Copyrighted Material PRINCIPLES AND PRACTICE OF CARDIOPULMONARY PHYSICAL THERAPY THIRD EDITION Copyrighted Material PRINCIPLES AND PRACTICE OF CARDIOPULMONARY PHYSICAL THERAPY THIRD EDITION Edited by: Donna Frownfelter, MA, PT, CCS, RRT NovaCare, Inc. Contract Services Region 7 Northwestern University Programs in Physical Therapy Chicago, IJlinois Committed to Excellence Glenview, Illinois Elizabeth Dean, PhD, PT Associate Professor University of British Columbia School of Rehabilition Sciences Vancouver, British Columbia With 22 contributors and 40] illustrations ��� Mosby St. Louis Baltimore Boston Carlsbad Chicago Naples New York Philadelphia Portland London Madrid Mexico City Singapore Sydney Tokyo Toronto Wiesbaden Copyrighted Material �T� Mosby Dedicated to Publishing Excellence � ATimes ;VJirror .. Cumpan� Vice President and Publisher: Don Ladig Editor: Martha Sasser Developmental Editors: Kellie White, Amy Dubin Project Manager: Deborah L. Vogel Production EdilOr: Mamata Reddy Designer: Pati Pye Manufacturing Supervisor: Linda Ierardi THIRD EDITION Copyright © 1996 by Mosby-Year Book, Inc. Previous editions copyrighted 1978, 1987 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Permission to photocopy or reproduce solely for internal or personal use is permitted for libraries or other users registered with the Copyright Clearance Center, provided that the base fee of $4.00 per chapter plus $.10 per page is paid directly to the Copyright Clearance Center, 27 Congress Street, Salem, MA 01970. This consent does not extend to other kinds of copying, such as copying for general distribution, for advertising or promotional purposes, for creating new collected works, or for resale. Printed in the United States of America Composition by Times Mirror Higher Education Group, Inc. Print Group Printinglbinding by RR Donnelley & Sons Company Mosby-Year Book, Inc. 11830 Westline Industrial Drive St. Louis, Missouri 63146 International Standard Book Number 0-8151-3340-5 96 97 98 99 00 / 9 8 7 6 5 4 3 2 1 Copyrighted Material CONTRIBUTORS Michael Wade Baskin, PT, RRT OwnerlExecutive Director GT Physical Therapy and Rehabilitation West Point, Mississippi Jean K. Berry, PhD, RN Senior Research Specialist Medical-Surgical Nursing University of Illinois at Chicago Chicago, Illinois Gary Brooks, MS, PT, CCS Associate Professor Health and Rehabilitation Sciences The Sage Colleges Troy, New York Susan M. Butler, MMSe, PT, CCS Division of Physical Therapy Department of Rehabilitation Medicine Maine Medical Center Portland, Maine Margaret K. Covey, MS, RN Senior Research Specialist and Doctoral Candidate Medical-Surgical Nursing U ni versity of Illinois at Chicago Chicago, Illinois L inda D. Cr ane, MMSe, PT, CCS Instructor Division of Physical Therapy University of Miami School of Medicine Miami, Florida Anne Mejia Downs, PT, CCS Department of Physical and Occupational Therapy Instructor, Division of Physical Therapy Department of Medical Allied Health Professions School of Medicine University of North Carolina Chapel Hill, North Carolina Willy E. Hammon, BSe, PT Chief of Rehabilitative Services The University Hospitals Special Instructor in Physical Therapy College of Health Clinical Instructor, College of Nursing University of Oklahoma Health Sciences Center Oklahoma City, Oklahoma Scott M. Hasson, EdD, PT Director Advanced Studies School of Physical Therapy Texas Woman's University Houston, Texas Lyn Hobson, PT, RRT Rush-Presbyterian-St. Luke's Medical Center Chicago, Illinois Gail M. Huber, MHPE, PT Instructor Programs in Physical Therapy Northwestern University Chicago, Illinois v Copyrighted Material Citv. lnaSS�l" UIIC<lIW. . '-''''vU,,",V, vi Preface Thomas Johnson, MD Associate Professor in Radiological Scienccs University of Oklahoma Health Sciences Center Oklahoma Oklahoma Susan K. MS, PT Rehabilitation Therapy Services Henry Ford Hospital Detroit, Michigan Mary President, Physical Illinois in Northwestern University Illinois Mary Mathews, BS, RN, CCRN, RRT Neonatal and Pediatrics Chest Coordinator Care Services Luke's Medical Center Lisa Mendelson, MS, CPAN Practitioner-Teacher, College of Rush Luke's Medical Center Rush Illinois Victoria A. Moerchen, MS, PT Doctoral Candidate in Motor Control of Kinesiology Early Intervention Waisman Center Pediatric Consultant and Lecturer of Wisconsin Madison, Wisconsin Claire Peel, PhD, PT Department of Physical Therapy School of and Allied Health Professions Creighton Omaha, Nebraska ArthurV. PhD Associate Professor of Rush Medical Illinois Elizabeth J. Protas, PhD, PT, FACSM Assistant Dean and Professor School of Therapy Texas Woman's University Houston, Texas Michael MD, Assistant Professor of Medicine Rush Medical Illinois MA,PT Assistant Professor Physical Program of Colorado Health Sciences Center Denver, Colorado Alexandra J. Education Coordinator University of Medical Center Physical Division Physical Medicine and Rehabilitation Ann Arbor, Michigan Maureen DNSc, R�, FAA� Satellite Site Coordinator Clinic Adjunct Clinical Rush College of Nursing of Illinois College of Chicago, Illinois Copyrighted Material To our students Present, and Future- For Their Inspiration, Inquiry, and Enthusiasm Copyrighted Material CONTEMPORARY DEFINITION OF CARDIOPULMONARY PHYSICAL THERAPY culation, livery of noninvasive interventions in the assessment, treatment, and follow-up) of patients with primary or secondary car­ diopulmonary dysfunction from acute, chronic, and acute-on-chronic conditions, and the cardiopulmonary/cardiovascular manifestations of disease. CPPT interventions include mobilization, body positioning, control, coughing and airway clearance maneuvers, and manual tech­ niques. Wherever possible and appropriate, CPPT is applied to oxygen and to or reduce the need for invasive medical including Patient education and patient-driven treatment planning are fundamental of CPPT. In addi­ tion, CPPT has an essential role in the promotion of optimal cardiopulmonary and cardiovascular health and fitness in the population. ix Copyrighted Material FOREWORD Donna Frownfelter and Elizabeth Dean have succeeded in creating a unique set of re­ sources for students and clinicians. The importance of the oxygen transport mecha­ nism is woven throughout this text and accompanying case study book, Clinical Case Study Guide. The disruption of the mechanism can create cardiopulmonary dysfunc­ tion and can result in reduced function, reduced functional work capacity, and death. A comprehensive understanding of oxygen transport and the factors that determine and influence it is therefore essential in order to assess the deficits of the mechanism and determine treatment interventions. The third edition of Principles and Practice of Cardiopulmonary Physical Therapy is not simply a new edition of the former, Chest Physical Therapy and Pulmonary Re­ habilitation. It is a totally new textbook, encompassing both the cardiac and pul­ monary systems in health and dysfunction. The two previous editions have been praised for their clinical relevance. The new books go a long way to support the state of the art clinical practice with documented scientific literature. The authors have many years of experience teaching undergraduate students as well as consulting and teaching in professional postgraduate courses. These books have been written in response to questions and concerns raised by students and clinicians. This is the only text in which Mary Massery has published her work on neuropul­ monary rehabilitation. Several chapters emphasize positioning for respiratory success and ventilatory strategies to improve rehabilitation potential. The books are very user-friendly. Each chapter of the text has key terms and questions for discussion to help the reader focus on the important concepts presented in the chapter. The combination of the text and case study guide will be an asset in teaching cardiopul­ monary physical therapy. However, either book can be effectively used independently of the other. The case study guide can be of assistance to physical therapists in helping them focus on patient evaluation, cardiopulmonary dysfunction, and treatment approaches. I applaud the authors for these new books and would highly recommend them for stu­ dents and clinicians. SaLLy C. Edelsberg, MS, PT Director and Associate Professor Programs in Physical Therapy Northwestern University Medical School xi Copyrighted Material PREFACE The work that has gone into this third edition has resulted in a completely new book! When we first discussed the possibilities of a new edition, we knew it would be a total change from Chest Physical Therapy and Pulmonary Rehabilitation. We wanted to present a new approach, not just a revision. Elizabeth's research and study of oxygen transport mechanisms in relation to patient treatment highlighted this concept as the primary thread that would pull the new book together. The cardiopulmonary system must be viewed as a whole, interacting with other body systems for optimal function. Therapy interventions must incorporate cardiopulmonary goals as well as neuromus­ cuiar and musculoskeletal goals for patients to reach maximal rehabilitation potential. We have attempted to pull together physiological as well as clinical data to meet the changing needs of health care to provide objective documentation for our interven­ tions. Yet we were diligent in maintaining a text aimed at the undergraduate student or practicing therapist with minimal background in cardiopulmonary physical therapy. To that end we have tried to keep the material readable and very user-friendly. Our hope is that virtually any question that may arise about treating a patient with car­ diopulmonary dysfunction would have some answers in this book. We both teach undergraduate physical therapy students and thank them for their input, questions, and concerns about patients with cardiopulmonary dysfunction who have helped us focus this text to meet students' needs. In addition, through our contin­ uing education seminars with postgraduate physical therapists, we have been chal­ lenged to apply the concepts in light of the changing health care scene. How can we be most effective and scientifically correct in choosing treatment techniques that have demonstrated improvement in the oxygen transport mechanism and patient function? We always learn when we teach, and we hope to share that learning with others through this text. We are excited about being able to present an accompanying text, Clinical Case Study Guide. We are attempting to show the physiological principles presented in our text, by identifying real-life case studies that physical therapists deal with every day in their practice. Our hope is that this will be used widely in teaching physical therapy students and will facilitate their understanding of how to effectively integrate car­ diopulmonary concepts in each of their patients, not just in patients with a primary cardiopulmonary diagnosis. To our knowledge, this is the first international book written dealing with car­ diopulmonary physical therapy. It is a blend of physiology and international ap­ proaches to the patient with cardiopulmonary dysfunction. We have had the privilege of teaching and consulting internationally and have tried to make this text applicable to all therapists regardless of their situation and the degree of sophisticated equipment. xiii Copyrighted Material suggestions xiv Preface We realize that in some Third-World hands-on therapy and positioning is the only mode of available. We believe that this is often all that is needed when with the proper concepts and thought processes. We are with the way this edition has come together. We have many new authors who have added and direction for both cardiac and monary foci. We are pleased this is finally completed and thank our families, friends, and col- for us and us the rough times to see this book Our hope is that this will be a welcome addition to your professional Ii­ and we welcome your comments and for future work. Donna Frownfelter Elizabeth Dean Copyrighted Material ACKNOWLEDGMENTS There are so many people that I want to thank and acknowledge for their support and contributions to this book. First, my family, for their understanding and support dur­ ing stressful deadlines and crunch spots. My husband David has been there for me since I went to physical therapy school and has always encouraged me to do what my vision led me to do. My three teenagers, Lauren, Daniel, and Kristin, have helped keep my life on track and grounded in the reality of daily life while taking time to "smell the roses." You are special gifts to me, and I love you. To my students, I thank you for your questions, concerns, and wonderings about what this cardiopulmonary stuff really means to your patients. You wonder if you can really be a better therapist because you take these things into account in evaluation and treatment. Please remember the difference between ordinary and extraordinary is just that little "extra." I believe that is what incorporating cardiopulmonary attention does; it adds the little extra. Be an extraordinary therapist, no matter what the health care environment. To the contributing authors, I thank you for your time and significant effort in bringing together the literature and clinical aspects of cardiopulmonary physical ther­ apy. Your dedication to this project has made it much more than Elizabeth and I could have done alone. You know how important it is to convey the message of treat­ ing the whole patient and helping them reach his or her potential. To my colleague and soul mate Mary Masse!)/, who I have taught with, travelled with, given seminars with, laughed with, and cried with, I thank you for all you have taught me and how special it is to have someone you can always count on to discuss a difficult patient or a personal issue. We have become quite a team, and I value our professional and personal relationships. Your contributions to the clinical chapters we have done together this time have been significant. I look forward to many more pro­ jects and fun times together. There is no greater pleasure for a teacher than to see a former student travel in that teacher's tracks and surpass her. Thanks Spike! My deepest thanks go to Elizabeth Dean. You have been an incredible colleague who has given new life to this book. You have, in a gentle way, helped to ensure that physiologic and scientific evidence be paired with our clinical experience and treat­ ment techniques. You have truly brought about a book that I could never have com­ pleted alone. Words are not enough to thank you for your commitment to this project and the countless hours you have spent in a major revision of the former textbook. I am delighted at what you have done and the depth of knowledge you have brought in your content and organization of this book. I am honored that you chose this text in which to share your work, and I have enjoyed working with you and learning from you. We share a common bond in the relationships we have with our students and our xv Copyrighted Material xvi Acknowledgements desire to spread the word about the importance of including cardiopulmonary con­ cerns in the patient's evaluation and plan of treatment. We have grown close in the last 10 years, and I value our friendship as well as our professional work together. Thank you hardly is enough, but 'Thanks!" To my friends, family, and fellow workers at NovaCare, Inc. Contract Services, I thank you for your patience and understanding of the demands on my time and your encouragement to continue and finish this project. Your support has meant a great deal and I hope you feel a part of this, for it is because of you this has really happened. I'm glad to have a work environment that supports personal and professional growth. To our Mosby staff: Martha Sasser, thanks for your ideas and vision for going with this new book. You saw the possibilities and were there with other suggestions to make it even better (even if some of them came when we thought we were donel). To Kellie White, you kept us on track and helped catch up with chapter authors who needed a nudge and still had time to have Julia Isabelle-quite an accomplishment! You will now find what we have, that motherhood is often harder than your other job! Best wishes! To Mamata Reddy and Amy Dubin, you have pushed us through the editing process with the gentle and firm hand that we needed and with much sup­ port and help. Thank you for your cooperation and critical eye in making this an ex­ cellent outcome. Finally, and most importantly, I thank God for the vision, strength, and energy to un­ dertake this book and see it through to completion. My involvement in spreading the word about the need for optimizing the cardiopulmonary system has always felt like a mission. It has been amazing to me how many therapists don't see the need and how they can have an "Aha!" experience in a seminar or class, or even just reading this book. If I can have a small part in that experience, my "mission" has been fulfilled, and for that I am grateful. Donna Frownfelter To Donna, for having made this dream come true. Our working relationship and friendship began 10 years ago when I first approached Donna to review a manuscript entitled 'The Pulmonary Effects of Body Positioning," published in Physical Therapy in 1985. This publication was the stepping stone to a prolonged and ever-growing in­ terest in oxygen transport and how it is affected by cardiopulmonary interventions such as body positioning and mobilization. The enthusiasm, interest, and support of Donna and my former graduate student, Jocelyn Ross, have fueled my energies in the exciting dynamic area of cardiopulmonary physical therapy. My heartfelt gratitude to you both. To Daniel Perlman, for your encouragement and support of my liaison with Donna at the outset and over the years. You knew a good thing when you saw it. To Doug Frost, for your support in getting this project into the end zone. Thank you for your support and for being there as the book continued to evolve. Copyrighted Material Acknowledgements xvii To our dedicated contributors, for your expertise, which has contributed to a vol­ ume on the principles and practice of cardiopulmonary physical therapy that is on the cutting edge with respect to the scientific and physiologic literature. Thank you for your contributions and team effort. To my cardiopulmonary physical therapy colleagues and students for your inquisi­ tiveness and enthusiasm. Thank you all for your inspiration. And not to forget the Mosby crew-Martha Sasser, Kellie White, Mamata Reddy, and Amy Dubin-I thank each one of you for your commitment to making this book the best it can be. Elizabeth Dean Copyrighted Material CONTENTS PART I CARDIOPUL MONARY FUNCTION IN HEALTH AND DISEASE, 1 Chapter 1 Oxygen Transport: The Basis for Cardiopulmonary Physical Elizabeth Dean Therapy, 3 Chapter 2 Cardiopulmonary Anatomy, 23 Elizabeth Dean Lyn Hobson Chapter 3 Cardiopulmonary Physiology, 53 Elizabeth Dean Lyn Hobson Chapter 4 Cardiopulmonary Pathophysiology, 71 Willy E. Hammon Scott M. Hasson Chapter 5 Cardiopulmonary Manifestations of Systemic Conditions, 99 Elizabeth Dean PARTII CARDIOPULMONARY ASSESSMENT, 1J 5 Chapter 6 Measurement and Documentation, 1J7 Claire Peel Chapter 7 History, 127 Willy E. Hammon Chapter 8 Pulmonary Function Tests, 145 Donna Frownfelter Chapter 9 Arterial Blood Gases, 153 Donna Frownfelter Chapter 10 Principles of Chest X-Ray Interpretation, 159 Michael Ries Thomas Johnson Chapter 11 Electrocardiogram Identification, 169 Gary Brooks Chapter 12 Multisystem Assessment and Laboratory Investigations, 189 Elizabeth Dean xix Copyrighted Material