Case studies

The following case studies provide examples of how to formulate a patient problem list. The reasoning for identifying each problem and the considerations for patient intervention are given. Assessment of the patient may reveal many features. The clinical features reported in these case studies include only those considered to be important in formulating the problem list for each case.

Table 6.1 Pulmonary function tests, case study 1

FVC, forced vital capacity; FEV_1, forced expiratory volume in 1 second; FRC, functional residual capacity; RV, residual volume; TLC, total lung capacity; TLCO, transfer factor of the lung for carbon monoxide

Table 6.2 Analysis of problems from case study 1

Current cardiopulmonary problems	Evidence for each problem based on clinical features	Most likely pathophysiological basis for each problem
Impaired airway clearance	Increased sputum production which has changed in colour and is now purulent; coarse inspiratory crackles in lower lobes Significant difficulty expectorating sputum Patient is febrile Sputum culture grew Pseudomonas aeruginosa	Increased production of mucus with altered composition due to colonization with pathogen
Dyspnoea	On conversation, on lying flat, mobilizing to toilet and around the bed	Increased work of breathing due to an increase in airways resistance: increased expiratory muscle work to effect airflow through narrow airways and increased inspiratory muscle work due to lung hyperinflation Increase in ventilatory requirements due to fever and hypoxaemia
Airflow limitation	FEV1/FVC indicates airflow obstruction, FEV1 indicates severe airflow obstruction Evidence of hyperinflation: chest X-ray findings, chest shape (barrel), poor chest expansion, increased TLC and FRC Adaptive breathing pattern: increased expiratory phase, PLB, increased abdominal effort, intercostal recession Expiratory wheeze on auscultation Tight cough	Loss of radial traction to airways due to a decrease in elastic recoil Mucus causing partial occlusion of airway lumen
Impaired gas exchange	Respiratory acidosis with CO2 retention. 28% oxygen required to maintain adequate PaO2 Reduced TLCO	Mixed causes for hypoxaemia, including / mismatch, diffusion limitation, wasted perfusion (intrapulmonary shunt) and hypoventilation Mixed causes for hypercapnia, including added load on the mechanics of breathing resulting in hypoventilation, increased CO2 and increased dead space as a fraction of VT
Decreased exercise tolerance	Reports needing significant help going to the toilet. Further assessment is recommended
Considerations for treatment	GORD and orthopnoea – a head-up position should be maintained during all interventions Patient thin and frail – consideration required in selection of intervention and implementation of treatment (e.g. care with patient handling) Patient acutely unwell – treatments should be short and interspersed with sufficient rest periods

Note: respiratory muscle dysfunction may be present (clinical features include orthopnoea, CO₂ retention and altered breathing pattern) and further assessment may be warranted

FEV₁, forced expiratory volume in 1 second; FVC, forced vital capacity; TLC, total lung capacity; FRC, functional residual capacity; PLB, pursed-lip breathing; TLCO, transfer factor of the lung for carbon monoxide; GORD, gastro-oesophageal reflux disorder; /, ventilation/perfusion ratio; V_T, tidal volume

Table 6.3 Analysis of problems from case study 2

Current cardiopulmonary problems	Evidence for each problem based on clinical features	Most likely pathophysiological basis for each problem
Reduced lung volume	Chest radiograph reveals collapse and consolidation Decreased breath sounds on auscultation Reduced chest expansion Abnormal breathing pattern – rapid shallow breathing	Atelectasis resulting from marked decrease in FRC, postoperative diaphragmatic dysfunction, reduced function of surfactant, airway obstruction from mucus plugging and abdominal incisional pain
Impaired gas exchange	Acute hypoxaemia: PaO2 7.8 kPa (59 mmHg) and SaO2 91% on room air	Mixed causes for hypoxaemia including / mismatch caused by a decrease in FRC
Impaired airway clearance	Patient is febrile, elevated WCC, moist cough	Possible colonization of sputum, possible systemic dehydration, impaired MCC from opioid, ineffective cough
Considerations for treatment	Reduced mobility further increases risk factors for PPC, a reduction of oxygen transport and risk of a deep vein thrombosis – mobilization of patient is a major goal of treatment IHD, hypertension and diabetes – careful monitoring required during treatment Incisional pain – patient needing encouragement to use PCA Patient feeling ill – consideration required during treatments (e.g. ensure optimal use of anti-emetic medication before treatment, short treatments)

FRC, functional residual capacity; MCC, mucociliary clearance; WCC, white blood cell count; PPC, postoperative pulmonary complication; IHD, ischaemic heart disease; PCA, patient-controlled analgesia, /, ventilation/perfusion ratio; PaO₂, partial pressure of oxygen in arterial blood; SaO₂, arterial oxygen saturation

The problem-solving approach to determining patient management not only assists with the identification of existing problems but also enables recognition of potential patient problems. For example, a high-risk surgical patient will develop reduced lung volume and has the added potential to develop problems of impaired airway clearance but if active treatment, such as early ambulation, is started during the at-risk period, these problems may be prevented. Some problems are not amenable to physiotherapy intervention or physiotherapy intervention may be detrimental.

For the patient with more than one problem, it is essential to prioritize the problem list and to establish the short and long-term goals of the patient and, where appropriate, their relatives and/or caregiver and any other service providers (e.g. other allied health professionals, nurses and medical practitioners). Some problems may only be short term, for example, reduced lung volume in the immediate postoperative period. Developing and prioritizing the problem list and developing the intervention should, whenever possible, take place in consultation with the patient. Some interventions may be determined by taking into consideration other factors such as the availability of resources and the model of service delivery.

Once the short- and long-term goals of the patient and, where appropriate, their relatives and/or caregiver and any other service providers have been established, the next stage is to identify the means of achieving these goals through physiotherapy intervention and the time frame over which they are to be achieved. The appropriate intervention requires selecting the optimal physiotherapy management strategy and this should be evidence based where possible. When a patient has several physiotherapy problems, the physiotherapy techniques selected should ideally address more than one of the high-priority problems. When selecting a treatment approach, the potential risks to the patient (e.g. the possibility of causing adverse physiological responses) and methods to minimize such risks must be taken into consideration. Other factors to be considered include ensuring that the intervention is appropriate for the patient’s age, occupation, ability to communicate, cultural beliefs, level of understanding and motivation and the presence of any psychosocial factors which may interfere with the treatment approach (e.g. fear, anxiety or depression). It is important also to determine the patient’s likes and dislikes; for example, patient preferences for types of activities are vital considerations when developing an exercise programme.

Common to the management of most problems is the education of the patient by the physiotherapist. This is essential to ensure that the patient takes responsibility for their own management and becomes actively involved in the management of their problem and the prevention of associated problems. If the problem is amenable to physiotherapy, treatment should be started. Conditions that are not amenable to physiotherapy intervention or that require the expertise of a specialist physiotherapist (e.g. a physiotherapist specializing in continence problems) should be referred appropriately. With some problems, a stage will be reached when the natural rate of recovery will no longer be augmented by physiotherapy intervention and treatment should then be discontinued.

The selection and use of appropriate outcome measures are fundamental to the evaluation of physiotherapy intervention. Healthcare fundholders increasingly require data demonstrating the effects of physiotherapy intervention, using instruments that are reliable and valid. Other parties requiring outcome data include the patient, the patient’s relatives and caregivers, employers of physiotherapists, clinicians, patient support groups and associations of patients with particular conditions (e.g. cystic fibrosis, heart failure), members of other healthcare professions and insurers. Thus, when selecting which outcome data to monitor it is important to consider the relevant stakeholders.

In this chapter the problems commonly encountered by the physiotherapist when managing patients with respiratory or cardiovascular dysfunction are discussed. The underlying pathophysiology for each problem is outlined and the clinical features that assist in the identification of the problem are described. The physiotherapy management is listed alongside each problem and discussed in greater detail in other chapters. The discussion of each problem concludes with guidelines for the choice of clinical outcome measures to be used to evaluate physiotherapy intervention.

Clinical features

The clinical features of impaired airway clearance are usually those resulting from excess or retained secretions. The history of usual daily sputum production obtained from the patient may reveal a chronic productive cough. Changes in the normal pattern of sputum production, such as an increase in the amount or a change in the colour or consistency of the sputum, are likely. Some patients report difficulty expectorating secretions. Further questioning may reveal an increase in the number of chest infections or hospitalizations for their illness compared with previous years. Patients with chronic lung disease may report signs of stress incontinence on coughing.

Examination of the patient may reveal an altered breathing pattern due to increased work of breathing (WOB). The presence of infection may produce fever and tachycardia. When the secretions cause marked airflow limitation, wheezing may be audible (see Problem – airflow limitation). Auscultatory findings include diminished or absent breath sounds, bronchial breath sounds, crackles or wheezes. The cough may be moist or dry and hacking, effective and productive or ineffective and weak. Some patients have a paroxysmal cough with associated adverse effects such as dizziness, syncope or exhaustion. The examination of any sputum expectorated may reveal an increase in the volume or weight compared with the patient’s normal expectorant. The colour of the sputum may have changed to yellow, green or brown and there may be blood present (haemoptysis). Also the consistency of the sputum may have altered and microculture may reveal colonization (e.g. with bacteria) (Chapter 1).

Chest radiographs sometimes show signs of lung collapse and/or consolidation or abnormalities reflecting the underlying disease process; for example bronchiectatic changes.

The clinical features of impaired airway clearance in the postoperative patient may include an increased volume of sputum expectorated compared with the patient’s usual expectorant; a weak, ineffective moist cough; possible bacterial contamination of expectorated sputum; fever; and chest radiographic changes consistent with atelectasis or pneumonia (Chapter 12).

Physiotherapy management

Physiotherapy is an integral part of the management of patients with impaired airway clearance but bronchial secretions only become a physiotherapy problem when they are excessive, retained or difficult to eliminate. Some patients expectorate a small amount of foul-smelling, tenacious sputum postoperatively but this is not a problem if the patient is conscious, able to cough effectively and self-ambulating.

Airway clearance techniques comprise a range of physiotherapy interventions used for the management of impaired airway clearance (Chapter 5). These techniques aim to promote clearance of excessive secretions from the distal airways and thereby prevent the consequences of obstruction and thus improve ventilation homogeneity and gas exchange. Airway clearance techniques may incorporate positive pressure or oscillation applied at the mouth or chest wall (manual or mechanical) and/or breathing strategies to aid the movement of secretions to the central airways. From the central airways, forced expiratory manoeuvres such as coughing or huffing are used to facilitate expectoration. Such manoeuvres aim to use high expiratory flow rates to shear secretions from the airway walls.

The physiotherapy management of impaired airway clearance is influenced by the underlying cause and acuity of the patient’s condition. For patients with chronic hypersecretory lung disease who regularly produce excess bronchial secretions, the use of daily airway clearance techniques is recommended (Jones & Rowe 1998, van der Schans et al 2000). The rationale for daily treatment is to reduce stagnation of secretions in an attempt to avoid contamination with pathogens and thereby reduce the destruction of airway walls caused by the inflammatory response. This may slow the cycle of progressive tissue damage. The physiotherapist’s role in this case is to prescribe and teach a daily airway clearance regimen that is individually tailored and acceptable to the patient. Factors to be considered when choosing an airway clearance technique include:

evidence supporting the technique

patient age and ability to learn the technique

patient motivation

patient preference and comfort

physiotherapist’s skill in teaching the technique.

The physiotherapist’s role may change in a patient with hypersecretory lung disease when the patient experiences a worsening of their condition such as during a chest infection. During a hospital admission for an acute illness the physiotherapist may take a more active role and the frequency and duration of treatments may increase. It may be that a change of technique is indicated and it is the physiotherapist’s role, in consultation with the patient, to select a technique that addresses the changing condition.

A number of additional measures are available that have been shown to enhance or improve airway clearance. Table 6.5 outlines these measures (Conway et al 1992, Elkins et al 2006, Houtmeyers et al 1999b, Jones et al 2003, Wark et al 2005, Wills & Greenstone 2006).

Table 6.5 Additional measures to enhance airway clearance

In the postoperative patient it is essential to establish whether the patient has excess secretions and whether they have difficulty managing their own airway clearance. This is one of the factors influencing the risk of the patient developing PPCs. The techniques to assist sputum clearance in the postoperative patient aim to increase alveolar ventilation and expiratory flow rates using, for example, upright positioning and ambulation at an adequate intensity with encouragement to take deep breaths. Expectoration of secretions can be facilitated by supported coughing or huffing (Chapter 12). If the patient has large amounts of secretions, techniques such as the active cycle of breathing techniques (ACBT) and vibrations may be used.

For patients who are reluctant or unable to cough, a spontaneous cough may be elicited by physical activity or a change of position. The cough reflex may be elicited using a tracheal rub or suctioning. Strengthening of the abdominal muscles and assisted cough techniques (e.g. abdominal support with an upward pressure) or a mechanical insufflation- exsufflation device may be helpful for patients with impaired cough due to weakness of the abdominal muscles (Chapter 16). For the intubated and ventilated patient, improved alveolar ventilation and increased expiratory flow rates can be achieved by positioning and manual hyperinflation, and secretions cleared by suctioning (Chapter 8).

Outcome measures

Short-term outcomes can be monitored by a change in sputum expectorated, as measured by weight, volume or rate of expectoration. Ease of sputum expectoration can be measured using a categorical scale or visual analogue scale (VAS). In acute conditions, chest radiographs and auscultatory findings may provide evidence for a change in the patient’s condition. Radio-aerosol clearance may be used as an outcome measure in studies of airway clearance techniques (van der Schans et al 1999).

Long-term outcomes in patients with hypersecretory lung disease may be assessed by the number of exacerbations, courses of antibiotics, hospitalizations and days lost from work/study per year. Quality of life scales, such as the St George’s Respiratory Disease Questionnaire (SGRQ), include a section that quantifies symptoms of cough and sputum (Jones et al 1992). Pulmonary function, in particular spirometry, has been used to evaluate the effects of airway clearance techniques but may be relatively insensitive to the intervention (van der Schans et al 1999).

In the high-risk postoperative patient with excess bronchial secretions, outcomes from physiotherapy intervention may be measured by the prevention of PPCs.

Improved cough or huff technique may be associated with a reduction in associated problems such as fatigue, dyspnoea, syncope, airflow limitation, arterial oxygen desaturation or stress incontinence.

Clinical features

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