patients who require postural drainage cannot ments in which secretions have accumulated. assume or cannot tolerate the positions optimal for postural 25Kisner (F)-25 3/9/07 12:55 PM Page 875

CHAPTER 25 Management of Pulmonary Conditions 875

drainage. For example, a patient with congestive heart failure may exhibit indications of orthopnea (shortness of breath while lying flat). After neurosurgery a patient may not be allowed to assume a head-down (Trendelenburg) position because this position causes increased intracranial pressure. After thoracic surgery a patient may have chest tubes and monitoring wires that limit positioning. Under these circumstances and others, positioning during postural drainage must be modified.25,51,60,66 The positions in which postural drainage is undertaken are modified consistent with the patient’s medical or surgical problems. This com- promise, although not ideal, is better than not administering postural drainage at all.

Home Program of Postural Drainage Postural drainage may have to be carried out on a regular basis at home for patients with chronic lung disease. Patients need to be shown how to position themselves using inexpensive aids. An adult may place pillows over a hard wedge or stacks of newspapers to achieve the desired head- down positions in bed. A patient also can lean the chest FIGURE 25.38 Normal lung volumes and capacities compared with abnor- over the edge of a bed, resting with the arms on a chair mal lung volumes and capacities found in patients with obstructive pul- or stool. A child can be positioned on an ironing board monary disease. (From Rothstein, J, Roy, A, Wolf, SL: The Rehabilitation Specialist’s propped up against a sofa or heavy chair. A family member Handbook, ed. 3. FA Davis, Philadelphia, 2005, p 428, with permission.) often must be taught proper positioning, percussion or shaking techniques, and precautions to assist the patient. Pathological Changes in the Pulmonary System ANAGEMENT OF ATIENTS M P Changes in chronic bronchitis and emphysema that occur WITH CHRONIC OBSTRUCTIVE over time are inflammation of the mucous membranes of the airways; increased production and retention of mucus; PULMONARY DISEASE narrowing and destruction of airways; and destruction of alveolar and bronchial walls.6,30,67 These structural changes Chronic obstructive pulmonary disease is a broad term are reflected in pulmonary function tests depicted in Figure encompassing a number of chronic pulmonary conditions, 25.38. These changes in the patient’s pulmonary status pre- all of which obstruct the flow of air in the conducting air- dispose the patient to frequent acute respiratory infections. ways of the lower respiratory tract and alter ventilation and gas exchange.6,30,67 Although a variety of pulmonary diseases are classified as obstructive in nature, each disease Impairments and Impact on Function has its unique features and clinical manifestations and is As a result of the pathophysiology of COPD, many physi- distinguished by the cause of the obstruction of airflow, the cal impairments develop over time. Patients typically have onset of the disease, the location of the obstruction, and the a chronic, productive cough and are often short of breath. reversibility of the obstruction. The characteristic impact of COPD on the pulmonary system is the inability to remove air from the lungs effectively, Types of Obstructive Pulmonary Disorders which in turn affects the ability of the respiratory system to transport oxygen into the lungs. Typically, peripheral airway disease, chronic bronchitis, Consequently, functional limitations and eventually and emphysema are classified as COPD; but other obstruc- disability occur consistent with the disablement process.42 tive pulmonary diseases that are chronic in nature, such as Impairments such as increased respiratory rate, decreased asthma, bronchiectasis, cystic fibrosis, and bronchopul- vital capacity and forced expiratory volume, increased use monary dysplasia, also may be included under this broad of accessory muscles of inspiration, and progressive chest descriptor. The focus of discussion and guidelines for wall stiffness are associated with decreased tolerance to management presented in this section of the chapter is on exercise, frequent episodes of dyspnea, decreased walking chronic bronchitis and emphysema because patients with speed and distance, and eventual inability to perform activ- these diseases commonly are seen in pulmonary rehabilita- ities of daily living at home or in the workplace or to tion programs.6,7,12,37,67 remain an active participant in the community. 25Kisner (F)-25 3/9/07 12:55 PM Page 876

876 MANAGEMENT OF PATIENTS WITH RESTRICTIVE PULMONARY DISORDERS

Management Guidelines: COPD Extrapulmonary Causes Lifelong management includes appropriate medical man- Chest wall pain secondary to trauma or surgery agement to lessen disabling symptoms and prevent infec- Chest wall stiffness associated with extrapulmonary tion, smoking cessation, and participation in a disease (e.g., scleroderma, ankylosing spondylitis) comprehensive pulmonary rehabilitation program. Impor- Postural deformities (scoliosis, kyphosis) tant aspects of management include breathing exercises, Ventilatory muscle weakness of neuropathic or myo- ongoing, airway clearance, and participation in an indi- pathic origin (e.g., spinal cord injury, cerebral palsy, vidually designed, graded exercise program that includes Parkinson’s disease, muscular dystrophy) upper and lower extremity strength training and aerobic Pleural disease conditioning.6,7,11,12,37,55,67,70 Common impairments and Insufficient diaphragmatic excursion because of ascites guidelines for management are described in Box 25.11. or obesity Focus on Evidence Pathological Changes in Patients with COPD who appear to benefit most from pul- the Pulmonary System monary rehabilitation are those with only moderate-level Pulmonary function may be altered as a result of pul- disease and without a substantial number of co-morbidities. monary or extrapulmonary conditions. These alterations in A combination of upper and lower extremity exercises have lung volumes and capacities are depicted in Figure 25.39. been shown to improve functional status more effectively Cardiopulmonary factors contributing to these changes are than either upper or lower extremity exercise alone.6 decreased pulmonary compliance caused by inflammation Systematic reviews of the literature of pulmonary reha- or fibrosis (thickening of the alveoli, bronchioles, or pleu- bilitation programs have demonstrated that the effects of a ra), pulmonary congestion, and decreased arterial blood program of breathing exercises (diaphragmatic and pursed- gases (hypoxemia). lip breathing) on respiratory function13 and the effects of inspiratory resistance training on exercise capacity50 are Management Guidelines: equivocal. However, peripheral muscle strengthening pro- Post-Thoracic Surgery grams improve physical functioning.55 Although any number of acute or chronic disorders can be the underlying cause(s) of restrictive lung dysfunction, only management after thoracic surgery is addressed in this MANAGEMENT OF section. Patients with cardiac or pulmonary conditions that require surgical interventions are at high risk for restrictive PATIENTS WITH RESTRICTIVE pulmonary complications after surgery. Thoracotomy, an PULMONARY DISORDERS incision into the chest wall, is necessary during many types of pulmonary surgery including lobectomy (removal of a Restrictive pulmonary disorders are characterized by lobe of a lung), pneumonectomy (removal of a lung), or segmental resection (removal of a segment of a lobe of a the inability of the lungs to expand fully as a result of 17,23,36,40 extrapulmonary and/or pulmonary disease or restriction.11,17 lung). In other words, the patient has difficulty taking in a deep Cardiac surgeries, such as coronary artery bypass graft breath. surgery, replacement of one or more valves of the heart, repair of septal defects, or heart transplantation also require thoracotomy.17,23,36,40 Acute and Chronic Causes of NOTE: Patients who undergo upper abdominal surgery Restrictive Pulmonary Disorders also have a high risk of developing postoperative pulmonary complications. Postoperative pain is often greater after There are a variety of acute or chronic disorders directly upper abdominal surgery than after thoracic surgery.73 This involving structures of the pulmonary system or extrapul- results in hypoventilation (55% decreased vital capacity for monary disorders that can cause restrictive pulmonary 11,17 the first 24 to 48 hours after surgery) and an ineffective dysfunction. cough, which place the patient at risk for developing pneu- Pulmonary Causes monia or atelectasis.17,40 A systematic review of the litera- Diseases of the lung parenchyma such as tumor, intersti- ture revealed that postoperative programs of tial pulmonary fibrosis (e.g., pneumonia, tuberculosis, cardiopulmonary physical therapy have beneficial effects 73 asbestosis), and atelectasis after upper abdominal surgery. Disorders of cardiovascular/pulmonary origin, such as Factors That Increase the Risk of Pulmonary pulmonary edema or pulmonary embolism Complications and Restrictive Lung Dysfunction Inadequate or abnormal pulmonary development (bron- After Thoracic Surgery chopulmonary dysplasia) The post-thoracotomy patient experiences considerable Advanced age chest pain, which leads to chest wall immobility, poor lung 25Kisner (F)-25 3/9/07 12:55 PM Page 877

CHAPTER 25 Management of Pulmonary Conditions 877

BOX 25.11 MANAGEMENT GUIDELINES—Chronic Obstructive Pulmonary Disease (COPD)

Impairments An increase in the amount and viscosity of mucus production A chronic, often productive cough Frequent episodes of dyspnea A labored breathing pattern that results in: • Increased respiratory rate (tachypnea) • Use of accessory muscles of inspiration and decreased diaphragmatic excursion • Upper chest breathing Inadequate exchange of air in the lower lobes Most difficulty during expiration; use of pursed-lip breathing Changes in pulmonary function • Increased residual volume • Decreased vital capacity • Decreased expiratory flow rates Decreased mobility of the chest wall; a barrel chest deformity develops Abnormal posture: forward-head and rounded and elevated shoulders Decreased general endurance during functional activities

Plan of Care Interventions

1. Decrease the amount and viscosity of secre- 1. Administration of bronchodilators, antibiotics, and humidification tions and prevent respiratory infections. therapy. If patient smokes, he or she should be strongly encouraged to stop. 2. Remove or prevent the accumulation of 2. Deep and effective cough. secretions. (This is important if emphyse- Postural drainage to areas where secretions are identified. ma is associated with chronic bronchitis or NOTE: Drainage positions may need to be modified if the patient is if there is an acute respiratory infection.) dyspneic in the head-down position. 3. Promote relaxation of the accessory mus- 3. Positioning for relaxation. cles of inspiration to decrease reliance on • Relaxed head-up position in bed: trunk, arms, and head are well upper chest breathing and to decrease supported. muscle tension associated with dyspnea. • Sitting: leaning forward, resting forearms on thighs or on a table. • Standing: leaning forward on an object, with hands on the thighs or leaning backward against a wall. Relaxation exercises for shoulder musculature: active shoulder shrugging followed by relaxation; shoulder and arm circles; horizontal abduction and adduction of the shoulders. 4. Improve the patient’s breathing pattern 4. Breathing exercises: controlled diaphragmatic breathing with mini- and ventilation. mal upper chest movement; lateral costal breathing; pursed-lip Emphasize diaphragmatic and lateral costal breathing (careful to avoid forced expiration). breathing and relaxed expiration; decrease the Practice controlled breathing during standing, walking, climbing work of breathing, rate of respiration, and use stairs, and other functional activities. of accessory muscles. Carry over controlled breathing exercises to functional activities. 5. Minimize or prevent episodes of dyspnea. 5. Have a patient assume a comfortable position so the upper chest is relaxed and the lower chest is as mobile as possible. Emphasize controlled diaphragmatic breathing. Have the patient breathe out as rapidly as possible without forcing expiration. NOTE: Initially, the rate of ventilation is rapid and shallow. As the patient gets control of breathing, he or she slows the rate. Administer supplemental oxygen during a severe episode, if needed. 6. Improve the mobility of the lower thorax. 6. Exercises for chest mobility, emphasizing movement of the lower rib cage during deep breathing. 7. Improve posture. 7. Exercises and postural training to decrease forward-head and rounded shoulders. 8. Increase exercise tolerance. 8. Graded endurance and conditioning exercises (see Chapter 4). 25Kisner (F)-25 3/9/07 12:55 PM Page 878

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Depresses the respiratory center of the central nervous system Decreases the normal ciliary action in the bronchial tree General Inactivity, Postoperative Weakness and Fatigue Pooling of secretions, particularly in the posterior basilar segments of the lower lobes, because of inactivity Decreased effectiveness of the cough pump because of postoperative weakness and fatigue Other risk factors not directly related to the surgery Patient’s age ( age 50) History of smoking History of COPD or restrictive pulmonary disorder because of neuromuscular weakness Obesity Poor mentation and orientation FIGURE 25.39 Normal lung volumes and capacities compared with abnormal lung volumes and capacities found in patients with restrictive pulmonary Thoracic Surgery: Operative and Postoperative disorders. (From Rothstein, J, Roy, A, Wolf, SL: The Rehabilitation Specialist’s Handbook, Considerations during Management ed. 3. FA Davis, Philadelphia, 2005, p 428, with permission.) Many factors contribute to a patient’s postoperative impairments, any one of which influences postoperative management.17,23 A patient who has undergone thoracotomy for a expansion, and an ineffective cough. In addition, pul- pulmonary or cardiac condition typically is hospitalized for monary secretions are greater than normal after surgery. a week or less. Postoperative impairments and guidelines for management of a patient who has undergone thoracic Therefore, the patient is more likely to accumulate pul- 16,17,23,36,40,41,71 monary secretions and develop secondary pneumonia surgery are summarized in Box 25.12. Thera- or atelectasis. Factors that increase the risk of postopera- peutic interventions begin on the first postoperative day tive pulmonary complications are noted in the following and include breathing and coughing exercises, shoulder sections.17,40 ROM, posture awareness training, and a graded aerobic conditioning program.16,23,36,40,41,71 General Anesthesia Co-morbidities and Related Dysfunction Decreases the normal ciliary action of the tracheo- In addition to the primary pulmonary or cardiac pathology bronchial tree (e.g., a malignant tumor, lung abscess, coronary artery dis- Depresses the respiratory center of the central nervous ease) the patient also may have related cardiopulmonary system, which causes a shallow respiratory pattern conditions, such as angina, congestive heart disease, chronic (decreased tidal volume and vital capacity) bronchitis, or emphysema. The patient with a long history Depresses the cough reflex of cardiac disease may have preoperative pulmonary dysfunction such as hypoxemia, dyspnea on exertion, orthop- Intubation (Insertion of an Endotracheal Tube) nea, or pulmonary congestion. Such co-morbidities and Causes muscle spasm and immobility of the chest related pulmonary or cardiac dysfunction can complicate Irritates the mucosal lining of the tracheobronchial tree, postoperative rehabilitation. which causes increased production of mucus Surgical Approach Decreases the normal action of the cilia in the tracheo- Pulmonary surgery typically involves a large posterolateral, bronchial tree, which leads to pooling of secretions lateral, or anterolateral chest incision. A standard posterolateral approach (Fig. 25.40), for example, is performed by Incisional Pain incising the chest wall along the intercostal space that cor- Causes muscle splinting and decreases chest wall com- responds to the location of the lung lesion. The incision pliance, which in turn causes a shallow breathing pat- divides the trapezius and rhomboid muscles posteriorly tern. Consequently, lung expansion is restricted and and the serratus anterior, latissimus dorsi, and external and secretions are not adequately mobilized. internal intercostals laterally. Restricts a deep and effective cough. The patient usually Postoperatively, the incision is painful, and the poten- has a weak, shallow cough that does not effectively tial for pulmonary complications is significant. Many mobilize and clear secretions. patients, quite understandably, complain of a great deal of shoulder soreness on the operated side. Loss of range of Pain Medication shoulder motion and postural deviations are possible Although pain medication administered postoperatively because of the disturbance of the large arm and trunk mus- diminishes incisional pain, it also: culature during surgery. 25Kisner (F)-25 3/9/07 12:55 PM Page 879

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BOX 25.12 MANAGEMENT GUIDELINES—Post-Thoracic Surgery

Impairments Reduced lung expansion or an inability to take a deep inspiration because of incisional pain Decreased effectiveness of the cough because of incisional pain and irritation of the throat from intubation Possible accumulation of pulmonary secretions either preoperatively or postoperatively Decreased chest wall and upper extremity mobility Poor postural alignment because of incisional pain or chest tubes Increased risk of deep vein thrombosis and pulmonary embolism General weakness, fatigue, and disorientation

Plan of Care Interventions

1. Ascertain the status of the patient 1. Evaluate orientation, color, respiratory rate, heart rate, breath sounds, sputum before each treatment. drainage into chest tubes. 2. Promote relaxation and reduce 2. Position the patient in a semi-Fowler’s position (head of bed elevated to 30 postoperative pain. and hips and knees slightly flexed). This position reduces traction on the thoracic incision. Coordinate treatment with administration of pain medication. 3. Optimize ventilation and re-expand 3. Begin deep-breathing exercises on the day of surgery as soon as the patient lung tissue to prevent atelectasis is conscious; diaphragmatic breathing; segmental expansion. and pneumonia. Add incentive spirometry or inspiratory resistance exercises to improve inspiratory capacity. Emphasize a deep inhalation followed by a 3- to 5-second hold and then relaxed exhalation. Continue deep-breathing exercises postoperatively, with six to ten consecu- tive deep breaths per hour until the patient is ambulatory. 4. Assist in the removal of secretions. 4. Begin deep, effective coughing as soon as the patient is alert and can cooperate. Implement early functional mobility (getting up to a chair, early ambulation). Institute modified postural drainage only if secretions accumulate. 5. Maintain adequate circulation in 5. Begin active exercises of the lower extremities, with emphasis on ankle the lower extremities to prevent pumping exercises on the first day after surgery. deep vein thrombosis and pul- Continue leg exercises until the patient is allowed out of bed and is monary embolism. ambulatory. 6. Regain ROM in the shoulders. 6. Begin relaxation exercises for the shoulder area on the first postoperative day. These can include shoulder shrugging or shoulder circles. Initiate active-assistive ROM of the shoulders, being careful not to cause pain. Reassure the patient that gentle movements will not disturb the incision. Progress to active shoulder exercises on the succeeding postoperative days to the patient’s tolerance until full active ROM has been achieved. 7. Prevent postural impairments. 7. Reinforce symmetrical alignment and positioning of the trunk on the first postoperative day when the patient is in bed. NOTE: The patient will tend to lean toward the side of the incision. Instruct the patient in symmetrical sitting posture when he or she is allowed to sit up in a chair or at the side of the bed. 8. Increase exercise tolerance. 8. Begin a progressive and graded ambulation or stationary cycling program as soon as the chest tubes are removed and the patient is allowed out of bed. Precautions Monitor vital signs throughout treatment. Be certain to show the patient how to splint over the incision to minimize incisional pain during coughing. Avoid placing traction on chest tubes when moving the patient. To prevent dislodging a chest tube for the patient who has a lateral incision, limit shoulder flexion to 90 on the operated side for several days until the chest tube is removed. If postural drainage must be implemented, modify positioning to avoid a head-down position. Do not use percussion over the incision. When turning a patient, use a logroll technique to minimize traction on the incision. 25Kisner (F)-25 3/9/07 12:55 PM Page 880

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chest cavity can be exposed. After completion of the surgical procedure, the sternum is closed with stainless steel sutures. Postoperatively, there is less incisional pain after a median sternotomy than after a posterolateral thoracotomy, but deep breathing and coughing are still painful. After a median sternotomy, a patient tends to exhibit rounded shoulders and is at risk for developing shortened pectoralis muscles bilaterally. Additional Considerations After any type of thoracotomy one or two chest drainage tubes are put in place at the time of the surgery to prevent a pneumothorax or a hemothorax. While these tubes are in place, crimping, clamping, or traction on the tubes must be avoided during postoperative interventions. FIGURE 25.40 A posterolateral approach commonly used in thoracic surgery Fatigue occurs easily during the first few postoperative incises and divides the trapezius, rhomboids, latissimus dorsi, serratus anterior, days, so treatment sessions should be short but frequent. and internal and external intercostal muscles. The duration of treatment sessions should be increased gradually during the patient’s hospital stay. Check the patient’s chart regularly to note any day-to- The most common incision used with cardiac surgery day changes in vital signs or laboratory test results. Always is a median sternotomy. A large incision extends along the monitor vital signs such as heart rate and rhythm, respira- anterior chest from the sternal notch to just below the tory rate, and blood pressure prior to, during, and after xiphoid. The sternum is then split and retracted so the every treatment session.

INDEPENDENT LEARNING ACTIVITIES

● Critical Thinking and Discussion referred to your outpatient facility to begin a graded conditioning program. 1. Describe the structure of the lower respiratory tract 2. How would you alter or change the focus of your exami- from the trachea to the alveoli and discuss the impact nation of a patient with a traumatic brain injury who is of pulmonary diseases on those structures and their on a ventilator or a patient who is 1 day post-coronary functions. artery bypass graft surgery? 2. Describe the thorax and its movements during ventila- 3. Practice auscultation of breath sounds. tion and the actions of the primary and accessory mus- 4. Practice a complete postural drainage sequence on your cles of ventilation. laboratory partner. Include manual techniques and cough 3. Organize a presentation that compares and contrasts the instruction. Perform the activity for a minimum of 1 to 2 characteristics and management of obstructive and minutes per position to begin to appreciate the endurance restrictive pulmonary disorders. needed by the therapist. Then have your partner perform 4. What factors contribute to placing the post-thoracic sur- the same sequence with you as the patient to appreciate gery patient at risk for the development of postoperative how it feels from the patient’s perspective to undergo complications? postural drainage. 5. Under what circumstances (types of impairment or 5. What methods of measurement should be used to docu- pathology) would it be appropriate to try to change a ment improvement in a pulmonary patient’s condition as patient’s breathing pattern? For what purpose? the result of a pulmonary rehabilitation program? Prac- 6. Analyze how ventilation and coughing are affected by a tice those techniques. spinal cord injury at a mid-thoracic level, a C6 level, and a C3 to C4 level. ● Case Study ● Laboratory Practice CASE 1 T.M. is a 62-year-old man who underwent thoracic surgery 1. Perform a systematic physical examination of a patient (right lower lobe lobectomy) yesterday for bronchogenic with a year history of chronic bronchitis who has been carcinoma. He has a posterolateral incision. Although his 25Kisner (F)-25 3/9/07 12:55 PM Page 881

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cough is currently nonproductive, he has had a chronic CASE 2 cough for years. He has also smoked more than a pack of B.A. is a 21-year-old student with a 15-year history of cigarettes a day for 35 years. He is currently febrile with a asthma. Her chief complaint is episodes of dyspnea 99.8F temperature. when she is physically active. She wheezes frequently, • What current and potential postoperative impairments particularly with physical activity but sometimes at rest. might you find in your examination? Wheezing also is worse when in contact with household • Design a comprehensive management program that pets at friends’ apartments. She is small for her age includes airway clearance, exercise, and functional mobil- and underweight but wants to participate in some form ity. How would you progress the program while the of regular physical activity for general health and patient is hospitalized? What precautions should be built fitness. What additional signs or symptoms would into his plan of care? you expect to find in an examination of this young • Design a program that the patient can follow when he woman? How would you manage her problems and returns home. needs?

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