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    8 views13 pages

    FT Acute Medical Condition 1

    Uploaded by

    Annas Diah L.

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    © All Rights Reserved
    Download as PDF or read online from Scribd
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    of 13
    CHAPTER 29 Individuals with Acute Medical Conditions KEY TERMS limitation Alveolar proteinosis Alveolitis = Asthma Atelectasis Bronchiolitis * Bronchitis ‘The purpose of this chapter isto review the physical therapy management of individuals with primary, acute cardio: pulmonary dysfunction. Such dysfunction may limit participation in life and its related activities inthe short- or long-term. Furthermore, such dysfunction can constitute life threat in the absence of limitations to life participation and {quality of life (eg., hypertension and dysrhythmias). Manage- iment principles for people with several types of common ‘acute medical conditions are described. Although medical conditions are usually classified as either primary lung disease ‘or primary cardiovascular disease, the heart and Tungs work synergistically to effect gas exchange and cardiac output and in series with the peripheral vascular circulation to effect tissue perfusion (Dantzker, 1983: Dantzker, 1988; Pryor et al, 2002; Wasserman & Whipp, 1975). Thus impairment of one Organ invariably has implications for the function ofthe other. ‘Threat to or impairment of oxygen transport has implications for all other organ systems, thus a multisystem approach is ‘essential for overall management (see Chapters | and 5). The primary, acute pulmonary conditions that are presented include atelectasis, pneumonia, bronchitis, bronchiolitis, Acute exacerbations of chronic airflow Elizabeth Dean Cystic fibrosis Hypertension Interstitial pulmonary fibrosis, Pneumonia Stable angina Stable myocardial infarction Tuberculosis alveolits, alveolar proteinosis, acute exacerbations of chronic airflow limitation, asthma, cystic fibrosis, interstitial pulmonary fibrosis, and tuberculosis. For further epidemiological and pathophysiological detail on these conditions refer to Bates (1989), the Epidemiological Standantization Project of the American Thoracic Society (1989), Murray and Nadel (2000), ‘and West (2003). The primary, acute cardiovascular conditions, presented include hypertension, medically-stable angina, and ‘uncomplicated myocardial infarction. For further details on these conditions refer to Cheitlin (2004), Kasper et al (2004), and Woods (2004) ‘The pathophysiology underlying the medical management of each condition extends the pathophysiology content of Chapter 5 and in tur provides a basis for each condition’s physical therapy management. The management principles presented are not intended to serve as treatment prescriptions for a particular patient, The treatment priorities presented are not only based on the underlying pathology but on the complexity of its manifestation in a given patient. Without discussion of a specific patient and knowledge of other significant factors (ie., the effects of restricted mobility, 507 508 > °C = sonary Physical Therapy: Acute Conditions PART IY Guidlines for te Delivery of Cardiovascular and Pulmonary © P BOX 20-4 to Atelectasis Pathophysiological Mechanisms Contributing Central Mechanisms Breathing a low lung volumes (e.g, when in pain or afer certain medications) Inability to generate adequate inspiratory pressure and volume Central disruption of breathing centers controlling, normal petiodic and rhythmic breathing patern ‘Extramaral Mechanisms ‘Chest wall deformity. Asymmetry of intrathoracic structures Respiratory muscle weakness (e.g, neuromuscular disease) Phrenic nerve inhibition (e.¢, secondary to upper abdominal of sccumulaon, Hood, plasma, and pus ‘Compression of lun parectyma during surgery ‘Redaced ling expansion secondary to redoced movement Compression of lung parenchyma secondary to static body positioning ‘Compression of lung pareachyma secondary to prolonged static body positioning « ‘Mechanical ventilation Increased alveolar surface tension ‘Mural Mechanisms Airway narrowing secondary to increased’ bronchial smooth ‘muscle tone Bae ee so or aero anticline of irvays Cain ential wal and epi {Intramural Mechanisms Insp ‘ered disibuton tio ps ‘Space-Occupying Lesions aera anda fd ine ing prechyma Foreign-body aspiration infannaton Other Factors Peal Gieplaees td dymamie lrway comprenin rote changes 1 the ing | oo a rece emp o bo Spee cing echt wall reiting normal de scat oa chew val moverent Pain and led breting pate Tt caton calng mics, sedatives, sd releans Seplonent oxygen monary seretions | Fryation of pulmonary secretions recumbency, and the effects of extrinsic and intrinsic factors) (See Chapter 17), however, the specific parameters of the treatment prescription cannot be completely established. Integration of patient-specific information is essential for treatment to be specific and maximally efficacious. Chapter 31 extends the principles involved with the management of ‘many of the acute medical conditions described in this chapter, detailing their subacute and chronic stages. Individuals with Atelectasis Pathophysiology and Medical Management ‘Atelectasis refers to partial collapse of lung parenchyma, ‘The pathophsiological mechanisms contributing to atelectai are multiple (Box 29-1). These mechanisms include physical ‘compression of the lung tissue (eg. resulting from increased pleural fluid, pus, pneumothorax, or adjacent areas of lung collapse) or obstruction of an airway (e.g., due to secretions ‘or tumor) with subsequent reabsorption of oxygen from the trapped ar by the pulmonary capillaries resulting in a collapse of te lung tissue distal to the obstruction (ie, reabsorption atelectasis). a ‘There are two primary types of atelectasis: microatelectasis ‘and segmental and lobar atelectasis Microatelectasis is characterized by a diffuse area of lung unit that ae perfused but not ventilated, leading to a right-to-left shunt Il and hospitalized patients who are deprived of being regula upright and moving have reduced lung volumes and are pros to breathing’ at low lung volumes, which leads t0 micro ‘atelectasis. Thus such patients require prophylactic messues to avoid significant effects of atelectasis on oxygen transport and gas exchange. When the conditions for normal vas inflation ae removed, alveolar collapse occurs instantly. Microatelecass i associated with reduced lung complies because of reduced lung expansion. Patients who st ‘mechanically ventilaied are prone to microatelectsis bes ‘he normal mechanics of breathing are violated, This may explained in part by restricted mobility, recumbency. 2 reduced arousal, in addition to reduced functional resid! ‘capacity (FRC). Positive end-expiratory pressure (PEEP) routinely added to minimize these effects. High vents" ‘system pressure is required to counter reduced lung compliats*: which indicates that atelectatic lung tissue it not readily expandable Microatelectasis is not detected readily with chest but is on the basis of clinical findings. Nonetheless, mic!” atelectasis can be anticipated in every ill and hospi? Patient whose normal respiratory mechanics are disrupt Particularly in recumbent, relatively immobile patients. Th fects are futher exacerbated in patients who are old. NCI, have abdominal masses, spinal deformities. f° ‘all asymmetry, smokers, and sedated patients. Commensurate with its distribution, atelectasis pres with reduced ches wall movement andeduccl beat nen over the involved area. A chest x-ray shows increased density over the involved areas with @ shift of the tachen aed mediastinum toward the collapsed lung tissue. The patent may be tachypneic and cyanotic because of shunting Segmental atelectasis results from significant progression af ricroatelectasis and obstruction of airways with reabsorption of gas inthe distal ung units ofa bronchopulmonary segment ote chopulmonary segment The patient whois dependent on a mechanical ventilator to breathe is predisposed to developing atelectasis because of an unnatural, monotonous breathing pattem restricted movement, and abnormal and prolonged recumbent body positions, These factors contribute to reduced mucociliary transport, abnormal distribution of pulmonary mucus, andthe accum. Jation of mucus in the dependent hing fields. Furthermore, production of mucus may be increased duet tracheostomy or the presence of an endotracheal tube. Mucociliary clearance is further compromised by reduced ciliary activity resulting from high concentrations of oxygen, medication, and loss of an effective cough due to an dificil airway The effect of atelectasis on oxygen transport reflects its type and distribution. Hypoxemia, right-to-left shunt, reduced lung compliance and increased work of breathing are common clinical manifestations, An increased temperature reflects an inflammatory o infective process and nt atelectasis per se Principles of Physical Therapy Management Because it can develop instantaneously when respiratory mechanics are disrupted, hicroatelectass shouldbe anticipated and prevented. Those factors that contribute to atelectasis for a given patent are countered accordingly with aggressive prophylactic management. Many of the eauses of atelectasis Outlined in Box 29-1 can be readily reversed. The assessment includes a detailed analysis of the underlying cause(s) and mechanism(s) so that these may be addressed directly. “Atelectasis is always treated aggressively because it ‘has the potential to worsen, develop into a severe clinical manifestation, and lead to pneumonia. Treatment i primarily directed at reversing the underiying contributing mechanisms whenever possible (Don ct al, 197; Ghiste, 1967; Lelane tt al, 1970; Lewis, 1980; Ray etal, 1974; Remolina etal, 1981). For example, atelectasis resulting from restricted mobility is remediated with mobilization. Atelectasis resulting from prolonged static positioning and monotonous tidal ‘emtlation is managed with mobilization, manipulating body position wo increase alveolar volume of the aelecttic area, thaniputating body position to optimize alveolar ventilation, ti some combination of these intervention, Atelectasis arising from reduced arousal is managed by reducing the causative factors contributing to reduced arousal coupled with frequent sessions of mobilization andthe upright position to increase arousal, promote greater tidal volumes and alveolar verilaton, increase one two (area of optimal ventilation and perfusion matching, increase FRC, and minimize closing volume 29 Individuals with Acute Medical Conditions _ 509 Breathing control and coughing maneuvers augment the cardiopulmonary physiological effects of mobilization and body positioning. Coordinating these interventions distributes. ventilation more uniformly rather than directing gas to already ‘open alveoli, which over-distends these units, The distribution of ventilation is primarily altered by body positioning and not by deep breathing (Roussos et al, 1977). Sustained maximal inspiratory effors may augment alveolar ventilation; however, the parameters necessary for such efforts to be maximally therapeutic have not been studied in detail If impaired mucociliary transport or excessive secretions fare obstructing airways and contributing to atelectasis, ‘mobilization of pulmonary secretions is the goal that may be affected by mobilization and a stir-up regimen (Dripps & Waters, 1941; Ross & Dean, 1989). In addition, postural drainage coordinated with breathing control and coughing maneuvers can facilitate airway clearance. The addition ‘of modified manual techniques may be indicated in some patients Individuals with Pneumonia Pathophysiology and Medical Management Pneumonia isa common complication and cause of ‘moxbidity and mortality in the hospitalized patient, particularly inthe very young and very old (Bartelett & Gorbach, 1976). ‘Comparable with other systemic infections, pneumonia results when the normal defense mechanisms of the respiratory system fail to adequately protect the lungs from infection Air inspired through the nasal passages is cleansed of particulate matter by filtration (cilia sweep it to the nasopharynx); impaction (iregular contour of the chamber ‘causes particles to rain out) swelling of hygroscopic droplet nuclei, which are either filtered or become impacted; and defense factors located in the mucous blanket, such as immunoglobulins (IgA). lysozymes, polymorphonuclear leukocytes, and specific antibodies. Particles that escape one fof these defense mechanisms in the nasopharynx may be prevented from entering the lower airways of the larynx. The ‘mucosa of the larynx is sensitive to chemical irritation oF ‘mechanical deformation and responds by eliciting the cough reflex. The high velocities created by the cough are sufficient to clear several branches ofthe tracheobronchial tree of particulate matter, The cough reflex is frequently absent or depressed in patients who are unconscious from drug ‘overdose, epilepsy, alcohol ingestion, or head injury. Patients with artificial airways are more susceptible to infection because the normal defense mechanisms are bypassed, causing ‘organisms to be deposited directly in the lower airways. in the lower airways the cough mechanism is rendered ineffective by endotracheal tubes, which prevent approximation of the vocal cords, and by tracheostomy tubes, which cause air to bypass the cords altogether. ‘The trachea and the tracheobronchial tree to the level of| the respiratory bronchioles are protected by the cough reflex, 510 PART IV. Guidelines forthe Delivery of filtration (again by cilia, which transport particles to the pharynx), impaction, and chemical factors (IgA). Below the level of the respiratory bronchioles, the cough reflex is ineffective and filtration and transportation of particles by cilia cannot occur because cilia are absent. The alveolar ‘macrophages play an important role in protecting these Airways from particulate matter. Macrophages ingest organisms and transport them to the lymphatic system or higher in the ‘wacheobronchial tree to where cilia can sweep them to the pharynx. This process of phagocytosis can be slowed or stopped bby hypoxia, alcohol ingestion, air pollutants, corticosteroids, immunosuppressant agents, starvation, cigarette smoke, and supplemental oxygen, Routes of Infection A patient who has impaired or ineffective defense mechanisms Of the respiratory tract becomes susceptible to a variety of organisms. The major routes of infection include airborne ‘organisms, circulation, contiguous infection, and aspiration. CLASSIFICATION OF PNEUIMONIA ~ Most respiratory viral infections are contracted by droplets from the respiratory tracts of infected persons. These viruses are responsible for interstitial pneumonias, tracheobronchitis, bronchiolitis, and the common cold. The ciliated cells ofthe respiratory tract are the most frequent site of infection. They become paralyzed and degenerate with areas of necrosis and

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