PTA103Pulmonary Conditions2019
PTA 103 Intro to Clinical Practice 2

Instructional Use Statement

The following information is used for instructional purposes for students enrolled in the Physical Therapist Assistant Program at Lane Community College. It is not intended for commercial use or distribution or commercial purposes. It is not intended to serve as medical advice or treatment.

Introduction

Understanding function of the pulmonary system is essential for safe and effective exercise selection and planning. 

Pulmonary dysfunction is encountered acidosis the life span and is significantly influenced by environmental and personal factors. Regardless of age, decreased breathing efficiency and effectiveness results in decreased activity tolerance and can limit full participation in work, home, and school activities.

Although industrial safety standards have improved and tobacco use is declining, there are several generations of clientele with decreased lung function as a result of one or often both of these exposure points. 

Optimal care and safe discharge planning often involves close coordination with nursing, Respiratory Care, and family. Treatment progression and discharge planning may include the use of supportive equipment, such as breathing apparatus and supplemental O₂ , instruction therapeutic positioning and postural control, breathing reeducation, and progressive reconditioning

Smoking decreases overall health, with primary effects on the cardiopulmonary system. In addition to implementing the PT plan of care, PTAs are also health advocates and communicate effectively with patients in health promotion and disease prevention.

This Quit Smoking Campaign video notes explicit vascular compromise in a deceased smoker. Effective education and outreach can change a life.

Lesson Objectives

1. Define ventilation and perfusion
2. Identify primary and secondary muscles of inspiration and exhalation
3. Describe signs and symptoms of pulmonary and respiratory dysfunction.
4. Compare and contrast obstructive with restrictive lung disease.
5. Describe pre-and post-operative risk factors associated with disorders of the respiratory system.
6. Explain how impaired lung function affects exercise tolerance.
7. Describe guidelines for stopping an exercise test/activity.
8. Select relevant test and measurement methods associated with interventions to reduce impairments in ventilation and respiration:
1. Observation: sitting preference, characteristics of digits (cyanotic, nicotine-stained, use of supportive devices (AD, oxygen)
2. Anthropometric characteristics: chest shape and body type
3. Thoracic/spinal ROM Chest mobility/palpation
4. Pain
5. Posture
6. Pulse oximetry
7. Breathing patterns and breath sounds (auscultation: normal and abnormal)
8. Cough efficiency and effectiveness
9. Exercise and pulmonary function testing (baseline or repeat measures)
9. Recognize and report normal and abnormal values (lung volumes, spirometry, pulse oximetry, arterial blood gas).
10. Describe the significance of cyanosis, hypoxia, and hypercapnia as it relates to activity tolerance.
11. Describe the continuum of assisted mechanical ventilation (0₂, ventilators).
12. Select appropriate interventions to reduce impairments associated with pulmonary dysfunction for selected case simulations
1. airway clearance (postural drainage, autogenic drainage, coughing, mechanical devices, manual techniques).
2. therapeutic exercises for inspiratory muscle training and optimal gas exchange (diaphragmatic, segmental, pursed lip).
3. energy conservation and pacing.
4. positioning and postural training.
13. Select documentation elements that demonstrate skilled and medically necessary care and coordination with the supervising PT in simulated pulmonary cases
14. Consider psychosocial and environmental contributors during clinical decision making and patient instruction in simulated pulmonary cases

Connecting Reading to Learning Objectives

One challenge with this unit is in how text book material is organized. Cameron follows the Guide to Physical Therapy Practice, so its chapters are based on specific practice patterns. Cameron and Pagliarulo provide excellent, comprehensive information on physical therapy uses knowledge of anatomy, physiology and pathophysiology to restore optimal function with safe and effective clinical and home exercise instruction. Specific sections of each chapter are included in the respective "Reading Assignments". In order to keep the amount of reading relevant and less redundant, be sure you complete your readings in the suggested order as you go through the lecture.

Anatomy and Physiology

The anatomy of the respiratory system will be a review of content from your A&P coursework and Pagliarulo from fall term. 

Reading and Web Exploration

• Cameron & Monroe, pp. 398-406
• "What do the lungs do"

Respiration and Ventilation

Breathing is an automatic action coordinated by the nervous system, the musculoskeletal system, and the anatomical structures that comprise the airways. Impairments that arise when their are dysfunctions within one or more of these systems can result in decreased endurance, decreased strength, postural abnormalities, and impaired airway clearance. When respiration or ventilation is impaired, a patient will work to generate compensatory strategies to maintain breathing function.

Why is an understanding of anatomy critical to optimizing ventilation and respiration? As we move forward in the lecture, we will be connecting anatomy and physiology to the basis for the interventions. For example, positioning for postural drainage requires that a PTA can integrate knowledge of lung lobes and respective airways and gravity to passively improve airway clearance, and therefore decrease muscular efforts and improve gas exchange. Although breathing is largely under autonomic control, PTs and PTAs take advantage of volitional breathing patterns and pathways to help patients and clients optimize respiration and ventilation.

As you refresh your knowledge of anatomy and breathing mechanics, start thinking about how each structure, such as the rib cage, intercostals, and respiratory zones play an essential role in breathing:

• skeletal components
• muscular components
• Primary breathing mm - diaphragm
• Accessory mm
• Internal intercostals - forced expiration
• lungs and airways

Respiration: "Respiration is the process of exchange of gases between the atmosphere and the tissues"

Ventilation: "Ventilation refers to the movement of a volume of air from the atmosphere in and out of the airways and is highly dependent on the ability of the respiratory muscles to generate force to bring air into the lungs"

Note the number of medical diagnoses (Cameron & Monroe, Box 26-1) that are associated with breathing impairments. In addition to COPD, neuromuscular disorders, infections, and musculoskeletal conditions, such as scoliosis, can present with breathing impairments as a primary contributor to disability. Can you see why a strong foundation of anatomy, physiology, and pathophysiology can improve patient outcomes in airway clearance, posture, and endurance?

Neural Control of Breathing

The take home message for PTs/PTAs is that abnormal level of O₂ and CO₂ trigger a change in respiration rate, effort, efficiency, perfusion, and overall function.

• Voluntary and involuntary neural control
• Chemoreceptors - these work to balance concentrations of oxygen (O₂) and carbon dioxide (CO₂) for optimal gas exchange
• Hypercapnia: High C0₂, high acidity, low pH: .
• As C0₂ increases, respiratory rate (RR) increases to remove C0₂
• Hypoxia: Low 0₂ detected by the receptors in larger proximal blood vessels triggers increase RR
• Mechanoreceptors
• stretch responses in skeletal muscle and related tissue can trigger increased ventilation
• ANS
• Vagus nerve (Cranial nerve X), associated cranial nerves associated with ventilation muscles are influenced by sympathetic and parasympathetic pathways
• Motor cortex allows use to voluntarily control of our own breathing. Everyday examples include:
• Blowing out birthday candles
• Blowing up and balloon
• Holding breath in and out of water

Pulmonary Function Measures

Lung volumes during different phases of breathing are used to assess the effects of pathology on ventilation. Remember, ventilation is the volume of air that moves in and out of the airways. PTs and PTAs teach patients interventions that aim to increase air in and improve the force by which air flows out, therefore foundational knowledge in pulmonary function measures provides some insight into the major barriers to ventilation (e.g. restrictive versus obstructive) and how lung volume measures compare to normal values. Measuring pulmonary function is accomplished through spirometry and is typically performed by Respiratory Care.

Shortness of breath is a sign that ventilation is insufficient to meet the oxygen demands of the activity. This can present at rest with advanced lung disease, and after exertion during mild to high intensity exercise and activity. In patients with pulmonary impairments, breathing rate is closely monitored as an indicator of exercise intensity and tolerance. Shortness of breath is one of the indicators of Work of Breathing (WOB).

Airway tissue resistance, elasticity, and compliance are major factors in respiration. PTs and PTAs apply knowledge of respiratory muscle function, posture, and breathing mechanics to optimize pressures for inspiration and exhalation, which can result in improved gas exchange. The video below provides a brief, yet thorough explanation of pulmonary function measures. You should be able to identify the variables in calculating:

• Total Lung Capacity (TLC)
• Vital Capacity (VC)
• Inspiratory Capacity (IC)
• Functional Residual Capacity (FRC)

Active Learning Exercise

As you view the video below, try how you can volitionally assess your own inspiratory capacity and your expiratory reserve. What muscles are you engaging to maximally inhale and maximally exhale?

Critical thinking question: Why do interventions to increase inspiratory capacity positively affect ventilation and respiration? Try your answers in the CAN YOU HELP ME? forum.

Incentive Spirometry

• Incentive spirometry (IS) is a bedside intervention used by a number of disciplines based on a clinical theory that its use decreases risk of post-operative pulmonary embolus or post-operative pulmonary complications due to changes in functional lung capacity
• Respiratory Care refers to this preventative intervention as a form of "Hyperinflation Therapy" and there are protocols that continue to be applied in hospital settings to guide decision-making in the use of IS
• Visual feedback and goal setting to reach a target volume and inhalation control is presumed to provide "incentive" to open alveolar space and optimize respiration
• Best practice is to use incentive spirometry with early mobilization and airway clearance techniques.
• Systematic literature reviews suggest mixed findings on the benefits of using incentive spirometry in a number of post operative situations (Freitas, Soares, Cardoso & Atallah, 2012; Restrepo, Wettstein, Wittnebel, Tracy, 2011).

Freitas, E. R., Soares, B. G., Cardoso, J. R., & Atallah, Á. N. (2012, September). Incentive spirometry for preventing pulmonary complications after coronary artery bypass graft. Cochrane Database of Systematic Reviews (9). doi 10.1002/14651858.CD004466.pub3.

Restrepo, R. D., Wettstein, R., Wittnebel, L., & Tracy, M. (2011). Incentive spirometry: 2011. Respiratory care, 56(10), 1600-1604.

Breathing Measures

Reading and Web Exploration

• Cameron & Monroe, Chapter 24, 368-376 (to Intervention)

• This resource provides information on a measurement device used at times by respiratory therapists to measure how you push air out of your lungs (American Lung Association, 2018). I have seen these on occasion when working with patients with a pulmonary health condition (2018).

 Breathing Patterns

Breathing pattern is documented in terms of rate, regularity, and location

Apnea - cessation of expiration; no airflow in or out of lungs. May be voluntary or involuntary. Prolonged apnea results in CO2 accumulation and triggers a healthy nervous system to increase arousal and breathing.

Tachypnea - shallow and rapid breathing, often present at rest with pulmonary and systemic infection

Bradypnea - shallow and slow breathing, present in coma, increased intracranial pressure

Dyspnea - labored breathing, shortness of breath

Orthopnea - difficulty breathing in supine; often experienced with obesity and lung disease

Hyperventilation - rapid and deep breathing, triggered by increased CO₂ ; also associated with pain, anxiety, asthma/obstructive lung disease, heart failure; Associated symptoms include dizziness, distal muscle cramping, weakness, syncope

Cyanosis - bluish appearance in nail beds or lips; sign of inadequate ventilation and perfusion

Image of cyanosis

Retrieved from https://commons.wikimedia.org/wiki/File:Blue_finger_tips_3.jpg

Shallow, deep, rapid, irregular, asymmetric are all qualitative observational terms to describe breathing patterns.

Breathing motion is assessed by palpation of the thoracic at upper, mid, and regions; motion is also assessed holistically based on the overall automatic pattern. Accessory muscle palpation provides qualitative information about muscle tone and activation during breathing at rest.

• diaphragmatic: often referred to as "belly breathing"; diaphragm is the primary muscle used in inhalation; abdomen rises and falls and chest wall is relatively still
• upper chest: shoulders and sternum rise and fall when initiating inhalation; indicates use of accessory muscles at rest
• paradoxical: upper chest rises and diaphragm pulls in during inhalation and pushes abdomen out during exhalation; typically associated with acute pneumothorax or palsy

Posture and Body Type

• Forward bend
• "professorial"
• cachectic (thin) - suggests high energy cost for breathing
• obese - increased risk for positional lung restriction and decreased endurance
• congential abnormalities
• pectus carinatum

By Jprealini (Own work) [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC BY-SA 4.0-3.0-2.5-2.0-1.0 (http://creativecommons.org/licenses/by-sa/4.0-3.0-2.5-2.0-1.0)], via Wikimedia Commons

• pectus excavatum

By Cchavoin (Own work) [CC BY-SA 4.0 (http://creativecommons.org/licenses/by-sa/4.0)], via Wikimedia Commons

• idiopathic scoliosis
• spinal curvature: kyphosis, scoliosis

Equipment Pulse Oximetry

Observation include noting the use of supplemental oxygen and flow rate or other devices to support breathing function during activity

Pulse oximetry measures oxygen saturation and is used to guide activity intensity and inform responsiveness of interventions to improve gas exchange. Normal values are 95%-100% (Cameron & Monroe, 2011).

Breath Sounds

• Web exploration: Physiological and pathological breath sounds

An excellent resource to explore breath sounds.

• Points of auscultation
• Use of a stethoscope; direct patient to breath deeply in and out with mouth open
• Normal
• Tracheal
• Vesicular
• Bronchial
• Bronchovesicular
• Adventitious or not normal - when a breath sound is heard in an unexpected region or creates dissonance (bad sound)

• Crackles (rales)
• Wheezes (rhonchi)
• Stridor
• Stertor
• Gurgling

 Percussion

• This technique is performed as a means to assess lung density during physical assessment
• Thoracic findings are largely documented as normal, dull (indicating increased density/less air), or tympanic (hollow, indicating more air)
• Literature suggests mixed findings for percussion as reliable in detecting evidence of lung disease when compared to radiographic imaging (Wipf, et al., 1999)

Standardized Assessments

PTs and PTAs use standardized assessment to monitor response to exercise. Common standardized assessments used in this population include:

• Dyspnea index
• Rate of Perceived Exertion
• Six Minute Walk Test

References

Wipf, J. E., Lipsky, B. A., Hirschmann, J. V., Boyko, E. J., Takasugi, J., Peugeot, R. L., & Davis, C. L. (1999). Diagnosing pneumonia by physical examination: relevant or relic?. Archives of Internal Medicine, 159(10), 1082-1087.

Pathology

Image of lung tissue riddled with cancer

Content for pathology should be a review from your anatomy and physiology courses. You are expected to be able to describe diseases of the respiratory system and how they may be classified (e.g. obstructive, restrictive, etc.). Respiratory refers to the gas exchange; pulmonary refers specifically to the lung organ.
There is a succinct listing of respiratory diseases included in Pagliarulo COPD and restrictive lung diseases pages 244-245. Focus on your ability to:

• recognize, signs, symptoms and characteristics of respiratory disease
• define and differentiate pulmonary diseases.

You should be able to provide an example of each disease listed below under the appropriate category. Notice some diseases fall in more than one category such as pneumonia:

Obstructive disease

In general, this limits the efficiency and effectiveness of exhalation. It is difficult to expel CO₂

Bronchial asthma or asthma

COPD

Chronic Obstructive Pulmonary Disease (COPD):

COPD describes a combination of two conditions

• Chronic bronchitis
• Inflammation of bronchial tissue, increased mucus production and cough
• Induced by bacterial, viral, or acute or chronic environmental exposure

• Emphysema
• A progressive thinning and degradation of the alveoli. Primary cause is smoking.

Restrictive disease

• Difficulty getting oxygen in
• Can be lung structure stiffness (scar tissue or protein deposits) that interferes with the lung's ability to expand, resulting in inefficient inhalation
• Can be due to muscle weakness in the chest wall, which limits effectiveness of inhalation

Common diagnosis and conditions that indicate restrictive disease are:

1. Radiation Fibrosis: scarring of lungs from radiation
2. Effects of quadriplegia such as from a spinal cord injury
3. Acute respiratory distress syndrome (ARDS) A prevention of 02 getting into the lungs. Life threatening
4. Infant respiratory distress syndrome: often a result of being born pre-mature: difficulty breathing due to small lungs
5. Pneumonia

Here is a link on what is the cause of pneumonia

 https://www.youtube.com/watch?v=yqwG-O3GR74

Infection

• Fluid accumulation in the lung space interferes with gas exchange

• Upper respiratory infection

• Tonsillitis
• Common cold
• Bronchitis

• Lower respiratory infection
• Pneumonia
• Active tuberculosis (TB): cough associated with TB

 

 

 

Pleural disease

1. Mesothelioma: lung cancer
2. Tension pneumothorax: often from a trauma such as an MVA, stabbing, or gun shot wound
3. Empyema: pus in lungs

Pulmonary Embolus

• A blood clot that prevents perfusion to lung tissue. Depending on the location within the blood vessel, this can be life threatening
• Sedentary lifestyle, pregnancy, smoking, birth control or other hormone therapies, cardiovascular disease, and recent surgery are all associated with increased risk for pulmonary embolus
• Treated with anticoagulants (blood thinners), thrombolytics (clot busters), and/or inferior vena cava filters
• Ankle pumps and compression stockings and intermittent compression devices are used to prevent blood clots

 Lung Cancer

• Cancer is covered in depth in PTA 205
• 15% of lung cancer the West occurs in non-smokers (Subramanian & Govindan, 2007)
• Can result in combined restrictive and obstructive symptoms

Self Study

You can check your understanding of the diseases, their descriptions and classifications by linking to the 
Self Study Activities.

Note only one disease per category for this activity, due to limitations of the formatting design of the self-study

References

Subramanian, J., & Govindan, R. (2007). Lung cancer in never smokers: a review. Journal of clinical oncology, 25(5), 561-570.

Interventions

Reading Assignment

 Cameron & Monroe p. 372-384; Pagliarulo, Pg 254, Box 10-2, 259-263

Note: There is mention in the text of interventions specifically for those who are using mechanical ventilation equipment. We will be covering specific retraining and ventilator weaning considerations in PTA 205.

You should be able to recognize the signs and symptoms of over exertion in this population and make appropriate clinical decisions regarding exercise modification and termination.

Specific interventions, that can be a part of the PT plan of care, and delegated to the PTA may include:

• Breathing Exercises
• Diaphragmatic breathing

• Segmental breathing
• This is assisted or self-directed manual techniques to direct breath into targeted lung segments
• Autogenic drainage
• In a recent systematic review, autogenic drainage was associated with improved sputum production/improved airway clearance in patients with obstructive lung disease (cystic fibrosis) (Morgan, Osterling, Gilbert, & Dechman, 2015)
• A sample patient handout is provided here
• Incentive Spirometry reinforcement

• Pursed lip breathing

• Preventing and relieving episodes of dyspnea

• Respiratory resistance training

• Coughing and Airway Clearance

• airway clearance can be treated with hand-held devices, such as Flutter, Acapella, or Positive Expiratory Pressure. High frequency chest wall devices include a vest and a compressor and may be used in the home, especially by those affected by CF.

• directed coughing is reported as the most effective intervention for airway clearance, with questionable benefit provided with manual approaches and postural drainage. Current practice advocates teaching as many options for improving airway clearance as possible to promote optimal function (Fink, 2007; van der Schans, 2007)

• manual approaches (percussion and vibration)

• positional drainage
• there are specific guidelines for positioning that optimize drainage from involved segments

• Ther ex for endurance

Exercise is an effective intervention for improving function in patients with obstructive and restrictive lung disease.

Physiological monitoring, medication use, such as bronchodilators (inhalers), and patient education in exercise monitoring are key components to an effective exercise, and the evidence is clear that exercise can reduce anxiety, body weight, and general cardiopulmonary efficiency (Spruit, et al., 2016). Patients with severe restrictive lung disease have shown improvements in quality of life with exercise and appropriate ventilator support (Ho, et al., 2013).

In general, cycling induces less oxygen desaturation than walking in patients with COPD. Desaturation during small muscle mass exercise (e.g. arm exercise) is not very common. (Pothirat, et al., 2015)

Sample exercise program

• Patient and family education
• Home Safety/assessment
• Supportive and assistive device training, equipment training
• Discharge planning
• Energy conservation/management

References

Fink, J. B. (2007). Forced expiratory technique, directed cough, and autogenic drainage. Respiratory care, 52(9), 1210-1223.

Ho, S.-C., Lin, H.-C., Kuo, H.-P., Chen, L.-F., Sheng, T.-F., Jao, W.-C., … Lee, K.-Y. (2013). Exercise training with negative pressure ventilation improves exercise capacity in patients with severe restrictive lung disease: a prospective controlled study. Respiratory Research, 14(1), 22. http://doi.org/10.1186/1465-9921-14-22

Morgan, K., Osterling, K., Gilbert, R., & Dechman, G. (2015). Effects of autogenic drainage on sputum recovery and pulmonary function in people with cystic fibrosis: a systematic review. Physiotherapy Canada, 67(4), 319-326.

Pothirat, C., Chaiwong, W., Phetsuk, N., Liwsrisakun, C., Bumroongkit, C., Deesomchok, A., … Limsukon, A. (2015). Long-term efficacy of intensive cycle ergometer exercise training program for advanced COPD patients. International Journal of Chronic Obstructive Pulmonary Disease, 10, 133–144. http://doi.org/10.2147/COPD.S73398

Spruit, M. A., Burtin, C., De Boever, P., Langer, D., Vogiatzis, I., Wouters, E. F., & Franssen, F. M. (2016). COPD and exercise: does it make a difference?. Breathe, 12(2), e38.

van der Schans, C. P. (2007). Conventional chest physical therapy for obstructive lung disease. Respiratory care, 52(9), 1198-1209.

Role of the PTA

Communication with the interdisciplinary team is very important. Equipment needs, environmental assessments for activity modification, and assist and supervision recommendations are a critical component to an effective and safe pulmonary rehabilitation program.

Typical treatment goals

1. Increase aerobic capacity/endurance
2. Educate in safety, wellness and prevention through HEP and self-monitoring
3. Improve gas exchange through facilitated manual and exercise techniques
4. Education in specific techniques for airway clearance
5. Recommend equipment and modifications to minimize the work of breathing at home/work/school
6. Management of equipment for safety and vitality

Psychosocial considerations

1. Decreased endurance and impaired gas exchange can impact all activities of daily living and interfere with participating in community activities. Patients may be having difficulty with continence due to impaired endurance (inability to get to bathroom on time). Often this is undisclosed by the patient. Watch for weight loss. Patients who mouth breathe may experience decreased nutritional intake, thus affecting muscle performance and endurance. Again, PTAs can educate the patient on energy conservation and make recommendations for follow-up assessment from the health care team (OT, dieticians, wheelchair vendors, etc.)
2. Decreased pulmonary function often leads to anxiety. The perpetual state of breathlessness is a sympathetic nervous system activator. Sleep is often poor due to apnea and sleep position, thus affecting attention and concentration. PTAs can help guide patients back to their physicians if sleep and mood are a barrier to progressing in PT. Relaxation exercises can benefit in both improving tidal volume and self-managing anxiety and depression.
3. As with all impairments of endurance, sexual function and expression of sexuality can be negatively impacted by pulmonary dysfunction. You may be asked for advice on positions and modifications in order to safely engage in sex. Rely on your knowledge of positioning for dyspnea and positioning to collaborate on positions of maximal comfort and minimal stress/WB to thorax. Discuss optimal times of day/night based on pulmonary symptom presentation. Integrate principles of perceived level of exertion into teaching patients how to gauge risk with any activity (including sexual)
4. Children with pulmonary dysfunction require hours of self-care administered by parents/caregivers (inhalation therapy, postural drainage, vibration, etc) in addition to frequent medical appointments. Disability impacts both the child and the parent/caregiver. If you make recommendations for a home program, be sure you inquire about any existing home program and ask how much time is currently dedicated to providing "rehab" care. Make sure your recommendations can be reasonably provided by family members/caregivers and be prepared to offer alternatives to avoid overloading activities. Be prepared with information on parent support groups so you can facilitate sharing this information as you develop a relationship. Burn-out of caregivers is a very real problem.

Documentation

1. Informed consent
2. Time spent ( in minutes) and billing codes (in units)
3. Subjective complaints, symptoms, progress, questions
4. Observations at rest (posture, breathing patterns) and with exertion
5. Vital sign, pulse oximetry, and lung function (if available) at rest and with activity
6. Inclusion of formal assessments of response to work/exertion as needed
7. Objective data: may include rib/chest excursion, ROM, strength, lung function (incentive spirometer) activity tolerance (reps, sets, time, upright tolerance, distance, assistive devices and assist levels, use of oxygen/support equipment).
8. Patient instruction in some form of self-care related to impairment/functional limitation/disability and result of the instruction
9. Communication with family, interdisciplinary team, and/or PT and the result of the communication
10. Assessment of patient response, demonstrating skilled services and thread to the plan of care.
11. Signature and date

 Case Study

Image retrieved from http://www.veteranshealthlibrary.org/GotoGuides/COPD/6B2011502_VA_Large.png

Bill is a 62 year old man with severe COPD. He is a high school educated, retired truck driver who lives with his wife and son. He walks without an assistive device and has difficulty walking on the flat, showering and carrying heavy loads. These activities produce breathlessness and low back pain as he has had a previous fracture to the pelvis. As a result, his wife assists him with most ADLs. He stopped smoking three months ago following an 80 pack year history of smoking.  The respiratory medications he uses are Seretide, Ventolin and Spiriva. He is keen to lose some weight and be able to return to gardening.

On assessment, his spirometry is FEV₁ / FVC = 0.63/1.2 with an FEV₁ (% pred) of 22%. His weight is 198 lbs, height 178 cm, BMI = 28.4. Resting HR = 85 beats/min; resting SpO₂% = 93%. The supervising PT asks you to test his performance on a six-minute walk test. He is able to walk 300 yards with two rests in the best of two six minute walk tests but desaturated to 86% on room air and felt very severely breathless (dyspnea score = 7) at the end of the walk. (Adapted from Pulmonary Rehabilitation Tool Kit)

Christina's Screencast Instructions

Active Learning Exercise

Classify elements in the case study according to ICF factors. Check your work by completing the associated labeling activity below

Now check your understanding of classifications

How did you do with your attempt to classify case elements? Can you think of how this mapping activity guides clinical planning and problem-solving within the physical therapy plan of care?

What exercises will you select to help Bill reach his goals? Given his desaturation response to walking, consider assistive devices and other physiological support that may help improve activity and conserve energy. What do you think is a likely intervention from the supervising MD based on the six-minute walk test result? What are you considering may be a best practice for patient and family education?

Want feedback on your reasoning? Post your ideas in the CAN YOU HELP ME? forum.

Optional Resources

A tool to help guide thinking around ICF classification: http://apps.who.int/classifications/icfbrowser/

A presentation on how the ICF system is used in patient care planning: https://www.cms.gov/medicare/billing/therapyservices/downloads/mapping_therapy_goals_icf.pdf

References

American Lung Association. 2018. Measuring Your Peak Flow Rate. Available at: https://www.lung.org/lung-health-and-diseases/lung-disease-lookup/asthma/living-with-asthma/managing-asthma/measuring-your-peak-flow-rate.html

Lung Foundation Austrailia (2016). Pulmonary Rehabilitation Toolkit. Retrieved from http://pulmonaryrehab.com.au/importance-of-exercise/case-studies/case-study-one/

 End of Lesson