Principles and application of

investigative and imaging

techniques in Physiotherapy
Presented by: Sayali Patil
1st year MPT
CONTENTS
• Complete Blood Count (CBC)
• Arterial blood gas (ABG) analysis
• Pulmonary function test (PFT)
• Dope testing
BLOOD TEST
• Blood test is a scientific examination of a sample of blood, typically
for the diagnosis of the illness or for the detection and measurement of
drugs or other substances.
• It includes three common panels:
1. Complete Blood Count (CBC)
• CBC is one of the most commonly used laboratory procedures.
• CBC is often done as part of a routine checkup. This test measures
different parts of the blood, including red blood cells(RBC), white blood
cells(WBC), Haematocrit , Haemoglobin, Mean corpuscular volume
(MCV) , and platelets.
RED
CELL
INDIC
ES
• Red blood cell levels that are higher or lower than normal could be a
sign of dehydration, anemia, or bleeding.
• White blood cell levels that are higher or lower than normal could be a
sign of infection, blood cancer, or an immune system disorder.
• Platelet levels that are higher or lower than normal may be a sign of a
clotting disorder or a bleeding disorder
• Hemoglobin levels that are lower than normal may be a sign of anemia,
sickle cell disease, or thalassemia
• Hematocrit levels that are too high might be a sign of dehydration.
Low hematocrit levels may be a sign of anemia. Hematocrit is a measure
of how much space red blood cells take up in the blood.
• Mean corpuscular volume (MCV) levels that are lower than normal
may be a sign of anemia or thalassemia. MCV is a measure of the
average size of your red blood cells.
2. White Blood Cell(WBC) Differential:
• White Blood cell (WBC) differential count is often done as part of
the Complete blood count.
• White blood cells are part of the immune system. They help your body
fight off infections and it is used to determine the values and percentages
of the different types of leukocytes present in the blood.
• There are five major types of leukocytes and there are often times
reported in percentages (i.e. to calculate the value it has to be the
percentage of the individual's total WBC)
3. Basic metabolic panel (basic electrolyte panel)
• The basic metabolic panel (BMP) is a group of tests that measures
different naturally occurring chemicals in the blood.
• It commonly includes sodium, Calcium, Potassium and Magnesium

Sodium: is one of the essential electrolytes in the extracellular fluid.

Normal range: 135 to 145 mmol/L
Hyponatremia is diagnosed when the serum sodium level is less than 135
mmol/L. Patients may present with headaches, confusion, nausea, and
delirium.
Hypernatremia occurs when serum sodium levels are greater than 145
mmol/L. Symptoms of hypernatremia include tachypnea, sleeping
difficulty, and restlessness.
Potassium: The sodium-potassium adenosine triphosphatase pump is
primarily responsible for maintaining osmotic equilibrium and membrane
potential across the cell. 3 sodium ions exit the cell while 2 potassium ions
enter the cell. Normal range: 3.6 to 5.5 mmol/L
Hypokalemia occurs when serum potassium levels are under 3.6 mmol/L.
The features of hypokalemia include weakness, fatigue, and muscle
twitching.
Hyperkalemia occurs when the serum potassium levels are above 5.5
mmol/L, which can result in arrhythmias. Muscle cramps, muscle
weakness, myoglobinuria may be presenting signs and symptoms of
hyperkalemia.
Calcium : It is involved in skeletal mineralization, contraction of
muscles, the transmission of nerve impulses, blood clotting, and secretion
of hormones. Normal range: 8.8 to 10.7 mg/dL
Hypocalcemia is diagnosed when the serum calcium levels are less than
8.8 mg/dL, as in vitamin D deficiency or hypoparathyroidism.
Hypercalcemia is when serum calcium levels exceed 10.7 mg/dL, as seen
with primary hyperparathyroidism. Humoral hypercalcemia presents in
malignancy, primarily due to parathyroid hormone-related protein
(PTHrP) secretion.
Magnesium: Magnesium is mainly involved in adenosine triphosphate
(ATP) metabolism, proper contraction of muscles and neurotransmitter
release. When muscles contract, calcium re-uptake by the calcium-
activated ATPase of the sarcoplasmic reticulum is brought about by
magnesium.
Normal range: 1.46 to 2.68 mg/dL
Hypomagnesemia occurs when the serum magnesium levels are less than
1.46 mg/dL. Alcohol use disorder, gastrointestinal conditions, and
excessive renal loss may result in hypomagnesemia.
Hypomagnesemia may also result from the use of certain medications,
such as omeprazole.
Arterial blood gas (ABG) analysis

• Arterial blood gases are assessment tools which measures the patient’s
oxygenation and ventilatory and acid–base status.
• Blood gas analysis can be performed on blood obtained from
anywhere in the circulatory system (artery, vein, or capillary) but most
commonly used is the arterial blood .
• A respiratory therapist commonly takes blood from the radial artery.
METHOD
• The specimen is obtained through an arterial puncture or acquired
from an indwelling arterial catheter.
• Once obtained, the arterial blood sample should be placed on ice and
analyzed as soon as possible to reduce the possibility of erroneous
results.
• Automated blood gas analyzers are commonly used to analyze blood
gas samples, and results are obtained within 10 to 15 minutes.
• An arterial blood gas test usually includes the following
measurements:
• Oxygen concentration (O2CT)
• Oxygen saturation (O2Sat): measures how much hemoglobin in blood
is carrying oxygen.
• Partial pressure of oxygen (PaO2): This measures the amount of
oxygen dissolved in the blood
• Partial pressure of carbon dioxide (PaCO2): This measures the amount
of carbon dioxide dissolved in the blood
• pH: This measures the balance of acids and bases in the blood, known as
your blood pH level.
• Base excess/deficit: This is calculated using the measured values of pH
and PaCO2.
• Bicarbonate(HCO3) : concentration of bicarbonate in arterial blood
Interpretation
• If the pH is below 7.35, the patient is considered to be in an ACIDOTIC
state which means an increase in the hydrogen ion concentration of the
blood, resulting in a decrease in pH
• If the pH is above 7.45, the patient is considered to be in an ALKALOTIC
state decrease in the hydrogen ion concentration in the blood, resulting in an
increase in pH.
• Alveolar ventilation is reflected in the partial pressure of carbon dioxide
(PaCo2)
• Normal PaCo2 values are 35 mmHg to 45 mmHg.
• If the PaC02 < 35 mmHg the patient is said to be in RESPIRATORY
ALKALOSIS. The patient will be hyperventilating (increased ventilation,
blowing off more C02 than normal)
• If the PaC02 > 45 mm Hg the patient is said to be in RESPIRATORY
ACIDOSIS. The patient will be hypoventilating , or not having enough
alveolar ventilation or not blowing off enough CO2 to maintain normal
alveolar ventilation.
• Arterial oxygen is measured as Pao2, the partial pressure of oxygen.
Normal value is 80 to 100 mmHg.
• If Pa02 < 80 mmHg the patient is said to be in hypoxemic state. A value
of 60 to 80 mmHg would be considered moderate hypoxemia, and less
than 40 mmHg is severe hypoxemia.
• The blood normally has a capacity to buffer acid metabolites. The normal
level of base HCo3 in the blood is 22 to 26 milimoles per liter (mmollL).
• This buffering capacity diminishes in the presence of acidemia or
alkalemia.
• When there is a decrease in the HCo3-, it is seen in a negative base
excess and referred to as a base deficit, which is usually seen as a
negative number on the blood gas report, that is, -3.
• Hemoglobin (Hgb) is crucial for oxygen transport. In patients that have
lost blood through surgical procedures or disease, the decreased
hemoglobin can account for their extreme weakness as a result of
decreased oxygen transport capacity.
• Patients with oxygen saturations less than 86% to 90% at rest (chronic vs.
acute disease, respectively) usually require supplemental O2 or an
increase in O2 dosage during exertion to avoid further desaturation.
• In addition, there is evidence that the use of supplemental O2 during
exercise by non-hypoxemic patients with moderate to severe COPD
allows patients to perform high-intensity exercise training and thus
achieve greater improvements in exercise capacity and breathing pattern.
 PULMONARY FUNCTION TEST
• Pulmonary function tests (PFTs) help in the evaluation of the
mechanical function of the lungs.
• A spirometer is a device with a mouthpiece hooked up to a small
electronic machine which is used to perform PFT.
• The patient is instructed with following command that is “take a deep
inspiration and then exhale rapidly and forcefully for atleast 6 seconds”
LUNG VOLUMES
• The lung has four volumes:
1. TV is the normal breath
2. Inspiratory reserve volume (IRV) is the maximal amount of air that
can be inhaled from the end of a normal inspiration
3. Expiratory reserve volume (ERV) is the maximal amount of air that
can be expired after a normal exhalation
4. Residual volume (RV) is the volume of gas that remains in the lungs
at the end of a maximum expiration
• An increase in RV means that even with maximum effort, the patient
cannot exhale excess air from the lungs. This results in hyperinflated
lungs and indicates that certain changes have occurred in the pulmonary
tissue, which with time may cause mechanical changes in the chest wall
for e.g., increased AP diameter of the chest and flattened diaphragms.
• These changes may be reversible in patients with partial bronchial
obstruction, such as young asthmatics, or irreversible, as in patients with
advanced emphysema.
LUNG CAPACITIES
• A lung capacity is two or more volumes added together.
• The capacities include:
1. Total lung capacity (TLC)
2. Vital capacity (VC)
3. Inspiratory capacity (IC)
4. Functional residual capacity (FRC)
• TLC is the amount of gas the lung contains at the end of a maximum
inspiration. An increased TLC is seen with hyperinflation such as
emphysema. A decrease in TLC may be seen in restrictive lung disease
such as pulmonary fibrosis, atelectasis, neoplasms, pleural effusions, and
hemothorax, as well as in restrictive musculoskeletal problems such as
spinal cord injury, kyphoscoliosis, or as secondary to morbid obesity or
pregnancy.
• Vital capacity (VC) is the maximum amount of gas that can be expelled
from the lungs after forceful effort following a maximum inspiration. A
decrease in VC can occur as a result of absolute reduction in distensible
lung tissue such as in pneumonectomy, atelectasis, pneumonia, pulmonary
congestion, occlusion of a major bronchus by a tumor or foreign object, or
restrictive lung disease. Other factors such as morbid obesity, pregnancy,
enlarged heart, and pulmonary effusion may involve the limitation of
expansion of the lungs.
• Inspiratory capacity (IC) is the maximal amount of air that can be
inspired from the resting expiratory level. It contains the IRV and the
TV.
• Functional residual capacity (FRC) is the volume of air remaining in
the lungs at the resting expiratory level. It contains the ERV and the RV.
An increase in FRC represents hyperinflation of the lungs.
• Forced expiratory volume (FEV) is the amount of air expired during
the first, second, and third seconds of the FVC test.
• Forced expiratory flow (FEF) is the average rate of flow during the
middle half of the FVC test.
• Peak expiratory flow rate (PEFR) is the fastest rate that you can force
air out of your lungs.
SPIROMETRIC MEASUREMENTS
• The Forced vital capacity (FVC) is the maximum volume of air that
can be breathed out as forcefully and rapidly as possible following a
maximum inspiration.
• For adults this forced exhalation should last at least 6 seconds however
persons with COPD may take considerably longer to exhale all the air.
Volume time curve showing the
exhalation phase for 6 seconds
• Forced expiratory volume in 1st sec (FEV1 ) the volume exhaled
during the first second of the FVC maneuver.
• Normally a healthy person can be expected to exhale 70-80% of the FVC
in the first second.
• Measures the general severity of the airway obstruction
Peak expiratory flow rates
• The highest instantaneous airflow rate measured during the FVC
maneuver.
• The peak flow rate in normal adults varies depending on age and
height.
• Normal : 450 ‐ 700 L/min in males
300 ‐ 500 L/min in females

PEAK EXPIRATORY FLOW

METER
• The primary measurement used to assess obstructive lung disorders will
be the ratio of forced expiratory volume in 1 second to forced vital
capacity expressed as a percentage, or FEV1/FVC%
• The normal ratio of FEV1/FVC is greater than 0.70.
Forced expiratory flow 25‐75% (FEF)
• Maximum Flow rate during the mid‐expiratory part of FVC maneuver.
Maximum Voluntary Ventilation (MVV)
• Measures ‐ speed and efficiency of filling & emptying of the lungs
during increased respiratory effort
• Maximum amount of air that a person can inhale and then exhale
during 15 seconds.
• It reflects peak ventilation in physiological demands
• Normal : 150 ‐175 l/min.
Flow Volume Curve
• The flow volume curve is helpful in diagnosing lung disease.
• In restrictive lung disease, the maximum flow rate is reduced, as is the
total volume exhaled.
• In obstructive lung disease, the flow rate is low in relation to lung
volume, and a scooped-out appearance is often seen.
• Another diagnostic test that uses forced expiration is the flow volume
loop. It is a graphical analysis of the flow generated during a forced
expiratory volume maneuver followed by a forced inspiratory volume
maneuver.
DIAGNOSIS OF RESTRICTIVE AND
OBSTRUCTIVE LUNG DISEASE
• A restrictive component describes conditions that limit the amount of
volume coming into the lungs (restriction to inspiration)
• An obstructive component generally relates to problems in exhalation air
flows and characteristic patterns of obstruction, such as in the first second
of expiration FEV 1 measurement)
• Normal range of FEV1 is 4.5 to 3.5 liters in males and from 3.25 to 2.5
liters in females
• The first step is to assess the FEV1/FVC ratio. If this ratio is less than the
lower limit of normal for the patient (included with the test report), an
obstructive defect is present (ie, the FEV1 has fallen to a greater degree
than the FVC).
• If this ratio is greater than the lower limit of normal, then either the
spirometry test is normal or a restrictive defect is present. In this
situation, if only spirometry is available, the next step is to look at the
FVC.
• If the FVC is less than the lower limit of normal, a restrictive defect is
suggested.
• Next step is to compare obstructive and restrictive lung patterns.
A low FVC is indicative of a restrictive disorder, and typically these
individuals will also have a low FEV1.
DOPE TESTING
• Doping is defined as the use of a substance (such as an anabolic
steroid or erythropoietin) or technique (such as blood doping) or
methods to unfairly improve the athletic performances.
REASONS FOR DOPING

• The aerobic metabolism of the athlete increases which increases

stamina
• Increases the protein synthesis in the body useful for Weightlifters and
bodybuilders.
• Dope testing is to be performed on routine basis for all the sports
persons.
• There is also provision for random drug testing of sports person by their
body for in- competition & out-of-competition testing.
• The samples for testing includes blood and urine.
• There are 2 types:
1. In-competition tests
2. Out-of-competition tests.

.
In-competition tests:
• Doping tests performed in connection with a competition event.
• Refers to a period starting 12hrs prior to competition and ending at the
end of the competition.

Out-of-competition tests
• Doping tests carried out outside of competitions
• Sample are tested for non-approved substances, anabolic agents, beta-2-
agonists, hormone and metabolism modulators, diuretics.
GENE DOPING
• WADA (World anti-doping agency) defines it as "The non-therapeutic
use of cells, genetic elements, or of the modulation of gene expression,
having the capacity to improve athletic performance".
• Example like increasing muscle growth, blood production, endurance.
BLOOD DOPING
• Blood doping is the practice of boosting the number of red blood cells in
the bloodstream in order to enhance athletic performance.
• Such blood cells carry oxygen from the lungs to the muscles, a higher
concentration in the blood can improve an athlete's aerobic capacity and
endurance.

Types of Blood Doping

• Blood transfusions
• Injections of erythropoietin (EPO)
• Injections of synthetic oxygen carriers
REFERENCES
• Principles and practice of cardiopulmonary physical therapy 3 rd edition
- Donna Frownfelter and Elizabeth Dean
• Physiotherapy for respiratory and cardiac problems 2 nd edition -
Jennifer A. Pryor and Barbara A. Weber
• Cardiovascular and pulmonary physical therapy 2 nd edition- Joanne
Watchie
• Clinical Sports Medicine 4th edition – Brukner and Khan’s