PROBLEMATIK FISIOTERAPI

pd KASUS RESPIRASI

Oleh : Nur Basuki, M.Physio

Classification of PT diagnosis in
Cardiovascular/pulmonary
Impairment pd ventilasi, respirasi/pertukaran
gas and kapasitas aerobik/endurance o/k
gangguan pembersihan jalannapas
Impairment pd ventilasi, respirasi/pertukaran
gas o/k kegagalan/dysfungsi ventilatory
pump
Impairment pd ventilasi, respirasi/gas
exchange o/k kegagalan respirasi
Impairment pd ventilasi, respirasi/pertukaran gas and
kapasitas aerobik/endurance o/k kegagalan respirasi
pd neonatal

Impairment dr sirkulasi o/k penyakit pd sistem limfe

Impairment pd kapasitas aerobik/endurance o/k

deconditioning

Impairment pd kapasitas aerobik/endurance o/k

disfungsi/failure dari cardiovaskular pump
 Problematik FT pd
Kasus Respirasi
Adanya perubahan patofisiologi pd saluran
napas dan jaringan paru
Perubahan mekanika pernapasan
Perubahan toleransi aktivitas
Sesak napas
Gangguan pembersihan jalan napas
Airflow limitation
Penurunan volume paru
Gangguan pertukaran gas
Disfungsi otot-2 pernapasan
Abnormal breathing pattern
Deformitas torak
Pain
Penurunan Toleransi aktivitas
IMPAIRED VENTILATION

o/k Airway clearance

Mrpk problematik FT yg penting,
sebab:

Infection
Major atelectasis
Impaired gas exchange
Airflow limitation
Beberapa faktor resiko atau konsekuensi
perub pathologi/pathofisiologi:
 Acute lung disorders COPD
 Acute or chronic Frequent or recurring
oxygen dependency pulmonary infections
 Bone marrow Organ transplants
transplants (heart, lung kidney)
 Cardiothoracic surgery Tracheostomy
 Change in baseline
breathsounds
 Change in baseline
Chest Radiograph
Hipoventilation Impaired gas exchange

Increased SOB
(VE = Vt X RR) Hypoxaemia

Increased ascessory
Cyanosis
muscle activity

•Dyspnea at rest or with

Increased WOB
exertion
•Inability to perform selfcare
Decrease due to dyspnea
Exc Tolerance •Inability to perform work
task due to dyspnea
 Pathophysiological Basis of Impaired Airway
Clearance
Pathophysiological basis Contoh klinis
PERUBAHAN KOMPOSISI MUKUS

• Peningkatan produksi Bronkitis kronis, asthma, cystic fibrosis,

bronchiectasis, an artificial airway,
tracheal intubation
• Kolonisasi mukus Infeksi paru
Pembuatan bypass dr sal napas atas 
tube cuff akan memblokir mucociliary
escalator & menyebabkan penumpukan
secresi  kolonisasi dan infeksi
• Dehidrasi sistemik Menyebabkan mucus menjadi kental dan
sulit dikeluarkan. Biasanya terjadi pd
kasus pasca operasi
ABNORMALITAS DR STRUKTUR Endobronchial suctioning  perdarahan dan
IMPAIRED MUCOLILIARY
CLEARANCE
• Usia
• Sleep
• Environmental pollutan
• Drugs
• High inspired Oxygen
• Hypoxia & Hypercapnia
ABNORMAL COUGH REFLEX
INEFFECTIVE COUGH akibat
ketidakmampuan untuk
menghasilkan expiratory airflow
Kecepatan mucociliary transport menurun
sekitar 60% pd lansia
Reduces mucociliary clearance
Mengganggu mucociliary clearance
General anaesthesia, morphine, narcotic 
menekan MC
Menurunkan aktifitas MC (mucociliary clearance)
Menurunkan aktifitas MC
Tidak sadar, GA, narcotic analgesic, nyeri,
kerusakan n.glossopharyngeal, Laryngectomy,
paralisis pita suara
Penurunan Vital Capacity yg berat, kelemahan
otot-2 expirasi, airflow limitation
 Factors for consideration when selecting
airway clearance technique
Patient motivation
Patient’s goal
Physiotherapist’s goals
Patient preferences
Effectiveness of considered technique
Limitation of technique
Patient’s age & ability to concentrate & learn technique
Ease of teaching & learning technique
Skill of physiotherapist with particulartechnique
Time necessary to use technique
Desirability of combining technique
 PHYSIOTHERAPY MANAGEMEN
PD(postural drainage)/GAD(gravity asisted
drainage)/AD (airway drainage)
Percussion/vibration
FET (force expiratory technique)/ACBT
(active cycle breathing technique)
PEP Masker, Flutter
Humidification/nebulizer
Exercise/mobilization
Breathing strategies (DBE (deep breathing
exc), SMI , TEE (thoracic Expansion Exercise)
 Anticipated Goals &
Expected Outcomes
IMPACT ON PATHOLOGY
• Atelectasis is decreased
• Tissue perfussion & oxygenation are anhanced

IMPACT ON IMPAIRMENTS
• Airway clearance is improved
• Cough is improve
• Endurance is increase
• Energy expenditure per unit of work is decreased
• Exercise tolerance is improved
• Ventilation and respiration/gas exchange is improved
• Work of breathing is decreased
IMPACT ON FUNCTIONAL LIMITATIONS
• Ability to performed physical actions, task or activities
related to self care, home management, work (job/school),
and leisure is improved
• Performance of ADL is improved
• Tolerance of position and activities is increased

IMPACT ON DISABILITIES
• Ability to assume or resume roles in community and
leisure roles is improved

RISK REDUCTION/PREVENTION
• Risk factors are reduced
• Risk of secondary impairment is reduced
• Safety is improved
• Self management of symptom is improved
Impaired Ventilation
Associated with ventilatory
pump dysfunction or failure
Kelemahan dan kelelahan dari otot-2 pernapasan
dapat terjadi pada berbagai macam kondisi
(National Heart, Lung and Blood Institute
Workshop Summary, 1990)

WEAKNESS/kelemahan -> ketidak mampuan

otot untuk menghasilkan tenaga maksimum yg
diharapkan
FATIGUE/kelelahan -> ketidak mampuan otot
untuk mempertahankan beban kerja tertentu.
 FAKTOR-2 PENYEBAB TERJADINYA
RESPIRATORY MUSCLE
DYSFUNCTION
Menurut Reid & Dechman (1995) dibagi menjadi 3
kelp:

1ST GROUP Menurunnya kemampuan otot

respirasi secara umum respiratory muscle :
• Patologi Neuromuscular
• Myopathy
• Gangguan Connective tissue
• Systemic abnormality (endocrine disorder
or metabolik abnormalities termasuk
hypoxia, hypercapnia.
2nd Group  Faktor-2 yg menyebabkan
peningkatan beban kerja pernapasan :
 Perubahan compliance paru (Fibrotic
lung disease, breathing at low lung
volumes, pulmonary congestion)
 Prubahan compliance thorax
Kyphoscoliosis, ankylosis spondylitis,
obesitas)
 Increase airway resistance

3rd Group  Faktor-2 yang menurunkan

efisiensi kerja otot-2 pernapasan :
Hyperinflasi paru
Beberapa faktor resiko atau konsekuensi
perub pathologi/pathofisiologi:
 Elevated diaphragm &  Pulmonary fibrosis
volume loss on chest  Restrictive lung disease
radiograph  Severe Kyphoscoliosis
 Neuromuskular  Spinal cerebral
disorder neoplasm
 Partial or complete
 Spinal cord Injury
diaphragm paralysis
 Poliomyelitis
 GAMBARAN KLINIS
Gambaran utama dari gangguan ini adalah ; Sesak
napas, penurunan toleransi ektivitas dan respiratory
failure.

Somnolence pd siang hari, sakit kepala pd pagi

hari, serta kemungkinan gangguan mental bila
terjadi desaturasi dan hypercapnia selama tidur.

Pada pasien yg sesak  pola pernapasan yg

abnormal : RR meningkat, penurunan Vt, penurunan
chest expansi, respiratory alternans, paradoxically
breathing (Mier, 1990; Wilkins et al, 1990)
 Gambaran paradoxically breathing “Hoover’s
sign” lebih mudah terlihat pd posisi tidur
terlentang (Laroche et al, 1988) Namun demikian
keadaan ini sulit diobservasi kecuali terjadi
paralysis atau penurunan kekuatan mencapai 25
% (Mier, 1988)
 Batuk yg lemah
 General muscle weakness
 Penurunan berat badan
 GAMBARAN FUNGSI PARU

 Gambaran fungsi paru bisa normal jika

kelemahan otot tak begitu nampak
 Jika ada kelemahan otot inspirasi  penurunan
VC & TLC
 Jika ditemukan kelemahan diafragma bilateral yg
berat  VC akan rendah dan akan lebih rendah
pada posisi supine
 Residual volume normal jika otot-2 ekspirasi
normal, oleh karenanya Ratio RV/TLC normal
atau tinggi.
 FRC menurun karena hilangnya daya tarik keluar
oleh otot-2 pd akhir ekspirasi
 Tekanan partial oxygen dan Saturasi oxygen 
rendah
 Jika VC turun > 50% predicted value 
Hypercapnia
 Pada pasien dengan kelemahan otot-2
pernapasan berat  hypercapnia pd malam hari
 Vt mengalami penurunan 15 -25%.
 Vt lebih dangkal pd Repid Eye Movement (REM)
dibandingkan dg non-REM.
 Respiratory muscle may operate at shorter length

Uncoupling of chest wall movements from lung movements

PLEURAL EFFUSION
Altered dynamics of the pleural space

Altered expansion

Altered distribution of the inspired breath

Leading to
Hypoventilation precipitating collapse
CHRONIC AIRFLOW LIMITATION

Degenerative changes of lung tissue

(destruksi & dilatasi alveoli)

Hyperinflation due togas trapping

Inefficient muscle function

Increased WOB

Muscle fatigue & weakness

 Impairments, functional limitations or
Disability
Abnormal or adventitious breath sounds
Abnormal increased RR & Decreased Vt at rest
Airway clearance dysfunction
Decreased to severely impaired strength &
endurance of ventilatory muscle
Dyspnea with self care
Dyspnea with work task
Paradoxically breathing at rest or with activity
Progressive decrease in arterial oxygen & increase
in carbondioxide
 PHYSIOTHERAPY MANAGEMEN
Deep Breathing Exercise, Sustain
Maximal Inspiration (SMI), TEE (thoracic
Expansion Exercise)
Diaphragmatic Breathing Exc
Pursed Lip Breathing
Respiratory muscle strength & endurance
training
Intensive upper limb exercise
Aerobic capacity/endurance conditioning
or reconditioning
 Anticipated Goals &
Expected Outcomes

IMPACT ON PATHOLOGY
 Atelectasis is decreased
 Pain is decrease
 Physiological response to increase O2
demand is improve
 Tissue perfusion & oxygenation are enhanced
IMPACT ON IMPAIRMENTS
• Aerobic capacity is increased
• Airway clearance is improved
• Endurance is increased
• Ventilation & respiration/gas exchange are improved
• WOB is decreased
• Muscle performance is increased

IMPACT ON FUNCTIONAL LIMITATIONS

• Ability to performed physical activities are improved
• Level of supervision required for task performance is
decreased
• Performance of ADL is improved
• Tolerance of positions & activities is increased
 IMPAIRED AEROBIC
CAPACITY/ENDURANCE
Associated with
Cardiovascular Pump
Dysfunction
Beberapa faktor resiko atau konsekuensi
perub pathologi/pathofisiologi:
 Angioplasty  Decrease in EF on exc
 Cardiomyopathy testing (EF 30-50% with
 Cardiothoracic surgery Dysfunction, < 30% with
failure)
 Complex ventricular
arhythmias
 Diabetes
 Complicated myocardial
 Exercise induced
infraction myocardial ischemia (1-2
mm ST segment depression
 Congenetal cardio
with dysfunction; > 2 mm
anomalies
ST segment depression with
 Valvular Heart Disease failure)
 Hypertensive Heart Disease
Impairments, Functional Limitations,
or Disability
Abnormal HR response to increased oxygen demand
Abnormal pulmonary response to increased oxygen demand
Decrease ability to performed ADL
Flat or falling BP response to increased oxygen demand
(failure)
Hypertensive BP response to increased oxygen demand
(dysfunction)
Impaired aerobic capacity < 5-6 METS
Impaired gas exchange
Inability or decrease ability to perform work roles
Presence or increase in cardiovascular symptoms in
 Symptoms of Inactivity  physically
cardiovascular disease deconditioned
(dyspnoea, pain, fatigue)

CENTRAL & PERIPHERAL MECHANISM

• Increased HR response to Exc
• Increased cardiac afterload
• Decrease muscle capacity for aerobic exc
• Decrease the skill & efficiency of physical
movement
• Higher level of cognitive function

Impairment of neurological or
musculoskeletal factors

Higher energy cost at any

given exc intensity
 PT Management
 Exercise program
 Endurance training (senam, ..)
 Strength training
 Breathing exercise
 Body mechanic & postural stabilization
 Play therapy (mendekati aktivitas yg
sebenarnya, fun, motivasi)
 Circuit Game (modifikasi exc)
 Relaxation exercise (
 Chest PT (if necessary)
 Anticipated Goals &
Expected Outcomes

IMPACT ON PATHOLOGY
 Atelectasis is decreased
 Pain is decrease
 Physiological response to increase O2
demand is improve
 Tissue perfusion & oxygenation are
enhanced
IMPACT ON IMPAIRMENTS
• Aerobic capacity is increased
• Airway clearance is improved
• Endurance is increased
• Postural control is improved
• WOB is decreased
• Relaxation is increased
• Muscle performance is increased

IMPACT ON FUNCTIONAL LIMITATIONS

• Ability to performed physical activities are
improved
• Level of supervision required for task performance
is decreased
• Performance of ADL is improved
• Tolerance of positions & activities is increased