Physiotherapy in Respiratory Care For Roger Physiotherapy in Respiratory Care A problem-solving approach to respiratory and cardiac management Second edition ALEXANDRA HOUGH Freelance lecturer, Senior Physiotherapist, Whittington Hospital, London, former Senior Lecturer, North London School of Physiotherapy I~nl SPRINGER-SCIENCE+BUSINESS MEDIA, B.v. First edition 1991 Reprinted 1992, 1993, 1994 Second edition 1996 © 1996 Alexandra Hough Originally published by Chapman & Hall in 1996 Typeset in by 10/12 Palatino by Photoprint, Torquay, S. Devon ISBN 978-1-56593-131-2 ISBN 978-1-4899-3049-1 (eBook) DOI 10.1007/978-1-4899-3049-1 Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the UK Copyright Designs and Patents Act, 1988, this publication may not be reproduced, stored, or transmitted, in any form or by any means, without the prior permission in writing of the publishers, or in the case of reprographic reproduction only in accordance with the terms of the licences issued by the Copyright Licensing Agency in the UK, or in accordance with the terms of licences issued by the appropriate Reproduction Rights Organization outside the UK. Enquiries concerning reproduction outside the terms stated here should be sent to the publishers at the London address printed on this page. The publisher makes no representation, express or implied, with regard to the accuracy of the information contained in this book and cannot accept any legal responsibility or liability for any errors or omissions that may be made. A catalogue record for this book is available from the British Library Library of Congress Catalog Card Number: 95-70862 @ Printed on permanent acid-free text paper, manufactured in accordance with ANSIINISO Z39.48-1992 and ANSIINISO Z39.48-1984 (Permanence of Paper). Contents Preface ix Acknowledgements ix 1 Overview of physiology in relation to clinical practice 1 1.1 Introduction 1 1.2 Defence 1 1.3 Control 3 1.4 Mechanics 3 1.5 Ventilation 6 1.6 Diffusion 7 1.7 Perfusion 8 1.8 Ventilation/perfusion relationships 9 1.9 Arterial blood gases 9 1.10 Oxygen delivery, consumption and extraction 15 1.11 Effect of ageing 15 1.12 Effect of obesity 16 1.13 Effect of smoking 17 1.14 Effect of exercise 18 1.15 Effect of bed rest 18 1.16 Effect of sleep 19 Recommended reading 19 2 Assessment of the respiratory patient 20 2.1 Introduction 20 2.2 Background 21 2.3 Subjective assessment 21 2.4 Observation 23 2.5 Auscultation 28 2.6 Palpation 31 2.7 Exercise testing 33 2.8 Chest X-ray 35 2.9 Respiratory function tests 43 Recommended reading 50 3 Respiratory disorders S1 3.1 Introduction 51 3.2 Obstructive disorders 51 3.3 Restrictive disorders 75 3.4 Other disorders 82 Recommended reading 88 4 General management 89 4.1 Introduction 89 4.2 Oxygen therapy 89 4.3 Nutrition 97 vi Contents 4.4 Drug therapy 99 4.5 Bronchoscopy and biopsy 107 Recommended reading 108 5 Physiotherapy management 109 5.1 Introduction 109 5.2 Methods to increase lung volume 109 5.3 Methods to decrease the work of breathing 122 5.4 Methods to clear secretions 128 Recommended reading 144 6 Management of breathlessness and pulmonary rehabilitation 145 6.1 Does pulmonary rehabilitation work? 145 6.2 The concept of breathlessness 147 6.3 Assessment for rehabilitation 149 6.4 Education 150 6.5 Breathlessness management 154 6.6 Breathing re-education 156 6.7 Exercise training 158 6.8 Inspiratory muscle training 162 6.9 Energy conservation 163 6.10 Home management, self-help and follow-up 166 6.11 Evaluation 167 Recommended reading 167 7 Physiotherapy for specific groups of people 169 7.1 People undergoing surgery 169 7.2 Elderly people 197 7.3 People who are dying 198 Recommended reading 203 8 Physiotherapy for people with hyperventilation syndrome 204 8.1 Introduction 204 8.2 Causes 204 8.3 Effects 205 8.4 Assessment 206 8.5 Education 208 8.6 Breathing re-education 210 8.7 Progression and home management 213 Recommended reading 214 9 Intensive care 215 9.1 Introduction 215 9.2 The environment 215 9.3 Mechanical ventilation 219 9.4 Monitoring 232 9.5 Support 239 Recommended reading 244 10 Physiotherapy in intensive care 245 10.1 Preliminaries 245 10.2 Assessment 246 10.3 Motivation and stress reduction 248 10.4 Handling patients who are critically ill 251 Contents vii 10.5 Techniques to increase lung volume 252 10.6 Techniques to clear secretions 256 10.7 End of treatment session 259 10.8 Recognition and management of emergencies 259 10.9 On calls 266 Recommended reading 268 11 Conditions in intensive care 269 11.1 Lung disease 269 11.2 Neuromuscular disorders 270 11.3 Fractured ribs and lung contusion 272 11.4 Acute head injury 273 11.5 Smoke inhalation 279 11.6 Poisoning, pulmonary aspiration and near-drowning 280 11.7 Shock 280 11.8 Disseminated intravascular coagulation 281 11.9 Acute respiratory distress syndrome 281 Recommended reading 285 12 Physiotherapy for children and infants 286 12.1 Physiotherapy for children 286 12.2 The neonatal unit 292 12.3 Physiotherapy for infants 295 12.4 Modifications for specific neonatal disorders 300 12.5 Emergencies in the neonatal unit 301 Recommended reading 302 13 Evaluation of chest physiotherapy 303 13.1 Introduction 303 13.2 Standards 304 13.3 Audit 305 13.4 Self-assessment 305 13.5 Outcome evaluation 306 13.6 Literature criticism 307 13.7 Research 309 13.8 Continuing education 310 Recommended reading 311 Glossary of definitions, abbreviations, symbols and normal values 312 Appendix A Transatlantic dictionary 321 Appendix B Postural drainage positions 322 Appendix C Resources and organizations 325 Appendix D Articles by patients 327 Appendix E Articles on outcome measures for pulmonary rehabilitation 328 Further reading 330 References 331 Index 357 Preface Respiratory care is an immensely satisfying branch of physiotherapy. It challenges our intellect, exploits our handling skills and employs our humanity to the full. Respiratory physiotherapy is both art and science. It is not an exact science, and effective treatment therefore depends on problem-solving. Analytic problem-solving requires the ability to define a problem and the knowledge to address it. Creative problem-solving requires a clear perspective of the individual patient's need. These are the aims of this book. Clinicians now expect explanations that are referenced and physiologically sound, meticulous attention to detail of technique and a patient-centred approach. This book is written for such readers and those who question fundamental assumptions and traditional rituals. Evaluation of practice is emphasized so that we are equipped to justify our protocol to ourselves and others. Carefully reasoned explanations and updated physiotherapy techniques are covered in precise detail. There is integration of theory and practice and emphasis on the hands-on aspect of physiotherapy. The glossary serves as a quick reference guide and an explanation of abbreviations, which are usually defined once only in the text. It has been greatly extended for the second edition and can be read in its own right as an extra physiology chapter. The text is enthusiastically written, highly readable and enlivened by quotations from patients whose experiences are a central theme throughout. The book is suitable for physiotherapists from student level to accom plished clinician because problem-solving requires thinking rather than experience. It is also aimed at specialist respiratory nurses. All readers will benefit from the patient quotations which enrich the text throughout. The clinician will find here the opportunity to achieve clarity of thought, breadth of vision and mastery in respiratory care. Enjoy it. Acknowledgements Profound thanks to the patients who have taught me much over the years. I am also indebted to Veronica Bastow for her perceptive insights, Clare Pain for her wisdom, John Widdicombe for his meticulous scrutiny of the physiology and Mel CaIman for his cartoons. Heartfelt thanks also to Alison Brown, Fiona Bryden, Joy Conway, Diana Davis, Stephanie Enright, Nicky Harvey, Bernadette Henderson, Avril Imison, Sue Pirrie, Marylin Place, Carolyn Roskell, Irene Rowbottom and Judith Sweeney, for their specialist advice. And to the students with whom it has been my privilege to work and learn, thank you.