Physiotherapy in Respiratory Care 3rd Ed - A. Hough (Nelson Thornes, 2001) WW PDF

VI
<lJ
C
L-
o
.c
�
c
o
VI
<lJ
C
P 4
I
ISBN 0-7487-4037-6
11111 11
9 780748 740376
Physiotherapy in
Respiratory Care
An evidence-based approach to respiratory

and cardiac management
THIRD EDITION
. Alexandra Hough .
Physiotherapy RespiratOry Specialist

Eastbourne District General Hospital
Sussex, UK
Text © Alexandra Hough 2001
The right of Alexandra Hough to be identified as author of this work has been asserted
by her in accordance with the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this publication may be reproduced or transmitted in any form or by
any means, electronic or mechanical, including photocopying, recording or any information
storage and retrieval system, without permission in writing from the publisher or under licence
from the Copyright Licensing Agency Limited. Further details of such licences (for reprographic
reproduction) may be obtained from the Copyright Licensing Agency Limited of 90 Tottenham
Court Road, London WH 4LP.
Any person who commits any unauthorised act in relation to this publication may be
liable to criminal prosecution and civil claims for damages.
First published in 1991 by:

Chapman & Hall
Second edition 1996
Third edition published in 2001 by:

Nelson Thomes Ltd
Delta Place
27 Bath Road
Cheltenham
Glos.
GL53 7TH
United Kingdom
03 04 05 / 10 9 8 7 6 5 4
A catalogue record for this book is available from the British Library
ISBN 0-7487-4037-6
Page make up by Acorn Bookwork, Salisbury, Wiltshire
Printed and bound in Italy by Canale
Every effort has been made to contact copyright holders of material published
in this book and we apologise if any have been overlooked.
CONTENTS
PREFACE IX
ACKNOWLEDGEMENTS X
1 PHYSIOLOGICAL BASIS OF CLINICAL PRACTICE 1

Introduction 1
Defence 1
Control 3
Mechanics 4
Ventilation 8
Diffusion 10
Perfusion 10
Ventilation/perfusion relationships 11
Arterial blood gases 11
The oxygen cascade 17
Effect of ageing 18
Effect of obesity 19
Effect of smoking 20
Effect of pregnancy 22
Effect of exercise 23
Effect of immobility 24
Effect of sleep 25
Effect of stress 25
Mini case study: Ms LL 26
Literature appraisal 27
Recommended reading 27
2 CLINICAL ASSESSMENT 28
Introduction 28
Background information 28
Subjective assessment 30
Observation 33
Palpation 39
Auscultation 41
Exercise tolerance 44
Imaging the chest 45
Respiratory function tests 54
Mini case study: Mr TA 63
3 OBSTRUCTIVE DISORDERS 65
Introduction 65
III
CONTI-.NTS
Chronic obstructive pulmonary disease 65

Asthma 73
Bronchiectasis 84
Cystic fibrosis 87
Primary ciliary dyskinesia 92
Allergic bronchopulmonary aspergillosis 92
Inhaled foreign body 93
Mini case study: Mr MB 93
4 RESTRICTIVE AND OTHER DISORDERS 96

Introduction 96
Interstitial lung disease 96
Pleural effusion 98
Pneumothorax 99
Neuromuscular disorders 100
Skeletal disorders 103
Pneumonia 103
Pleurisy 107
HIV, AIDS and immunosuppression 107
Pulmonary tuberculosis 107
Abscess 108
Lung cancer 108
Sleep apnoea 110
Pulmonary manifestations of systemic disease 112
Chest infection 116
Respiratory failure 117
Mini case study: Ms TP 117
5 GENERAL MANAGEMENT 119

Introduction 119
Oxygen therapy 119
Nutrition 131
Drug therapy 133
Bronchoscopy and lavage 143
Mini case study: Mr FJ 144
6 PHYSIOTHERAPY TO INCREASE LUNG VOLUME 1 47

Introduction to respiratory physiotherapy 147
What is loss of lung volume, and does it matter? 147
Controlled mobilization 148
Positioning 149
IV
Co:\n:-;I '>
Breathing exercises 152

Mechanical aids to increase lung volume 155
Outcomes 163
Mini case study: Ms MB 163
7 PHYSIOTHERAPY TO REDUCE THE WORK OF BREATHING 166

Introduction 166
Breathlessness 166
Handling breathless people 169
Sleep and rest 169
Positioning 169
Relaxation 170
Breathing re-education 171
Tips on reducing breathlessness 173
Pacing 174
Other respiratory problems 174
Mechanical aids 175
Outcomes 181
Mini case study: Ms IU 181
8 PHYSIOTHERAPY TO CLEAR SECRETIONS 184

Sputum in perspective 184
Hydration and humidification 185
Exercise 192
Postural drainage 192
Manual techniques 193
Breathing techniques 194
Mechanical aids 198
Cough 202
Pharyngeal suction 205
Nasopharyngeal airway 208
Minitracheostomy 208
Outcomes 209
Mini case study: MS 209
9 PULMONARY REHABILITATION 211

Introduction 211
Assessment 214
Education 221
Reduction in breathlessness 230
Exercise training 232
v
CONTENTS
Inspiratory muscle training 239

Energy conservation 241
Follow-up, home management and self-help 244
Outcomes 245
Mini case study: Mr EH 246
10 PHYSIOTHERAPY FOR PEOPLE UNDERGOING SURGERY 248

Introduction 248
Respiratory complications of surgery 249
Other complications of surgery 250
Preoperative management 252
Pain management 253
Postoperative physiotherapy 259
Abdominal surgery 263
Lung surgery 264
Pleural surgery 268
Chest drains 268
Heart surgery 270
Transplantation 273
Repair of coarctation of the aorta 276
Oesophagectomy 277
Breast surgery 277
Head and neck surgery 277
Case study: Mr LS 283
11 PHYSIOTHERAPY FOR SPECIFIC GROUPS OF PEOPLE 287

Overview of cardiac rehabilitation 287
Hyperventilation syndrome 291
Elderly people 306
People who are dying 309
Case study: Ms SJ 315
12 INTENSIVE CARE, MONITORING AND SUPPORT 317

Introduction 317
The environment 317
Monitoring 322
Support 333
Mini case study: Mr FA 340
VI
CONTENTS
13 MECHANICAL VENTILATION 343

Introduction 343
Indications 343
Airway 343
Principles 345
Benefits 345
Complications 346
Settings 349
Modes 350
Positive end-expiratory pressure (PEEP) 353
High-frequency ventilation 354
Weaning and extubation 355
Mini case study: Ms CM 359
14 PHYSIOTHERAPY FOR PATIENTS IN INTENSIVE CARE 361

Assessment 361
Handling patients who are critically ill 366
Techniques to increase lung volume 372
Techniques to clear secretions 376
Exercise and rehabilitation 379
Recognition and management of emergencies 381
On calls 387
Case study: Mr AP 389
15 DISORDERS IN INTENSIVE CARE PATIENTS 393

Lung disease 393
Neuromuscular disorders 394
Chest trauma 406
Systems failure 408
Multisystem failure 409
Acute respiratory distress syndrome 412
Poisoning and parasuicide 418
Smoke inhalation 418
Near-drowning 420
Case study: Mr CA 420
Quiz 423
16 PHYSIOTHERAPY FOR CHILDREN AND INFANTS 425

Physiotherapy for children 425
The neonatal ICU 434
Physiotherapy for neonates 438
Vll
Cm,rrF NTS
Modifications for specific neonatal disorders 443

Emergencies in the neonatal unit 445
Mini case study: JW 446
17 EVALUATION OF RESPIRATORY PHYSIOTHERAPY 449

Introduction 449
Definitions 449
Research 450
Standards 452
Outcome evaluation 452
Cost effectiveness 454
The audit cycle 455
Education and continuing education 458
Mini case study: Mr FF 459
G LOSSARY OF ABBREVIATIONS, DEFINITIONS, SYMBOLS AND VALUES 461
A pPENDIX A: TRANSATLANTIC DICTIONARY 470
ApPENDIX B: POSTURAL DRAINAGE POSITIONS 471
A pPENDIX C: RESOURCES 472
A pPENDIX D: ARTICLES ON PATIENTS' EXPERIENCES 476
A pPENDIX E: OUTCOMES FOR PULMONARY REHABILITATION 477
A pPENDIX F: CONVERSIONS 479
ANNOTATED BIBLIOGRAPHY 480
REFERENCES 482
INDEX 539
VIIi ----
PREFACE
Respiratory care is an immensely satisfying There are patient handouts, tables of

branch of physiotherapy. It challenges our exerCIses, flow charts and many illustrations in
intellect, exploits our handling skills and the third edition. Outcomes are identified for
employs our humanity to the full. each problem, and evaluation of practice
Respiratory physiotherapy is both art and continues to be developed in response to the
science. It is not an exact science. Effectiveness needs of patients, clinicians and employers. The
depends on problem-solving. This requires glossary serves as a quick reference guide or can
practice in defining problems, evidence-based be read in its own right.
knowledge to address problems, and a clear An abbreviated case study with each chapter
perspective of patients' needs. Clinicians, reinforces problem-solving, goal-setting and x
students and educationists expect integration of ray interpretation. Snippets of literature
theory and practice, explanations that are refer appraisal are interspersed to hone critical
enced and physiologically sound, and exact thinking. Patient experiences and research
detail of technique. This book is written for such findings are incorporated throughout.
readers and for those who question fundamental The book is suitable for physiotherapists from
assumptions and traditional rituals. student level to accomplished clinician because
The third edition is updated for a health-care problem-solving requires thinking rather than
system that is discharging patients from hospital experience. It is also suitable for specialist
'quicker and sicker'. This edition also takes respiratory nurses. The clinician will find here
account of patients who have become more the opportunity to achieve clarity of thought and
knowledgeable through the media and the develop mastery in respiratory care. Enjoy it.
Internet. There is extra coverage of practical and
safety tips because pressures on students allow
less time for practice.
IX
ACKNOWLEDGEMENTS
Profound thanks to the patients who have taught Ruffle, Arti Shah, Ruth Vardy, Nick Watson,
me much over the years. I am also indebted to Fran Woodard and Christine Young. Many
Veronica Bastow for her wisdom, perception thanks to Mel CaIman for his cartoons and
and meticulous criticism of the manuscript, to Nicholas Taylor for his photographs. And to the
Sarah Davies for her invaluable advice, and to students with whom it has been my privilege to
Clive Liles for his detailed manuscript review. work and learn, thank you.
Specialist advice has been gratefully received Royalties donated to Amnesty International.
from Alison Aldridge, Jon Anderson, Helen
Davies, Diana Davis, Suzanne Roberts, Liz Dedicated to Carol.
x -------
1 PHYSIOLOGICAL BASIS OF CLINICAL PRACTICE
SUMMARY
Introduction • Oxygen dissociation curve

Defence • Hypoxia and hypoxaemia
• Nose • Acid-base balance
• Pharynx The oxygen cascade

• Bronchoconstriction Effect of ageing
• Mucociliary escalator • Clinical implications
• Cough Effect of obesity
• Other lung defences • Clinical implications
Control Effect of smoking
Mechanics • Clinical implications
• The respiratory muscles Effect of pregnancy

• Pressure • Clinical implications
• Resistance Effect of exercise

• Compliance • Clinical implications
• Work of breathing Effect of immobility

• Inspiratory muscle fatigue • Clinical implications
• Inspiratory muscle weakness Effect of sleep

Ventilation • Clinical implications
Diffusion Effect of stress
Perfusion • Clinical implications
Ventilation/perfusion relationships Mini case study

Arterial blood gases Literature appraisal
Recommended reading
INTRODUCTION against the elements. This chapter will place less

emphasis on the textbook lungs of hefty young
Breathing is the basic rhythm of life.
males than on those of patients who may smoke
Hippocrates
and may be overweight, stressed and past
Breathing is unique. Most of us give it little middle-age. Keep a finger in the Glossary
thought, yet it can be automatic or voluntary throughout.
and is preserved in unconsciousness. It is asso
ciated with a respiratory system of remarkable
DEFENCE
ingenuity. An understanding of how this system
works creates a foundation for logical practice. Every day, 300 million alveoli in the adult lung
The respiratory system is involved in the expose a surface area of 80 square metres, or
pumping of gas into the lungs, gas exchange nearly the size of a tennis court, to a volume of
from lungs to tissue cells, acid-base balance, air and pollutants that could fill an average
metabolism, speech, and defence of the body swimming pool (Hanley and Tyler, 1987). It is
1
CHAPTER 1 PHYSIOLOGICAL BASIS OF CLINICAL PRACTICE
Direction
only by means of a sophisticated biological of flow
barrier that the body does not succumb to this •
onslaught. Indeed, so effective is the pulmonary �G""Y"

defence system that the lung is normally sterile
below the larynx (Ferdinand, 1 998). However, Sol layer
the lung is vulnerable to systemic events such as
septicaemia (Murch, 1 995). Epithelial layer
Lung defence is based on a network of filters, Figure 1 . 1 The mucociliary escalator. The sol layer is a
secretions, reflexes and specialized cells. permanent source of water in the airways and enables the
Physiotherapists treat patients whose defences cilia to beat efficiently. Claws on the tips of the cilia grip the
are breached when the nose is bypassed by gel layer (mucus) and a whip-like movement propels it
mouth-breathing or artificial airways, cilia mouthwards.
damaged by smoking or disease, and cough
Bronchoconstriction
inhibited by pain or weakness.
If irritant particles are inhaled, normal broncho
Nose constrictor tone is increased reflexly to protect
The nose is the gatekeeper of the respiratory the airway. In diseases such as asthma, this
tract, providing the first line of defence by mechanism is exaggerated and is then termed
means of: bronchospasm, which increases the work of
breathing and interferes with gas exchange.
• sensing suspicious smells
• sneezing in response to irritating substances Mucociliary escalator
• filtering large particles Particles that escape filtration in the nose are
• protecting against cold dry air and insulating trapped on a sticky mucus blanket lining the
against swings in atmospheric temperature airways, then carried by cilia from the terminal
and humidity. bronchioles to the throat over a period of several
hours (Pavia, 1991). This moving staircase
During inspiration, the nasopharynx exposes (Figure 1 . 1 ) propels the mucoid secretions to the
inspired gas to a large area of highly vascular, pharynx and larynx, from where they are
moist mucus membrane. The respiratory tract swallowed or, if excessive, expectorated. Secre
loses an average 250 mL of water a day tions are propelled by cilia beating synchro
(Branson, 1 999), but nasal mucosa can supply nously at approximately 20 strokes a second.
nearly a litre of fluid to inspired air a day if They move at speeds of between 0.5 mm!min in
required (Eubanks and Bone, 1994, p. 50). the small airways and 20 mm/min in the trachea
During exhalation, the upper airways reclaim a (Rankin, 1 998).
majority of the heat and moisture added during The mucociliary blanket normally clears 10-
inspiration. Nose-breathing is three times as 100 mL secretions a day, or up to 300 mL when
efficient at humidification as mouth-breathing. necessary (Hodgkin et ai., 1993, p. 469). Other
protective functions of the mucus are humidifica
Pharynx tion, waterproofing, antibacterial activity and
The entrance to the oropharynx is guarded by insulation.
tonsils and adenoids, the removal of which This finely co-ordinated mechanism is
renders children extra vulnerable to passive compromised by dehydration, smoking, hypoxia,
smoking (Chen et aI., 1 998). The lower pharynx inflammation or pathological conditions that
houses the epiglottis, a leaf-like lid that snaps affect the viscosity of mucus or function of cilia.
shut over the larynx during swallowing to Impaired mucociliary clearance predisposes to
prevent aspiration into the trachea. infection Gansen, 1995).
2
CONTROL
people with obstructive airways disease because

Cough of poor expiratory flow rates and airways that
Clearance of secretions depends primarily on tend to collapse on expiration. Coughing may
mucociliary transport and secondarily on cough. fail in the presence of coma, neuromuscular
The cough is the body's strongest physiological disease or postoperative pain. It is weakened if
reflex whose function is to clear blockages in the the glottis is bypassed by intubation or tracheost
upper airway and, as a reserve mechanism, to omy.
expel secretions and debris when mucociliary Bronchospasm and exhaustion may follow
clearance is damaged or overwhelmed. sustained bouts of coughing. The abdominal
A cough occurs by voluntary effort, or reflexly pressure associated with coughing predisposes
from irritants inside or outside the lung that people with a chronic cough to stress inconti
stimulate inflammatory, chemical, mechanical or nence. Despite high pressures, overdistension of
thermal receptors. These are located in the pleura, alveoli and barotrauma (p. 344) are avoided by
the airways between the larynx and segmental the presence of the rib cage and contraction of
bronchi, and, unexpectedly, in the external intercostal and abdominal muscles to buttress
auditory canal. They are most sensitive at the the chest wall.
glottis and carina and least sensitive beyond the
fourth-generation bronchi. Stimulation of the Other lung defences
pharynx causes a gag rather than a cough. Further mechanisms await pollutants that evade
A cough comprises: the above defences. They include an immunoglo
bulin in respiratory secretions called IgA, 600
• an inspiratory gasp to 900/0 of total lung
million scavenger macrophages (multiplied
capacity
fourfold in smokers) and alpha l -antitrypsin, a
• closure of the glottis and trapping of air in
plasma protein that combats proteolytic enzyme
the lungs to create intrathoracic pressures of
activity, which would otherwise destroy alveoli.
up to 300 mmHg (Irwin et at., 1998),
Asbestos particles circumvent these and other
narrowing the trachea and main bronchi by
defences because of their peculiar shape. Gases
60% (Rees, 1987)
can pass through the alveolar-capillary
• sudden opening of the glottis, causing air to
membrane, a process that forms the basis of
explode outwards at up to 500 mph or 85%
chemical warfare, carbon monoxide poisoning
of the speed of sound (Irwin et at., 1 998),
and inhalational anaesthesia (Denison, 1996).
shearing secretions off the airway walls.
The entire blood volume passes through the
Coughing is accompanied by violent swings in lungs, which help to detoxify circulating foreign
intrapleural pressure which cause dynamic substances, perform a range of metabolic
compression of airways and speeding of gas functions and act as a filter to protect the
flow. Dynamic compression is initiated in the arterial system, particularly the coronary and
trachea at high lung volumes and extends cerebral circulations, from blood clots, fat cells,
peripherally as lung volume decreases, ensuring detached cancer cells, gas bubbles and other
that the full length of the tracheobronchial tree debris. Extracorporeal support systems such as
is affected (Irwin et aI., 1998). In most people, cardiopulmonary bypass include a filter to
the airways reopen with a subsequent deep perform some of these functions.
breath but in those unable to take a deep breath
they stay closed for lengthy periods (Nunn et at.,
CONTROL
1965). Beyond about the 10th generation (Pavia,
1991), airflow cannot attain sufficient speed to Breathing is normally controlled with such
expel inhaled irritants by coughing. exquisite sensitivity that O2 and CO2 in the
The cough mechanism is less efficient 1ll blood are maintained within exact limits despite
3
CHAPTER 1 PHYSIOLOGICAL BASIS OF CLINlCAL PRACnCE
unpredictable metabolic changes. Clusters of ance is reached, outwards against the lower rib
neurones in the pons and medulla receive and cage, causing expansion of the lower chest. The
integrate a multitude of stimuli from the rib abdomen protrudes out on inspiration unless
cage, lungs, chemoreceptors, metabolic and prevented voluntarily or by tight clothing.
other systems. They then discharge impulses to The external intercostal muscles stabilize the
the respiratory muscles, which, unlike cardiac chest wall so that diaphragmatic contraction can
muscle, do not contract spontaneously. create these pressure changes. Other necessary
The respiratory centres perceive and respond respiratory muscles are the scalenes, which
to altered posture, exercise and other variables. stabilize the upper rib cage to prevent it being
Respiratory control occurs at a subconscious pulled downwards (Tobin, 1990), and pharyn
level but can be overridden by voluntary action geal muscles, which prevent collapse of the
such as breathing exercises or reflexes such as upper airway. Accessory muscles become major
speech, laughter, emotion, pain, sudden cold and inspiratory muscles when there is increased work
some pathological states. of breathing, e.g. by airflow obstruction or
exercise, leading to sequential recruitment of
chest wall, mandibular and facial muscles
MECHANICS
(Breslin, 1996). During arm activity, intercostal
and accessory respiratory muscles are obliged to
The respiratory muscles stabilize the torso, leaving the diaphragm to take
Respiratory muscles are the only skeletal muscles a greater load.
vital to life. They provide the power for the
'respiratory pump'. Other components of this Expiration
pump are the chest wall, nerves and respiratory Normal expiration is largely paSSIve, lung
centres. The chest wall comprises the rib cage elastic recoil providing the driving pressure.
and abdominal-contents-plus-diaphragm, which Elastic recoil is caused firstly by surface tension
act as a mechanical couple. Respiratory muscles acting throughout the vast gas-liquid interface
extend from the mastoid process to the pubic lining the alveoli, and secondly by elasticity of
symphysis. lung tissue that has been stretched during
inspiration. If not counterbalanced by outward
Inspiration recoil of the chest wall, elastic recoil would pull
The diaphragm separates two compartments of the lung inward to a litre below its natural
markedly different densities, the thorax and resting position (Sykes and Young, 1999, p.
abdomen, and generates two-thirds of the vital 22). Elastic recoil pressure decreases at low
capacity (Denison, 1 996). This muscle was lung volume.
thought to be the seat of the soul by the ancient The transition between inspiration and
Greeks but, despite this distinction, its exact expiration is smoothed by a brake on expira
mechanism is still a source of some mystery. It is tory flow caused by airway resistance, especially
a dome-shaped sheet of muscle upon which the at the larynx, and continued low-grade inspira
lungs sit, and is attached to the bottom of the rib tory muscle activity. Airways are narrower
cage. At rest it extends upwards almost to nipple during expiration than inspiration so that it is
level. Contraction flattens it, displacing the more difficult to empty the lungs than to fill
abdominal viscera downwards by 5 -7 cm and them. This becomes significant in obstructive
creating negative intrathoracic pressure, which airways disease, when abdominal and internal
sucks air into the lungs. intercostal muscles may be recruited to augment
The contracting diaphragm presses down passive recoil. These expiratory muscles are
against the fulcrum of the abdominal contents thought to tire more easily than inspiratory
and, when the limit of abdominal wall compli- muscles (Fuller et ai., 1996). Active expiration
4
MECHANICS
Pharynx Rapid
also occurs with exercise, speech, coughing, and
sneezing. � j� turbulent
_______ ��_c�i ______ { ______ �� _____
Pressure Bronchioles Slow

)\,
t laminar
Alveolar pressure: pressure inside the lung A Iveoli . . . ..:. -,; III ' �.-:- _
' '..
\ I
I �
\ _
\ \ :...:.
\ \ �===
. �w==
Pleural (intrapleural/intrathoracic) pressure: -===:::::..
:: :.....:..
7
pressure in the pleural space Gas exchange surface
Transpulmonary (transmural) pressure: pressure of 300 million alveoli
difference inside and outside lung, i.e. the differ Figure 1 .2 Increase in total cross-section of airways as
ence between the above two pressures, represent they subdiv ide.
ing the driving pressure responsible for inflating
the lungs.
Alveolar pressure is negative on inspiration and The nasal passages contribute 50% of normal
slightly positive on expiration. Pleural pressure airway resistance (Turner, 1 997). The rest is
is normally negative because of inward pull from shared out (Eriksson, 1 996) :
lung recoil and outward pull from chest wall • larynx: 25%
recoil. This creates an average negative pleural • trachea to 8th generation: 200/0
pressure of -2 cmH20 at end-expiration and • peripheral airways: 5%.
-6 cmH20 at end-inspiration. The inward and
outward recoil forces are in equilibrium at the These differences are most relevant when
end of a quiet exhalation (functional residual turbulence and resistance are increased by
capacity). Recoil of the chest wall assists inspira obstructive airways disease. The nasal route
tion, especially from low lung volumes. A resists airflow more than the oral route, which is
change in alveolar pressure of only 1 cmH20 is why we breathe through the mouth when breath
usually enough for airflow but diseases that less or exercising.
obstruct airflow or restrict lung expansion cause Airflow resistance is responsible for about
an increase in this requirement. 80% of the work of breathing. Lung parenchyma
These pressures are disturbed by: contributes the remaining 20% (Levitzky, 1995,
p. 34) .
• pneumothorax, which neutralizes pleural
pressure so that the lung's inward pull is
unopposed and it shrivels inwards Compliance
• emphysema, which reduces lung elastic change in volume
recoil, so that the outward pull of the chest Compliance --;--.=...
:-----
..-
change in pressure
=
wall is unopposed and the lung hyperin

flates. Compliance is the ease with which the lungs
inflate. It reflects their ability to extend and
Resistance recoil. It is represented by the relationship
Resistance is present whenever there is airflow between volume and pressure, which is curved
through a tube because gas slides against the rather than linear (Figure 1 .3). The lung is least
walls and over itself. Airflow resistance depends compliant, i.e. stiffest, at either extreme of lung
on the calibre of the airway. Peripheral airflow volume, so that it is difficult to inflate alveoli
resistance is low because the large number of that are closed or hyperinflate those that are
small airways creates a wide total cross-sectional fully inflated, in the same way that blowing up a
area (Figure 1 .2). The upper respiratory tract, balloon is most difficult at either extreme.
whose total cross-section is narrow and airflow The contribution of lung parenchyma to
turbulent, causes higher resistance. compliance is related partly to tissue elasticity
5
6
Supine
position 5
cw
42
Q)
E
3 .2
0
>
0>
c:
2 --l
:::J
-2 0 2 4
0
Pressure (kPa)
Figure 1 .3 Pressure-volume curve describing compliance of lung (L), chest wall (ON) and total respiratory system (RS).
Complian ce is greatest on the steep part of the curve, and more pressure (effort) is needed to increase lung volume at either
extreme of inflation. Examples for a low-volume state are atelectasis or fibrosis, and for a hyperinflation state, emphysema or
acute asthma. The dotted line shows the lower fun ctional residual capacity in supine. Residual volume excluded. (From Sykes,
K. (1999) Respiratory Support, BMJ publishing, London)
but mostly to surfactant in alveolar fluid. This in diseased lungs if regional variations in compli
acts like detergent to decrease surface tension ance and resistance mean that alveolar filling is
and prevent the wet alveolar walls sticking not completed during inspiration.
together, a force that can be likened to trying
to peel open a plastic bag that is wet inside. Work of breathing
Surfactant stabilizes the lungs by preventing Work is done during inspiration to overcome the
small alveoli collapsing and emptying their resistive and elastic forces of airways, lungs and
contents into large alveoli. It also has antioxi chest wall. Work of breathing (WOB) can be
dant and anti-inflammatory properties defined in two ways:
(Nicholas, 1 997). • the pressure required to move a volume of
The contribution of airways to compliance
gas, I.e. transpulmonary pressure x tidal
relates to their calibre, resistance being increased volume
and compliance decreased by bronchospasm,
• oxygen consumed by the respiratory
oedema, the floppy airways of emphysema and,
muscles, i.e. the oxygen cost of breathing
to some extent, secretions in the large airways
(Tobin and Yang, 1990).
where there is greater overall resistance.
Low compliance occurs with obstructed The maxImum pressures achievable are
airways, fibrotic lungs, a stiff chest wall, low + 1 20 cmHzO for a forced expiratory effort with
lung volumes and disorders of surfactant produc open glottis and -80 cmHzO for forced inspira
tion such as the respiratory distress syndromes. tion (Levitzky, 1995, p. 40). Normally,
Static compliance is measured during a breathing is surprisingly efficient, helped by
breath-hold such that equilibrium is achieved slippery fluid coating the moving surfaces of
between alveolar pressure and mouth pressure, alveoli and pleura. The pleura, however, does
alveoli being filled to a volume determined by not appear to be essential, and serves mainly as a
their regional compliance. Dynamic compliance 'drip pan' for pulmonary oedema fluid. The
is measured during breathing. It normally pleura is also handy for thoracic surgeons, who
approximates static compliance but may be less would find it difficult to operate if humans had
6
MECHANICS
evolved in the same way as elephants, which Inspiratory

muscle
Respiratory
workload
have no pleura (Hamm and Light, 1 997). performance
In healthy people, WOB uses 2-50/0 of total
oxygen consumption at rest. This can be
increased to 30% during exercise and 40% in
patients with chronic obstructive pulmonary Normal
disease (COPD) at rest (Pilbeam, 1 998, p. 1 1 1 ).

When it reaches over 50%, as in shock, oxygen
is stole'n from white blood cells, which may be
battling infection, and the kidneys and liver,
which are trying to detoxify byproducts of the COPD
shocked state (Pilbeam, 1998, p. 141).

Deep breathing increases the work performed
against elastic resistance, while rapid breathing
increases the work against airways resistance
(Lumb, 2000, p. 1 28). Most patients find the Neuromuscular disease
right balance, but some need assistance to find
the optimal breathing pattern to minimize their Figure ,.4 Balance between inspiratory muscle
WOB (p. 171). performance and respiratory workload . Normally the
balance favours the inspiratory muscles, but severe COPD
Inspiratory muscle fatigue or neuromuscular disease increases the load and impairs
endurance. (From Tobin, M. J. ( 1 994) Principles and Practice
Fatigue is loss of the capacity to develop force of Mechanical Ventilation, McGraw Hill, New York, with
in response to a load, and is reversible by rest. permission.)
It is usually associated with a more abrupt
decrease in respiratory muscle strength than
weakness. It can be due to failure of any of the
links in the chain of command from brain to occur if energy demand exceeds supply, as when
muscle. Failure within the central nervous WOB is increased by severe airflow obstruction
system is called central fatigue and failure at the (Figure 1 .4). However, fatigue is often prevented
neuromuscular junction or within the muscle is by control mechanisms that reduce respiratory
called peripheral fatigue. Both types of fatigue drive and protect the muscles from damage
are thought to affect the diaphragm (Roussos, (Shneerson 1 996b).
1996) and respiratory muscle fatigue has been Subjectively, fatigue of respiratory muscles
identified in 10% of patients hospitalized with creates or increases breathlessness, which can be
an exacerbation of COPD (Ramonatxo et ai., modified by release of endogenous opioids
1995). during loaded breathing (Roussos, 1 996).
Inspiratory muscle fatigue is less common Management of fatigue is by rest, energy conser
than systemic muscle fatigue because the vation including use of efficient breathing and
diaphragm has a large reserve capacity. It differs activity patterns, and sometimes non-invasive
from other skeletal muscles in its requirement ventilation.
for a lifetime of sustained action against elastic Fatigue serves a protective function to avoid
and resistive loads rather than irregular action depletion of enzymes; if the diaphragm is
against inertial loads. It is equipped for this by allowed to fatigue, recovery may take at least
having a high proportion of fatigue-resistant 24 hours (Bruton et at. , 1999). Procedures
fibres and by the unusual way in which perfusion that force patients to overuse fatigued muscles
increases instead of decreases during contraction can cause damage (Goldstone and Moxham,
(Anzueto, 1992). It is thought that fatigue can 1991).
7
Inspiratory muscle weakness

Volumes
Tidal volume
500 ml
-1- Minute volume
7500 mllmin
Flows
Weakness is failure to generate sufficient force in Anatomical dead

space 150 ml
Frequency 15/min
an otherwise fresh muscle. It is not reversible by Alveolar ventilation

rest but is treated by addressing the cause and, if Alveolar gas 5250 mllmin
appropriate, encouraging activity. Causes of 3000 ml
respiratory muscle weakness are: Pulmonary capillary

blood 70 ml
Pulmonary blood
flow 5000 mllmin
• neuromuscular disorder
• disuse atrophy
• malnutrition Figure 1.5 Lung unit with average volumes and flows of
• hypoxaemia gas and blood for both lungs. (From West, J. B. ( 1 995)
hypercapnia or acidosis Ventilation/Blood Flow and Gas Exchange, 5th edn, Blackwell,
•
Oxford, with permission.)
• low calcium, potassium or phosphate
• excess alcohol
• steroids that gets into alveoli and participates in gas
• sepsis and multisystem failure. exchange
• dead space ventilation (VD), which does not
Weakness predisposes a muscle to fatigue. contribute to gas exchange.
Fatigue differs from weakness in that even a
normal muscle can become fatigued with suffi Most dead space is made up of anatomical dead
space (Figure 1 .5), which is air in the conducting
cient effort. Fatigue and weakness often coexist,
passages that does not reach the alveoli, i.e. that
especially in respiratory failure or during
which is last in and first out.
weaning from mechanical ventilation. The
It comprises one-third of tidal volume (VT) in
clinical features of fatigue and weakness are
an average human, more in a giraffe. Alveolar
similar (p. 37) . Both are expressed by breathless
dead space, representing air that reaches the
ness, which is covered in Chapters 7 and 9.
alveoli but does not get into the blood, is
minimal in normal lungs.
VENTILATION
The sum of anatomical and alveolar dead
Breathing: the process by which the ventilatory space is called physiological dead space. The
pump creates ventilation presence of dead space is one reason why it is
Ventilation: gas movement between the outside more economical to increase ventilation by
of the body and the alveoli, i.e. inspiration and breathing deeper rather than faster. Dead space
expiration is most usefully expressed in relation to tidal
Respiration: (a) exchange of gases between envir volume (VD/VT)'
onment and tissue cells (by external respiration Ventilation is not distributed evenly within
at alveolar-capillary level and internal respira the lungs (Figure 1 .6). In most spontaneously
tion at capillary-tissue level); (b) regulation of breathing adults, dependent regions are better
the acid-base, metabolic and defence functions ventilated, for two reasons:
of the respiratory system.
• Alveoli in upper regions are more inflated,
Minute ventilation or minute volume: ventilation
but mostly with dead space gas. Gas travels
per minute, i.e. tidal volume x respiratory rate.
more easily at first to the open spaces of
Gas that moves in and out of the lungs is made these non-dependent regions, but the nearly
up of: inflated alveoli are rapidly filled and gas then
preferentially travels to dependent regions.
• alveolar ventilation, which IS the fresh aIr Alveoli in dependent regions are compressed
8
VENTILATION
Perfusion Ventilation
gradient gradient
Perfusion Ventilation o 0
gradient gradient
o o
o
o Pressure
from
abdominal
contents
Figure 1.6 Effect of gravity on the distribution of ventilation and perfusion in the lung in the upright and lateral positions.
by the weight of the lungs, heavy with blood, This provides the lower lung with twice the
above and around them. They therefore have ventilation of the upper lung (Lumb, 2000, p.
more potential to expand, allowing greater 1 22). Although fresh gas in the lower lung
ventilation with fresh gas to dependent provides a greater contribution to gas exchange,
reglOns. the upper lung is more expanded and therefore
• In the horizontal position, the excursion of responds most to deep breathing exercises to
the dependent portion of the diaphragm is increase lung volume. For most clinical
greater than that of the upper portion problems, patients are usually placed with the
because the lower fibres are more stretched affected lung upwards (p. 1 5 1 )
by abdominal pressure and therefore The ventilation gradient i s slight and
contract from a position of mechanical therefore responsive to minor upsets. It is oblit
advantage. erated in the prone position because of pressure
from the abdominal contents. It is reversed in
This distribution of ventilation therefore grossly obese people (p. 1 9), in children (p. 426)
causes a gradient with greater ventilation in and those on some modes of mechanical ventila
dependent areas. This is augmented in the side tion (p. 345).
lying position (Figure 1 .7), partly because of the Quiet breathing creates a tidal volume of one
greater vertical distance and partly because the tenth the vital capacity, but oscillations in VT
mediastinum is lifted on inspiration by the and involuntary sighs every 5-10 minutes help
cushion of air that preferentially enters the prevent alveolar collapse. Patients who are
lower lung. drowsy or sedated lose this mechanism.
9
Maximal PERFUSION
inspiration
The lungs have a dual circulation: the low
pressure pulmonary circulation and the high
pressure bronchial circulation supplied from the
aorta. The bronchial circulation services the lung
tissue itself but is not essential to survival, as is
shown after lung transplant when the bronchial
vessels are tied. The lungs are awash with blood
from the dominant pulmonary circulation, which
is equivalent to 7000 km of capillaries (Denison,
1 996) but acts more like a sheet enwrapping the
alveoli. Alveoli are more like pock marks than
bunches of grapes.
At any one time, 100/0 of the cardiac output
(CO) is in the pulmonary circulation and 200;6 of
the capillary beds are normally perfused. The
pulmonary vasculature can respond to changes
Figure 1.7 Lung volumes in the lateral position. There is in flow with little change in pressure, reducing
greater volume change in the dependent lung because resistance by widening the calibre of capillaries
gravity causes greater pressure from abdominal contents
against the lower side of the diaphragm. Greater volume and recruiting others that are closed (West,
change means greater ventilation. (From Nunn, J . F. (1993) 1 995).
Applied Respiratory Physiology, 2nd edn, Butterworth This low-pressure system responds to gravity
Heinemann, London, p. 122, with permission.) to create a perfusion gradient from top to
bottom of the lung (Figure 1 .6). This is steeper
than the ventilation gradient because of the
density of blood. The perfusion gradient is repre
DIFFUSION
sented by the following zones (West, 1995):
The wide total cross-section of the peripheral
airways means that airflow essentially ceases and • Zone I (non-dependent lung), where alveolar
gas movement from the respiratory bronchioles pressure exceeds pulmonary arterial pres
to alveoli continues by gaseous diffusion. In the sure: capillaries are flattened and no blood
alveoli, diffusion of gases across the alveolar flows
capillary membrane occurs in both gaseous and • Zone II (middle), where pulmonary arterial
liquid states, leading to equilibration of gas pressure exceeds alveolar pressure, which
between air and blood. exceeds venous pressure
The alveolar-capillary membrane is just 0.2- • Zone III (dependent lung), where venous
0.5 Ilm thick, the blood flowing between two pressure exceeds alveolar pressure . .
sheets of endothelium held together by occa
sional connective tissue supports. Only 0.01 There is no blood flow in zone I, whjch in
second is needed for oxygen to combine with health is small or non-existent, but in the apex
haemoglobin. Diffusion is so efficient that of the upright lung, the vessels collapse easily if,
oxygen tension is equalized in one-third of the for example, hypovolaemic shock reduces
time that the blood takes to pass each alveolus. arterial pressure or mechanical ventilation
Defects in diffusion do not play a major role in increases alveolar pressure. In the base of the
gas exchange abnormalities. Diffusion IS upright lung, where zone III predominates, the
measured by TLCO (p. 60). pressure of blood may lead to airway closure.
10
ARTERlAL BLOOD GASES
Distribution of perfusion is also affected by: Table 1 . 1 Shunt fractions with typical implications
• lung volume: vessels are stretched in the Shunt (%) Implications

hyperinflated state and compressed in low
5 Normal 'physiological shunt'
volume states < 10 Shunt compatible with normal gas exchange
• position, e.g. perfusion is more uniform in 15 Typical first-day postoperative shunt
prone than supine (Nyren, 1 999) 15 Lung collapse
15-20 Elderly person with lung disease
• pathological change, e.g. alveolar destruction 20 Persistent hypoxaemia despite Fn2
in ' of 1,0
perfusion than to ventilation. > 30 Significant cardiopulmonary support required
> 50 Critically ill patient
F102 = fraction of inspired oxygen

VENTILATioN/PERFUSION RELATIONSHIPS
It is no good having a well-ventilated alveolus if

it is not supplied with blood, or a well-perfused
alveolus that is not ventilated. Fresh air and arteriolar walls, constricting the arterioles,
blood need to be in the same place at the same limiting wasted perfusion and improving VNQ
time for gas exchange to occur. The matching of distribution. When the lung bases are affected,
these two essentials is expressed as the ratio of e.g. in the early stages of COPD or pulmonary
alveolar ventilation to perfusion (VNQ). oedema, local shutdown of vessels forces blood
VAIQ matching varies within the normal to the better ventilated upper regions, shown on
lung. In the upright lung, the base receives 1 8 X-ray as upper lobe diversion (p. 49). Hypoxic
times more blood and 3.5 times more gas than vasoconstnctlOn becomes counterproductive
the non-dependent apices (Thomas, 1 997). A when alveolar hypoxia occurs throughout the
degree of VNQ mismatch can be due to either lung, as in advanced COPD, when generalized
a high or low VA/Q ratio. A low ratio means vasoconstriction causes pulmonary hypertension.
that lung is perfused but not adequately venti
lated. This creates a shunt, defined as the We breathe to ventilate and ventilate to
fraction of cardiac output that is not exposed respire.
to gas exchange in the pulmonary capillary Tobin 1991
bed. Shunt is measured by comparing arterial
and mixed venous blood (p. 329), expressed as
ARTERIAL BLOOD GASES
% of cardiac output. A small shunt is normal
because part of the bronchial circulation P02
mingles with pulmonary venous drainage • partial pressure or tension of oxygen.
(Table 1. 1). Pa02
The mixing of shunted venous blood with • partial pressure of oxygen in arterial
oxygenated blood is known as venous blood, i.e. oxygen dissolved in plasma
admixture, normally 5% of cardiac output. • normal: 1 1 -14 kPa (80-100 mmHg) .
Systemic hypoxia stimulates selective vasodila Sa02
tion to assist perfusion of vital tissues. extent to which haemoglobin in arterial
•
Pulmonary hypoxia stimulates the opposite blood is saturated with oxygen, i.e.
response. If a fall in alveolar P02 is detected in capacity of blood to carry oxygen
the pulmonary circulation, an ingenious • normal: 95-980/0.
mechanism called hypoxic vasoconstriction helps Oxygen content

maintain gas exchange. Pulmonary hypoxia • total amount of oxygen in blood, i.e.
causes increased tone in the muscles of adjacent oxygen in both plasma and haemoglobin.
11
CHAPTER 1 PHYSIOLOGICAL BASIS OF CLINICAL PRACfICE
PaC02 nation at tissue level, and resting Pa02 does not

• partial pressure of CO2 in arterial blood reflect Pa02 during exercise, nor predict accu
• the basis of respiratory acid-base balance rately the nocturnal Pa02 (Hodgkin et al.,
• normal: 4.7-6.0 kPa (35-45 mmHg). 1993, p. 66).
Hypoxaemia
• reduced oxygen in arterial blood
Oxygen dissociation curve
• Pa02 < 8 kPa (60 mmHg) or 5a02 The relationship between 5a02 and Pa02 is
<90%. expressed by the oxygen dissociation curve,
Hypoxia which represents the normal variation in the
• reduced oxygen at tissue level amount of oxygen that combines with Hb. Its
• final common pathway of the peculiar shape illustrates the protective mechan
cardiorespiratory system, more relevant to isms that function in both health and disease
body function than hypoxaemia but more (Figure 1.8). An understanding of the curve
difficult to measure. helps to complete the physiological picture and
Hypocapnia/hypocarbia can be used, with oximetry, to assist respiratory
• reduced CO2 in arterial blood. assessment when blood gases are not available
Hypercapnia/hypercarhia (Goodfellow, 1997).
• increased CO2 in arterial blood.
Fr02
• fraction of inspired oxygen, e.g. F,02 of
0.6 60% inspired oxygen.

=
Left shift
! Body temperature
Arterial blood gas measurements give an indica !2,3-0PG
100 !PC02
tion of ventilation, gas exchange and acid-base i pH
status. Readings should be related to previous
values, the clinical state of the patient and the
level of inspired oxygen (FI02)' Arterial blood Right shift
samples are taken either by intermittent i Body temperature
i 2,3-0PG
puncture of the radial artery using local anaes l i PC02 (Bohr effect)
50
thesia, from an indwelling arterial catheter, or 0'"
V)
!pH
by using arterialized capillary blood from the
earlobe (Dar, 1 995).
Neither oxygen tension nor saturation tell
exactly how much oxygen is being carried in
blood. Pa02 describes only the 3% of oxygen
50 100
dissolved in plasma. It determines the extent to P02 (mmHg)
which haemoglobin (Hb) can be saturated with I I I I I I I I
oxygen and reflects the pressure needed to push 2 4 6 8 10 12 14 16
P02 (kPa)
oxygen from blood into tissue cells. Sa02
describes the 97% of oxygen that is bound to Figure 1.8 Oxygen dissociation curve relating oxygen
Hb. An anaemic person may have a normal saturation to oxygen tension. 2,3-DPG is an enzyme in red
5a02 but deliver a subnormal load of oxygen. blood cells, increased in chronic hypoxaemia, which allows
Only oxygen content describes the total easier unloading of O2 to hypoxic tissues. Pso is the Pa02 at
which Hb is 50% saturated with oxygen. It is the most
amount of oxygen carried in the blood, and
sensitive indicator of a shift in the curve because the middle
incorporates Pa02, Sa02 and Hb. In practice, portion of the curve displaces to a greater degree than
oxygen content is assumed from Pa02 or Sa02' either end. High val ue suggests poor affinity of Hb for
None of these terms give a measure of oxyge- oxygen. Shaded area represents critical tissue hypoxia.
12
ARTERw.. BLOOD GASES
Upper flat portion of the curve

At the plateau of the curve, the combination of Hypoxia and hypoxaemia
oxygen with Hb is favoured by a high POz,
and its stability is not unduly disturbed by Cau s es
changes in PaOZ. In health, this encourages Causes of hypoxia are:
loading of oxygen in the high P02 environment
• hypoxaemia
of the lung, and discourages unloading of
oxygen before blood reaches the capillary bed. • reduced CO, e.g. myocardial infarct
In disease, a drop of PaOz to 10.7 kPa • reduced oxygen carrying capacity of the
blood, e.g. anaemia, sickle cell disease
(80 mmHg) hardly affects the amount of
• reduced blood flow, e.g. haemorrhage,
oxygen in the blood.
peripheral vascular disease
Haemoglobin cannot be more than fully
saturated, and hyperventilation cannot supersa • disrupted blood flow, e.g. multisystem
failure
turate arterial blood supplied by functioning
• reduced ability of tissues to extract oxygen,
alveoli to compensate for hypoxaemia resulting
e.g. septic shock.
from poorly functioning alveoli.
Causes of hypoxaemia are:
• low VAlQ ratio due to wasted perfusion (i
Steep portion of the curve
shunt)
The dissociation of Hb becomes proportionately
greater as POz falls, so that small changes in • high VAlQ ratio due to wasted ventilation (j
dead space)
PaOZ greatly affect Sa02. In health, this means
• hypoventilation
that Hb can offload quantities of oxygen at
• diffusion abnormality
cellular level with maintenance of oxygen
• F10Z, e.g. fire entrapment, high altitude,
tension in the blood. In disease, large amounts
inadequate oxygen therapy.
of oxygen can be unloaded when tissues are
hypoxic. A PaOZ of 7.3 kPa (55 mmHg) marks Wasted perfusion occurs when blood is
the point where a significant reduction in oxygen shunted through consolidated, collapsed or
delivery to the tissues begins, and further small damaged lung without picking up oxygen,
drops in PaOZ result in tissue hypoxia. leading to VAlQ mismatch (Figure 1.9),
somewhat attenuated by hypoxic vasoconstric
tion. Hypoxaemia associated with shunt shows
Shift of the curve limited response to oxygen therapy because
Another singular way in which the body added oxygen cannot reach the shunted blood.
responds to need is to adjust the affinity of Hb Wasted ventilation occurs when a perfusion
for oxygen, as reflected by a shift of the curve. A defect such as pulmonary embolism prevents
right shift means that Hb unloads oxygen more fresh gas from reaching arterial blood. This
easily at a given P02• In health, this occurs increases alveolar dead space and causes VAlQ
during exercise, when active muscle generates mismatch at the other end of the spectrum
heat and makes blood hypercapnic and acidic. In (Figure 1.9).
disease, this occurs with fever and when tissues Diffusion abnormalities occur in disorders
need extra oxygen. A left shift occurs when Hb such as pulmonary oedema or fibrosing alveoli
holds tightly on to its oxygen, as occurs in tis.
hyperventilation, hypometabolism or a cold Hypoventilation leads to a fall in PaOZ that is
environment. Pink ears and noses on frosty roughly equivalent to the increase in PaCOZ. It
mornings are due to the reluctance of Hb to can be distinguished from other causes of hypox
unload oxygen. aemia by the PA-a02 (see Glossary).
13
Pulmonary
embolus
Normal Atelectasis Consolidation
l�__________��
Y __________�)
Wasted
Shunt or wasted perfusion
ventilation
(� VA/O) (t VA/O)
Figure 1 .9 Alveoli and surrounding capillary network, showing how impaired ventilation or perfusion can upset IirJQ
balance.
Effects their responses. Gut monitoring (p. 330) is in its

Prolonged or repetltIve hypoxaemia is thought infancy. Kidney failure is identified by reduced
to be worse than a single episode (Hanning, urine output and increased potassium, creatinine
1995). The brain is exquisitely sensitive to or urea. Table 1.2 shows how the body responds
ischaemia and typically responds to hypoxia as to hypoxaemia and hypercapnia.
follows: The circulatory response to acute hypoxia is
to increase CO and improve blood flow to the
Pa02 < 7.3 kPa (55 mmHg) : memory defect,
brain, respiratory muscles and liver, at the
impaired judgement
expense of reduced flow to gut, skin and bone
< 5.3 kPa (40 mmHg) : tissue damage
(Kuwahira, 1993). Significant cardiac arrhyth
< 4 kPa (30 mmHg) : unconsciousness
mias can occur when Sa02 drops below 800/0
< 2.7 kPa (20 mmHg) : death.
(RCP, 1999).
The gut lining and kidney are also sensitive to Hypercapnia reflects hypoventilation due to
hypoxia, which can be identified by monitoring respiratory depression, severe weakness, fatigue
Table 1 .2 Clinical features of hypoxaemia and hypercapnia
Hypoxaemia Hypercapnia
I
Cyanosis Flapping tremor of hands
Tachypnoea Tachypnoea
Tachycardia ---> arrhythmiaslbradycardia Tachycardia ---> bradycardia
Peripheral vasoconstricton Peripheral vasodilation leading to warm hands and headache
Respiratory muscle weakness Respiratory muscle weakness
Restlessness ---> confusion ---> coma Drowsiness ---> hallucinations ---> coma
Sweating
Tachycardia = rapid heart rate; tachypnoea = rapid respiratory rate
14
ARTER.lAl BLOOD GASES
or an attempt to avoid fatigue by reducing venti base required to restore pH to normal. It

lation and inspiratory muscle overload (Green measures metabolic acid-base balance but takes
and Moxham, 1993). Both hypoxaemia and buffering of red blood cells into account. It
hypercapnia impair endurance of the diaphragm therefore provides more complete analysis of
(Tobin, 1988). metabolic buffering than HC03-, which
accounts for only half the buffering capacity of
Interpretation blood. BE is calculated from pH, PaC02 and
Pa02 is affected by one or a combination of the haematocrit.
causes of hypoxaemia. PaC02 is affected only by • normal: minus 2 to plus 2 mmollL
ventilation because CO2 is freely diffusible and • metabolic acidosis: < -2 mmollL
not affected by VAiQ mismatch. PaC02 IS • metabolic alkalosis: > 2 rnmol/L.
therefore us"e d to assess ventilatory adequacy.
Examples of blood gas abnormalities are:
Regulation
• 1 Pa02 with i PaC02, i.e. hypoxaemia with Acid-base balance is disturbed if removal of
hypercapnia: exacerbation of lung disease in CO2 from the lungs is abnormal (respiratory
a patient who is unable to ventilate acidosis or alkalosis) or production of acid from
adequately the tissues or elimination elsewhere is abnormal
• 1 Pa02 with 1 PaC02, i.e. hypoxaemia with (metabolic acidosis or alkalosis).
hypocapnia: exacerbation of disease in a Body cells and chemical reactions are acutely
patient who is breathing rapidly, e.g. pneu sensitive to the pH of their environment, and
monia, fibrosing alveolitis, pulmonary any deviation from the normal slight alkalinity
oedema, pulmonary embolus of body fluids is fiercely resisted, at whatever
• normal Pa02 with 1 PaC02: emotion, hyper cost, by three homeostatic mechanisms. These
ventilation syndrome, painful arterial punc work to dispose of the acids that are continually
ture or any cause of hyperventilation. produced by the body's metabolic processes,
The above examples could, in reverse order, mostly by the interaction of CO2 and water to
represent a developing asthma attack. create carbonic acid.
If we reduce our minute ventilation, PaC02 1. The buffer system acts as a chemical
rises and Pa02 falls, but the reverse is not true. sponge, which neutralizes acids or bases by
Increased ventilation will blow off PaC02 but means of reactions that give up or absorb
Pa02 is maintained because Hb cannot be super hydrogen ions, all within seconds. The bicarbo
saturated. nate base-buffer equation depends on the disso
ciation of carbonic acid in solution, acting as a
sink for hydrogen ions:
Acid-base balance
The pH reflects acid-base balance. It responds H20 + CO2 H H2C03 H H+ + HC03-.
to metabolic and respiratory change but cannot An increase in PaC02 shifts this equilibrium to
differentiate between them. Body functions the right, increasing H+ and causing respiratory
occur optimally at a pH of 7.35-7.45. acidosis. A decrease in PaC02 shifts the equation
Bicarbonate ion concentration (HC03-) to the left, decreasing H+ and causing respira
measures metabolic acid-base balance. tory alkalosis.
Standard bicarbonate may be used in order to
• normal : 22-26 rnmollL
eliminate the influence of acute changes in
• metabolic acidosis: < 22 mmol/L
PaC02. The measurement is adjusted as if PaC02
• metabolic alkalosis: > 26 mmol/L.
were valued at a standard 5.3 kPa, and allows
Base excess (BE) is the quantity of strong acid or evaluation of the purely metabolic component.
15
CHAPTER 1 PHYSIOLOGICAL BASIS OF CLlNlCAL PRACTICE
Standard bicarbonate is similar to bicarbonate in • ! HC03- or BE means metabolic acidosis.

a person with normal acid-base status.
A change in pH due to respiratory or
2. If buffering is not adequate, the lungs then
metabolic disturbance is usually offset by a
present an avenue for regulating CO2, Hyper- or
compensatory change in the other system so that
hypoventilation can stabilize the acid-base
pH normalizes. Respiratory compensation is
balance within 1-15 minutes.
quicker than metabolic compensation.
3. If this is still not adequate, the kidneys then
When pH is restored to normal, full compen
begin to eliminate acid, but take up to 3 days to
sation has occurred. The stages can be identified
normalize pH. Bicarbonate or base excess
as follows:
indicates the extent of renal compensation and
quantify the metabolic component of an acid • Abnormal pH + change in PaC02 or bicar
base disturbance. bonate/BE non-compensation, i.e. a recent
=
process
Interpretation • Abnormal pH + change in PaC02 and bicar
Step 1 : look at pH: bonate/BE partial compensation
=
• Normal pH + change in PaC02 and bicarbo

• ! pH means acidosis
nate/BE full compensation.
i pH means alkalosis.
=
Respiratory and metabolic factors are often

Step 2: look at PaC02: does it account for the
combined, and complex interactions can occur.
abnormal pH?
If pH is below 7.2, assessment for mechanical
• i PaC02 means respiratory acidosis assistance is mandatory.
• ! PaC02 means respiratory alkalosis. Table 1.3 clarifies the causes, effects and
recognition of arterial blood gas imbalances.
Step 3: look at HC03 -: does it account for
Table 1.4 gives examples. Table 1.5 shows how
the abnormal pH?
two respiratory disorders can affect arterial
• i HC03- or BE means metabolic alkalosis blood gas readings.
Table 1.3 Interpretation of arterial blood gas trends
Condition Causes Effects Recognition
Acute respiratory acidosis Hypoventilation, e.g. exhaustion, i PC02, .!. pH , normal HC03" Shallow breathing, slow breathing,
weakness (no time for renal compensation) drowsiness
Chronic (compensated) Chronic hypoventilation i PC02, normal pH , i HC03", BE > 2 Chronic severe respiratory
respiratory acidosis (conservation of HC03 to restore pH) disease, e.g. CO PO
Respiratory alkalosis Acute hyperventilation, e.g. excess .!. PC02, i pH , .!. HCOl, BE> 2 (renal Breathlessness, hyperventilation,
mechanical ventilation, anxiety, excretion of HC03) distressed breathing pattern
pain, acute asthma
Metabolic acidosis Ketoacidosis, e.g. diabetes; loss of .!. PC02, .!. pH , .!. HC03", BE < -2 Hyperventilation
alkali, e.g. diarrhoea; renal (respiratory compensation to blow
failure off PC00
Metabolic alkalosis Volume depletion; diuretics; i PC02, i pH , i HC03", BE > 2 Delirium

removal of acid, e.g. vomiting (renal excretion of HCOD
Note that if the primary problem is metabolic, pH and bicarbonatelBE change in the same direction, while if the primary problem is
respiratory, pH and PaC02 change in opposite directions.
16
THE OXYGEN CASCADE
Table 1 .4 Examples of acid-base interpretation
I . pH 7.3 Partially compensated respiratory acidosis, since both PaC02 and HC03" are increased but pH is low
PaC02 6.5 kPa (49 mmHg)
HC03" 30 mmol/L
2. pH 7.5 Partially compensated respiratory alkalosis, since both PaC02 and HC03" are decreased but pH is high
PaC02 4 kPa (30 mmHg)
HCO:l 1 9 mmol/L
3 . p H 7.48 , Uncompensated metabolic alkalosis, since both HC03' and pH are high but PaC02 has barely moved
PaC02 6.0 kPa (45 mmHg)
HC03" 30 mmollL
4. pH 7.45 Fully compensated respiratory alkalosis

PaC02 6. 5·kPa (34 mmHg)
HC03' 20 mmollL
Table 1.5 Arterial blood gas responses to two disorders reserve capacity, and D02 is normally three or
(numbers in brackets indicate mmHg) four times greater than V02 (Epstein and
Normal Acute asthma COPD
Henning, 1993).
Oxygen availability to the tissues depends on:
Pa02 1 2.7 (95) 9.3 (70) 7.3 (55)
PaC02 5.3 (40) 3 . 3 (25) 8 (60) • oxygen content
pH 7.4 7.5 7.4 • cardiac output
24 29
HCO:l 24
• distribution of CO
Both disorders show hypoxaemia. PaC02 values reflect • oxygen dissociation curve.
breathlessness in acute asthma and hypoventilation in COPD. pH
and HC03' values reflect an acute non-compensated condition in OXYGEN DELIVERY
acute asthma and full compensation in COPD.
1 00
THE OXYGEN CASCADE (Figure 1 . 1 0)

80
The raison d'etre of the cardiorespiratory system
is to get oxygen to the tissues. Even if ventila Oi
I
tion, diffusion and perfusion are in order, E
60
oxygen still has to reach and enter the tissues. .s

Pli02
I
Oxygen transport is the passage of oxygen to the

'"
0 40
Q..
tissues. This term is often used synonymously
with, and is virtually the same as, oxygen 20
delivery, which is the oxygen presented to the OXYGEN
tissues. Tissue oxygenation depends on the CONSUMPTION
o
oxygen content of blood, CO, haemoglobin
levels and local perfusion. Oxygen consumption Figure 1 . 1 0 The oxygen cascade, representing the journey
(uptake) by the tissues is roughly equivalent to of oxygen through the body. Pv02' Pa1v02 and Pa02 are the
oxygen demand, determined by the metabolic partial pressures of oxygen in the pulmonary artery, alveoli
need of the tissues for oxygen. and arteries respectively. P02 is reduced in the capillaries as
it is extracted by the tissues and further reduced in the tissues
Tissue oxygenation is determined by a balance as it is consumed. CI oxygen content. See Appendix F for
between supply (oxygen delivery or D02) and
=
conversion of mmHg to kPa. (From Tobin, M. J. ( 1 994)

demand (oxygen consumption or V02). The Prin ciples and Practice of Mechanical Ventilation , McGraw
respiratory system, like other systems, has Hill, New York, with permission .)
17
CHAPTER 1 PHYSI OLOGICAL BASIS 01
' CLINICAL PRACTICE
V02 varies with metabolic rate. An increase in • 1 elastic recoil, dilation of alveoli, i lung
V02 is usually met without difficulty by volume ('senile emphysema'), leading to
increased D02 (mostly through a rise in CO, reduced surface area for gas exchange Oans
partly through increased minute ventilation) and sens et at., 1999)
increased oxygen extraction by the tissues. Once • narrowing of small airways, leading to raised
maximum oxygen extraction is reached, further closing volume (Figure 1 . 1 1), premature
increases in demand, or falls in supply, lead to closure of small airways, alveolar collapse
hypoxia. and VP)Q mismatch
Critically ill patients with sepsis can demand • i residual volume because closure of small
50-60% extra oxygen, while patients with airways prevents full exhalation (this appears
multiple trauma, septic shock or burns may need as hyperinflation on X-ray, which can be
1 00% extra oxygen (Epstein and Henning, misinterpreted as emphysema)
1993). If the body is not able to transport, • greater dependence on collateral ventilation
deliver, extract and utilize this oxygen, sustained because of airway closure
lactic acidosis occurs. • 1 diffusion, leading to i PA-a02
Compared to gas exchange in the lung, which • 1 respiratory muscle strength, strongly corre
is easily monitored in arterial blood, tissue lated with nutritional status Oanssens et at.,
oxygenation has to be measured from the 1999) and sedentary lifestyle
pulmonary artery, which contains the only • 1 vital capacity by 30 mL per year (Bach and
reserves of oxygen in the body (Ahrens, 1999a). Haas, 1 996)
• 1 FEV 1 by 30 mLlyear (45 mLlyear in
smokers) (Fehrenbach, 1 998), and 1
EFFECT OF AGEING
response to �z-agonist drugs such as salbu
The gas exchange function of the ageing lung is tamol (Connolly, 1995)
affected by the cumulative effect of the environ • 1 exercise capacity by an average 10% per
ment on this 'outdoor' organ. Maximal function decade (Hellman, 1994)
is reached in the early 20s Oanssens et at., • 1 chest wall compliance
1 999), after which it is all downhill. The pump • 1 ventilatory response to both hypoxaemia
function of the respiratory system is affected by and hypercapnia Oanssens et at., 1999)
ageing muscle, which has lost up to a third of its • 1 total blood volume, which impairs circula
mass by the age of 50 (Bach and Haas, 1 996, p. tory function (Davy and Seals, 1 994)
263). • postural hypotension
Changes with age that are relevant to • prolonged reaction times, 1 coordination
physiotherapy include the following: (Laporte et at., 1999)
f\ f\ f\ f\
LV V V L
Functional residual
_ _
capacity (FR G )
_ _ -
__
Increased CV,
e.g. smoking,
Closing
ageing
volume (CV)
Decreased FRC,
e.g. obesity,
supine posture
Figure 1 . 1 1 Factors that shift tidal breathing into the closing volume range, leading to airway closure in the lung bases
d uring quiet breathing.
18
EFFECT OF OBESITY
• i blood pressure (BP), especially systolic

(Hellman, 1994), which helps maintain
tissue perfusion because a greater pressure is
needed to overcome the resistance of hard
ening arteries.
Clinical implications
It is necessary to take time when assisting elderly
patients out of bed, in case of postural hypoten
sion. During deep breathing, collateral ventila
tion can be exploited with an end-inspiratory
hold (p. 153). During exercise training, an
ageing cardiovascular system is less able to adapt
to the stress of exercise. During weaning from
mechanical ventilation, extra help is needed
because lung volume is especially compromised
by the supine posture and low tidal volumes.
EFFECT OF OBESITY
Obesity: weight 20% greater than ideal body

weight
Morbid obesity: weight 100% greater than ideal
body weight
Figure 1. 1 2 Effect of obesity on the mechanics of
Malignant obesity: weight 2000/0 greater than breathing. When upright, the weight of the viscera (dotted
ideal body weight. arrow) is normally bome by the pelvis but in obese people
it pulls down on the ribs (solid arrow) and increases the
Obesity is the commonest chronic disease in the work of i nspiration . When supine, the pressure of the
USA (Guernelli et al. , 1999), and Britain is viscera on the diaphragm hinders i nspiration. (From Wilkins,
catching up. The obese and the elderly share a R. L., Sheldon, R. L. and Krider, S. J . ( 1 99S) Clinical
tendency towards poor basal ventilation. Obesity Assessment in Respiratory Care, Mosby, Toronto, p. 350.)
reduces lung volumes (Carella, 1999 and Figures
1.1 1 and 1.12) and lung compliance (Jenkins
and Moxham, 1991). The normal downward cardiovascular disease, diabetes, digestive disease
ventilation gradient is obliterated or reversed (Chen et al. , 1993), gallstones, gout, skin
because of compression from the abdomen disease, musculoskeletal problems, sleep apnoea
(Hurewitz, 1985), leading to reduced ventilation and some cancers (Guernelli et al., 1999). Risk
in the well-perfused bases, VA/Q mismatch and of sudden cardiac death is 40 times greater than
some hypoxaemia. Hypercapnia is also a risk normal (Guernelli et aI. , 1999). Functioning
(Begin, 1991). Exercise demands high oxygen lung volume may be reduced by half during
consumption. Breathing patterns tend to be surgery, compared to a 20% reduction in non
rapid, shallow and apical. Morbidity and obese people (Wahba, 1991). During surgery,
mortality are increased by cardiovascular, position-related complications are above average
pulmonary, metabolic and sleep abnormalities and are not reduced by increased tidal volume or
(Carella, 1999). PEEP (p. 351) (Buckley, 1997).
Morbid obesity threatens body functions, Obesity does not ensure good nutrition
leading to increased risk of respiratory disease, because inactivity and ster61d medication are
19
common in lung disease. Hospitalization can

worsen the nutritional status of obese people.
Head-down postural drainage is inadvisable for
obese people because of the extra load on the
diaphragm. Activity needs to take into account
the fat infiltration of muscle and heavy
workload. After surgery, an obese patient should
barely have emerged from anaesthesia before the
physiotherapist becomes involved in pain control
and positioning, particularly the well-forward
side-lying position (Dean, 1997).
EFFECT OF SMOKING
A custom loathsome to the eye, hateful to

the nose, harmful to the brain and
dangerous to the lungs.
King James I
Smokers were excommunicated by Pope Urban

VIII and decapitated by Alexis I (Thomas,
1996a). Now in the 21st century, smoking is a
form of legal drug addiction and the main
preventable cause of premature death (Balfour,
1 993). It is escalating most in the developing
world, where cigarettes tend to have a higher tar
and nicotine content (Panos, 1994). Smoking
kills half of all persistent smokers worldwide,
including one person every 5 minutes in the UK
(Venables, 1994). This comes as no surpnse
considering the 6000 chemicals in tobacco
smoke (Hoozen, 1 997), including cyanide,
butane, ammonia, carbon monoxide and 50
known carcinogens (Kritz, 1 995).
Carnage to the respiratory and cardiovascular
systems is well-known (Figure 1 . 13) but virtually
every organ system is affected (British Medical
Journal, 1 997). The cumulative effect is shown
in Figure 1 . 14 and the litany of destruction is
outlined below.
• Smoking worsens outcome in rheumatoid
arthritis (Saag, 1 997) and ankylosing spon Figure 1. 1 3 Effect of smoking on the heart, vascular
dylitis (Averns, 1 996); is associated with low system, foetus and potency. (From Milne, A. ( 1 998)
back pain and widespread musculoskeletal Smoking: The Inside Story, Woodside, Stafford, with
pain (Andersson, 1998) ; accelerates ageing permission. Artist: James Northfield)
20
EFFECT OF SMOKING
<i
E
0
c
Z
0
i=
u ..
�
z
::> �
..
u.
-e
l? 0
.0
Z
::>
...J
'"
E
�
0
C
.0
'"
dX=H
Figure 1 . 1 4 Long-term effects of smoking. Top: Lifelong non-smoker continuing with active life. Middle: Smoker recovering
some lung function with smoking cessation and rehabilitation. Bottom: Continuous smoker faces loss of function and premature
death. (From Haas, F. and Haas, S. S. ( 1 990) The Chronic Bronchitis and Emphysema Handbook, John Wiley, Chichester, with
permission. )
(Kauffmann, 1993); doubles the risk of hypertension, reduced exercise tolerance

dementia (Ott et ai. , 1 998); depletes vitamin (Gidding, 1 994), anxiety and depression
C by 30% (Strachan, 1991); ulcerates the Gorm et ai. , 1999).
gut (Thomas, 1996a) ; dislodges teeth Gette, • Nicotine is the ingredient that imprisons
1993); causes cataract (Christen, 1992), glue smokers in the habit. It is more addictive
ear (Couriel, 1994) and squint in children than heroin, seven times as addictive as
(Medical Monitor, 1992); demineralizes alcohol (Haas and Haas, 1990, p. 67) and is
bone (Prescott, 1998); depletes antioxidants delivered to the central nervous system
(Li, 1996); causes more bronchial hyperreac within seven seconds (Fisher et al., 1990). It
tivity than cocaine (Tashkin et al., 1 993); initially stimulates the brain, then acts as a
increases the risk of diabetes (Rimm, 1995), sedative. The one redeeming feature of nico
head and neck cancer (Koufman and Burke, tine is that it is reported to ameliorate
1997) and breast cancer (Bennicke, 1995); ulcerative colitis in the active phase
causes 87% of deaths from lung cancer (Thomas, 1996a), and nicotine patches have
(Dresler, 1996); and increases the risk of been advised.
postoperative complications two to six times • Smoking increases bronchial secretions
(Bluman et al. , 1998), macular degeneration while reducing mucociliary clearance
two to three times (Christen, 1996), subar (Bluman et al., 1 998) and causes high
achnoid haemorrhage sixfold (Partridge, closing volumes and mismatched VAlQ
1992) and pneumothorax 13-fold (Light, (Figure 1 . 1 1). Smoking increases the risk
1993). Smoking weakens the immune of pneumonia (Almirall et al. , 1 999).
system; damages cilia (Verra, 1995) and Premature closure of small airways occurs
surfactant (Pearce, 1984); and leads to before the onset of symptoms or lung
------ 21
function test abnormality, after which there (Coultas, 1998). For infants, passive smoking
is a doubling of the normal increase in increases mortality and morbidity, and impairs
airflow obstruction over time (Zadai, lung development (Gidding, 1994). Marriage to
1991). The carbon monoxide in tobacco a smoker increases the risk of lung cancer by
smoke dislodges oxygen from haemoglobin 26% (British Medical Journal, 1997). And one
to create 'functional anaemia'. tree is killed per fortnight to cure the tobacco
• Smoking doubles or triples female infertility for one average smoker (HEA, 1995).
(Partridge, 1992). It kills 5000 foetuses and Smoking cessation virtually eliminates the
infants a year in the UK (Couriel, 1994), excess risk of coronary heart disease and stroke
including a trebling or quadrupling of cot within 2-4 years and the overall risk of
deaths (Blair, 1996). Smoking during preg mortality in 10-15 years (Simonds et al., 1996,
nancy causes marginally more damage than p. 86).
postnatal maternal smoking (Brown and
Halonen, 1999). It creates offspring who are 'How I wish that I'd listened to Mum
intellectually impaired (Olds, 1994), more As I smoked and drank and blew gum.
likely to be brain-damaged (Thoresen, Dh the smoke rings I blew
1999), hypertensive (Beratis, 1996), smaller, But if only I knew
slower growing and with increased respira That the moment of reckoning would come. '
tory and allergic disease throughout life Barton, 2000 (jusr before dying while awairing
(Partridge, 1992). The low birthweight is a lung rransplanr)
associated with greater mortality up to the

teenage years (Power and Li, 2000). Even Clinical implications
grandchildren do not escape, mothers born Motivate, educate and cajole.
to women who smoked during pregnancy
being more likely to have a miscarriage
(Golding, 1994). One cigarette a week can EFFECT OF PREGNANCY
cause menstrual problems (Charlton and
White, 1996) and, because smoking lowers Pregnancy requires a 20% increase in oxygen
oestrogen levels, it creates early menopause consumption to service the extra metabolism.
and brings postmenopausal women's risk of Demand is met by a 40-50% increase in minute
cardiovascular disorder closer to that of men ventilation (MV) , which lowers PaC02 and
(Prescott, 1998). causes mild respiratory alkalosis. The swelling
• Smoking is neither virile nor sexy. uterus restricts resting lung volume, but vital
Smoking damages sperm, and 15% of all capacity is maintained at the cost of increased
childhood cancers have been attributed to work of breathing. Three-quarters of pregnant
paternal smoking (Sorahan, 1997). Most women expenence breathlessness (Nelson
smokers also have breath that smells like Piercy, 1996).
an ashtray.
• Smoking exacerbates the poverty of those on
the lowest incomes (Smeeth, 1998).
Patients on bedrest are at risk of loss of lung
Passive smoking creates lung carcinogens in volume and will need monitoring of their chest
the recipient within hours (Hecht, 1993), retards and attention to positioning. Those beyond 20
foetal growth, increases age-related hearing loss weeks gestation should not be nursed supine in
(Cruickshanks, 1998) and increases risk of case of aortocaval occlusion which could
coronary heart disease by 70% (Brannon et a/., compromise mother and baby (Bird, 1997). For
1998, p. 388) and risk of asthma by 50% patients whose respiratory system is already
22
EFFECT OF EXERCISE
compromised, the late stages of pregnancy may diffusing capacity ensures equilibrium (Dantzker,
require other measures; for example, kyphosco 1983). This might explain the excessive hypox
liotic patients with nocturnal hypoventilation aemia seen in some exercising patients with
may benefit from non-invasive ventilation interstitial lung disease, whose diffusion is
(Restrick et aI., 1997). The course of asthma in impaired.
pregnancy is unpredictable, with as many 4. Metabolic acidosis may develop if buffering
patients improving as deteriorating (Nelson mechanisms are unable to cope with the extra
Piercy, 1996). CO2 and lactic acid.
The commonest cause of obstetric admission 5. Vascular resistance drops precipitately
to intensive care is pre-eclampsia or eclampsia, and, in the lungs, previously closed capillaries
which is the gravest form of pregnancy-induced are recruited and distended. Muscle blood flow
hypertension. Relevant complications are can increase 2S-fold (Epstein and Henning,
pulmonary oedema and coagulation problems, 1993).
but physiotherapy is not indicated unless a 6. Dead space can drop from a third to a fifth
seizure causes aspiration. Most obstetric admis of tidal volume (Bach and Haas, 1996, p. 248).
sions to the intensive care unit are post-partum 7. Pa02 is usually maintained because distribu
but, for pregnant patients, a caesarean section tion of perfusion and VA/Q become more
pack must be available. uniform and diffusion increases. Oxygen extrac
tion by the tissues can increase 20-fold (Epstein
and Henning, 1993).
EFFECT OF EXERCISE 8. pH is usually maintained because extra
hydrogen ions stimulate the arterial chemorecep
Those who think they have not time for
tors to increase ventilation.
bodily exercise will sooner or later have to
9. Bronchodilation occurs so long as asthma is
find time for illness.
not present.
Edward Stanley, Earl of Derby, 1826-93
10. Mucus transport increases (Houtmeyers,
During exercise, oxygen delivery, consumption 1999).
and extraction increase. Extra oxygen is 1 1. Work of breathing increases because high
delivered to the heart and skeletal muscles by flow rates increase turbulence and active expira
several mechanisms. tion causes dynamic compression of airways.
MV above 40 L/min is usually accompanied by
1. Ventilation can increase from 6 L/min to mouth breathing.
200 L/min (Salazar, 1991). During low-intensity 12. Mouth breathing and raised MV increase
exercise, deeper breathing makes the largest the inhalation of pollutants. A marathon runner
contribution to MV, while at high intensity, can inhale in 3 hours the same air and pollutants
rapid breathing is the main contributor. as a sedentary person in 2 days (Atkinson,
2. CO can increase fourfold in an uncondi 1997). This may be one factor precipitating
tioned young adult and up to sixfold in a fit exercise-induced asthma.
male (Epstein and Henning, 1993), mostly as a
result of increased heart rate. Systolic BP Cardiovascular delivery of oxygen to the
increases in proportion to oxygen consumption peripheral muscles imposes the primary limit to
and may reach over 200 mmHg in a healthy exercise in normal subjects (Hsia, 1993). When
man. Diastolic pressure increases slightly during blood flow becomes inadequate to maintain
isotonic exercIse and significantly during aerobic metabolism, the anaerobic threshold is
isometric exercise. reached, demand exceeds supply and lactic
3. Increased CO means a shorter transit time acidosis develops, with a disproportionate
as blood rushes past the alveoli, but increased increase in MV relative to oxygen consumption.
23
Obstructive lung disease may cause a lower

EFFECT OF IMMOBILITY
Pa02 with exercise. Restrictive disease can cause
a precipitate drop in Pa02 (Wagner, 1 992). Look at the patient lying long in bed.
Inspiratory muscle fatigue may develop in What a pathetic picture he makes.
people with reduced respiratory compliance. The blood clotting in his veins,
Subjectively, exercise can be experienced as inca The lime draining from his bones,
pacitating, joyful or somewhere in between. The scybola stacking up in his colon,
The effects of exercise training are more The flesh rotting from his seat,
related to cardiovascular and muscle metabolism The urine leaking from his distended
than to the respiratory system. bladder,
The following have been described after And the spirit evaporating from his soul.
regular physical activity: Asher, cited by Morris 1 999
• 1 morbidity and mortality (Kerr, 1 999) Times have changed since bed rest was consid
• i respiratory muscle strength (Ioli et aI., ered 'the greatest advance of which practical
1991) medicine can boast in the last quarter century'
• 1 blood lactate levels for a given amount of (Playfair, 1 8 8 1). Immobility is now known to
exerCIse increase the risk of pneumonia, deep vein throm
• 1 requirements for oxygen uptake, CO2 bosis, osteoporosis and bedsores (Allen et aI.,
output and ventilation for a similar degree of 1 999), to reduce lung volume, cognition, co
exerCIse ordination (Bach and Haas, 1 996, p. 201) and
• i maximum oxygen uptake, mainly due to i lead to constipation, urine retention, decondi
maximum cardiac output tioning and depression (Mulley, 1 993).
• 1 resting heart rate The acute stage of contractures begins immedi
• 1 hypertension, heart disease, diabetes, ately, especially in extension (Trudel et aI.,
osteoporosis, some cancers, anxiety and 1 999), although this is not significant for the
depression (Powell and Pratt, 1 996) average respiratory patient who is immobile for a
• i glucose tolerance few days. Disuse muscle atrophy is most marked
• 1 cigarette smoking (Todd, 1 996) in the first week, but subsequent loss is more than
• for a trained athlete, enlargement of the 1 0% per week (Dobson, 1 993). Twenty days' bed
heart by up to 50% (Wilkins et ai. , 1 995) rest can reduce work capacity by 3 0%, returning
• with swimming training, i lung volumes to normal only after 3 weeks of intensive exercise
(Gaultier and Crapo, 1 997) . (Saltin et aI., 1 968). Muscles lose 20% of their
strength per week (Sciaky, 1 994). Tendons and
ligaments may take months to recover, and
Exercise that is vigorous, regular and current
cartilage shows irreversible changes within a
reduces the risk of myocardial infarction by 50%
fortnight (Morris, 1 999).
(Todd, 1 996).
Loss of gravitational stimulus to the cardio
vascular system causes a negative fluid balance
within 24 hours and augments deconditioning.
Clinical implications Reduced circulating blood volume and impaired
When supervising exercise, judgement is aimed vasoconstrictive ability cause postural hypoten
at achieving optimum activity without losing the sion, increased work of the heart and increased
patient's co-operation or causing complications. work of breathing (Dean and Ross, 1 992). And
Much encouragement is required to assist a far from being a treatment for chronic fatigue
patient towards a lifestyle of regular exercise. syndrome, bed rest creates its symptoms (Sharpe,
1 998);
24 --
---
EFFECf OF STRESS
Deterioration occurs more rapidly in the which can be twice that experienced during
respiratory and cardiovascular systems than the exercise (McNicholas, 1 997)
musculoskeletal systems, and recovery is slower • bronchoconstriction, which is of little conse
than deterioration (Dean and Ross, 1992). The quence except in people with asthma
more immobile the patient, the higher the risk of (Douglas, 1993)
developing respiratory complications and • arrhythmias, variable heart rate and BP
pressure sores. (Wilkins et aI., 1 995, p. 356).
REM sleep occupies about 20% of total sleep
time and is the restorative, dreaming and physio
If immobility is caused by pain, fatigue or logically eventful phase when oxygen consump
depression, these should be addressed, e.g. by tion is highest. It is also the time when changes
analgesia, rest or a listening ear, so that they are greatest and when respiratory patients are at
do not prevent mobilization. If immobility is their most vulnerable.
unavoidable for medical reasons, regular Sleep and COPD have a particular relation
position change reduces some of the complica ship. Nocturnal oxygen desaturation speeds
tions of bed rest. Passive and/or active pulmonary hypertension and hypercapnia
exercise are necessary, and encouragement of (McNicholas, 1 997), and sleep itself is disturbed
upright positions minimizes orthostatic intoler by breathlessness and coughing. Sleep-disor
ance. dered breathing is a risk for people with COPD,
the elderly and the obese (Fletcher, 1 992). Sleep
also has a particular effect on asthma (Chapter
EFFECT OF SLEEP 3).
Sleep is restorative but, for some respiratory Clinical implications
patients, risky. Changes during sleep include:
Sleep . . .
Balm of hurt minds, great Nature's second
• 1 mucociliary clearance (Houtmeyers, 1 999)
course,
• 1 cough
Chief nourisher in life's feast.
• 1 muscle tone, including muscles that
William Shakespeare, Macbeth II, 1
preserve patency of the airway in the throat
(McNicholas, 1 997) People on home oxygen should use it continu
• dissociation of diaphragmatic from inter ously during the night because the normal
costal activity during rapid-eye-movement nocturnal dips in Sa02 can be damaging for
(REM) sleep (Mohsenin, 1994) people who are already chronically hypoxaemic.
• for people whose respiratory system is Hospitalized patients on oxygen should maintain
already compromised, possible diaphrag this at night, sometimes with a higher flow rate.
matic fatigue Certain postoperative patients may need
• 1 ventilatory response to hypoxia and hyper nocturnal oxygen for a longer period than
capnia (McNicholas, 1 997) daytime oxygen (p. 250). Death from lung
• 1 MV by 10-1 5%, with consequent rise in disease usually occurs at night.
PaC02 of 0.4-1.1 kPa (Laursen, 1988)
• 1 lung volumes (McNicholas, 1 997)
EFFECT OF STRESS
• during REM sleep, 25% drop in tidal
volume (Lumb, 2000, p. 346). All ill people suffer some degree of stress,
• VAlQ mismatch due to 1 lung volumes and usually as a result and sometimes as a predispos
hypoventilation (Schenkel, 1 996) ing factor of illness. Stress has adverse effects on
• for people with COPD, oxygen desaturation, the cardiovascular, gastrointestinal and central
25
nervous systems, and other organs and physiolo

gical processes (Basmajian, 1 998). The physiolo Background
gical effects of stress relevant to physiotherapy RM H : heart fai lure, hypertension
are: H PC : i SOB two weeks
ABGs on air: Pa02 1 0.2, PaC02 6.4, pH 7.4, HC03-
• i secretion of catecholamines, glucocorti
28.
coids and insulin
• i catabolism and protein breakdown, which Subjective assessment
consumes energy that could otherwise be
Can't stop coughing.
used for healing (O'Leary and Coakley,
Occasionally brings up phlegm.
1996)
Can't sleep.
• ! gastric emptying and i risk of aspiration
Daren't lie down.
(Beards and Nightingale, 1 994)
Exhausted.
• i respiratory rate, heart rate and BP
• release of thyroid hormones (which further Objective assessment
increase oxygen consumption), and anti
Apyrexial.
diuretic hormone (ADH, which retains fluid)
Oxygen via nasal cannu lae at 2 LJmin.
• perceptual distortion and impaired judge
Rapid shallow breathing with prolonged expiration.
ment and memory, which limit response to
Fluid chart and clinical assessment indicate
advice and education
dehydration.
• sleep disruption, which further augments
Speaking sets off paroxysms of coughing.
stress
Wheezy cough, usually non-productive.
• tendency to infection, gastric ulceration,
Clutches between legs when coughs.
muscle tension and blood clotting abnormal
Sits in chair day and n ight.
ities
Can mobilize slowly.
• depression
• exhaustion (Brannon et at. , 1 998). Questions
I . Analysis?
Clinical implications 2. Problems?
Stress depends less on the extent of illness and 3. Goals?
more on the circumstances, including how the 4. Plan?
patient is handled. Helplessness is a common ABGs arterial blood gases; HPC
= history of present
=
accompaniment to illness, especially in hospita complaint; RMH =relevant medical history; SOB =
lized patients, and the physiotherapist can do shortness of breath.

much by giving patients choices, listening to
their needs, involving them in decisions and
writing down advice to compensate for forgetful I;!f;gel�;;,'e';ii�iEMIiIi)->1
ness.
I . Analysis
Breathing pattern suggests i WOB.
Blood gases indicate hypoxaemia, hypercapnia and
I;ii�i'%1;IiIi) II;�j!, -
compensated respi ratory acidosis.
Uncontrolled coughing is largely i neffective and
Identify this 62-year-old patient's problems from contributes to fatigue.
the selected details of her case study, and answer Coughing, stress incontinence, immobil ity and fluid
the questions. She has an exacerbation of COPD. restriction are i nter-related.
26 ------
RECOMMENDED READING
2. Problems
SOB.
RESPONSE TO LITERATURE APPRAISAL
Fatigue.
Sputum retention. There is no logic to comment on!
Stress incontinence.
1 mobility.
RECOMMENDED READING
3. Goals Anderson, S. ( 1 990) ABG's - six easy steps to
Short term: control cough. clear chest. balance rest interpreting blood gases. Am. ]. Nurs. , 90(8), 42-
and exercise. 45.
Cornock, M. A. ( 1 996) Making sense of arterial blood
Long term: -educate patient and carers for home
gases and their interpretation. Nurs. Times, 92(6),
management.
3 0-3 1 .
4. Plan Gunning, M. P. and Hayes, M. A . ( 1 999) Oxygen

transport. Curro Anaesth. Crit. Care, 10, 3 1 9-324.
• Identify cause of poor sleep. e.g. SO B/cough/ Halliwell, B. ( 1 994) Free radicals, antioxidants, and
noise/anxiety. then remedy as able human disease: curiosity, cause or conse q uence?
• Educate on cough suppression for use when Lancet, 344, 721 -724.
cough is uncontrolled and non-productive Higgins, T. L. and Yared, J.-P. ( 1 993) Clinical effects
• Educate on mucociliary clearance. including fluid of hypoxemia and tissue hypoxia. Respir. Care, 38,
intake 603 -6 1 6.
• Educate on effective cough for when secretions Leach, R. M. and Treacher, D. F. ( 1 998) Oxygen
transport: tissue hypoxia. Br. Med. ]., 3 1 7, 1 3 70-
are accessible
1 3 73 .
• Show breathlessness management strategies
Mitchell, P . ( 1 999) Smoking i s a major cause of
• Teach pelvic floor exercises. including duri ng
blindness. Med. J. Austr. , 1 7 1 , 1 73 - 1 74.
coughing
Shapiro, C. M. and Flanigan, M. J. ( 1 99 3 ) Function
• Mobilize to toilet of sleep. Br. Med. ]., 306, 3 8 3 - 3 8 5 .
• Provide written daily program me for self-chest Stringfield, Y. N . ( 1 993) Acidosis, alkalosis, and
management and self-mobility ABGs. Am. ]. Nurs. , 93, 43-44.
• Liaise with team re oxygen therapy. getting Tobin, M. J. ( 1 9 8 8 ) Respiratory muscles in disease.
dressed. mobil ity Clin. Chest Med., 9, 263-286.
• Refer to specialist colleague for assessment of Treacher, D . F . and Leach, R. M. ( 1 998) Oxygen
continence transport: basic principles. Br. Med. ]., 3 1 7, 1 3 02-
1 3 06.
• Rehabi litate to independence. including family.
Wagner, P. D. ( 1 99 1 ) Clinical advances in pulmonary
gas exchange. Am. Rev. Respir. Dis. , 143, 8 8 3 -
888.
Westbrook, J. L. and Sykes, M. K . ( 1 992)
LITERATURE APPRAISAL Peroperative arterial hypoxaemia. The interaction
between intrapulmonary shunt and cardiac output.
Comment on the logic of the following conclu Anaesthesia, 47, 3 07-3 1 0.
sion from a research study.
Our data suggest that the use of postural

drainage and chest percussion in patients
without sputum production is not indicated.
CheH 1 980; 78: 559-64
--
-- 27
2 ASSESSMENT
SUMMARY
Introduction • Systemic hydration

Background information • Trachea
• Ward reports and meetings • Capillary refill
• Medical notes • Tactile vocal fremitus
• Patient observation charts Auscultation

Subjective assessment • Technique
• Respiratory symptoms • Breath sounds

• Other symptoms • Added sounds
• Functional limitations • Voice sounds
Observation Exercise tolerance

• General appearance Imaging the chest
• Colour • Systematic analysis
• Hands • Lateral film
• Oedema • Other tests

• Jugular venous pressure Respiratory function tests
• Chest shape • Working definitions
• Respiratory rate • Measurement of airflow obstruction
• Breathing pattern • Measurement of lung volumes
• Sputum • Gas transfer
• Sputum specimen and sputum induction • Respiratory muscle function

Equipment • Other tests
Palpation Mini case study
• Abdomen Literature appraisal
• Chest expansion Recommended reading
• Percussion note
INTRODUCTION of the assessment should be repeated after

Accurate assessment is the linchpin of physiother treatment to assess outcome.
apy and forms the basis of rational practice. A Specific aspects of assessment for rehabilita
problem-based assessment leads to reasoning such tion, intensive care and children are in Chapters
as: 'This patient cannot cough up his sputum by 9, 14 and 16.
himself. Why? Because it is thick. Why? Because
he is dehydrated. Why? Because he feels too ill to BACKGROUND INFORMATION
drink.' Illogical assessment leads to reasoning
such as: 'This is COPD, therefore I will turn the Ward reports and meetings
patient side-to-side and shake her chest.' It is the physiotherapist's job to clarify the indi
A thoughtful assessment will lead to both effec cations for physiotherapy to other staff and to
tiveness and efficiency because time will be saved explain which changes in a patient's condition
by avoiding unnecessary treatment. Relevant parts should be reported. No patient is 'too ill' or 'too
28
BACKGROUND INFORMATION
well' for physiotherapy. The ward report or phils, are part of the immune system and are
handover also provides the opportunity to check increased with infection. Clotting studies indicat
essentials such as whether the patient is drinking ing that a patient might bleed easily include low
and eating. platelet count, prolonged prothrombin time and
Apart from a daily report from the nurse in raised INR (see Glossary for details).
charge, any other opportunity to communicate"
should be taken, such as ward rounds and Chemistry
meetings. This not only improves patient care and The following are common electrolytes:
job satisfaction, it also boosts efficiency (Gosbee, • Sodium (Na + ) affects the osmotic pressure
1998). If physiotherapy notes are kept separately
of extracellular fluid.
from the medical notes, verbal communication
1 serum Na + (hyponatraemia) is due to
can be reinforced by writing physiotherapy infor
excess water administration or
mation in the medical notes, e.g. a resume of
inappropriate ADH secretion
treatment or request for a minitracheostomy.
i serum Na + (hypernatraemia)
Medical notes indicates dehydration
Necessary details from the doctor's notes • Potassium (K+) can impair diaphragmatic
include: contraction if its value strays either way
from normal
• Past and present relevant history
1 serum K+ (hypokalaemia) pre
• Social history, accommodation
disposes to cardiac arrhythmias and
• Other disorders requiring physiotherapy
can be caused by nebulized sym
• Conditions requiring precautions in relation
pathomimetic drugs (Hung et ai.,
to certain treatments, e.g. light-headedness,
1 999) or respiratory alkalosis
bleeding disorder, history of falls, swal
i serum K+ (hyperkalaemia) suggests
lowing difficulty/tendency to aspirate
kidney failure.
• Relevant investigations
• Chloride (Cn is the chief anion in extracel-
• Response to medical treatment
• Recent
lular fluid
cardiopulmonary resuscitation
1 serum Cl- accompanies acidosis,
(requiring close X-ray examination in case of
some kidney problems and prolonged
gastric aspiration or fracture)
vomiting
• Possibility of bony metastases
i chloride in the sweat can be
• Long-standing steroid therapy, leading to a
diagnostic of cystic fibrosis.
risk of osteoporosis
• History of radiotherapy over the chest. Urea is formed from protein breakdown and is
The last three findings contraindicate percussion excreted by the kidneys. High levels are caused by
or vibrations over the ribs. kidney failure, resulting from either disease or
impaired perfusion due to heart failure or shock.
Haematology Creatinine is formed from muscle breakdown and
A full blood' count assesses blood cells and is also renally excreted. Levels rise with kidney
coagulation. Haematocrit (packed cell volume) is failure and drop with malnutrition.
the ratio of red blood cells to whole blood. Albumin is secreted by the liver and forms
Haemoglobin is the protein that carries oxygen over 60% of serum protein. Reduced levels, due
to the tissues and acts as a buffer for acid-base to malnutrition, liver disease, nephrotic
balance. Reduced haemoglobin indicates syndrome, chronic inflammation or severe acute
anaemia, which causes fatigue and is poorly disease, reduce osmotic pull from the vascular
tolerated in people with heart disease. White space so that fluid escapes and causes oedema,
blood cells, including neutrophils and eosino- including pulmonary oedema.
---- 29
CHAPTER 2 AsSESSMENT
Microbiology/bacteriology heart rate of over 100 (tachycardia) may reflect

Microorganisms are identified by culturing increased sympathetic activIty, hypoxaemia,
specimens of sputum, pleural fluid or blood on hypotension, dehydration, anxiety, pain, fever or
various media which promote their growth. drugs such as the sympathomimetics, caffeine
Most bacteria grow in 24-48 hours but the and nicotine. The effect is to increase myocardial
tubercle bacillus may require 6 weeks. Sensitivity oxygen demand. HR below 60 (bradycardia)
tests identify appropriate antibiotics capable of may indicate profound hypoxaernia, arrhythmia,
killing the bacteria. heart block, effect of drugs such as beta-blockers
or vagal stimulation due to suctioning. Bradycar
Patient observation charts dia may be normal during sleep and in the physi
Charts record the vital signs of body tempera cally fit.
ture, blood pressure (BP), heart rate (HR) and Drugs and oxygen are documented on the
respiratory rate (RR). prescription chart. Their effects are monitored
Core temperature is one of the most tightly by, for example, peak flow and oxygen satura
guarded of physiological parameters and is main tion. Details are given in Chapter 5. The fluid
tained within 0.2°C of normal in humans chart should show a positive daily balance of
(Lenhardt, 1 997). It should be checked at every about a litre, because of insensible loss from the
visit because fever is the main harbinger of skin and respiratory tract (Luce et aI., 1 993, p.
infection. It also helps to clarify diagnosis 4 1 ). There are many reasons for a wide
because patients may be incorrectly referred with variation in this, including major fluid shifts
'a chest infection' when they have a different after surgery. However, a trend towards fluid
problem such as sputum retention or pulmonary overload might be associated with pulmonary
oedema. Fever may be accompanied by increased oedema, while a trend towards a negative
RR and HR because excess heat raises metabolic balance increases the risks of dehydration. Fluid
rate and oxygen consumption, causing 1 0% loss to the interstitial space is caused by altered
elevation for every 1 °C rise in temperature. hydrostatic or oncotic pressures, or increased
Clinical examination may distinguish respiratory capillary membrane permeability, leading to
from other infection. Pyrexia can have a non effective hypovolaemia.
infectious origin, e.g. atelectasis, pulmonary
embolism, lung fibrosis, blood transfusion and
SUBJECTIVE ASSESSMENT
drug reaction or overdose (Meduri, 1 990). A
slight pyrexia following surgery is a normal Osler supposedly said, 'Listen to the
reaction to tissue trauma, but fever beyond 48 patient. He is telling you the diagnosis', to
hours raises susplClOns of infection. The which I would add 'And she just might be
mechanism of fever is thought to be phagocyto telling you the best management too'.
SIS. Pitkin, 1998
Normal BP is 1 20/80. BP persistently above
The subjective assessment is what matters to the
140/90 is hypertension. BP below 90/60 in
patient. Problems such as breathlessness are
adults is hypotension. Patients with a diastolic
more closely related to quality of life than to
pressure above 95 mmHg should not normally
physiological measurements (Mahler, 1 995).
be tipped head down. Those with a systolic
A well-lit area is needed that is quiet, warm
pressure below 90 mmHg should be mobilized
and private. We can minimize the inequality of
only with close observation for light-headedness.
the relationship by:
The relevance of BP to exercise training, heart
surgery and manual hyperinflation is discussed in .• positioning ourselves at eye level if possible
Chapters 9, 1 0 and 14. • addressing adults by their surname, even if
HR is normally 60- 1 00 bpm in adults. A they are comatose (Wilkins et al., 1 995)
30
SUBJECflVE ASSESSMENT
• asking permlSSlOn before assessment and pneumonias, pneumothor�, fractured ribs

treatment. or pulmonary embolism.
• Angina pectoris: paroxysmal suffocating
Permission not only encourages patients' sel£. pain, greater with exertion or stress, due to
respect, it is a legal necessity in some countries. myocardial ischaemia. It is substernal or left
It is also good practice to ask before moving anterior, sometimes radiating to the left arm
personal items. or Jaw.
Before asking questions, introductions and • Musculoskeletal pain: e.g. costovertebral
explanations are required because the public tenderness due to hyperinflation, abdominal
perception of physiotherapy is often limited to muscle strain due to chronic coughing.
football and backache. Patients then need to • Raw central chest pain: worse on coughing,
define their problems and how these influence caused by tracheitis and associated with
their lifestyle. It is worth building up rapport at upper respiratory tract infection or excessive
this stage to encourage accuracy and set the coughing.
foundations for a co-operative relationship.
Respect for a patient's opinion is a potent moti Breathlessness may be cardiovascular,
vating factor. metabolic, neurogemc, neuromuscular or
respiratory. Respiratory breathlessness reflects
Respiratory symptoms excess work of breathing and is abnormal if
How long have symptoms been troublesome? inappropriate to the level of physical activity.
What is their frequency and duration, their Patients may deny breathlessness if it has
quality and severity? Are they getting better or developed gradually. Significant breathlessness is
worse? What are aggravating and relieving indicated by a need to pause during undressing
factors? The four cardinal symptoms of chest or talking, or an inability to walk and talk at
disease are wheeze, pain, breathlessness and the same time. A key question at each visit can
cough with or without sputum. be a comparative measurement for that indivi
A wheeze is caused by narrow airways and dual, e.g. how much can you do at your best/
increases the work of breathing. The feeling worst, what are you unable to do now because
should be explained to patients as tightness of of your breathing?
the chest on breathing out, not just noisy, If breathlessness increases in supine it is called
laboured or rattly breathing. Is the wheeze orthopnoea. In lung disease this is caused by
aggravated by exertion or allergic factors, pressure on the diaphragm from the abdominal
suggesting asthma? Is it confirmed objectively by viscera. In heart disease a poorly functioning left
auscultation? ventricle is unable to tolerate the increased
Is there pain? Chest pain may be musculoske volume of blood returning to the heart in
letal, cardiac, alimentary or respiratory in origin. supine. Paroxysmal nocturnal dyspnoea is
Many patients associate chest pain with heart breathlessness at night caused by orthopnoeic
attacks, and anxiety may modify their perception patients sliding off their pillows during sleep,
and description of it. Lung parenchyma contains leading them to seek relief by sitting up over the
no pain fibres but chest pains relevant to the edge of the bed.
physiotherapist are the following: Breathlessness caused by lung or heart
disorders can be distinguished by peak flow
• Pleuritic pain: this denotes the nature of the readings (McNamara, 1 992), auscultation, X-ray
pain rather than the pathology. It is sharp, signs or exercise testing. Detailed measurement
stabbing and worse on deep breathing, of breathlessness is described in Chapter 9.
coughing, hiccuping, talking and being Cough is abnormal if it is persistent, painful
handled. Causes include pleurisy, some or productive of sputum. It is caused by inflam-
31
Table 2.1 Characteristics of cough
Type of cough Possible causes
Dry Asthma, interstitial lung disease, recent viral infection, pollutants, hyperventilation syndrome, ACE
inhibitor drugs, mucosal irritation
Productive COPD. bronchiectasis, cystic fibrosis, chest infection
With position change or lying down Asthma, GOR, heart failure, bronchiectasis
Early morning COPD, postnasal drip
Chronic persistent Postnasal drip or GOR
With eating or drinking Aspiration of stomach contents, e.g. neurological disease, elderly people
With exertion Asthma, COPD, interstitial disease
Inadequate Weakness, pain, poor understanding
Paroxysmal Asthma, aspiration, upper airways obstruction
mati on, irritation, habit or excess secretions, but may be missed on auscultation but stimulated by
may be underestimated by smokers and people a cough. It is best to ask patients to show how
who swallow their sputum. Suggested questions they would cough to clear secretions, rather than
are: to ask them to 'show me a cough'.
• What started off the cough? Other symptoms
• Is there sputum?
Fatigue, weakness or both may be present,
• If so, what is the sputum like?
exacerbated by chronic disease, anaemia, depres
• Has it changed in quality or quantity?
sion or anxiety. Fatigue is closely associated with
• Is there sometimes blood?
breathlessness (Kellner et al., 1992) and depres
• Does the cough occur at night (suggesting
sion (Small and Graydon, 1 992), which can
gastro-oesophageal reflux (GOR) and/or
reduce motivation and the ability to co-operate.
asthma)?
Depression and anxiety may be expressed as
• Does it cause pain?
pain (Duckworth, 1999).
Table 2. 1 identifies the causes of different Dizziness needs to be clarified (Lakhani,
coughs. 1 996). Does the patient mean true vertigo, i.e. a
A cough caused by asthma or GOR should spinning feeling suggesting a lesion of the 8th
disappear once the condition is controlled. ACE cranial nerve or brain stem? Does s/he have
inhibitor drugs cause a cough in 1 0% of patients postural hypotension or hyperventilation
(Mathewson, 1 997), which disappears about 4 syndrome? Does dizziness precede a fall?
months after starting the drug. Other non A history of falls needs to be related to the
productive and 'habit' coughs, such as those history. Are falls related to blackouts, weakness,
following viral infection, usually disappear over breathlessness, footwear, eyesight, balance, lack
time, but dry coughs can perpetuate themselves of confidence or one of the causes of dizziness?
by irritating the airways. Factors that exacerbate Fainting or near-fainting may be caused by cardi
coughing include irritants such as perfumes and ovascular disorder, hyperventilation syndrome
cigarette smoke, or a change in air temperature, or 'cough syncope' following paroxysms of
especially when breathing through the mouth. A coughing.
postnasal drip is identified by the feeling of Reasons for poor mobility need to be identi
secretions sliding down the back of the throat, fied. Reduced mobility can lead to constipation,
followed by throat-clearing. exacerbated by dehydration, and urinary inconti
Listening to the cough will help the clinician nence, exacerbated by excess coughing. It is
to check for weakness and pick up sounds that useful to adopt the practice of asking patients
32
OBSERVATION
the cause of their symptoms. Their perceptions presence. Detailed observation can then be
are often surprisingly accurate. undertaken.
Functional limitations General appearance
Problems with activities of daily living, finance, Does the posture suggest fatigue, pain, altered
employment and housing loom large for people consciousness or respiratory distress? Breathless
with respiratory disease. How much daily people characteristically brace their arms so that
exercise do they take? Are they employed? How their shoulder girdle muscles can work as
many stairs are there at work or home? Is the accessory muscles of respiration. For mobile
environment well-heated, smoky, dusty? Do they patients, the gait gives an indication of mood,
live alone, eat well, smoke? Is it difficult to co-ordination, breathlessness or lack of arm
bathe, dress or shop? What support is available? swinging, which suggests muscle tension.
Limitation of activity is not in itself an accurate Is the patient obese, thus compromising
indicator of respiratory disease because of the diaphragmatic function, or cachectic, indicating
many variables, but a change in activity level is poor nutrition and weakness? If the patient is
noteworthy. unkempt, does this reflect difficulty with self
How does the patient feel about the disease? care or a measure of how the disease has
This question provides the opportunity for affected self-esteem? Is the patient restless or
patients to describe their feelings but does not incoherent, possibly because of hypoxia?
pressurize them. Anxiety is common if
symptoms are unpredictable. Other distressing Colour
factors are frustration, embarrassment, restricted Pallor is associated with anaemia, reduced
social function and a feeling of loss of control. If cardiac output or hypovolaemic shock. A
the patient spends the day flopped in front of plethoric appearance shows as a florid face indi
the TV, is this because of preference, exercise cating the excess red blood cells of polycythae
limitation or depression? mia. Cyanosis is blue coloration due to
A questionnaire is an efficient way of assessing unsaturated haemoglobin in the blood, caused by
symptom-related problems, functional activity respiratory or circulatory disorders.
and the patient'S emotional reaction to the Peripheral cyanosis shows at the fingers, toes
disease (e.g. Box 9.2). If the patient is unable to and ear lobes, and signifies a problem with circu
give a history, relatives can be questioned, lation. Stagnant blood gives up its oxygen and
bearing in mind that they may identify fewer the peripheries appear blue. Causes are a cold
problems and see them from a different perspec environment or pathology such as peripheral
tive. Details of previous experience with vascular disease.
physiotherapy give an indication of which inter Central cyanosis shows at the mouth, lips and
ventions have been beneficial. tip of the tongue, and indicates a gas exchange
Quality of life scales are sensitive to mild problem. It is an unreliable guide to hypoxaemia
disease (Ferrer, 1 997), more related to clinical and is identified at Sa02 levels that vary between
decisions than pulmonary function tests (Osman, 72% and 95% (Martin, 1 990b). Its detection
1997) and a useful predictor of survival (Squier depends not just on haemoglobin in the blood
et at., 1995). These are discussed in Chapter 9. but also on skin pigmentation, patency of
vessels, ambient lighting and keenness of the
observer's eye. It can be masked by anaemia or
OBSERVATION
exaggerated by polycythaemia. Cyanosis is a
Preliminary observation of the breathing rate warning rather than a measurement and its
and breathing pattern should be made before the absence should not lead to a false sense of
patient IS aware of the physiotherapist's security.
33
CHAPTER 2 AsSESSMENl
Hands Jugular venous pressure

The hands are a rich source of information. A In advanced lung disease associated with
poor cardiac output causes cold hands. CO2 pulmonary hypertension, pulmonary vascular
retention is indicated by warm hands caused by resistance impedes emptying of the right
peripheral vasodilation, and a flapping tremor of ventricle and engorges the jugular vein. With the
the outstretched hands (asterixis) that disappears patient lying at 45°, the head symmetrical and
when the hands drop to the patient's side. A fine supported to prevent accessory muscle activity,
tremor may be a side effect of bronchodilator elevated venous pressure is indicated by jugular
drugs, particularly in the elderly. Generalized venous distension. A flickering impulse repre
muscle wasting may be seen most clearly in the sents jugular venous pressure OVP). If the JVP is
hands. For patients who are unable to give a more than 3-4 cm above the sternal angle at
smoking history, nicotine stains provide irrefuta end-exhalation, the patient usually has right
ble evidence of the deadly habit. heart failure secondary to left heart failure or
Clubbing is recognized by loss of the angle chronic hypoxaemia. In the absence of cardio
between nail and nail bed, and in later stages by vascular disease, JVP represents the volume
bulbous ends to the fingers. Causes are: status of the patient. JVP increases with
abdominal contraction, decreases in dehydrated
• pulmonary: 75% patients and may not be visible in obese patients.
• cardiac: 1 0%
• liver or gut: 1 0% Chest shape
• other: 5% (Jefferies and Turley, 1999, p. The chest and abdomen should be as visible as
1 1 7). the patient feels comfortable with. A normal
chest shape is shown in Figure 2. 1 . Chronic lung
Pulmonary causes include fibrosing alveolitis and disease can lead to a rigid, barrel-shaped, hyper
infective disorders such as cystic fibrosis and inflated chest, with horizontal ribs and increased
abscess. Recent-onset clubbing may be the first anteroposterior diameter relative to transverse
sign of bronchial carcinoma (Sridhar et aI., diameter (p. 68).
1998). The exact mechanism of clubbing is Abnormalities of the chest wall may increase
unknown but it is associated with increased local the work of breathing (WOB); for example, a
perfusion due to fluid accumulation (Currie and restrictive defect can be caused by kyphoscolio
Gallagher, 198 8). Physiotherapist find clubbing sis. A kyphotic curvature exceeding 70°
supremely uninteresting because it is not affected increases the risk of respiratory failure and a
by physiotherapy. In relation to lung pathology, curvature exceeding 1 00° is associated with
it is only known to be reversed by lung resection hypoxaemia and cor pulmonale (Ras et at.,
or transplantation. 1994). Rarer conditions are pigeon chest (pectus
carinatum), which protrudes the sternum, and
funnel chest (pectus excavatum), which
Oedema depresses the sternum; these do not usually
Oedema is excess fluid in interstitial spaces. restrict lung function but may require cosmetic
Peripheral oedema accumulates at the ankles or surgery.
sacral area, depending on posture, and is usually
caused by kidney, liver, cardiac or respiratory Respiratory rate
disease. In the respiratory patient, it is associated A full minute is required to count the respiratory
with poorly perfused kidneys due to chronic rate acurately. Measurement obtained by
hypoxaemia and heart failure. More details are counting for 15 seconds and multiplying by 4 is
given on page 72. now considered worthless (Barnes, 1994, p. 17),
34
OBSERVATION
Upper lobe
}
Horizontal
R lung
fissure
only
Oblique fissure
Middle lobe
Lower lobe
Right
Left upper lobe
upper lobe
Left
lower lobe Right
lower lobe
Diaphragm
Figure 2.1 Lateral and posterior views of the lobes and fissures of the lung.
35
CHAPTER 2 ASSESSMENT
Table 2.2 Causes of abnormal respiratory rate
tRR �RR
Lung or heart disease Drug overdose

Pain or anxiety Brain damage
Anaemia Diabetic coma
Inspiratory muscle fatigue or weakness Exhaustion
Pulmonary embolus
Spontaneous pneumothorax
Fever
partly because of the wide adult range of 9-30

breaths/min (average 1 0-20/min). Tachypnoea,
or RR over 40/min, leads to respiratory alkalosis
and increases WOB because of extra turbulence.
RR below 8/min increases PaC02 and leads to
respiratory acidosis (Table 2.2).
Breathing pattern
Normal breathing is rhythmic, with active
inspiration, passive expiration and an inspiratory
to expiratory (I:E) ratio of about 1:2. Many indi
vidual variations are normal, the same ventila
tion being achieved by different combinations of
rate and depth or different combinations of
chest and abdominal movement. Other patterns Figure 2.2 Malnourished patient with soft tissues
suggest increased WOB and/or neurological draped over the bones and prominent stemomastoid
muscle.
defect. Laboured breathing is shown by the
following:
• Obvious accessory muscle contraction with forced expiration, adopted to stabilize

(Figure 2.2); prominence of the sternomas the airways internally and delay expiratory
toid muscle is also related to malnutrition, collapse. Although necessary for some
not just hypertrophy (Peche, 1996) patients with obstructed airways, PLB
• Indrawing/recession/retraction of soft tissues increases the overall work of breathing
of the chest wall on inspiration, caused by (Roa, 199 1 ), offers no mechanical advan
excessive negative pressure in the chest, tage (Ingram, 1967) and does not increase
which sucks in supraclavicular, suprasternal flowrate (Freedman, 1987). However it is
and intercostal spaces found beneficial by some patients during
• Forced exhalation with active contraction of acute episodes and may improve Sa02,
abdominal muscles, which compresses the although it does not improve oxygen
airways and increases WOB yet further uptake (Breslin, 1992), probably because of
(Ninane et ai., 1 992) without speeding impaired cardiac output (Cameron and
expiratory flow (Tobin, 198 8) Bateman, 1990). More details are In
• Pursed lip breathing (PLB), often associated Chapter 9.
36 --
--
OBSERVATION
t t
---- ...
'� (""--\f'
-----�/ ... ,� .
l
��
---
Figure 2.3 Paradoxical inward movement of the abdomen on inspiration, due to weakness or fatigue of the diaphragm.
Paradoxical breathing increases WOB, e.g. : raised PaC02' This is a danger sign indicating
that the patient may need mechanical assistance.
• Rib fractures may lead to a flail chest (p.
Periods of apnoea with waxing and waning of
407), when part of the chest wall is sucked in
the rate and depth of breathing are called
on inspiration and pushed out on expiration.
Cheyne-Stokes breathing when regular and
• The flattened diaphragm that occurs with
Biot's breathing when irregular. These indicate
hyperinflation can become in effect an
neurological damage, but Cheyne-Stokes
expiratory muscle, pulling in the lower ribs
breathing is also associated with end-stage heart
on inspiration (Hoover's sign, p. 69)
failure due to impaired blood supply to the
• If there is increased inspiratory load, or
respiratory centres, or may be normal in some
severe diaphragmatic weakness or paralysis,
elderly people. Irregular breathing often occurs
abdominal paradox may be observed, in
in normal REM sleep. Sighing respiration may
which the ineffective diaphragm is sucked up
indicate hyperventilation syndrome.
into the chest by negative pressure generated
in the chest during inspiration so that the
abdomen is sucked in (Figure 2.3). Palpation Sputum
distinguishes this from active contraction of Sputum is expectorated mucus from the respira
the abdominal muscles. tory tract. It is always abnormal because
bronchial secretions are swallowed in healthy
The following three signs indicate inspiratory
people. The characteristics of sputum are listed
muscle fatigue, weakness and/or overload
in Table 2.3.
(Mador, 1991):
Haemoptysis is expectoration of sputum
• abdominal paradox, as described above containing blood, which can be an alarming
• rapid shallow breathing, which reduces experience for the patient. It varies in severity
elastic loading (Mador, 1991) from slight streaking to frank bleeding. It is
• less commonly, alternation between abdom bright red if fresh, pink if mixed with sputum,
inal and rib cage movement so that each or rusty brown if it is old blood. Causes are:
muscle group can rest in turn, similar to
• bronchiectasis (intermittent, bright red)
shifting a heavy suitcase between alternate
• lung cancer (persistent)
hands.
• pulmonary tuberculosis (intermittent)
Tests for severe weakness or paralysis are • lung abscess (copious)
described on page 6l. • pneumococcal pneumonia (rusty red)
Exhaustion is presaged by lowered RR with • pulmonary oedema (pink, frothy)
37
Table 2.3 Characteristics of sputum
Appearance Possible cause
Serous, i.e. frothy (mixed with air), sometimes pink (blood squeezed
into alveoli) Pulmonary oedema
Mucoid, i.e. clear, grey or white, like raw egg white COPD, cancer
Thick Infection, dehydration
Purulent, yellow, green Infection, allergy, stasis of secretions e.g. bronchiectasis
Purulent, rusty red Pneumococcal pneumonia
Thick plugs Asthma
Stringy Asthma, poor oral hygiene
Thick, green, musty-smelling Pseudomonas infection
Blood-stained See haemoptysis, p. 37
• pulmonary embolus (bright red) For patients who require suction, a sterile
• blood clotting abnormality (fresh) mucus trap is incorporated into the circuit. This
• trauma such as intubation, tracheostomy, should be kept upright during suction to prevent
lung contusion or frequent tracheal suction the specimen bypassing the trap.
(fresh). Sputum induction is used when secretions
cannot be produced by mucociliary clearance
Haematemesis occurs when blood is vomited,
techniques and coughing, or when specimens are
and may be confused with haemoptysis. It is
required from the lower respiratory tract. It can
more likely to contain blood mixed with food
provide a greater yield than bronchoscopy
than with mucus and is distinguished by acidity
(Anderson, 1995) but tends to produce
and a dark brown colour that resembles coffee
specimens contaminated with oral pathogens,
grounds. It may be accompanied by melaena
especially with hospitalized or immunocompro
(digested blood passed per rectum) or nausea.
mised patients.
Close questioning is needed to identify whether
Hypertonic saline is used to irritate the airway
expectorated blood has been swallowed and
walls and draw water into the airways. Side
vomited or if vomited blood has been aspirated
effects include bronchospasm, breathlessness,
and expectorated.
oxygen desaturation and nausea. If TB or HIV
are suspected, a negative-pressure room is
Sputum specimen and sputum induction
required to mlmmlze cross-infection. The
Sputum cultures help to identify the pathogen
following sequence is advised:
responsible for a chest infection so that the
appropriate antibiotic can be given. They can • Explain procedure to patient including
also identify whether the presence of eosinophils possible side effects, obtain consent
or neutrophils indicate an allergic or inflamma • Ask patient to avoid food for two hours to
tory component respectively. However, often reduce risk of nausea
only upper respiratory organisms are identified • Ask patient to remove any dentures, then to
(Thistlethwaite, 1998) and most specimens are brush teeth, tongue, cheeks and gums with
contaminated by these bacteria, especially in water, not toothpaste, and a new toothbrush
intubated patients (Meduri, 1990). Patients are • Pretreat with a bronchodilator (Magnussen
advised to blow their nose, rinse their mouth and Holz, 1999)
and spit out saliva before expectorating • Attach oximeter to patient, prepare oxygen
(Gershman, 1996). Bronchoscopic brushings equipment in case of desaturation
provide cleaner specimens (p. 143). • Deliver 20-30 mL hypertonic (2.70/0 3 x =
38
PALPATION
N) saline by ultrasonic nebulizer over 1 0-20

minutes, the patient sitting up and taking
occasional deep breaths
• If Sa02 drops, give oxygen
• If Sa02 cannot be maintained above 90%, or
if there is haemoptysis, vomiting or distress,
stop
• Ask patient to gargle with sterile water to
reduce oral pathogens, then spit out saliva
• Ask patient to cough and expectorate into a
sterile container
• If mor.
discard the first Figure 2.4 Palpation for expansion. The fingers hold the
• Deliver promptly to the laboratory, as it sides of the chest and the thumbs rest lightly an each side of
must be processed within 2 hours the spine. On inspiration, symmetrical separation of the
(Magnussen and Holz, 1999) thumb tips indicates equal chest expansion. (From Wilkins,
If secretions are not forthcoming, teach R. L., Sheldon, R. L. and Krider, S. J. (1995), Clinical
•
Assessment in Respiratory Care, Mosby, Toronto)
ACB/AD (p. 1 94) or other mucociliary clear
ance technique
• Continue monitoring Sa02 for 30 minutes
• Record procedure and outcome in medical
notes Chest expansion
• Ensure patient is fed. Chest movement gives an indication of lung
expansion. It can be evaluated by inspection or
Successful specimens are usually watery and
palpation. Apical expansion is best assessed by
look like saliva to the naked eye.
standing at the foot of the bed and observing the
supine patient. For the rest of the chest, the
Equipment patient sits over the edge of the bed if possible,
Is oxygen being used as prescribed? Is it comfor and the clinician palpates from behind (Figure
table? Is the humidifier working? Are drips, 2.4).
drains, chest drains and machinery in order? While palpating for expansion, other signs
Details of equipment are covered in the relevant may be identified such as the crackling of
chapters. Oximetry is described on page 323. sputum or, around the neck and upper chest, the
popping of surgical emphysema (air in subcuta
neous tissue), which feels like crackling cello
phane.
PALPATION
Abdomen Percussion note

The abdomen enjoys a close relationship with A percussion note (PN) is elicited by tapping the
the diaphragm and should be gently palpated at chest wall (Figure 2.5). This is similar to tapping
every assessment. A distended abdomen inhibits a wine barrel to check how full it is, or tapping a
diaphragmatic movement, restricts lung volume wall to see if it is hollow. The PN evaluates the
and increases WOB. Causes include pain and density of underlying tissue to a depth of 5 cm
guarding spasm, obesity, flatulence, paralytic (Wilkins et al. , 1 995, p. 6 1 ) . It is useful for
ileus, constipation, enlarged liver, ascites and confirming breath sounds (e.g. bronchial
acute pancreatitis. breathing or diminished breath sounds) and is
39
Systemic hydration
Dehydration predisposes to:
• sputum retention
• pressure sores
• constipation
• confusion
• hypernatraemia (Palevsky, 1996)
• fatigue and 1 exercise tolerance (Barr, 1999).
A minimum 1500 mL of fluid is required per

day, which may not be achieved by people who
are ill or in an unfamiliar environment. Patients
at particular risk are:
• people who feel too sick to drink
• patients not on intravenous fluids
• the elderly, who often have reduced total
body water, altered perception of thirst,
impaired renal function and reduced mobi
Figure 2.5 Eliciting a percussion note over the chest.
One finger is placed firmly along an intercostal space and
lity, which inhibits self-regulation of fluids
struck by a finger of the opposite hand. To avoid damping and increases fear of urinary incontinence.
the vibrations, the percussing finger should recoil sharply like
a woodpecker striking a tree. (From Wilkins, R. L. , Sheldon, A patient who has cor pulmonale and does not
R. L. and Krider, S. J. (1995), Clinical Assessment in have swollen ankles should be closely examined
Respiratory Care, Mosby, Toronto) for dehydration.
Dehydration causes inelastic skin - but so
does ageing; it produces a dry tongue and lips -
but so do mouth breathing, oxygen therapy and
especially helpful if breath sounds are obscure, a blocked nose. Clinical assessment for dehydra
e.g. in patients unable to take a deep breath, tion is imperfect but the following are guide
those on noisy CPAP (p. 156) or those with loud lines:
crackles or wheezes. Each side of the chest
should be percussed alternately for comparison, • The skin over the sternum shows little loss
remembering that the upper lobe predominates of elasticity in the elderly. When pinched
anteriorly and lower lobe posteriorly. gently, it should bounce back rather than
The PN is resonant over normal lung tissue. 'tent', which indicates reduced turgor and
Hyperresonance indicates excess air, as in hyper dehydration
inflation or a large pneumothorax. A stony dull • The axilla has a dry, velvety feel in most
note is an unmistakable sound heard over a dehydrated people (Eaton et at., 1994).
pleural effusion larger than 500 mL. The PN is
an inexact guide to these conditions, which are Dehydration is also suspected in a patient
more easily detected by X-ray. Most useful to with dark urine, postural hypotension with a
the physiotherapist is the dull note of atelectasis, racing pulse, or increased urea, creatinine,
when air has been absorbed and alveoli have sodium and potassium levels. Weakness, malaise,
collapsed, or consolidation, which increases lung headache, nausea, vomiting, cramps and low
density by filling alveoli and creating a semi grade fever are indicative of, but not specific to,
solid area of lung. dehydration.
40
AUSCULTATION
Trachea Technique
Tracheal deviation is detected by palpating with The underlying lobes and fissures (Figure 2. 1 )
one finger on each side of the trachea. In the should b e visualized i n order to avoid listening
absence of thyroid enlargement, deviation is due optimistically for breath sounds over the kidney.
to shift of the mediastinum away from a large The diaphragm of the stethoscope is used for the
pleural effusion or tension pneumothorax, or a high frequencies of breath sounds. The bell is
shift towards upper lobe atelectasis or fibrosis, as used for the low frequencies of heart sounds and
confirmed by X-ray. A hyperinflated chest forces for small children. The ear pieces face forward
down the diaphragm and causes a tracheal tug in into the ears and the diaphragm is pressed firmly
which the thyroid cartilage is pulled down on on the chest to minimize extraneous sounds,
inspiration .. including the rustle of chest hair. The patient is
asked to breathe through the mouth, slightly
Capillary refill deeper than normal but not rapidly because this
With good circulation, pressing briefly on the causes light-headedness. Each area of lung is
fingernail is followed by rapid return of blood compared on alternate sides, asymmetry usually
flow. If capillary refill is slower than 3 seconds, indicating pathology.
reduced cardiac output or impaired digital The patient is best positioned sitting upright
perfusion is suspected. over the edge of the bed with arms forward to
protract the scapulae. Leaning forward in bed
Tactile vocal fremitus from long-sitting can be used as a compromise,
Palpation for the vibration of the voice gives but this position squashes the lung bases, and
similar information to vocal resonance (p. 43). breath sounds over this important area may be
Vibrations are reduced in people who are obese indecipherable. In patients who cannot sit up,
or very muscular. side-lying can be used, with allowance for a
louder sound in the dependent lung (Jones et at.,
1999) because of greater turbulence through
AUSCULTATION
more compressed airways and stronger sound
Auscultation is used to verify observed and transmission through denser lung. However,
palpated findings before and after treatment. there may be quieter sounds from the dependent
Prior to reaching for the stethoscope, it is worth lung if it is so compressed that airflow is
listening for sounds at the mouth, which are reduced. The diaphragm of the stethoscope
barely audible in a person with normal lungs. should be cleaned with alcohol wipes between
Noisy breathing indicates increased airflow patients (Smith et aI., 1996).
turbulence due to obstructed upper airways,
manifest as crackles or wheezes or both. Breath sounds
Crackles heard at the mouth should be cleared Breath sound intensity indicates either regional
by coughing in order to prevent them masking ventilation or factors that affect their transmis
other sounds during auscultation. A monophonic sion. Breath sounds are generated by turbulent
(single note) wheeze in the upper airways creates airflow in the large airways, then transmitted
a faint strangled sound at the mouth, greater on through air, liquid and solid to the chest wall,
inspiration, called stridor. This is a serious sign each substance attenuating the sound to a
denoting laryngeal or tracheal narrowing to a different degree. Sounds at the surface are
diameter as small as 5 mm (Thomas and Manara, filtered versions of those at the trachea. Sounds
1998). Stridor is a warning that nasopharyngeal are not generated beyond lobar or segmental
suction should be avoided and the patient's head bronchi because the total cross-sectional area is
kept elevated to minimize oedema. too wide to create turbulence (Jones, 1 995a).
--
-- 41
CHAPTFR 2 AsSESSMENT
The term 'breath sounds' is more accurate acoustically like a lump of meat in the lung, the
than 'air entry', because air may enter the lung solid medium transmitting sounds more clearly
but transmission of the sound can be blocked. than air-filled lung (Figure 2.6). Bronchial
Breath sounds may be normal, abnormal or breathing is also heard over small areas of
diminished. collapse provided there is a patent bronchus.
Normal breath sounds are muffled because air Bronchial breathing can also be heard over
in the alveoli filters the sound. Expiration is the upper level of a pleural effusion. The
shorter and softer than inspiration. Normal displaced and compressed lung transmits the
breath sounds are quieter in the base than the sound as if consolidated (Sapira, 1995). Low
apex because the greater volume of the lung pitched bronchial breathing may be heard over
bases filters the sound further. If breath sounds fibrotic lung tissue. Bronchial breath sounds
are difficult to hear and the patient is unable to indicate loss of functioning lung volume.
help by voluntary deep breathing, it is possible Diminished breath sounds are heard if:
to utilize the natural deep breathing following
exertion by listening immediately after the • the patient is obese, in a poor position or
patient has talked or turned or been suctioned. not breathing deeply
Bronchial breathing is an abnormal sound that • there is no air entry to generate the sound,
is distinguished by: e.g. atelectasis with occluded airway
• there is air entry but transmission of sound
• a hollow blowing quality on expiration
is deflected by an acoustic barrier such as
• long expiration
the air-solid or air-liquid interface of a
• a pause between inspiration and expiration.
pneumothorax or pleural effusion (Figure
It is heard over consolidation, which acts 2.6)
Sound generation
.
Sound transmission
Figure 2.6 Normal, abnormal and diminished breath sounds heard at the chest wall. BS: breath sounds.
42
AUSCULTATION
• there is air entry but insufficient airflow to may be heard in dependent regions, especially in
generate sound, or excess air in the lung that elderly obese people who have been recumbent
filters sound, e.g. hyperinflation as in emphy for some time. Late-inspiratory crackles are
sema or acute asthma (Pasterkamp, 1997). sometimes called fine crackles, dry crackles,
Velcro crackles or crepitations. Crackles are
Hyperinflated chests can sometimes be heard predominantly on inspiration but both
manually deflated to reduce FRC so that breath inspiratory and expiratory crackles are heard in
sounds are clearer. bronchiectasis (coarse) and fibrosing alveolitis
Inaudible breath sounds over the chest of a (fine).
person with acute asthma are a danger sign (p.
77).
Wheezes
Wheezes are generated by vibration of the walls
Added sounds of a narrowed airway as air rushes through.
Added sounds are superimposed on breath Expiratory wheeze, combined with prolonged
sounds. They are sometimes more obvious and expiration, is usually caused by bronchospasm.
can mask breath sounds. If added sounds are Wheeze on inspiration and expiration can be
louder on one side of the chest than the other, caused by other forms of airways obstruction
this may be caused by increased added sounds such as mucosal oedema, pulmonary oedema,
on the same side or reduced breath sounds on sputum, tumours and foreign bodies. A mono
the opposite side. Non-respiratory sounds occur phonic wheeze can mean local airway obstruc
independently of the breathing cycle and may be tion from a foreign body or tumour. A wheeze
transmitted from the abdomen, voice or water in increases the work of breathing.
humidifier tubing.
Pleural rub
Crackles Inflammation of the pleural surface occurs in
Crackles indicate secretions or parenchymal pleurisy, producing the sound of roughened
disorder (Piirila et aI., 1991) and are created surfaces rubbing on each other. This pleural rub
when air is forced through airways that have sounds like boots crunching on snow and is
been narrowed by oedema, inflammation or localized but best heard over the lower lobes
secretions, or when airless alveoli or peripheral because excursion of the pleura is greater basally.
airways snap open. They are principally heard
on inspiration and their timing depends on the Voice sounds
source. Early-inspiratory crackles arise in the The vibrations of the spoken word can be felt by
large airways, may be heard at the mouth, are the hands (tactile vocal fremitus) or heard through
independent of gravity and are often heard in the stethoscope (vocal resonance). The patient is
COPD. Early and mid-inspiratory crackles are asked to say '99' or engage in conversation.
characteristic of bronchiectasis or other hyper Voice sounds are normally an unintelligible
secretory disease. Absence of crackles does not mumble because vowels are filtered through air
always indicate absence of secretions Oones filled lung. Increased voice sounds, known as
and Jones, 2000). Late-inspiratory crackles bronchophony, are usually associated with
originate in alveoli and peripheral airways as bronchial breathing and are heard when the
they open at the end of inspiration and are voice is transmitted through a denser medium,
associated with pneumoma, fibrosis or e.g. consolidation or atelectasis with a patent
pulmonary oedema. airway. Reduced voice sounds are heard when
The weight of the lung itself causes a degree there is atelectasis with a blocked airway, or
of airway closure so that late-inspiratory crackles with pneumothorax or pleural effusion. Voice
------ 43
Table 2.4 The relation of respiratory conditions to clinical signs
Observation Percussion Breath sounds (BS) Added sounds Vocal

note resonance/tactile
vocal fremitus
Consolidation Normal Dull Bronchial breathing Increased
Atelectasis with Expansion sometimes Dull Bronchial breathing Increased

patent airway decreased over
affected area
Atelectasis with As above Dull BS decreased Decreased

occluded airway
Pneumothorax Expansion normal Hyperresonant Normal or decreased Normal or

or decreased or absent decreased or absent
Pleural effusion Expansion normal Stony dull BS decreased Decreased

or decreased Aegophony at upper Increased at upper
level of effusion level of effusion
Acute asthma Hyperinflated chest Hyperresonant BS decreased or absent Expiratory wheeze Normal
Emphysema Prolonged expiration Hyperresonant BS decreased Normal or

Pursed lip breathing decreased
Barrel chest
Chronic Normal Resonant, Normal Early inspiratory Normal

bronchitis i.e. normal crackles ± wheeze
Bronchiectasis Normal Resonant Normal Inspiratory and Normal

expiratory crackles
Pulmonary Normal Resonant Normal Crackles at bases Normal

oedema ± wheeze
Interstitial lung Expansion symmetrically Resonant Normal or decreased End-inspiratory Normal

disease decreased crackles
sounds transmitted above the liquid-air interface

EXERCISE TOLERANCE
at the top of a pleural effusion have a character
istic nasal bleating quality, a slightly different Exercise testing is used to assess patients for
form of increased vocal resonance called exercise trammg and to provide outcome
aegophony. measures. Other applications include assessing
Another confirmatory test is to ask the patient the effects of lung surgery, for which the
to whisper '99'. Over normal lung tissue, dynamic values of exercise testing are more
whispered words are barely audible, but through accurate than the static values of spirometry
a solid medium such as consolidation, individual (Tsubota et at., 1994).
syllables are recognizable. This is known as whis Exercise capacity is best assessed functionally
pering pectoriloquy. because:
Table 2.4 relates physical signs to different
disorders and Table 2.5 differentiates the sIgns • lung function tests are not a good predictor
of excess sputum and pulmonary oedema. of excercise capacity (Bradley et aI., 1999)
44
iMAGING THE CHEST
Table 2.5 Comparative signs of excess secretions and pulmonary oedema
Excess secretions Pulmonary oedema
History Lung disease Heart disease (may be secondary to lung disease)

Temperature i if chest infecton Normal
Fluid balance chart Normal Fluid retention usually
Crackles Patchy Bilateral, late-inspiratory, dependent
Secretions Mucoid or purulent Frothy, white or pink
Clearance of secretions By cough or suction By diuretics
Chest X-ray Normal, or related to lung disease Bilateral hilar flare, often enlarged heart, sometimes pleural effusion
Albumin Normal May be reduced
• laboratory tests are for physiological measure taken, in which the beam is directed from the
ment rather than monitoring of progress back (Figure 2.7).
• the patients own estimate of exercise toler This makes for an optimum view of the lungs,
ance is not objective and accommodates to a the patient taking a deep breath in the standing
slowly deteriorating capacity position with shoulders abducted so that the
medial borders of the scapulae do not obscure
Details are on page 2 19.
the lungs. The erect position ensures that gas
passes upwards, so that a pneumothorax is easier
IMAGING THE CHEST to detect, and fluid passes downwards, so that a
pleural effusion is easier to see.
The chest X-ray provides a unique insight into
the state of the lungs and chest wall. It does have
certain limitations, and physiotherapists should
not fall into the trap of 'treating the X-ray'.
• X-ray findings tend to lag behind other
measurements; for example, they are a later
indication of chest infection than pyrexia,
and pneumonia may have been resolved for
days or even weeks while X-ray SIgns still
linger.
• A normal radiograph does not rule out
disease because its contribution is structural
only. For example, the physical damage of
emphysema is more apparent than the hyper
secretion of chronic bronchitis because secre
tions do not show on X-ray, and
postoperative patients with impaired oxyge
nation may have a normal film (Wiener,
1992).
• The two-dimensional representation of a
three-dimensional object can obscure the
relationship between certain structures and Costophrenic
angle Stomach
hinder the accurate location of lesions.
If possible, a posteroanterior (PA) view IS Figure 2. 7 Normal PA film.
45
For less mobile patients, a portable film is Symmetry is correct if the spinous processes,
taken, with the rays passing anteroposteriorly which appear as teardrop shapes down the spine,
(AP), and the patient sometimes unable to take a are midway between the medial ends of the
deep breath. The heart is magnified by 1 5-20% clavicles. This check avoids misinterpretation
(Wiener et ai., 199 1), the anterior ribs are less about displacement of the heart, which is at the
clear and the lung fields are partly obscured by front of the chest. If the patient is rotated to
the scapulae and a raised diaphragm. Pleural either side, the heart shadow appears shifted
effusions appear as non-specific homogenous towards that side.
densities that are difficult to identify, although
they differ from parenchymal densities in that Trachea
vascular markings are visible through the The dark column of air overlying the upper
density. Whether patients are slumped ('erect vertebrae represents the trachea, which is in the
portable' film) or supine, results are similar. midline down to the clavicles and is then
Dense structures absorb rays and are opaque, displaced slightly to the right by the aortic arch
while air has a low density and appears black. before branching into the main bronchi. It may
Allowance should be made for normal variations move with the mediastinum if the heart is
between individuals such as different-shaped displaced, or it can be locally displaced (Figure
diaphragms. Chest films show bilateral symmetry 2.8).
for many structures, enabling opposite sides to
be compared.
Systematic analysis
Abnormalities can be identified as:
• too black
• too white
• too big
• in the wrong place.
A systematic approach is necessary to avoid
becoming diverted by the first obvious abnormal
ity. With practice this takes 30 seconds. Previous
films should be available for comparison. It is
useful to observe first from a distance and then
close up.
Preliminary checks
The patient's name and the date should be
checked. Then the projection is noted to see
whether it is a PA or AP film. This avoids misin
terpretation about the heart or diaphragm.
The exposure is then checked. An overex
posed film appears too black, and low-density
lesions can be missed. An underexposed film
appears falsely white. Correct exposure means Figure 2.8 Fibrosis in the right upper lobe pulling the
that vertebral bodies are visible through the trachea to the right. Fibrosis and an abscess are visible in the
upper but not the lower heart shadow. right mid and lower zones. The patient has TB.
46 --
--
IMAGING THE CHEST
Heart
The heart, sandwiched between the lungs, is the
main occupant of the mediastinum. Points to
note are:
1. Size: The transverse diameter is normally less
than half the internal diameter of the chest in
the PA film. An apparently big heart could be
the result of ventricular enlargement,
pulmonary hypertension or poor inspiratory
effort. A narrow heart is caused by
hyperinflation, when the diaphragm pulls
down the mediastinum (Figure 2.9), or it may
be normal in tall thin people.
2. Shape : In right ventricular hypertrophy, the
heart is boot-shaped, i.e. enlarged with the
apex lifted off the diaphragm. A rounded
heart might indicate pericardial effusion.
3. Position: The heart is normally extended
slightly left of midline. If displaced, it is
Figure 2. 1 0 A large pleural effusion fills the left chest,

obliterating the left lung and pushing the mediastinum away
from the effusion. The patient has TB.
pushed away from, for example, a large

pleural effusion (Figure 2. 1 0) or tension
pneumothorax (see Figure 14. 1 0) and pulled
towards a significant unilateral collapse
(Figures 2. 1 1, 2. 1 2), resection (see Figure
10. 1 2) or fibrosis (Figure 2.8).
4. Borders: These are obscured (silhouette sign)
if there is a lesion abutting the heart, e.g. in
middle lobe consolidation or collapse. A
lower lobe lesion does not obliterate the
border because it is on a different plane from
the heart. Lower lobe collapse may show as
flattening of the normally curved heart
border ('sail sign') plus loss of clarity of the
medial aspect of the hemidiaphragm.
Figure 2.9 Hyperinflation. The dark lung fields, low flat The term 'silhouette sign', strangely, means
diaphragm and narrow heart suggest that this patient has blurring of a border when air-filled lung on the
emphysema. same plane as the border is replaced by an
------ 47
Figure 2. 1 1 Atelectasis of the right lung, showing a

unilateral opacity with the mediastinum pulled towards the
collapse. The lung has collapsed because the right main Figure 2. 1 2 Atelectasis of RLL, showing shift of the
bronchus is blocked by a tumour. mediastinum towards the lost lung volume. RLL right lower
=
lobe.
opacity. Specific lobes are collapsed or consoli

dated if the following borders are obscured: seen in cross-section. Bilateral enlargement of
hilar shadows could be caused by pulmonary
• LLL: left hemidiaphragm
hypertension or lymph node enlargement.
• RLL: right hernidiaphragm
Unilateral enlargement raIses suspICIOns of
• LUL: aortic arch
malignancy.
• RUL: right upper mediastinum
• lingula: left heart border
Diaphragm
• middle lobe: right heart border.
1 . Height : On full inspiration, the diaphragm
(LLL = left lower lobe; RUL = right upper should be level with the 6th rib anteriorly,
lobe, etc.) 8th laterally and 1 0th posteriorly (Figure
2. 1), with the right side about 2 cm higher
Hila than the left because it is pushed up by the
Blood and lymph vessels make up the hilar liver. A low, flat diaphragm suggests
shadows, the left hilum being slightly higher due hyperinflation (Figure 2.9). An elevated
to the left main pulmonary artery passing above diaphragm could be:
the left main bronchus. Hila are elevated by - positional as in an AP film
upper lobe fibrosis, atelectasis or lobectomy and - physiological due to lack of a full
depressed by lower lobe atelectasis. Ring inspiration
shadows near the hilum are normal large airways - pathological due to pressure from below,
48
IMAGING THE CHEST
e.g. abdominal distension, or a shrinking

lung above, e.g. generalized lung fibrosis.
If one side of the diaphragm is raised, this
could be due to lower lobe atelectasis,
paralysed hemidiaphragm or, on the left,
excess gas in the stomach.
2. Shape : The diaphragm should be dome
shaped and smooth. Flattening is caused by
hyperinflation. Tenting is caused by fibrotic
lungs pulling upwards. Loss of clarity of the
smooth surface may be caused by lower lobe
or pleural abnormality.
3 . Costophrenic angles: These may provide the
first clue to problems that lurk behind the
dome of the diaphragm. The normal acute
angle may be obliterated by the patchy
shadow of consolidation or the meniscus of a
small pleural effusion. 200 mL of fluid needs
to accumulate in the pleura before blunting
the costophrenic angle.
4. Subphrenic: Air under the right
hemidiaphragm is expected after abdominal
surgery. If it persists more than a week
postoperatively, or appears spontaneously, it
Figure 2. 1 3 Right pneumothorax.
may indicate a subphrenic abscess or
perforated gut. An air bubble under the left
hemidiaphragm, sometimes containing fluid,
is usually in the stomach and therefore
indicates a pneumothorax (Figure 2. 1 3 ),
normal.
sometimes seen more clearly when the film is
turned horizontal. In conditions which reduce
Lung fields
Lungs that are too dark suggest hyperinflation ventilation to the bases, such as COPD or
pulmonary oedema, hypoxic vasoconstriction
(Figure 2.9). Lungs that are too white usually
causes upper lobe diversion by squeezing blood
indicate infiltrates or consolidation. Normal and
from the bases to match the better ventilated
abnormal features of the lung fields are the
upper lobes (Figure 2. 14).
following:
2. Horizontal fissure. If this is visible, it is
1 . Vascular markings. The fine white lines opposite the right hilum and meets the 6th rib in
fanning out from the hila are blood vessels, the axilla. More than a 1 0° incline is considered
which should be: abnormal.
3. Diffuse shadowing, e.g. :
• larger in the lower zones to reflect the
greater perfusion • ground glass appearance, a hazy density like
• visible up to 2 cm from the lung margin a thin veil over the lung, suggesting alveolar
• more prominent with poor inspiration. pathology
• reticular or a coarser honeycomb pattern,
A black non-vascular area demarcated representing progressive damage in intersti
medially by the white line of the visceral pleura tial disease (Figure 2. 15)
49
C HAPTER 2 AsSESSMENT
• • perihilar pattern fanning out from the hila,

suggesting pulmonary oedema (Figure 2. 14)
• the snowstorm appearance of acute respira
tory distress syndrome (see Figure 15. 1 0).
4. Localized opacities. Consolidation is repre
sented by a patchy opacity, often seen with
pneumonia, and usually occupying a lobe or
segment (see Figure 4.5). Bronchial tumours are
usually located proximally, while metastases may
be scattered. Streaky shadowing with some
traction on moveable structures suggests fibrosis
(Figure 2.8).
5. Unilateral white-out. Dense opacities can
be caused by lung collapse (Figure 2. 1 1) or
Figure 2. 1 4 Pulmonary oedema, showing enlarged pneumonectomy (see Figure 10. 1 2), which pull
heart, hilar flare and upper lobe diversion. The patient has a the mediastinum towards the lesion, or a large
coincidental fractured clavicle, which has been wired. pleural effusion, which pushes the mediastinum
away (Figure 2. 1 0).
Figure 2. 1 6 Diffuse shadowing of lung fields indicating

generalised pneumonia. Ring shadow at left costophrenic
Figure 2. 1 5 Interstitial lung disease, showing reticular angle is a bulla. Endotracheal tube and ECG leads are
pattern of lung fields and blurred heart borders. present.
50
IMA(.JNG THE CHEST
Figure 2. 1 7 PA and lateral films showing a lung abscess in the posterior basal segment of the middle lobe.
6. Ring shadows. These represent: mediastinum, fissure, hilum) towards the

collapsed area. There may also be crowding of
• a bulla (Figure 2. 1 6), which has a hair-line
vascular markings, with compensatory hyper
border, is air-filled and associated with
aeration of adjacent lung which appears darker.
emphysema or barotrauma
• a cyst, with a wall thickness over 1 mm,
Bones
often associated with bronchiectasis
The bones are examined with care following
• an abscess, sometimes containing a fluid level
cardiopulmonary resuscitation or other trauma,
(Figures 2.8 and 2. 17).
or if the patient is suspected of having osteo
7. Air bronchogram. Airways are visible if they porosis or malignant secondary deposits. A fresh
are contrasted against an opacity (Figure 2. 1 6). rib fracture is seen as a discontinuation of the
If an area of collapse has no air bronchogram, border of the rib, to be distinguished from over
the airway is obstructed. lapping structures that can be misleading. Old
8. Fluid line. This is a horizontal line, fractures are identified by callous formation.
sometimes with a meniscus at the edge, atop a Bony secondaries may appear as densities.
dense opacity. If it spans the width of the lung, If a patient has fractured ribs and the film has
it suggests a pleural effusion (Figure 2. 1 8). not yet been reported, it is advisable to ask a
radiologist to check the film before contemplat
Shadows caused by collapsed lung tissue may ing any positive pressure treatment because a
not be obvious, but atelectasis is indicated by pneumothorax may be hiding behind the cluster
shift of an adjacent structure (diaphragm, of rib shadows at the apex.
51
unless the ongm is identified. Breast shadows

may obscure the costophrenic angles in obese
people, and rolls of fat pressed against the plate
may be visible.
Hardware
A nasogastric tube is identified by its thin radio
opaque line and should pass into the stomach.
The distal end of the tracheal tube should rest
above the carina. Other tubes and lines are
discussed on pages 325 and 329.
Lateral film
A lateral film (Figure 2. 19) shows the lungs
superimposed on each other so that various
structures are either more or less distinguishable
than in the PA film.
Lesions that were concealed behind the
diaphragm or heart are now apparent, e.g. :
• lower lobe collapse may appear as a white
triangle at the costophrenic angle
• a pleural effusion of just 50 mL can now
blunt the costo phrenic angle
• if the oblique fissure is visible, any lesion
behind it is in the lower lobe.
Figure 2.20 shows middle lobe collapse, seen
through the heart shadow as a shrunken opacity
with clear margins indicating the fissures. The
horizontal fissure is no longer horizontal because
it has been pulled downwards by the collapsing
middle lobe. Lateral films are also useful if
accurate postural drainage is required, e.g. for an
abscess.
Other tests
Fluoroscopy
Fluoroscopy projects moving images onto a
Figure 2. 1 8 Lateral and PA films showing the fluid line monitor. Diaphragmatic paralysis can be identi
of a pleural effusion. Lateral film shows fluid seeping up into
the oblique fissure.
fied.
Radionuclide imaging
A VIr;), scan maps the distribution of ventilation
Soft tissues and perfusion in the lung. Radioactive gas is
Extrathoracic tissues cause shadows that project inhaled and then radioactive material is injected
onto the lung fields and can cause confusion into the blood stream. The distribution of each
52 --
---
IMAGING THE CHEST
Anterior ----.
Air in trachea
Aortic arch -r----_�

Sternum
Hilum
Heart
R hemidiaphragm
L hemidiaphragm
Costophrenic
angle
Figure 2. 1 9 Lateral film of a normal lung. The aorta is seen arching above and behind the heart. Dark spaces in front and
behind the heart are where the two lungs touch each other. The vertical white borders of the scapulae and the dark outline of
the trachea can be seen. The patient has a tracheostomy bib.
is traced by gamma camera, and the two images Computed tomography (CT)
are projected and compared. Areas of poor CT scans provide computed digital imaging
perfusion but good ventilation suggest pul from cross-sectional X-rays, viewed as if from
monary embolism or thrombosis (Figure 2.2 1). the patient's feet. Computer manipulation of
the data produces images in any plane, creating
Arteriography and bronchography greater sensitivity to soft tissues than conven
A pulmonary arteriogram is obtained by tional X-rays without interference from
injecting contrast medium through a peripheral overlying structures, at the cost of 1 00 times
vein, via the right heart and into the pulmonary the radiation dose of a plain chest film. CT
artery. This opacifies the pulmonary vascular scans identify consolidation, atelectasis,
tree and identifies pulmonary emboli. A bronch abscesses, cavities, pleural effusions, bullae, the
ogram involves injecting a contrast medium into thick-walled dilated airways of bronchiectasis
the airways to identify the dilated airways of and the progressive destruction of emphysema
bronchiectasis (see Figure 3 . 14). Angiography (Morgan, 1992) . They are particularly useful
and bronchography have been largely superseded with pneumothorax (Engdahl, 1993) and hyper
by the less invasive li/O, scan. inflation conditions (Newman et at., 1994).
53
Variations are:
• high-resolution CT, which uses thinner slices
for greater sensitivity to diffuse lung disease
and bronchiectasis
• spiral CT, which scans the whole chest with
one breath-hold, reducing radiation expo
sure and motion artefact due to breathing.
Magnetic resonance imaging (MRI)

MRI scans uses the magnetic properties of the
hydrogen atom to produce clear images of soft
tissues.
RESPIRATORY FUNCTION TESTS
ERV: expiratory reserve volume

FEV 1 : forced expiratory volume in one second
FRC: functional residual capacity
FVC: forced vital capacity
IRV: inspiratory reserve volume
PF: peak flow
RR: respiratory rate
Figure 2.20 Lateral view of atelectasis of middle lobe.

RV: residual volume
The shrunken lobe is seen through the heart shadow, its TLC: total lung capacity
lower boundary bordered by the oblique fissure and upper VC: vital capacity
boundary bordered by the horizontal fissure. The horizontal VT: tidal volume
fissure is no longer horizontal because it has shifted WOB: work of breathing
downwards to take up the lost volume.
Figure 2.2 1 Ventilation-perfusion scan showing normal ventilation (left) and patchy abnormal perfusion (right), suggesting
multiple pulmonary emboli.
54
REsPIRATORY FUNCTION TESTS
Respiratory function tests (RFTs) quantify lung indicates ability to breathe deeply and cough,
function in order to: reflecting inspiratory and expiratory muscle
strength. VC is sometimes reduced in obstructive
• define an abnormality, e.g. distinguish disorders and always in restrictive disorders. It is
restrictive from obstructive disorders also reduced by malnourishment (Lewis et ai.,
• indicate the progress of a disease or response 1986) and obesity (Buckley, 1 997). It is subject
to treatment to day-to-day fluctuations.
• provide risk assessment and preoperative
assessment. • Normal : 3-6 L, or approximately 80% of
Tests for airflow obstruction can be vital TLC
when used for detecting an impending asthma • For adequate cough: > 1 L.
attack in an asymptomatic patient.
Measurements vary with posture, sex, ethnic Forced vital capacity
origin, stature and age. Charts of 'predicted Forced vital capacity (FVC) : as above but with
values' take these into account. Some measure forced exhalation.
ments depend on fitness and time of day or year.
Respiratory function tends to be best in late • Normal: equal to VC
afternoon and worst in the early morning (Buff • COPD: FVC < VC because the manoeuvre
et ai., 1995).
causes airway collapse.
Working definitions Forced expiratory volume in one second (FEV 1 ) :

If two or more subdivisions of lung volume are the volume of gas expelled in the first second by
taken together, the sum is called a capacity. All a forced exhalation from a full inhalation.
values are approximate. The part of FVC that is most sensitive to
airways resistance is the first second of expira
Peak expiratory flow or peak flow (PF): the tion. This is a similar measurement to peak flow
highest flow that can be achieved during a but more accurate (Morice, 1 998), although the
forced expiration from full inspiration. accuracy of both measurements is limited in
PF measures the ease with which the lungs are people with hyperinflated chests because of the
ventilated and reflects resistance in the large effect of the deep breath on FRC (Pellegrino et
airways, expiratory muscle strength and effort. It at., 1 998).
is more useful in assessing the effectiveness of Low FEV1 relates to smoking (Dresler, 1996)
drug therapy for airflow obstruction than as a and progression of obstructive lung disease. It is
tool for clinical assessment (Holleman, 1 995). It an important indicator of disease severity, but
is one of the parameters measured on the flow there is only weak correlation with breathless
volume loop (p. 321). ness and quality of life.
Decline in FEV 1 averages 70 mL/yr in COPD
• Normal value: 300-600 L/min and 5 ml/yr in asthma (de Guia, 1 995). As with
• Severe airways obstruction: 75-100 L/min. any forced manoeuvre, it is difficult for breath
less patients to perform, may bring on bronchos
Vital capacity (VC): the volume of gas that
pasm in susceptible patients and is impaired
can be exhaled after a full inspiration (Figure
when muscles are weakened by poor nutrition. It
2.22) . is subject to day-to-day fluctuations.
VC represents the three volumes under voli
tional control (IRV, VT, ERV, see definitions • Normal : 70-800/0 of VC, or 2-4 L
following) and is useful for measuring ventila • Severe aIrways obstruction: < 60%
tory reserve in a co-operative patient. It predicted
55
C HAPTER 2 AsSESSMENT
IRV
I RV
VC
VT
TLC
ERV VT
ERV
FRC
} FRC
RV
RV
(a) Standing Supine
TLC
TLC
1I
T 1 fl�UU\l
A A AAA
RV
TLd'1'U
Normal
1 Obstructive
1 �
Restrictive
defect with defect
(b) hyperinflation
Figure 2.22 (a) Volumes and capacit ies. From Levitzky, M . G . (1999) Pulmonary Physiology, 5th edn, McGraw Hill, New
York) (b) Variations for different disorders. Hyperinflated lungs show increased TLC RV and FRC. Restrictive disorders show a
decrease in all volumes.
FEV1/FVC are reduced but there is a greater drop in

This expresses FEV 1 in relation to vital capacity FEVl)
and is more accurate than FEV 1 alone. • Restrictive disease: up to 1 00 (both · values
reduced but a greater drop in FVC).
• Normal: 70-80, i.e. FEVl = 70-80% of
FVC Total lung capacity (TLC) (Figures 2.22, 2.23):
• Moderate airflow obstruction: 50-60 total volume of gas in the lungs after maximum
• Severe airflow obstruction: 30 (both values inspirati on.
56
REsPIRATORY FUNCfION TESTS
and exhaled during one respiratory cycle (Figure

2.22).
This reflects the functions of the respiratory
centres, respiratory muscles and the mechanics
of the lung and chest wall. Tidal volume mixes
fresh gas with residual gas but never empties the
lungs, as when the sea refreshes a tidal pool.
• Normal: 1 0% of VC, approximately 3 00-
800 mL, average 7 mLlkg
• Increased to up to 500/0 of VC on exerCIse
(Luce et at., 1 993, p. 2 1 ).
Inspiratory reserve volume (IRV) : the extra

Figure 2.23 Volumes and capacities and the effect of a volume of gas that can be inhaled voluntarily
deep inspiration and deep expiration. Arrows represent the from end-inspiratory tidal volume (Figure 2.22).
direction of chest wall movement. (From Luce, J . M. and This is usually kept in reserve, but is used
Carver, B. H. ( 1 982) Respiratory muscle function in health
and disease. Chest, 8 1 ( I ), 82-90, with permission.) during deep breathing. It is determined by
inspiratory muscle strength, inward elastic recoil
of the lungs and the size of the starting point
(FRC + VT).
This is the sum of the four primary lung • Normal: 3 . 1 L.
volumes (VT, IRV, ERV, RV). Respiratory
muscles need to generate transpulmonary Expiratory reserve volume (ERV): the extra
pressures of 30-40 cmH20 (MacIntyre, 1 996). volume of gas that can be exhaled forcefully
from end-expiratory tidal volume (Figure 2.22).
• Normal: 3-8 L.
This is decreased with obesity, ascites or after
upper abdominal surgery.
Functional residual capacity (FRC) (Figures
2.22, 2.23): the volume of gas remaining at the • Normal: 1 .2 L.
end of a tidal exhalation.
This is a useful indicator of lung volume Residual volume (RV) : the volume of gas
because it does not depend on effort. It reflects remaining in the lungs after maximum exhala
the resting position when inner and outer elastic tion (Figure 2.22).
recoils are balanced. FRC decreases with restric RV is inhaled with the first breath at birth and
tive disorders. It increases with air trapping, and not exhaled until death, because the chest wall
the ratio of FRC to TLC is an index of hyperin prevents the lungs emptying completely.
flation. At low lung volumes, RV prevents the lungs
One purpose of the large volume of FRC is to collapsing, which would otherwise require a
dilute extreme changes in alveolar oxygen mighty inspiratory effort for reinflation.
tension with each breath. RV is measured by gas dilution or body
plethysmography. It is reduced with restrictive
• Normal in standing: 40% of TLC, approxi
disease and increased with air trapping or age.
mately 2.4 L
The ratio of RV to TLC is an index of hyperin
• Normal in supine: up to 2.2 L
flation.
• COPD: up to 80% of TLC.
• Normal: 20-30% of TLC, average 1 .2 L
Tidal volume (VT) : the volume of air inhaled • Hyperinflation: approximately 75% of TLC.
57
Minute volume/ventilation: The volume of gas • Demonstrate the technique with a separate
breathed in or out per minute, i.e. VT x RR mouthpiece
• Ensure the patient holds the meter horizon
• Normal: 5-7 L/min
tally
• COPD: approximately 9 L/min
• Ask the patient to take a deep breath, then
• Acute respiratory failure: approximately
to make a firm seal on the mouthpiece and
1 0 L/min, but the patient may not be able to
blow 'short, sharp and as hard as possible'.
sustain the WOB required to maintain a
stable PaC02 The limitations of PF measurements are that
• On brief hard exercise: up to 150 L/min. they depend on motivation and are inaccurate
for children under 4, sensitive only to resistance
Maximum voluntary ventilation (MVV): volume in the large airways, inadequate for monitoring
of air inhaled and exhaled with maximum effort annual decline in lung function (Tirimanna,
over 1 5 seconds. 1 99 6 ) and variable in reliability at middle and
Correlates with FEV 1 but particularly relates high flows (Miller and Ouanjer, 1 994) . PF
to maximum ventilation on exercise. Susceptible meters should be tested regularly, the portable
to motivation. Reduced with smoking (Dresler, models replaced annually, and the same device
1 99 6 ) . used for the same patient. They are available on
• Normal: 50-200 L/min. prescription in the UK.
Measurement of airflow obstruction Spirometry

Serial measurements should be taken on well A spirometer such as the Vitalograph is used to
rested patients in the same posture at the same measure FEV 1 and FVC (Figure 2.24). It is more
time each day. This minimizes the normal daily tiring than measuring peak flow, and values vary
variation, which can be greater than the with posture and effort.
improvement with bronchodilator drugs (Burge, Instructions are similar but, instead of a short
1 992) . In asthma, peak flow and FEVl are sharp blow, patients are exhorted to 'blow the
lowest in the early morning. living daylights out of the machine and keep
blowing until your lungs are empty'. Much unin
Peak flow hibited encouragement is required, repeated on
A peak flow meter provides a quick and simple subsequent measurements. Nose clips are not
indication of airways obstruction. Three tests are necessary (Pina et at., 1 997).
performed, with a rest in between, and the best If a relaxed, not forced, vital capacity is
is recorded. Suggested guidelines are: required, the patient blows out from maximal
• Ask the patient to avoid tight clothes, a full inspiration but at a comfortable and sustained
bladder, vigorous exercise within the last 30 speed until no more can be exhaled (BTS, 1 994).
minutes, a heavy meal within 2 hours and, if
possible, smoking within 2 4 hours (BTS, Further measurement of large airways resistance
1 9 94) Airflow resistance in the large airways depends
• Explain the purpose and technique of the on flow at the mouth and the pressure difference
test, because the meter is effort-dependent between mouth and alveoli. Flow at the mouth
and reliability depends on the patient under is measured by a pneumotachograph" which
standing and not feeling hurried detects the pressure drop across a slight resis
• Have the patient seated upright if possible, tance placed in the airstream. Pressure difference
avoid occluding the exhaust holes, check the is measured in an airtight body box called the
pointer is at zero plethysmograph.
58
During inspiration, flow is dependent on

"0
FVC effort throughout. During expiration, the
�
'0.
)(
highest flow occurs initially, where it is effort
Q)
Q)
dependent and represents large airway function.
E After a small proportion of VC has been
::J Normal
'0
>
expired, flow is independent of effort because
FEVl of greater dynamic compression with more
- = 70
FVC positive intrapleural pressures (Levitzky, 1 995,
p. 47). Flow then depends solely on elastic
1 sec recoil and small airways resistance. In obstruc
tive disease, expiratory flow shows a concave
appearance representing sudden attenuation of
"0
�
expiration as floppy airways collapse or
'0.
)(
narrowed airways obstruct. Interstitial restrictive
Q)
Q)
disease shows rapid flow during exhalation due
FVC
E
::J
to stiff lungs.
'0
> FEV1
Maximum mid-expiratory flow (MMEF,
Obstructive MEFso or FEF2S_7S or FEFso) is the mean forced
defect expiratory flow during the middle half of FVC
1 sec
and is used to measure small airways resistance.
It is independent of effort because only the
"0
�
inspiratory phase and first 25% of the expiratory
0.
)(
phase is effort-dependent.
Q)
Q)
E Measurement of lung volumes
::J FVC
'0 FEV1
> The lung cannot be completely emptied volunta
FEV1
-- > 70
Restrictive rily and always retains a residual volume of gas,
FVC defect so lung volumes are measured indirectly. FRC is
1 sec estimated by one of the following:
Figure 2.24 Spirograms, Normal trace shows most of • plethysmography: air in the chest is
the FVC expelled within I second , The decreasing slope of compressed and lung volume calculated from
the curve is caused by progressive airway compression and the change in pressure
lower elastic recoil as the subject exhales, Obstructive • gas dilution: air in the lungs is mixed with
pattern shows prolonged expiration, Restrictive pattern
shows reduced FVC, all of which is expelled within I second
an inert gas such as helium, the dilution
due to augmented recoil. of which gives an indication of lung
volume
• nitrogen washout: the nitrogen content of
air is known to be about 8 0%, and lung
Further measurement of small airways resistance volume can be calculated by having the
Detection of resistance in the 'silent zone' of the patient breathe nitrogen-free gas and
small airways, where changes occur in the early measuring the expired nitrogen.
stages of COPD, can improve the success of
treatment before changes are irreversible. TLC and RV can be measured by using one of
The flow-volume loop records flow and these measurements plus spirometry.
volume during forced inspiration and expiration Table 2.6 compares the RFTs for obstructive
(Figure 2.25). and restrictive lung disease.
59
Normal COPD Asthma
t
�
0
"§
.0
Q)
x.
"§ W
==
0 0
u::
�
0
"§
.0.
(/)
c
1 TLC Lung volume

RV
Restrictive disease
Figure 2.25 Flow-volume loops. The inspiratory loop is below the line and the expiratory loop above the line. Increasing
severity of obstructive lung disease (asthma and COPD) is reflected by increasing concavity of the effort-independent portion of
the expiratory curve. Restrictive pattem is represented by a small loop and rapid expiration .
transfer capacity for carbon monoxide (TLCO)

Gas transfer is measured by the patient taking a single deep
Gas transfer (transfer factor) indicates the breath of a gas that includes carbon monoxide,
transfer of gas by measuring the surface area of breath-holding for 1 0 seconds, then exhaling.
the alveolar-capillary membrane. The total lung The amount of expired carbon monoxide reflects
its diffusion across the alveolar-capillary
membrane.
Table 2.6 Effect of obstructive and restrictive disease on Reduced TLCO indicates VAlQ abnormality,
volume and flow measurements low haemoglobin, advanced age or impaired
diffusion due to an abnormal alveolar-capillary
Obstructive Restrictive
membrane, especially in relation to smoking
Tidal volume N N od (Dresler, 1 996). TLCO is closely correlated with
VC N or 1 1 exercise limitation (Wijkstra, 1 994) and breath
Peak flow 1 N or 1 lessness due to emphysema or lung fibrosis
FEVI 1 N
FVC N or 1 1 (O'Donnell and Webb, 1992). It is reduced in
FEV1/FYC 1 N or i bronchiectasis and emphysema. It is low in
RV i N or 1 heavy smokers (who have excess carboxyhaemo
FRC i 1
TLC i 1 globin), malnutrition and anaemic states, and
high in polycythaemia.
60
Gas transfer is affected by diffusion proper fitness and compliance of the lung and
ties, alveolar volume and capillary blood. The chest wall.
old term 'diffusing capacity' is less accurate • Maximum static mouth pressures (Chatham
because it encompasses only the passage of gas et a!. , 1 994) can measure inspiratory or
from alveoli to blood. expiratory pressures:
maximum inspiratory pressure (MIP),
indicating strength of the inspiratory
Respiratory muscle function
muscles is measured from either RV or
Inspiratory muscle strength is proportional to FRC and maintained for one second
exercise capacity (Wijkstra, 1 994). Bilateral - maximum expiratory pressure (MEP),
paralysis or severe weakness of the diaphragm indicating strength of the expiratory
shows the following signs: muscles, is measured from TLC.
A pressure gauge or transducer is connected
• orthopnoea unexplained by heart or lung
to a mouthpiece, the patient inhales or
disease
exhales sharply, keeping a firm lip seal and
• accessory muscle activity unexplained by
taut cheeks, and the best of three efforts is
lung disease
recorded. A small leak in the system prevents
• abdominal paradox during inspiration, espe
inspiratory mouth suction, which would give
cially in supine when the weakened
artificially high readings for MIP. Technique
diaphragm is unable to counteract pressure
must be meticulous and patient position
from the abdominal contents
standardized because normal values vary 1 0-
• postural fall in vital capacity of 50% in
fold (McKenzie, 1 994) as a result of
supine compared to upright (Tobin and
variations in:
Yang, 1 990)
- initial lung volume
• symptoms of nocturnal hypoventilation such
- learning effect of the test
as morning headache and daytime somno
patient effort
lence
- ventilatory drive
• non-specific symptoms such as breathlessness
- nutritional status.
or recurrent chest infections.
MIP and MEP above 80 cmH20 indicate
Bilateral diaphragmatic paralysis effectively adequate inspiratory muscle strength and
removes a portion of the chest wall. When ability to cough respectively. High values
upright, patients exhale by contracting the exclude muscle weakness but the reverse is
abdominal muscles to push up the diaphragm, not necessarily true because low values may
then allow passive inspiration by relaxing them. be due to insufficient patient co-operation
Unilateral diaphragmatic paralysis shows (Siafakas et a!. , 1 999).
nocturnal hypoxaemia due to VAiQ mismatch in
supine, unilateral abdominal paradox on sniffing Other tests include the following:
and a raised hemidiaphragm on X-ray.
The following tests for inspiratory and expira • For non-paralysed ventilated patients,
tory muscles are suitable for patients who are inspiratory strength can be measured with a
able to co-operate: one-way valve, after explaining to the
patient that the airway will be briefly
• Vital capacity (VC) is simple but relatively occluded (Wilkins et at., 1 995, p. 257).
insensitive and non-specific. Small pressures • The following non-volitional tests measure
are required to inflate the lung and a fall the strength of the diaphragm only (Harris
in VC only occurs with severe muscle and Moxham, 1998):
weakness. Results are influenced by effort, - transdiaphragmatic pressure is obtained
61
by comparing oesophageal (pleural) and

gastric (abdominal) pressures, usmg Other tests
swallowed balloons
Oxygen consumption (V02) and carbon dioxide
- phrenic nerve stimulation or relaxation
production (VC02)
rate of muscle are relatively accurate
V02 and VC02 are measured by analysis of
measurements
inhaled and exhaled gas volumes. When
magnetic nerve stimulation monitors the
compared to predicted values for age and sex,
progression of muscle weakness and
aerobic and anaerobic contributions to metabolic
assists diagnosis.
activity can be assessed .
• Nocturnal hypercapnia suggests that inspira
tory muscle strength is below 3 00/0 of normal
Maximum oxygen consumption (V02 max )
(Hahn et ai. , 1 997).
V02 max quantifies maximum exercise tolerance
Respiratory muscle endurance is difficult to by indicating the point at which the anaerobic
measure and cannot necessarily be inferred from threshold is reached. Normal V02 max is
strength. It is assessed by MVV (p. 58), which is > 25 mLlkglmin, or 25 times the resting level,
influenced by co-ordination, pulmonary representing the point at which oxygen demand
mechanics and effort. It is not valid in people exceeds availability and lactic acid is produced.
with COPD who are unable to generate high It is an exhausting test that entails measuring
flow rates (Hopp et al. , 1 99 6 ) . expired air while workload is increased. Less
Box 2. 1 Checklist of the major points of pulmonary assessment
Patient's notes • Chest shape

• History (past, present, social, • Respiratory rate
occupational) • Breathing pattern
• Investigations • Sputum
• Risk factors
Equipment
Charts • Oxygen, oxygen analyser, oximeter
• Temp, BP, HR, RR • Humidification
• Medication • Drips, drains, chest drains
• Oxygen prescription • Monitors, ventilator
• Oxygen saturation
Palpation
• Arterial blood gases
• Abdomen
• Peak flow
• Chest expansion
• Fluid balance
• Percussion note
Subjective assessment • Hydration
• Symptoms
Auscultation
• Functional limitations
• Breath sounds
Observation • Added sounds
• Appearance • Voice sounds
• Colour
Exercise tolerance
• Hands
• Oedema Chest X-ray
62
LITERATURE APPRAISAL
distressingly, submaximal V02 max can be used Subjective

to estimate V02 max' V02 max is not a reliable U nable to speak because of cerebral palsy.
guide to aerobic capacity in patients with Patient's mother says he feels tired and would like
respiratory disease if peak exercise is limited by to go home. He has not eaten for a week since
breathlessness. It is expensive and lengthy, and is returning to the ward.
normally used for research or clinical purposes
such as assessing suitability for lung resection Objective
(Bolliger, 1998). Cachectic.
Kyphoscoliotic.
Oxygen cost of breathing Curled up in bed.
This is assessed by determining the total V02 at Breathing pattern shallow but not distressed.
rest and the increased level of ventilation Chest clear.
produced by hyperventilation. The added Observations normal.
oxygen uptake is attributed to metabolism of the
Questions
respiratory muscles.
I . Analysis?
2. Patient's problems?
3. Goals?
4. Plan?
RESPONSE TO M I N I CASE STUDY
I. Analysis
Figure 2.26 shows a pneumothorax in the left
upper zone and bulla in the left lower zone,
probably due to protracted mechanical ventilation
and malnutrition. The radiograph also shows diffuse
opacities, probably due to multiple aspirations of
food into the lu ngs because of difficu lty swallowing.
Kyphoscoliosis is due to cerebral palsy. Lung
problems would not be directly responsive to
physiotherapy.
2. Problems
Swallowing difficulties and malnutrition.
I m mobi lity.
Figure 2.26 Mr TA
3. Goals
Identify this young man's problems after he has
Improve nutrition through mu ltidisciplinary
returned to the ward following lengthy mechanical
teamwork.
ventilation and difficult wean ing. Then answer the
Optimize mobil ity.
questions.
Rehabilitate to home circumstances.
Background
4. Plan
Impaired swal lowing due to cerebral palsy.
Lives at home with his mother who is his carer. Liaise with speech-language therapist, doctor, head
Fully dependent. nurse, dietician
63
Daily written programme of bed mobility exercises, with postural drainage. Exercise performance
using diary to document progress may or may not improve with inspiratory muscle
Liaise with patient's mother over manual handling training, depending on the limiting factors.
Liaise with social worker and occupational therapist
for home support.
RECOMMENDED READING
Hodgkinson, D. W., O'Driscoll, B. R. and Driscoll, P.

A. ( 1 993) Chest radiographs. Br. Med. ]. , 307,
LITERATURE APPRAISAL 1 202-1 206, plus correction: Br. Med. ]. , 307,
1417.
Comment on the logic of the following
McCord, M. and Cronin, D. ( 1 992) Operationalizing
statement in a study evaluating exercise perfor
dyspnea: focus on measurement. Heart Lung, 2 1 ,
mance: 1 67- 1 79 .
[We] examined . . . leg muscle training, Muldoon, M . F. ( 1 99 8 ) What are quality o f life
inspiratory muscle training and postural measurements measuring? Br. Med. ]. , 3 1 6, 542-
545.
drainage . . . the largest effect occurring
Pasterkamp, H. ( 1 9 97) Respiratory sounds. Am. ].
with leg muscle training.
Respir. Crit. Care Med. , 156, 974-987.
Austr. ]. Physiother. 1 992; 3 8 : 189 - 1 93
Quanjer, P. H. ( 1 993) Lung volumes and forced
ventilatory flows. Eur. Respir. ]., 6(suppl.), 5-40.
Worthy, S . ( 1 995) High resolution computed
tomography of the lungs. Br. Med. ]. , 3 1 0, 6 1 5-
6 1 6.
Not surprising. Training is specific. Exercise Zurek, A. M. and Swinburn, C. R. ( 1 995) Pulmonary
performance would not be expected to improve function tests. Care Crit. Ill. , 1 1 , 230-234.
64
3 OBSTRUCTIVE DISORDERS
SUMMARY
Introduction Allergic bronchopulmonary aspergillosis

Chronic obstructive pulmonary disease Inhaled foreign body
Asthma Mini case study
Bronchiectasis Literature appraisal
Cystic fibrosis Recommended reading
Primary ciliary dyskinesia
INTRODUCTION CHRONIC OBSTRUCTIVE PULMONARY DISEASE
It would be convenient to divide lung diseases The insidious onset, lacking the jolt of a
into those of airways and those of parenchyma, first heart attack, may take away its ability
thus identifying them according to the functions to provide a sharp motivational shock.
of ventilation and gas exchange, but the body Jarvis, 1995
refuses to be neatly classified, and conditions
such as COPD straddle the fence. Lung disorders The common disease entity of chronic bronchitis
are usually divided into obstructive and restric and emphysema is known as COPD (chronic
tive disease, plus those that fit neither or both obstructive pulmonary disease), COAD (chronic
categories. obstructive airways disease), CAO (chronic
The management of the problems associated airflow obstruction) or CAL (chronic airflow
with these disorders is covered in Chapters 5-9 limitation). Asthma can overlap with COPD
but, when specific to a disease, management is (Figure 3 .2) but is usually classified separately,
also discussed in this chapter and Chapter 4. even though it is a chronic obstructive disease of
Rare disorders are defined in the Glossary. the airways. COPD is a slowly progressive
Airways obstruction increases airflow resis disease and most airways obstruction is fixed,
tance and the work of breathing, as indicated by although some reversibility may be demonstrated
decreased peak flow rates. Causes are: with medication (O'Driscoll, 1 9 97).
COPD is laden with gloomy statistics:
• reversible factors, e.g. inflammation, bronch
ospasm or mucus plugging • It is the third most common cause of certi
• irreversible factors, e.g. fibrotic airway walls fied illness in the UK (Gravil et at. , 1 9 9 8 )
or floppy airways as a result of loss of the • I t i s the fifth greatest cause o f disability
elastic recoil that normally supports them worldwide (WHO, 1 996)
(Figure 3 . 1 ) • It is the only major cause of death increasing
• localized lesions, e.g. upper airway tumour in prevalence (Oh, 1 997, p. 228)
or foreign body. • It is common in elderly people but often
65
CHAPTER 3 OBSTRUCTIVE DISORDERS
(a)
Airway held open by elastic

recoil of adjacent lung tissue
�g
Elastic recoil affecting
alveolus
/ \
(b )
Reversible component Irreversible component

�A� �\(
__ �A� �\
(�
____________ ______ ____________ ________ ____________
Fibrosis I
,
Inflammation ,
,
Mucus ,
,
Bronchospasm I
Floppy airways I
due to loss of Loss of elastic
tethering effect recoil and
of elastic recoil breakdown of
alveolar wall
Figure 3.1 Mechanism of airways obstructi on: (a) normal ; (b) COPD,
underdiagnosed and undertreated despite its

8 9 symptoms (Kinsman et at., 1 9 8 3 ) Pathophysiology
• I t i s largely preventable (Huib, 1 999).
Chronic bronchitis
Causes Chronic bronchitis is a disease of the airways. It
Smoking is the major contributor to COPD. Risk is characterized by excess mucus secretion and
factors are poverty (Prescott, 1 999) and being productive cough. The cough is called a
male, which are both associated with smoking. smokers' cough in the early stages but once
Other factors are occupation, housing, climate, mucus production has been excessive for 3
childhood respiratory illness (Clarke, 1 9 9 1 ) and months a year for over 2 years, this becomes the
in utero exposure to smoking or malnourishment inadequate but traditional definition of chronic
(Barnes, 1 995). bronchitis.
66
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
Chronic
bronchitis
Asthma
Emphysema
Figure 3.2 Rel ationship between the commonest

obstructive lung diseases.
Repeated inhalation of tobacco smoke

irritates the sensitive lining of the airways, Figure 3.3 Destruction of the alveolar walls caused by
leading to inflammation, mucus hypersecretion smoking. (From M il ne, A. (1998) Smof<jng: The Inside Story,
and sometimes bronchospasm. Inflammation is Woodside, Stafford, with permission. Artist: James
the key process. It causes narrowing first in the Northfield)
distal small airways and then in the proximal
large airways. Acute inflammation resolves but a disease of alveoli and smallest airways, with
chronic inflammation leads to fibrotic changes secondary effects on other airways. It is usually
and scarring. Mucus hypersecretion due to caused by damage to the alveoli from smoking.
mucosal damage is associated with a rampant Occasionally a congenital lack of alphal-anti
increase in the size and number of mucus trypsin causes primary emphysema in earlier life
secreting goblet cells. Excess mucus has tradi (Wencker et ai. , 1 9 9 8 ) .
tionally engaged the attention of physiothera Protein breakdown I S the villain of
pists but causes little overall airways obstruction emphysema (Figure 3 .3), leading to erosion of
and does not correlate with physiological distur alveolar septa, dilation of distal airspaces (Figure
bances (Faling, 1 986) nor mortality (Wiles and 3 .4) and destruction of elastic fibres.
Hnizdo, 199 1 ) . Breathlessness is more significant The walls of the terminal bronchi are
to the patient and more related to inflammatory normally supported by radial traction exerted by
damage and airway narrowing (Bach and Haas, alveolar septa, but loss of elastic tissue means
1996). Bronchospasm, when present, is thought that, during expiration, compressive forces are
to be caused by acetylcholine release due to not opposed by radial traction and the floppy
inflammatory stimulation of the parasympathetic airways collapse (Figure 3 . 1 ) .
nervous system. Two types o f emphysema are described,
although they may coexist. Centrilobular
Emphysema emphysema affects mainly the respiratory
Emphysema usually occurs with chronic bronchi bronchioles. Panlobular/panacinar emphysema
tis and shares a similar aetiology, but is primarily affects the alveoli.
67
(a) (b)
Figure 3.4 (a) Representation of the tight sponge-like appe arance of a healthy l ung. (b) The l arge air spaces resulting from
destruction of the alveol ar walls by emphysema. (From Haas, F. and Haas, S. S. (1990) The Chronic Bronchitis and Emphysema
Handbook, John Wiley, Chichester, with permission.)
The obstructed airways of emphysema lead to expelled before the next inspiration starts,
hyperinflation by two mechanisms: causing air trapping distal to the obstructed
airways and positive pressure in the chest known
• Passive hyperinflation is caused by reduced
as intrinsic PEEP (Figure 3.5), especially during
elastic recoil, which allows the airways to
exacerbations or with rapid breathing. The lungs
collapse on expiration, causing gas trapping.
are prevented from emptying to their usual
• Dynamic hyperinflation is caused by the
relaxed volume between inflations by an average
patient having to actively sustain inspiratory
positive pressure of 2 cmH20 (Ninane et al.,
muscle contraction in order to hold open the
1 993 ). This imposes an extra threshold load at
airways (McCarren, 1992) . This unfortunate
the start of inspiration because the inspiratory
but necessary process is achieved at the cost
muscles have to offset this positive pressure
of excess work of breathing (WOB), a barrel
before inspiration can begin (Ninane, 1 997). It
chest, reduced diaphragmatic contribution to
also hinders cardiac output and impairs
breathing and a lung volume that can exceed
perfusion to the labouring inspiratory muscles
the predicted TLC (Decramer, 1 997) .
(Kawagoe, 1 994). Stabilization occurs at
Airways obstruction reduces expiratory flow, volumes and pressures that are higher than
which prevents expired air from being fully normal, which reduces lung compliance (see
Figure 1 .3). The distended alveoli require a
greater than normal pressure for inflation, thus
} Tidal
}
overturning the old concept that emphysematous
volume lungs are overcompliant (Macklem and
Trapped Eidelman, 1 990) .
gas Excess WOB is required to:
• overcome the resistance of obstructed

Figure 3.5 Development of intrinsic PEEP. The sloping airways
line indicates FRC. • assist expiration, which becomes active
68 ------
Thoracic cage elastic

recoil directed inwards
Horizontal ribs
Shortened
muscle fibres
Decreased .�
diaphragmatic
curvature
� Medial orientation of
diaphragmatic fibres
Figure 3.6 The detrimental effects of hyperinflation on the mechanics of breathing. (From To bin, M. J. ( 1 988) Respiratory
muscles in disease. Clinics in Chest Medicine, 9, 263-286, with permission.)
rather than passive when air has to be forced these muscles are richly supplied with muscle
out through narrow airways spindles and tendon organs to increase afferent
• sustain inspiratory muscle action throughout feedback (Chatham, 1 995 ). Normal muscle is
the respiratory cycle so that high lung able to respond to increased load by hypertro
volumes are maintained, alveoli being phy, but an emphysematous diaphragm often
opened at a high point on the compliance labours under further handicaps such as malnu
curve (see Figure 1 .3) trition, and diaphragmatic weakness is common
• compensate for the altered geometry and (Duranti, 1 995). Although the patient often feels
interaction of the respiratory muscles, the exhausted, the diaphragm itself may avoid
flat diaphragm having to work paradoxically fatigue (Mador et aI. , 2000).
by pulling in the lower ribs on inspiration, Malnourishment is common, caused by excess
thus becoming expiratory III action energy demand and impaired energy supply (p.
(Hoover's sign) 1 3 1 ) . This leads to cannibalism of the respiratory
• compensate for loss of the bucket handle muscles for their protein. Malnutrition acceler
action of the ribs (Figure 3 . 6) ates the process of emphysema (Schlichtig and
• compensate for reversed action of rib cage Sargent, 1 990) and is an independent risk factor
recoil, which in the hyperinflated chest is for mortality (Landbo, 1 999). Muscles are
directed inwards rather than outwards, thus weakened further by physical inactivity, chronic
resisting instead of assisting inspiration heart failure, electrolyte imbalance and
(Figure 3 .6) prolonged steroid use (Heijden et at. , 1 996).
• overcome threshold resistance at the start of People with emphysematous disease show more
inspiration, caused by intrinsic PEEP. than twice as much oxygen cost of breathing as
those with chronic bronchitis (Jounieaux, 1 995 ) .
Some patients can only inhale by lifting up
their entire rigid rib cage with their accessory Chronic bronchitis a n d emphysema
muscles. These accessory muscles have a dual The gradual patchy airway narrowing of chronic
role when unsupported arm actlvltles are bronchitis, augmented by the floppy airways of
required. Excess use of accessory muscles emphysema, leads to uneven distribution of
increases the sensation of breathlessness because ventilation. Damaged alveoli further hinder gas
69
CHAPTER 3 OSSTRUCfIVE DISORDERS
Chronic bronchitis Emphysema
t t
Airway damage Alveolar damage
�
Patchy damage Hypoxic vasoconstriction
�
Extensive damage Pulmonary hypertension
�
/ Cor pulmonale
�
Right heart failure
Hypoxaemia ---. Polycythaemia

!
Left heart failure
� � Oxygen delivery
/
Figure 3.7 Progression of COPD. Polycythaemia: excess red blood cells.
exchange, and anaerobic metabolism develops overcome the increased right atrial pressure and
(Mathur, 1999) . The inexorable downhill path maintain cardiac output. This process eventually
of advanced COPD is illustrated in Figure 3 .7. strains the left ventricle and leads to left heart
Chronic hypoxia leads to compensatory failure. Meanwhile lung damage is continuing,
proliferation of red cells, known as polycythae and death is ultimately due to inadequate gas
mia. This increases the oxygen-carrying capacity exchange rather than cardiac involvement
of blood at first but, once packed cell volume (Harris, 1 989) .
reaches 55%, the thickened blood impairs
oxygen delivery, burdens the heart, augments Clinical features
pulmonary hypertension and causes headaches. The natural history of COPD spans 20-50
If the disadvantages of polycythaemia outweigh years, but the disease is asymptomatic at first
the advantages, haematocrit can be reduced by because changes in small airways barely affect
multiple venesections (blood-letting), exchange total airways resistance. Patients may not seek
transfusion or haemodilution (Wedzicha, 1 986). medical advice until symptoms become trouble
Well-managed long-term oxygen therapy can some and FEV 1 has declined to 70% of normal
stabilize or reverse polycythaemia. (Quanjer, 1 993) because a morning cough is
Capillary destruction and widespread hypoxic tolerable and considered normal for smokers.
pulmonary vasoconstriction further augment Once hyperinflation develops, this becomes a
pulmonary hypertension. This increases the load major cause of symptoms (Brusasco and Fitting,
against which the right ventricle must pump, 1 998). The extra energy expenditure of
leading to hypertrophy and dilation of the right breathing is accompanied by reduced physical
ventricular wall, a condition known as cor activity (Hugli, 1996) . Fatigue is widespread and
pulmonale. Once nocturnal oxygen saturation sleep of poor quality (Girault et al. , 1996).
drops below 90%, right heart failure develops Significant depression is present in over half of
(Vos et aI. , 1 995 ). Systemic BP rises in order to people with COPD (Bach and Haas, 1996,
70
p. 342) and 82% of people with severe COPD airflow obstruction (Gorini, 1 996). The variation
(Lacasse et at. , 1 998). in blood gas response to COPD is represented by
Objectively, there is a rich tapestry of signs the spectrum of the 'pink puffer' (PP) patient, who
such as laboured breathing, a plethoric or maintains near-normal blood gases at the expense
cyanotic appearance, weight loss, barrel chest, of breathlessness and weight loss, and the 'blue
forced expiration with pursed lip breathing, and bloater' (BB) patient (Figure 3 . 8 ) .
prolonged expiration with I:E ratio of 1 : 3 or The BB patient is less breathless, abandons
1 :4. Soft tissue recession and other signs of the fight for normal blood gases, suffers more
laboured breathing are evident (see Figure 2.2) nocturnal hypoxaemia (Sliwinski, 1 994) and
as a result of inspiratory effort and malnutrition pays for symptomatic relief with oedema, poor
(Tobin, 1 9 8 8 ) . Patients may lean forward on gas exchange and double the mortality of the PP
their elbows to force the diaphragm into a more patient (Clague and Calverley, 1 990). Some BB
efficient dome shape and stabilize the shoulder patients can tolerate a PaC02 of over 12 kPa
girdle for optimum accessory muscle action. (90 mmHg) for years (Hodgkin et ai. , 1 993, p.
Auscultation demonstrates the crackles of 436). This is manageable because the chief disad
chronic bronchitis (Piirila et ai., 1 9 9 1 ) or the vantage of hypercapnia, acidosis, is normalized
quiet breath sounds of emphysema. by kidney retention of bicarbonate.
Gas exchange is preserved in the early stages, It was originally thought that repeated hypo
VAlQ match being maintained by collateral venti ventilation in BB patients desensitized their
lation (Morrell, 1 994). However, hypoxaemia chemoreceptors to hypercapnia so that they
gradually takes over, with nocturnal oxygen became dependent on low oxygen tension as a
desaturation playing a particularly damaging role stimulus to breathe. However, the respiratory
(Mulloy, 1 996). Levels of hypoxaemia out of centres continue to be fully active, and the
proportion to FEV 1 raise suspicions of sleep purpose of hypoventilation may be to preserve
apnoea (RCP, 1 999). the respiratory muscles by 'choosing' the wise
Hypercapnia is a sign of advanced disease and is option in order to rest the muscles (Begin,
related to hyperinflation (Gibson, 1 996), although 1 9 9 1 ), thus preventing breathlessness and fatigue
patients do not have to retain CO2 to have severe (Gorini, 1 996).
(a)
)
--
.---
/�
Figure 3.8 Patie nts with (a) pink puffer and (b) blue bloater characteristics of COPD. (From Brewis, R. A L. (1977) Lecture
Notes in Respiratory Disease, Bl ackwell, Oxford, with permission.)
--
-- 71
CHAPTER 3 OBSTRUCTIVE DlSORDERS
The relevance to physiotherapists of the PP/ bations occur on average one to four times a
BB spectrum is that PP patients in particular year (Postma, 1 998). The airways of 40% of
tend to show the following characteristics : people with stable COPD are chronically
colonized with bacteria (Zalacain et ai., 1 999),
• anxiety and physical tension
which may double when infection is added.
• a counterproductive tendency to rush at
Exacerbation is commonly due to infection, but
activities
bacteria may be absent (Smith et ai., 1 999).
• more daytime hypoxaemic episodes
Other causes are panic attacks (Tiep, 1 99 1 ) , cold
(Sliwinski, 1 9 94)
temperature (Donaldson, 1 999), inflammation
• tendency to desaturate on exercise (Mulloy,
due to air pollution (Anderson et ai., 1 997) and
1 996).
the effects of hypoxia on the central nervous
Half of all COPD patients aged over 50 have system or cardiovascular system (Curtis, 1 994) .
cardiovascular disorders (Hodgkin et ai., 1 993, Exacerbation causes increased airflow obstruc
p. 66) because of the common aetiology of tion, hyperinflation, breathlessness and sputum
smoking. production, but not necessarily fever (Tiep,
The appearance of peripheral oedema is a 1 9 9 1 ) . Mucus clearance is hampered by cilia
turning point in the progression of COPD, indi rendered inefficient by damaged epithelium,
cating Pa02 below 7.3 kPa (55 mmHg; Stewart airway collapse and abnormal hydration
and Howard, 1 992) and 5-year survival of less (Smalldone, 1 993). Hospital mortality is 1 0%,
than 50% (Baudouin, 1 997). Although asso or 250/0 if hypercapnic respiratory failure
ciated with heart failure, oedema in COPD is develops (Baldwin, 1 997), and 40% die within a
caused by impaired renal perfusion (Baudouin, year (Postma, 1 998).
1 997), especially in patients with no renal
reserve (Sharkey, 1 997). The gut lining is also Medical management
sensitive to hypoxia, leading to the association The pathological process is irreversible. Smoking
of COPD with peptic ulceration. cessation can slow the damage and, without this,
Respiratory function tests are useful indicators treatment is akin to running a bath without the
of obstruction but relate weakly to breathlessness plug. Oxygen therapy can reduce hypoxaemia
(Lareau, 1 999), hypercapnia (Gorini, 1 996), and some of its effects, such as oedema (Howes
nocturnal desaturation (Miyahara, 1 995) or func et ai., 1 995). Long-term oxygen reduces
tional impairment (Mahler, 1 995). But once FEV 1 mortality for patients with persistent hypoxae
falls below 1 L, most daily activities are affected mia at Pa02 < 8 kPa (60 mmHg; Leach and
(Donner and Carone, 1 9 9 8 ) . Low gas transfer is a Treacher, 1 998). Bronchodilators reduce airflow
sensitive test for emphysema and distinguishes it obstruction in two-thirds of patients with
from chronic bronchitis. Peak flow is of some chronic disease, thereby reducing hyperinflation
relevance but it measures airflow in early exhala and possibly breathlessness (Tantucci et ai.,
tion, which reflects large airway function. 1 99 8) , but should be used according to need
X-ray signs may be insignificant at first, then because continuous use can worsen lung
upper lobe diversion becomes apparent, and, function (Huib, 1 999). Combination therapy
with emphysema the signs of hyperinflation and with different classes of bronchodilator may be
sometimes bullae caused by breakdown of lung the most beneficial approach (Manning, 2000).
tissue. CT scanning shows areas of low density A quarter of patients respond to theophylline
and blood vessel attenuation (Morgan, 1 992). (Mahon, 1 999). Steroids have been advised for
exacerbations but in the chronic state they
Exacerbation reduce airways obstruction in only 10% of
Survivors of exacerbations are usually left with a patients, and continued use is associated with
reduced quailty of life (Arunabh, 2000). Exacer- myopathy (Davies et ai., 1 9 99). However, indivi-
72
ASTHMA
duals vary and should be individually assessed best provided in the form of pulmonary rehabili
(Yildiz, 2000). tation (Chapter 9).
Drug assessment should include quality of life
scores, peak flow monitoring and sequential End stage
testing of different bronchodilators, steroids, There is a striking difference between the
combinations and various delivery systems (p. management of people with end-stage COPD
1 3 8 ) . Short-term reversibility studies should not and that of those dying from cancer. COPD
be substituted for long-term assessments. patients tend to be subjected to invasive treat
Inhalers are indicated for acute and chronic ments and experience poor symptom control
disease unless nebulizers are objectively found to (Connors, 1 996). The physiotherapist can be
be more effective (BTS, 1 997). Some patients instrumental in ensuring recognition of the
respond to· drugs for breathlessness (p. 1 3 6) . patient's needs and a teamwork approach to
Many COPD patients have disturbed sleep, for palliation. Some patients would like the option
which the hypnotic drug zolpidem has been of non-invasive ventilation at home if it has been
found to be beneficial without affecting oxygena carefully explained to them.
tion, ventilation or physical performance
(Girault et at., 1 996).
ASTHMA
Severe exacerbations may indicate the need
for non-invasive (Poponick, 1 999) or invasive Asthma is more common, more serious and
ventilation. Severe chronic emphysema may more manageable than is generally thought. It is
indicate the need for surgery, varying from laser the only treatable life-threatening condition in
ablation of giant bullae to lung volume the Western world with a rising death rate. It
reduction, discussed in Chapter 1 0 . shows the following trends :
Physiotherapy • Prevalence has doubled over the last two to

three decades and asthma now affects 5% of
For exacerbations, physiotherapy is often
adults and 1 0- 1 5 % of children in the UK
required to help clear secretions and reduce
(Flood and Partridge, 1 996), killing nearly
WOB, including non-invasive ventilation to
2000 people a year (Cruickshank and
prevent intubation. Most patients survive hospi
Lumley, 1 999), many of them young
talization but the ensuing 6 months see high
• Over 1 0 years, prescriptions for asthma have
levels of morbidity, mortality, readmission and
increased by three-quarters and the GP
relocation to long-term care (Connors, 1 996).
consulting rate has more than doubled
Physiotherapy must therefore include educating
(Hospital Update, 1 995)
the patient and family about restoration and
• Despite this, some GPs treat less than half
maintenance of exercise tolerance and basic self
the asthmatics in their practice, while up to
management. A trip to the gym before discharge
half the patients treated will only take half
is motivating. If patients just sit beside their bed
the dose prescribed (Pearson, 1 996)
in their nightclothes and take the odd potter to
• Up to 8 6% of asthma deaths are considered
the toilet, they may find that when they get
preventable (GRASSIC, 1 994)
home they are so deconditioned that they cannot
• Asthma is more frequent in advanced age
get up their front steps.
than in young adults but is frequently over
In stable disease, quality of life is primarily
looked because of the medical perception of
affected by breathlessness, exercise limitation
its association with younger people (Plaza et
(Engstrom et at., 1 996) and the interaction of
at., 2000).
depression and fatigue (Breslin et at., 1 998).
Mortality is directly related to ability to cope People die because they, their relatives or
(Ashutosh, 1 997). Physiotherapy is therefore doctors do not see asthma as a potentially fatal
73
Table 3.1 Distinguishing features of asthma and COPD
Asthma COPO
Smoking history Not necessarily Yes

May start in childhood Yes No
Onset Variable Slow
Atopy Sometimes No
Timing of symptoms Episodic, diurnal, seasonal Minor variations only
Provocation of symptoms Weak stimulus, e.g. cold air Strong stimulus, e.g. infection
Cough at night Patient wakes coughing Wakes then coughs
Sputum Contains eosinophils Contains neutrophils
Bronchodilator response Yes Sometimes
Steroid response Yes Sometimes
disease, nor grasp the importance of prevention, tiny creature whose purpose in life is to multiply
nor recognize deterioration. in bedding and clear up dead skin cells shed by
Asthma is a chronic inflammatory condition humans. Viral infection can contribute to the
of the airways, characterized by undue respon pathogenesis of the disease or trigger an attack
siveness to stimuli that are normally innocuous, (Watson, 1 997). Viruses share with passive
a mechanism known as hyperreactivity. Airway smoking a tendency to damage epithelium so
narrowing usually reverses spontaneously or that it becomes more sensitive to allergens. Junk
with treatment. It is distinguished by the varia food may play a part because of reduced antioxi
bility and reversibility of its presentation, which dant intake (Soutar, 1 997). Contributing factors
makes evaluation of severity difficult, especially include sleep, thunderstorms (Anto and Sunyer,
as the symptoms of wheeze, breathlessness and 1 9 97), premenstruation (O'Connor, 1 997) and
cough are general respiratory complaints. pollution (Cogswell, 1 994).
Asthma shares with COPD the pathology of Two phases of response occur (Figure 3 . 9):
small airways obstruction, but the differences are
1 . The sensitization stage, which occurs in
shown in Table 3 . 1 .
atopic people: exposure to allergens,
Diagnosis is made from a history o f recurrent
especially in foetal or early life, stimulates
attacks, then confirmed by respiratory function
production of excess immunoglobulin-E
tests. If the peak flow (PF) varies by more than
antibodies (IgE) in the serum. IgE becomes
1 5 %, either diurnally, after exercise or after
fixed to mast cells, which then react to
bronchodilator treatment, the patient is consid
antigens by releasing bronchoconstrictor
ered to have asthma. This is confirmed by a 1 5 %
mediators such as histamine. Serum IgE levels
increase in FEV 1 after a 1 4-day trial with predni
are five-times higher in asthma patients than
solone (Fehrenbach, 1 9 8 8 ) or by induced
in controls (Silkoff and Martin, 1 998).
sputum (Pin, 1 992).
2. The hyperreactive stage: continued exposure
Causes and pathophysiology to allergens, or response to other stimuli,
leads to mast cell degranulation and release
Predisposing factors include poverty (Smy,
of inflammatory cytokines such as
1 995), smoking parents, anxious parents, in
interleukins and eosinophils (Allen, 1 996).
utero allergen sensitization, history of a stressful
Chronic low-grade inflammation damages the
birth, lack of breast feeding or a gene that causes
surface epithelial layer, causing bronchial
atopy (Brown and Halonen, 1 999). An atopic
hyperreactivity.
person is one who is prone to allergy and who
may develop asthma if exposed to allergens, e.g. Once asthma is established, hyperreactive
certain foods, or the faeces of house-dust mite, a airways develop bronchospasm intermittently in
74
ASTHMA
Allergen exposure Other causes
\
IgE increase and
sensitization
\
Inflammation and hyperreactivity, i.e. chronic asthma
1
(Trigger)
1
Asthma attack
Figure 3.9 Development of asthma.
response to a variety of stimuli, which increases non-steroidal anti-inflammatory drugs, beta

the work of breathing. Over time, structural blockers or aspirin (Empey, 1 9 92)
changes stiffen the airway walls and parenchyma, • stress, through multiple central nervous
contributing further to airway narrowing (Sterk, system interactions (Busse, 1 995)
1 994). • chest infection, especially in infants
The mechanism for the persistence of asthma • warm-blooded pets
is thought to be localized because asthmatic reci • pollen
pients of transplanted lungs lose their asthma • car exhaust
while non-asthmatic patients who receive • hyperventilation (Groen, 1 979)
asthmatic lungs develop the disease (Corris and • frustrated expression of emotion (Groen,
Dark, 1 993). Once allergic asthma has 1 979)
developed, removal from the allergen, if delayed, • active or passive smoking.
does not always prevent continuing asthma.
When hyperreactivity is established, other Some factors may be cause, effect or both.
factors, which may or may not be related to the Anxiety, depression and social isolation are
original cause, can trigger an asthma attack, e.g. : associated with asthma (Ramsay, 1 994).
Symptoms of gastro-oesophageal reflux (GOR)
• allergenic foods, e.g. dairy products, eggs, are found in 8 2% of patients (Harding et ai.,
wheat, nuts, fish, additives, cola or other 1 9 99), especially when symptoms worsen at
acidic drinks night, after meals, on lying down or after
• exercise without warm-up exercise. GOR may be due to microaspiration
• weather, especially change in temperature of acid into the upper airway, or lower oeso
• drugs such as timolol (used for glaucoma), phageal relaxation caused by bronchodilators.
75
CHAPTER 3 OBSTRUCTTVE DISORDERS
Treatment of GOR reduces asthma symptoms is increased by airflow resistance up to 15 times

(Field, 1 99 8 ) . normal (Mador, 1 9 9 1 ) and hyperinflation
Inflammation and hyperreactivity lead to (Wheatley, 1 990). VAiQ mismatch reduces Pa02
airways obstruction by mucosal oedema and, in and rapid breathing reduces PaC02• Monitoring
the acute phase, by bronchospasm and by oximetry is usually adequate but blood gases
sometimes mucus plugging. Persistent inflamma are required if 5a02 falls below 92% Ouniper
tion leads to fibrosis of airway walls and irrever and Davies, 1 998) or PF drops below 30%
sibility. predicted (Levy et al. , 1998). Patients feel as if
Allergic asthma, known as extrinsic asthma, they are breathing through a narrow straw, and
occurs in early life. Intrinsic asthma occurs with many are extremely frightened.
normal IgE levels, develops in adulthood, is
more fulminant and less responsive to treatment. 'The attack is like being in the sea when
you can't swim.'
Castledine, 1993
Classification and clinical features
Severe acute asthma
Mild chronic asthma
This usually develops slowly, sometimes after
This manifests as an intermittent dry cough,
several weeks of wheezing. Deterioration can be
often at night, or a morning wheeze once or
deceptive and even paradoxical : subjectively,
twice a week. PF varies by less than 25%. Even
there may be denial or a blunted perception of
when asymptomatic, peripheral airflow resis
dyspnoea (Weiner et aI. , 2000) and objectively,
tance can be five times normal (Wagner, 1 992),
the patient may appear less distressed (but more
and severe attacks are possible. Deconditioning
drowsy). Medical help should be sought if the
is common because of the dislike of breathless
patient shows the signs in Table 3 .2 or the
ness.
following:
Severe chronic asthma

• pallor or sweating
This means frequent exacerbations and
• peak flow < 50% predicted or < 200 Umin
symptoms that affect quality of life. Psychosocial
• 1 response to bronchodilator
factors play a more prominent role than other
• as fatigue progresses, decreased respiratory
factors (Miller and Barbers, 1 999). PF varies by
effort, retention of PaC02 (Figure 3 . 1 0),
more than 25%, and daily anti-inflammatory
drugs are required.
Brittle asthma
Table 3.2 Some features of acute asthma
The most severe form of chronic asthma is
unstable or brittle asthma, which shows greatly Severe Ufe-
fluctuating peak flows, persistent symptoms threatening
despite multiple medication, and unpredictable
Pa02 t H
drops in lung function (Balfour-Lynn, 1 999). RR > 25 t
PaC02 t r
Acute asthma
Pulse > 110 t
BP r t
This reflects failure of preventive management PF < 50% predicted Unrecordable
and/or exposure to a relevant stimulus. The Speech Difficult Impossible
Auscultation Wheeze Silent
large airways are obstructed by bronchospasm
Colour Any change
and the small airways by oedema and Consciousness Any change
sometimes mucus plugging. Work of breathing
76
AsTHMA
Danger
kPa �
I
14.0 h-TTT7"'TTrnrr;rr;.-;r;;'77.-:b7777TTh:T7:TT;'7>'7>i?777'77n
Pa02
Normal range
�7777��rT.TT�7�?>��7.T.7 PaC02
�CLCLLLLL..u��LLL.fLL�:.L..<:..L..<'-"-''-..L.� Normal range
o L------L--�--�
Normal Mild-moderate Severe Acute
asthma asthma respiratory
failure
Figure 3.10 Progressive changes in arterial blood gases during acute severe asthma. (Fro m Smith, M. (1982) In case of
emergency. Nursing Mirror, IS4(suppl. ), I I with permission. )
,
which is associated with FEV 1 < 20% 1 997). The commonest predisposing factor is
predicted (McFadden and Warren, 1 997) failure to recognize the seriousness of the final
• loss of wheeze, and silent chest on ausculta episode (McFadden and Warren, 1 997).
tion if airflow is too slow to oscillate the
All one's strength, that one feels becoming
alrways
weaker and weaker, is concentrated into
• hypotension as pulmonary capillaries are
one last effort to take one slight breath that
compressed by the hyperinflated chest
will allow the respiration to continue.
• cyanosis or altered consciousness, which
Ruiz, 1993
only occur in 1 % of cases but indicate grave
illness (McFadden, 1 995 ) .
Status asthmaticus
I f PaC02 rises over 6.7 kPa (5 0 mmHg), This term is sometimes used interchangeably
intensive care is required (Rossi et ai., 1 993). with severe acute asthma, but specifically
Very breathless patients cannot produce describes an asthma attack prolonged over 24
reliable PF or spirometry readings and, in those hours, leading to dehydration and exhaustion.
too breathless to speak, the manoeuvre can
exacerbate bronchospasm (Fanta, 1 992) . Asphyxic asthma
Some attacks may be accompanied by only Otherwise known as 'catastrophic asthma', this
mild inflammation and little mucus plugging acute attack leads to respiratory arrest within
(Gibson, 1 995). Sudden deaths have been hours, or occasionally within minutes (Levy et
reported without exacerbation of airflow al., 1 99 8 ) .
obstruction, in which case impaired respiratory
drive has been implicated, related to depressed Exercise-induced asthma
mood (Allen et ai., 1 994). This is present in 8 0% of asthma sufferers and in
Near-fatal attacks should be closely investi some is the only manifestation of the disease.
gated because 1 00/0 of patients will die of their Hyperventilation during exercise, especially in
illness within a year (McFadden and Warren, cold weather, leads to evaporation of airway
77
surface liquid, hyperosmolality and heat loss, Premenstrual asthma

causing bronchospasm (Clark and Cochrane, This presents as particularly severe monthly
1999). Bronchospasm occurs during or up to 10 attacks, possibly associated with endometriosis
minutes after exertion (Suman, 1995) and affecting the pleura.
recovery is usually complete 30 minutes later.
Preventive measures include training to improve Difficult asthma
physical fitness, warm-up and cool-down People who have symptoms that do not match
periods, a scarf over the mouth on cold days to up or respond to medication are sometimes
warm the inspired air, and a drug such as described as having difficult asthma. This may be
sodium cromoglycate or a bronchodilator before because the patient does not actually have
exercise. Routine unnecessary bronchodilators asthma. The commonest misdiagnosis is hyper
can worsen exercise-induced bronchospasm ventilation syndrome (Morice, 1996).
(Inman, 1996).
Education and prevention
Nocturnal asthma
People with asthma benefit from pulmonary
This occurs in 80% of people with asthma
rehabilitation (Chapter 9), including education,
(Douglas, 1993), mostly during REM sleep. It is
exercise trammg, breathing techniques and
diagnosed from a morning dip in PF of over 200/0
relaxation (Emtner et ai., 199 8 ) . Prevention by
compared to the previous evening. The term is
education is central because the characteristics of
used loosely, but accurately applies only to those
asthma discourage patients from adhering to
who suffer at night and are symptom-free in the
treatment. It is a chronic condition with long
day. It causes fatigue and interferes with sexual
periods of remission, and drug regimes may
activity, but there is sometimes lack of awareness
show no immediate benefit. Patients tend to
of the treacherous diurnal variation.
underestimate their symptoms (Crockett, 1997),
Possible trigger factors are an exaggerated
and most do not monitor PF during an exacerba
bronchial response to cold bedrooms, reduced
tion nor call an ambulance during a life-threaten
lung volume in supine, allergens in bedding,
ing attack, probably because of anxiety
GOR due to reduced lower oesophageal
(Milgrom and Bender, 1997) . Following life
sphincter tone, or hormonal circadian oscilla
threatening acute asthma, a 40% incidence of
tions in airway patency. Airways are narrowest
denial and fear has been identified (Yellowlees,
at about 4 am (Bellia, 1993).
19 89).
Once avoidable factors are removed,
Comprehensive preventive measures have
treatment consists of a slow-release bronchodila
shown:
tor and, if nocturnal attacks are recurrent, anti
inflammatory drugs, preferably not steroids in • a 73% reduction III acute admissions
the first instance (Bellia, 1993). If the asthma is (Lahdensuo, 199 6)
triggered by snoring, a sleep study may identify • freedom from symptoms for most people
sleep apnoea (Douglas, 1993 ) . with stable disease (Crockett, 1997)
• 1 medication use and i quality of iife (Make,
Occupational asthma 1994)
This may take weeks or years to develop. • the potential to reduce asthma deaths to zero
Symptoms usually worsen during the week and (Cochrane, 1995).
ease at weekends but several work-free days may
be needed before improvement is apparent. It is Structure
usually diagnosed by a fall in FEV1 of more than Information by booklets alone does not change
20% over the working day or working week behaviour (Thorax, 1997). Personal instruction
(Bright, 1996). is the most effective method (Make, 1994).
78
AsTHMA
::1, , ,
Education during hospitalization has the
advantage that motivation is high but the disad
vantage that information is not taken in if
anxiety is high. It may be best to use the acute
phase to explain that prevention is the key, help , , , , , , , , , , , , , , , , ,
patients identify their own needs and motivate Up and down scores like these point to asthma
them to attend follow-up education.
Quick reaction Slow reaction
.. ):
Content I I
1 . Self-management by drugs is based on identi

fying the individual best peak flow and
adjusting medication when it falls below this.
Optimal peak flow is identified by measuring PF
within 30 minutes of waking and in the I
I I
evening, and adjusting bronchodilators until I I
best values are achieved. If this is less than 80% 1 hour 24 hours ----+
predicted for sex, age and height, a 2-week These scores show a quick reaction to cats and
course of anti-inflammatory drugs, and a slower one to flu
sometimes bronchodilators, is needed to find
the maximum PF. If a nebulizer is used, an
initial period of saline reduces the placebo 300
effect. Thereafter, PF readings should be taken
twice daily for people with chronic asthma and 200
four times a day for those with severe chronic

100
asthma (D'Alonzo, 1 995), using charts and
advice from asthma organizations or drug
manufacturers (Figure 3 . 1 1 ) . The following The less 'up and down' the score, the better the
medicines are working
action is then advised:
• PF > 800/0 of optimal: continue routine 350
treatment
• PF 50-80% of optimal: start preplanned 300
drug regime, e.g. extra bronchodilator and
250
steroid inhalers, and/or oral steroids
• PF < 5 0% of optimal : start self-treatment 200
and seek urgent medical attention as
arranged in advance (Partridge, 1 9 94).
A drop in score is warning you of an attack
2. Zero tolerance of symptoms. Figure 3.11 Asthma education booklet on peak flow
3. Identification of precipitating factors, e.g. readings. (From National Asthma Campaign booklet (see
Figure 3 . 1 2. Glossary))
4. Preventive measures based on this informa
tion, e.g. keeping pets out of bedrooms, using a scenano of an inhaler in one hand and a
DIY mask for dusty jobs, regularly washing soft cigarette in the other.
toys and bedding or putting them in the freezer 5. Identification of individual warning signs of
to kill house dust mite, removing curtains and an exacerbation, e.g. reduced exercise tolerance,
carpets, avoiding spray polishes, bottom bunk waking at night, reduced effectiveness of bronch
beds, certain foods and the not-uncommon odilator.
79
ASTHMA DIARY
Times when I felt extra breathless or wheezy
Time of day What made me What did I do to help

Date or night breathless or wheezy? myself? How much did it help?
Figure 3.12 Example of a diary for the self-management of asthma.
80 ------
ASTHMA
6. Explanation on the action and administra these do not prevent inflammatory damage to
tion of drugs, with emphasis on the importance the airways. They can be used regularly for acute
of taking preventive drugs even when feeling asthma or severe chronic asthma (Niederman,
well. Inhaler technique should be regularly 1 99 8 ) but otherwise regular use is unhelpful
checked because poor technique contributes to because:
80% of inadequate asthma control Gones and
• smothering of symptoms means that a
Barrett, 1 995).
wheeze no longer acts as a warning to avoid
7. For women with a family history of asthma,
the offending stimulus
low consumption of allergenic foods during
• in the acute state, over-reliance may cause
pregnancy and breast feeding, with similar care of
delay in seeking medical assistance
the baby's diet in the first year of life.
• used inappropriately, bronchodilators can
8. For people who have taken long-term
actually worsen asthma (Harrison, 1 999)
steroids, advice on bone mineral density checks
and lengthen hospital stay (Bradding et al.,
(Laatikainen, 1 999).
1 999).
9 . Smoking cessation if relevant and, until this
is successful, augmented vitamin C intake The paradox is that �rstimulants can be
(Butland et ai., 1 999) beneficial immediately but detrimental in the
1 0. Reduction of nocturnal asthma by trying long run.
different drug timings, sleeping positions, room
temperatures and a stress-free period before bed. Chronic asthma
1 1 . Identification and treatment of GOR (p. The frequency of the need for bronchodilators
1 1 5). provides a useful marker for adjusting prophy
12. Avoidance of room humidifiers, which lactic treatment. Accurate monitoring and a
nurture house dust mite. stepwise protocol are advocated (Box 3 . 1 ) .
1 3 . For high-risk patients, advice to keep with Charts o n the recognition and drug management
them at all times their inhalers, subcutaneous of chronic and acute asthma are published in the
salbutamol and, if necessary, an auto-injector for British Medical Journal (BTS, 1 993).
adrenaline (Barrow, 1 998), an information For patients not controlled on steroids, the
bracelet (BTS, 1 990) and a note from their GP
for ambulance personnel to administer unrest Box 3.1 Stepwise use of drugs in chronic asthma with
ricted oxygen. Spare inhalers should be kept in increasing severity of disease
the car and at work.
14. Information on organizations such as the Step 1 Short-acting bronchodilator as
National Asthma Campaign, which provides diary required
cards and educational material (Appendix C). Step 2 Add inhaled anti-inflammatory drug
Step 3 Add long-acting bronchodilator
Drug management Step 4 Increase dose of anti-inflammatory
Underuse, overuse and inappropriate use of drug
drugs is common. Medication should hinge on Step 5 Sequential trials of different bronch
drugs to prevent and suppress inflammation (p. odilators and oral steroids.
1 1 8) because prolonged inflammation can
double hyperreactivity, thus increasing morbidity If 'as required' bronchodilators (step 1 ) are
and mortality (Cockcroft et aI., 1 993). Surveys needed more than once a day, taken appro
on asthma deaths invariably implicate underuse priately, patients move to step 2. Patients
of steroids prior to the fatal attack (Neville et who are still symptomatic move through the
ai., 1 9 9 1 ) . steps until symptoms are controlled.
Patients find bronchodilators attractive but
81
antileukotrienes may reduce inflammation with • Inhale through your nose, slowly enough to
one oral daily dose. They work specifically on the eliminate the wheeze, while increasing the
inflammatory leukotrienes that cause long-lasting depth of your breathing temporarily to
smooth muscle contraction (Weisberg, 2000). compensate for the slow breath
They may cause oedema if combined with predni • Adjust the rate as breathing becomes comfor
sone (Geller, 2000). table and there is less hunger for air, a
hunger that will be modified by feeling III
Acute asthma control
High concentrations of oxygen and high-dose • Observe and modify any muscle tension
nebulized bronchodilators may be required, • Smoothly inhale in three different segments,
either in small frequent doses (Bennett, 1 9 9 1), abdominal, lateral costal and then upper
continuously (Weber, 1 999) or intravenously chest expansion, then exhale in reverse order
(IV) (Nelson, 1 995). Oral or IV steroids are • Re-check muscle tension
usually given, although their role is less clear in • Progress to unsupported sitting and standing
acute episodes than in chronic asthma (Allen, positions.
1 996). Inhaled heliox may prevent the need for
intubation in acidotic patients (p. 1 3 1 ) . Antibio The physiotherapist can start by breathing
tics are not recommended (Cruickshank and alongside the patient, but the aim is for patients
Lumley, 1 9 99). to recognize their ability to manage their own
condition.
The Buteyko technique is based on reducing
Breathing techniques minute volume by slowing the respiratory rate
Certain breathing strategies can be used to aid with breath-counting, using distraction by
relaxation, give patients a feeling of control and rocking and walking, and at night lying on the
improve the efficiency of breathing. If a patient left side and taping the mouth closed. The
finds a technique helpful, this should be rationale is that hyperventilation causes bronch
practised regularly, then used if an attack is ospasm, which is true but simplistic in that there
anticipated, but not in place of appropriate are many other causes of bronchospasm. Bowler
medication. The emphasis is on gentle improve et at. ( 1 99 8 ) attempted to provide evidence but
ments in the efficiency of breathing, not deep their study was flawed by:
breathing, which can exacerbate bronchospasm
(Lim et at. , 1 98 9) . • unequal groups in that the Buteyko group
Girodo e t at. ( 1 992) showed how simple initially required 1 V2 times the steroids of
relaxed abdominal breathing (p. 1 54) can reduce the control group
symptoms. Peper ( 1 992) used biofeedback to • the fact that the Buteyko group received
facilitate abdominal breathing, resulting in seven times as many follow-up phone calls as
reduced drug use and asthma attacks. Innocenti the control group, plus extra breathing
( 1 974) described how patients could gain control classes
by learning to change back and forth between • no significant difference being fO\lnd in end
abdominal and upper chest breathing and to alter, tidal CO2 or quality of life scores at the end
breath by breath, the rate and depth of breathing. of the trial
Weissleder ( 1 976) claimed that asthmatic attacks • most patients proving either not to have
could be aborted by teaching the 'complete breath asthma or to have unstable asthma.
technique', which consists of the following
However, there is strong anecdotal evidence of
instructions, with the patient in supported sitting:
excellent results in some patients, indicating that
• Listen to and feel the quality of your the overlap between hyperventilation syndrome
breathing, including any wheeze and asthma is often missed. The physiotherapist's
82
AsTHMA
role is to give any patients diagnosed with asthma reduce the incidence of acute asthma but there
the simple Nijmegen questionnaire (p. 298) to is no evidence that it is helpful during an
identify coexisting hyperventilation syndrome, attack.
then treat appropriately. Muscle tension and a habitually hyperinflated
chest are occasionally evident, for which
Exercise postural advice and emphasis on exhalation are
indicated. Exhalation is not to be encouraged
Asthma and exercise have a strange relationship.
during acute episodes when hyperinflation is
Exercise can trigger an acute episode, but
necessary to hold open obstructed airways.
aerobic training with appropriate precautions
It has been claimed that inspiratory muscles
has shown the following outcomes (Emtner et
can be damaged during an attack and that the
at. , 1 996):
risk is reduced by strengthening these muscles.
• 1 exercise-induced asthma Weiner et at. ( 1 992) found that 6 months of
• i conditioning inspiratory muscle training, using a pressure
• i confidence and independence threshold device for 30 minutes five days a
• 1 asthma attacks. week, reduced symptoms, medication use and
hospitalization.
Adherence rates tend to be good (Emtner,
Coughing can relieve or exacerbate asthma
1 998), even at high intensity training, and
(Young et at. , 1 9 9 1 ) and the physiotherapist can
Emtner et at. ( 1 996) successfully motivated
advise on effective coughing or cough suppres
patients to exercise at 8 0-90% maximum heart
sion (p. 204) or both.
rate. Outdoor exercise is best taken in the least
Outcome measures have traditionally
polluted areas and times of day. Face masks
comprised respiratory function tests, hospitaliza
protect against some pollutants but the filter
tion and death rates, but functional measures
must be changed regularly, and they may
most usefully relate to physiotherapy outcomes.
increase the work of breathing (Atkinson, 1 997).
Quality of life questionnaires are described by
Rowe ( 1 993) and Juniper ( 1999a).
Other physical measures for chronic asthma
Relaxation is well-established as a therapy for Physical assistance for acute asthma
asthma, and is highly valued by patients (Most conversations in A&E are directed
(Emtner et al., 1 998). Freedberg et at. ( 1 987) over and about me, and rarely involve me
showed objective benefit by increased PF in any meaningful way, which is a pity as I
readings. Techniques that achieve profound believe that I know quite a bit about myself
relaxation have shown positive outcomes, espe as an asthmatic. '
cially meditation, yoga (Fried, 1 993, p. 234) Carter, 1 995
and hypnotherapy (Morrison, 1 9 8 8 ) . Acupunc
Some patients do not want to be touched
ture can increase PF and decrease medication,
during an attack. Some do not want to be talked
and homeopathy is sometimes useful (Lewith,
to. Most do not want to be left alone. All want
1996). Naturopathic assessment techniques may
to be consulted. Noise, light and crowding
indicate a need for supplementary vitamin C
should be minimal.
and antioxidants, or use food exclusion diets
Some of the following strategies may be
to identify certain additives and allergens
helpful for some patients.
(Lewith, 1 996). The majority of patients have
tried complementary therapy, and breathing • Sit upright, or lean slightly forward resting
techniques have been found the most popular the arms on a table, or sit astride a chair
(Ernst, 1 998). This indicates the scope for backwards with the arms resting on the
physiotherapy. Complementary therapy may chair's back.
83
• Keep warm. reduce the work of breathing are described in

• Sit near fresh but not cold air. Chapter 7.
• Take sips of warm water (some patients Mucus may be present with a slow-onset
prefer cold), although this should not be attack (Picardo, 1 996), in which case slow
attempted in the throes of a bad attack. percussion can both promote relaxation and
• Breathe through the nose unless breathless help clear secretions. If secretions are too thick
ness makes this impossible. to shift, warm humidification with normal saline
• If there is dizziness with tingling hands and may be indicated (Phillips and Millard, 1 994)
feet, breathing is faster than it needs to be. but this can increase airflow resistance in
This can be reassuring and indirectly help children or those with severe airways obstruction
slow the breathing. (Wissing, 1 9 8 8 ) and close observation for desa
• Practise previously learned techniques of turation is required.
relaxation, abdominal breathing and control Patients who continue to tire may need rehy
over breathing. These should be started at dration and mechanical assistance. Low to
the first intimation of an acute episode. medium levels of CPAP will relieve inspiratory
• The Innocenti technique to raise resting lung muscles from their exhausting work of holding
volume (p. 1 73) may help to open the open the obstructed airways (Shivaram et at.,
narrowed airways. Extra elastic work 1 9 8 7). If CPAP is not available, IPPB (p. 159) or
imposed by hyperinflation is offset by less non-invasive ventilation (Mak et at. , 1 995) can
airflow resistance so that total work is be used to ease the work of breathing. If positive
reduced (Wheatley, 1 990). Some patients pressure aids are needed, the X-ray should be
will have already achieved optimal inflation checked beforehand in case of pneumothorax.
spontaneously. Mechanical ventilation for asthma is discussed
in Chapter 1 5 , and children's asthma in Chapter
The patient can be asked if s/he would like 1 6.
relatives to be involved, which may reduce
family anxiety so that they are less likely to
transmit their own fear. Patients know best B RONCHIECTASIS
what helps them but relatives can be shown how Bronchiectasis is characterized by chronic irre
to apply acupressure by pressing or massaging versible distortion and dilation of the bronchi. It
the bronchospasm or breathless points (Ellis, has been called the orphan disease because its
1 994) : incidence is unknown, its diagnosis is often
• CVI 7 : anterior midline between nipples, missed and its prognosis is poorer than that of
level of 4th intercostal space asthma (Keistinen, 1 997).
• Lu I : just below each coracoid process Bronchiectasis is not a final diagnosis so much
• BI 1 3 : 1 % thumb-widths lateral to the lower as a common pathway of several conditions
border of each T3 spinous process. predisposing to persistent lung infection. It is
associated with severe respiratory infection,
General stress points are sometimes helpful, foreign body inhalation, cystic fibrosis, purulent
e.g. C04 on each dorsal thumb web (to be rhinosinusitis, tuberculosis, smoke inhalation,
avoided in pregnant women as it may bring on inflammatory bowel disease, primary ciliary
premature labour), or Li3 on each dorsal space dyskinesia and a reactive form of rheumatoid
between first and second metatarsals. arthritis in which joint pain responds when anti
Some patients find it helpful to cuddle a warm biotics are given for the bronchiectasis (Steinfort
hot water bottle or vibrating pillow. Some et aI. , 1 9 87). Causes of bronchiectasis may be
benefit from rhythmic slow chest percussion to multiple or unknown. The disease is diminishing
help promote relaxation. Other techniques to in countries where living standards are rising and
84
BRONCHIECfASIS
Damaged airways
(bronchiectasis)
1
Airways
...----
�
'oflammatioo
)
obstruction
Bronchospasm
Infection
Excess
thick
mucus
r
Abnormal gene
(cystic fibrosis)
Figure 3.13 Vicious cycle that augments the processes of cystic fibrosis and bronchiectasis. CF is progressive, whereas the
course of bronchiectasis varies according to cause and management.
where children are vaccinated against diseases starts in early childhood before the lungs are
such as whooping cough and measles. fully developed. Progressive destruction occurs
in anything between 3% and 48% of patients
Pathophysiology (Munro, 1 992), depending partly on medical
Chronic inflammation damages the elastic and and physiotherapy intervention to protect the
muscular components of subsegmental airways airways. Advanced disease brings pulmonary
and sometimes the parenchyma. The warm moist hypertension and cor pulmonale.
environment of the lung combines with excess
mucus to set up a VICIOUS cycle of infection, Clinical features
persistent inflammation and further obstruction Voluminous quantities of sputum are produced
(Figure 3 . 1 3 ). despite the inefficient clearance mechanisms
Thick mucus sits heavily on the tender cilia caused by corrugated airways and damaged cilia.
and causes further damage. An over-exuberant Mucosal ulceration can cause haemoptysis, indi
immune response to the colonizing microbes cating that the airways are particularly vulner
releases toxic inflammatory chemicals, which able to infection, and some physicians
impair lung defences. Continuous inflammation recommend prophylactic antibiotics at this time.
leads to fibrosis and sometimes sets off bronch Secretions and collapsing airways on expiration
ospasm, which augments the cycle. Abscesses cause coarse wheezes and crackles (Piirilii et aI. ,
may occur. 1 9 9 1 ) . A variant called 'dry bronchiectasis'
Anatomical disorganization is greatest if it appears to be a contradiction in terms but occa-
85
Table 3.3 Distinguishing features of bronchiectasis and shadows represent dilated airways seen end-on,
chronic obstructive pul monary disease usually clustered in groups. Neglected disease
Bronchiectasis COPD
shows 'glove finger shadows', which are dilated
bronchi full of thick secretions, and the ring
Age Varied Older shadows may have fluid levels. A normal X-ray
Smoking history Not necessarily Usually
does not exclude the diagnosis, and CT scanning
Auscultation Noisy. may be localized Diffuse crackles
Sputum Excessive. often thick is more sensitive. A bronchogram outlines the
and green Moderate dilated airways (Figure 3 . 14).
Haemoptysis Sometimes No
Finger clubbing Sometimes No
X-ray Specific Variable
Medical treatment
Liberal use of antibiotics helps control infection,
with the trend towards infection-specific rather
sionally patients have few secretions and no than continuous prescription. Patients are given
chronic infection. a store of antibiotics to be taken at the first sign
Other features are fatigue, loss of appetite, of colour change in their sputum. For patients
finger clubbing and dyspnoea. Chest ache may who deteriorate every winter, regular antibiotics
occur, usually associated with the affected lobes can be taken in the cold months.
(Munro et at. , 1 998). Bronchiectasis tends to be Antibiotics do not control the persistent
misdiagnosed as COPD. Table 3 . 3 clarifies the inflammation that may be progressively destroy
distinction. ing the airways (Shum et aI. , 1 993) but inhaled
X-rays show focal or diffuse signs. In severe steroids can assist this and reduce the volume of
disease, parallel tramlines represent thickened sputum (Elborn et at. , 1 992). Other drugs that
airway walls and 1 cm 'bunch of grapes' ring may decrease sputum volume are dry powder
mannitol (Daviskas, 1 999) and erythromycin
(Tsang et aI. , 1 999). Bronchodilators are used if
there is demonstrable hyperreactivity.
Surgical resection of non-perfused lung may
be indicated for localized and disabling disease
(Ashour, 1 996). Occasionally, transplantation is
possible in late-stage disease. Sometimes the
cause of the disorder might be treatable, e.g.
topical steroids for rhinosinusitis to prevent
mucus sliding from the back of the nose into the
lung.
Physiotherapy
Bronchiectasis reduces mucociliary clearance to
an average 15% of normal (Houtmeyers et at. ,
1 999) and patients need education ' in sputum
clearance to compensate for this. A daily
programme is required that is sufficient to
eliminate coughing in between clearance
sessions. Hydration, an exercise programme and
ACB/AD (p. 94) are often adequate but other
Figure 3.1 4 Bronchogram illustrating the dilated airways
of bronchiectasis in the right lower lobe. The straight left measures (Chapter 8) may be required,
heart border (sail sign) i ndicates previous left lower sometimes including postural drainage. Patients
lobectomy should be discouraged from coughing until they
86 ------
CYSTIC FIBROSIS
are ready to expectorate in order to mlOlmlze the rogue gene, prenatal diagnosis and organ
fatigue and cough-related stress incontinence. transplantation. But improved survival (Figure
Much encouragement is needed to help patients 3 . 1 5 ) is mainly due to attention to detail in
set up a life-long programme that is effective and conventional treatments, i.e. antibiotics,
suited to their lifestyle. Thereafter, occasional physiotherapy and nutrition. However, the
reviews are needed. disease is still eventually fatal and treatment is
Non-invasive ventilation is not well-estab aimed primarily at improving quality of life.
lished in progressive end-stage disease, but it can
benefit those with diffuse disease (Benhamou et Pathophysiology
al., 1 997). In most cells the gene encoding CF is dormant,
but in epithelial cells it is switched on. This
impairs ion and water transport across epithelial
CYSTIC FIBROSIS
surfaces of the body, causing dehydration of
Cystic fibrosis (CF) IS a chronic progressive secretions and obstruction of various body
obstructive disorder affecting the exocrine lumens. In the gut, this causes malabsorption
glands. It is the commonest lethal inherited and pancreatic insufficiency. In the lungs,
disease among white people (Ramsey, 1 996), sodium and chloride ions cannot escape from
acquired as an autosomal recessive disorder. The the epithelial cells into the airways in order to
gene is carried by 1 in 25 Caucasians and comes maintain hydration of mucus, which becomes
to life when inherited from both parents. Two thick and sticky. Viscid mucus encourages
carriers have a 1 -in-4 chance of having an bacterial adherence (Figure 3 . 1 3 ) , augmented by
affected baby and a 1 -in-2 chance that their baby inflammatory mediators such as neutrophils
will be a carrier. (Costello, 1 996). Dying neutrophils release
The diagnosis is suspected if infants show DNA, whose strands bind together and thicken
failure to thrive, meconium ileus or repeated secretions further.
chest infections. Confirmation is by a test for The respiratory component determines the
abnormally salty sweat at age 6 weeks. quality of life and is the usual cause of death.
Recent developments include identification of The lungs are structurally normal at birth, but
inflammatory changes are evident as early as 4
weeks old Gaffe et ai. , 1 999) and intractable
40
infection soon becomes established, even when
35 the patient is clinically well, leading to progres
30 sive damage by a smouldering course of bacterial
25 colonization punctuated by exacerbations.
�
til
Viruses and fungi play a role, and long-term
20
� antibiotics predispose the lungs to Aspergillus
15
colonization (Bargon et ai., 1 999).
10 The range of bacteria is curiously restricted.
5 Staphylococcus aureus causes significant harm
and the acquisition of Burkholderia cepacia, the
0
55 60 65 70 75 80 85 90 organism responsible for onion rot, poses a
Year of birth particular threat; some strains are untreatable
and reduce lifespan by 1 0 years, 20% of patients
Figure 3.15 Projected median survival of patients with
developing fatal fulminant pneumonia (Ledson,
CF by year of birth. (From Elbom, j. S, Shale, D. j. and
Britton, j. R. ( 1 99 1 ) Cystic fibrosis: current survival and 1 99 8 ) . Preventive measures against Burkholderia
popul ation estimates to the year 2000. Thorax, 46, 88 1 - cepacia include segregation of patients who do
885. ) and do not have the organism, at great personal
87
cost to those who have previously socialized naturally, because the sperm tail is structurally
freely. Even sibling separation is tolerated by similar to cilia, but fatherhood is possible
some families. Respiratory equipment and (McCallum, 2000). Women can have children,
treatment locations are segregated, and in which case optimum nutrition and respiratory
physiotherapists must wash their hands in an care are required prior to pregnancy.
antiseptic such as Hibiscrub. By the age of 3 months, 5 0% of babies have
Malnutrition may contribute to impaired respiratory symptoms in some form (Dinwiddie,
respiratory defence. Pneumothorax occurs in up 2000). Objectively, auscultation gradually shows
to 1 0% of children and 20% of adults, as a wheezes as a bronchiolitis-like process develops
result of rupture of a subpleural bleb or bulla in the small airways, then widespread crackles
(Noppen et aI. , 1 994). Resting energy expendi develop. Other signs are similar to bronchiecta
ture is 200/0 higher than normal in adults, half of sis. If there is hepatomegaly, diaphragmatic
it caused by the inefficiency of breathing with function is impaired. The radiograph is normal
hyperinflated lungs (Elborn, 1 996). at first, then shows patchy opacities in the apical
Survival to adulthood is now the norm regions, then signs of widespread bronchiectasis,
(Elborn, 1 996), which has given rise to new diffi emphysema and finally cor pulmonale.
culties. The liver and gall bladder can cause Growth may be stunted because of energy
problems, pancreatic fibrosis can lead to diabetes imbalance, energy supply being reduced by
and dehydration, vasculitis can affect joints, skin malabsorption and anorexia, and energy demand
and brain, bronchial artery hypertrophy may lead increased by up to 25% (Shepherd, 1 9 8 8 )
to pulmonary haemorrhage, and excessive because o f excess WOB. However, good
coughing predisposes to stress incontinence nutrition means that the patient should not
(White et at., 1 999). A sixfold increase in the appear malnourished except in the terminal
incidence of gut cancer (Webb and Govan, 1 99 8 ) phase or if the liver is involved. The fact that
may b e related t o survival of a n older population patients usually look well leads to misunder
and/or gastro-oesophageal reflux. Most patients standings about fatigue and other invisible
die of respiratory and cardiac failure. problems (Eigen et aI. , 1 9 8 7).
Exacerbation is indicated by weight loss or
Clinical features worsening respiratory symptoms. If the cause is
respiratory, secretions are thicker than normal
'Coughing and spluttering like an old man
and the patient may become less rather than
does not endear one to the general public,
more productive.
and neither does the popular misconception
In the later stages, FEV1 declines, PaO2 falls
that one is scattering infections round like
and eventually PaC02 rises. The inexorable dete
confetti. . . . My fingers are like spoons and
rioration is anticipated by patients, who each
I can't wear nail polish. . . . It doesn't do
respond in their individual way. They often form
too much for one's confidence to know that
strong attachments to each other, which provide
one has probably got halitosis - so I tend to
comradeship but can be devastating . when one
talk to people sideways on . . . . '
dies.
Hall , 1984
The antisocial nature of the disease is caused by General management

features such as incessant coughing, small Children and adults should always be under the
stature, delayed puberty, flatus, increasing care of a cystic fibrosis centre (Mahadeva et al. ,
breathlessness and unrelenting weariness. If chest 1998).
pain occurs, it may be due to pleural inflamma
tion, muscle strain from excessive coughing or Prevention
pneumothorax. Most males cannot conceive Screening is possible at three stages. Carrier
88
CYSTIC FIBROSIS
screening helps when making decisions about 1 996), either electively every 3 months, or symp
reproduction; if two carriers want to have a tomatically (Elbom et ai., 2000). This can be
child they can be offered in vitro fertilization, managed at home, which reduces nosocomial
genetic screening and implantation of a healthy infection, is cheaper and is usually preferred by
embryo. Prenatal diagnosis provides information the family, but disadvantages include lack of
on which to base a decision about continuing a respite for the family and increased fatigue for
pregnancy, but this only occurs after the birth of the patient (Wolter, 1 997). Close supervision is
the first unexpected cystic child or if there is a essential for it to be effective (Bosworth and
family history of CF. Neonatal screening leads to Nielson, 1 997). Nebulized antibiotics are
early diagnosis but is not yet routine. suitable for some patients but are time
Research into gene therapy is proceeding at a consuming, polluting and variable in effect.
dizzy pace. The accessibility of the airway means The drug rhDNase (recombinant human deox
that patients could inhale a normal copy of the yribonuclease) contains a clone of the gene
gene on an adenovirus, so long as the body does responsible for breaking down DNA, and when
not build immunity to the virus. Treatment given as an aerosol can decrease sputum
would be required monthly because of cell viscosity, improve FEV] , reduce exacerbations
turnover, and the damage that had already by 3 0% (Conway, 1 997) and lessen intractable
occurred would not be reversible. atelectasis (Shah et ai., 1 994). It benefits 50% of
patients and nearly doubles the cost of their care
Education (Conway, 1 9 97), with some of the cost being
When a baby with CF is born, education for the offset by reduced infectious episodes (Bollert et
parents begins as soon as they have accommo ai., 1 999). If the drug causes deterioration, it
dated sufficiently to the diagnosis. General does so by overliquefying secretions so that
points to note are: mucociliary clearance becomes as difficult as
eating soup with a fork.
• No-one should smoke in the home.
A specialist centre is needed to evaluate
• CF children are of normal intelligence and
rhDNase. It is tested at different times of the day
should go to normal schools.
to take account of when the chest is clearer, and
• Within their limitations they should take
with accurate monitoring by spirometry and
part in normal physical activities.
subjective scores. A positive response may not be
• They are not infectious.
demonstrated for weeks or even months
• They should share with healthy siblings the
(Conway and Littlewood, 1 997). The drug
disciplines and standards of the family.
should be taken after bronchodilators and
Lifelong treatment is time-consuming and the physiotherapy to maximize distribution and at
nature of the disease places stresses on the least 30 minutes before nebulized antibiotics to
family that can double the divorce rate prevent them denaturing the rhDNase protein. A
Gennings, 1 992). Self-help groups and profes mains-powered specialized jet nebulizer is
sional support limit family isolation and allow required and should not be used for other drugs.
attention for siblings. Aerosolized alpharantitrypsin helps replenish
the patient's defences (Briars and Warner,
Medication 1 993). Aerosolized amiloride, a sodium channel
At present the backbone of medical management blocker, helps restore normal hydration to secre
is an unremitting onslaught against bacteria. tions but requires up to four treatments a day
High doses of antibiotics compensate for diffi and has been challenged as no better than
culty in reaching the lungs through obstructed inhaled saline (Middleton et ai., 1 993). Anti
airways and poor perfusion. Access is by periph inflammatory therapy is either by steroids or
eral line or an implantable venous device (yung, non-steroidal anti-inflammatory drugs (Konstan
89
CHAPTER 3 OBSTRUCfIVE DISORDERS
et al. , 1 9 95). Bronchodilators show objective desperate patient alive. Living-related transplan
benefit in a minority of patients but can para tation has given rise to further ethical dilemmas
doxically increase airways obstruction in as but, if acceptable, a lower lobe may be donated
many (Dinwiddie, 2000). Mucolytic drugs have by each parent, or by two siblings (Dark, 1 997).
been considered ineffective in CF (Fiel, 1 993), Patients must be free to make their own
but some patients love them. choices, especially in the later stages. Options
include gentle autogenic drainage (p. 1 96),
Nutrition nocturnal oxygen therapy (Coates, 1 992), non
Malnutrition is associated with poor survival invasive ventilation (Regnis, 1 994) and/or pallia
(Elborn, 1 996), and is closely tied to respiratory tion.
status (Davis et al. , 1 996). Up to 200% of
normal calorie intake is required, as well as Physiotherapy
enzyme supplements to make up for pancreatic Once CF has been diagnosed, physiotherapy is
insufficiency. These supplements can cause started immediately, even if no secretions are
constipation, especially if a full meal is not taken produced, with the intention of minimizing the
after the enzymes. Supplementary feeds in cycle of excess secretions and airway damage.
advanced disease slow the decline in lung Physiotherapy is the most gruelling and least
function (Elborn, 1 996). tolerated aspect of treatment and shows
adherence rates below 5 00/0 (Abbott et aI.,
Surgery 1 994). Daily treatment regimes produce no
A pneumothorax is managed by chest tube immediate improvement in well-being, and
drainage if minor, but recurrent pneumothoraces sputum quantity is the only reinforcement to
require thoracoscopic pleurodesis (Noppen et encourage this repetitive task. Parents of CF
al. , 1 994). children generally adhere to treatment, but Fong
Evaluation for transplant of heart, lung and/or ( 1 994) found that less than half of CF adults
liver depends on the rate of decline in FEV 1 believe physiotherapy to be effective. Some
(Milla, 1 99 8 ) . Transplantation can transform a physiotherapists consider that it is not necessary
chair-ridden invalid into an active individual for all patients (Samuels et al. , 1 995) but most
within weeks of the operation. Most of the consider it central to CF management.
pulmonary problems of CF can be eliminated Treatment to clear secretions is best individua
because donor lungs do not have the genetic lized according to patient preference.
abnormality. But the obstacles are formidable, If convenient for the patient and family,
including the stress of waiting for donor organs, physiotherapy should be co-ordinated with
lifelong immunosuppressive drugs for the nebulizer treatments, i.e. before antibiotics so
successful, and devastated families if the wait is that absorption of the drug is not hampered by
too long or the transplanted organs are rejected mucus-filled airways, and after bronchodilators or
(Whitehead and Leval, 1 994). nebulized saline. Hypertonic saline clears more
Selection criteria include short life-expec secretions than isotonic saline (Riedler, 1 996) and
tancy, oxygen dependence, cor pulmonale and has been considered superior to rhDNase in one
high motivation. Exclusion criteria may include study (King et al., 1 997). Details of sputum
multiresistant organisms and questionable clearance techniques are given in Chapter 8, with
psychosocial support. Children have their own aspects specific to CF outlined below.
criteria (Gaynor, 1 9 9 8 ) . The shortage of donors The active cycle of breathing, autogenic
has raised moral issues. Gentle palliative drainage and devices such as the PEP mask and
management may now be supplanted by flutter are popular because they encourage inde
vigorous gastrostomy feeding, mechanical venti pendence. Interesting data has emerged suggest
lation and other heroics to keep an increasingly ing that abdominal breathing with biofeedback
90
CYSTIC FIBROSIS
can reduce alfways obstruction (Delk et at., Inspiratory muscle endurance is normally
1993). already elevated because of the extra work
Exercise has the advantage that most patients required to breathe through obstructed airways,
will actually do it (Abbott et at. , 1 9 94). but it has been claimed that inspiratory muscle
Outcomes of exercise training include reduced training can improve exercise tolerance (Sawyer
breathlessness, improved lung function (Dodd, and Clanton, 1 9 9 3 ) .
1 9 9 1 ) and increased exercise tolerance, muco The optimal frequency for physiotherapy is
ciliary clearance and well-being (Bye et aI. , not known (Eigen et at., 1 9 8 7) but is usually
1 9 97). An exercise programme has enabled some performed twice daily, with vanatlOns
motivated patients to recover from partial depending on secretions and remission or
disablement to a near-normal life (Heijerman, exacerbation. Treatment is best continued until
1 992). Exercise usually complements other tech sputum is no longer expectorated or a rest is
niques but in less severe cases can be the primary needed.
treatment (Andn!asson et aI. , 1 9 8 7 ) . Swimming Parents should be given advice and support
is especially beneficial, but patients should until children are able to manage themselves.
choose their favourite activity. Early independence should be encouraged, with
For training, patients exercise to a pulse rate young children actively participating and 1 0-
of 50-75% of their maximum exercise capacity, year-olds able to do their own treatment when
aiming at a minimum 30 minutes four times a staying with friends overnight. Older children
week. A little-and-often approach may be more are advised against cough suppression, by which
suitable for some patients, because fatigue is they attempt to conceal the illness from their
common. Successful exercise training requires peers.
regular reviews with a physiotherapist and The 'optimum' recommended treatment
commitment from the patient and family. Assess programme is not always the most effective in
ment can take the form of a 2-minute walk test, the teenage years. Management is best nego
which is more suited to children than the tiated, with the physiotherapist 'complying' with
somewhat tedious 6-minute distance, a 3-minute the patient's wish rather than the other way
step test with metronome and stopwatch round. People with CF are particularly worth
(Balfour-Lynn et at., 1 99 8 ) or modified shuttle listening to because they are medically streetwise
test (Bradley et at. , 1 9 9 9 ) . Patients with and understand much about their treatment.
advanced disease are less likely to benefit from When patients are hospitalized, motivation is
exercise, partly because of fatigue and partly enhanced by simple measures such as offering a
because little extra tidal volume can be superim choice of treatment times and techniques.
posed on hyperinflated lungs. Patients require 3-monthly physiotherapy
If postural drainage is the chosen treatment, reviews (RCP, 1 99 6 ) . Outcomes are based on
drainage time is about 15 minutes in younger quality of life measures such as exercise
children, more in older people or if there are tolerance, questionnaires and well-being scales
excessive secretions. Length of time depends on (Orenstein and Kaplan, 1 9 9 1 ) .
fatigue, patient preference, quantity of secretions
and effectiveness of other measures. Percussion Precautions
and vibrations are often included if they produce History and symptoms should be checked for
more sputum or if the patient finds them gastro-oesophageal reflux, which has been found
effective. Some authorities consider them unne in 8 1 % of young children with CF, 25% of older
cessary (Sutton et aI. , 1 9 8 5 ) , and they can be a children (Malfroot and Dab, 1 9 9 1 ) and
burden for the family, but the combination of all frequently in adults (Tattersall et aI. , 1 9 97).
three techniques has shown positive outcomes These patients should avoid head-down postural
(Reisman, 1 9 8 8 ) . drainage when possible (p. 1 1 5 ) .
--
-- 91
Patients should not be asked to cough unne in sweat and a tendency to underestimate fluid
cessarily because excessive coughing causes needs. Haemoptysis contraindicates exercise
collapse of central airways with impairment of training.
sputum clearance (Zapletal et aI., 1 983), and can
cause fatigue, haemoptysis and stress inconti
PRIMARY CILIARY DYSKINESIA
nence.
When using CPAP or non-invasive ventilation Primary ciliary dyskinesia (PCD) is an inherited
(Chapter 7), high pressures are not necessary for condition whose prevalence is thought to be
respite from fatigue and should be avoided underestimated and diagnosis made either late
because of the risk of pneumothorax. (Bush et aI., 1 998), or mistakenly as bronchiecta
Liver cirrhosis occurs in 1 0% of patients, sis or CF. It is characterized by an uncoordinated
which may lead to oesophageal varices and ciliary beat, leading to excess secretions and an
haematemesis, in which case all physiotherapy effect similar to an escalator malfunctioning in
except abdominal breathing is contraindicated rush hour. The outcome is recurrent infection of
until bleeding is controlled. ears, sinuses and lungs.
Blood streaking of sputum is common in CF PCD is suspected in children with a perpe
and should be disregarded, but frank haemopty tually runny nose, glue ear and frequent chest
sis should be reported and physiotherapy infections. Males are subfertile. Half of patients
temporarily halted. have mirror-image organ arrangement so that
Measures to prevent cross infection include the X-ray shows dextrocardia and the middle
scrupulous hand-washing, the covering of lobe is on the left (Bush et al. , 1 998).
sputum pots and single-patient use of PEP and PCD is not a progressive disorder but the twin
flutter devices. pillars of selective antibiotics and regular
Osteoporosis is universal in adults with late physiotherapy are needed to delay the onset of
stage disease (Aris, 1 99 8 ) , manifest as increased bronchiectasis. Reflexology or homeopathy may
kyphosis and fracture risk, but it begins during help boost the immune system (Pollack, 1 999).
skeletal growth and deficits in total bone mineral Some patients benefit from rhDNase drugs
average 200/0 in children and young adults (Berge, 1 999) but �ragonists can cause dete
(Henderson, 1 999). Causes include abnormal rioration, so both should be monitored objec
bone growth during childhood, steroid use and tively. Ear grommets are contraindicated because
immunosuppressive drugs after transplantation. of ensuing ear discharge (Hadfield, 1 997).
Prevention is by optimum nutntlOn in
childhood, minimizing long-term steroids and
ALLERGIC BRONCHOPULMONARY
teaching impact exercise.
ASPERGILLOSIS
It is not known if transient oxygen desatura
tion during exercise is harmful, but those with Aspergillosis is an inflammatory disease manifest
an FEV 1 below 50% predicted are likely to ing mainly in the lungs as allergic bronchopul
show desaturation. When exerclSlng, they monary aspergillosis. It is a reaction to the
should avoid desaturating by more than 5% or Aspergillus fungus, which is responsible for more
an absolute level below 80% (Dodd, 1 99 1 ), than half of all fungal infections (Calvo et al.,
using interval training, reduced workload or 1 999). It rarely invades immunologically
added oxygen. In advanced disease, added competent people but occurs in 1 0% of people
oxygen allows longer periods of exercise and with CF (Sharma, 1 998) and sometimes in cavi
may postpone the development of pulmonary tating lung diseases such as TB.
hypertension (Marcus, 1 992). Fluids and free Patients present with malaise, weight loss,
access to the salt shaker are needed in hot breathlessness, fever, haemoptysis and a cough
weather because of the high salt concentration productive of brown rubbery mucus casts,
92
INHALED FOREIGN BODY
sometimes in the shape of the bronchial tree. X then arise, such as localized wheeze, stridor,
ray signs are cavitating lesions containing white persistent cough refractory to treatment, occa
fungus balls. The disorder may continue for sional haemoptysis and, if there is complete
years, with episodes of pulmonary infiltration obstruction, gradual atelectasis over 1 8 -24
and wheezing, sometimes leading to fibrosis and hours as a result of absorption of trapped air
cor pulmonale. (Figure 3 . 1 6).
Diagnosis is by bronchoscopy or CT scan. Foreign bodies tend to lodge preferentially
Treatment is by inhaled steroids (Slavin, 1 996) in the right bronchial tree in adults and
to help prevent the development of bronchiecta centrally in children (Baharloo, 1 999). Small
sis, which tends to affect the upper lobes. Anti objects can be retained for months or even
fungal agents can be delivered bronchoscopically years, causing no symptoms or a chronic
or percutaneously. Surgical resection may be cough. Many foreign bodies are made of
required Oackson et aI. , 1 993). vegetable matter and do not show on X-ray.
Most are capricious and, in young children,
difficult to diagnose.
INHALED FOREIGN BODY
Physiotherapy is contraindicated because of
Children are prone to inhale objects which the risk of shifting the object to a more
they put in their mouths, and 70% of patients dangerous location. The foreign body is best
who aspirate a foreign body are under the age removed by bronchoscopy, following which
of 3 (Denholm and Goodwin, 1 995). There is there can be inflammatory secretions or localized
usually a history of choking and paroxysmal collapse that may require physiotherapy.
coughing, followed by a relatively asympto
matic interval (Tariq, 1 999). Clinical signs may
I;ii:i141IiIi)••;i;';i:1
This 25-year-old man has primary emphysema due
to alph a l -antitrypsin deficiency.
Background
H PC: recurrent childhood infections.
SH: Unemployed, lives alone, 'finished with
girlfriend because I'm too busy with hospital
appointments'. Non-smoker.
Subjective
Yellow sputum, cleared independently.
SOB worse since admission last April.
Watch TV much of the time.
Hoping for lung transplant.
Objective
Hyperinflation.
Breathing pattern normal.
Figure 3.16 Following aspiration of a foreign body by i RR on sl ight exertion.
this young child, the left lower lobe has collapsed, shifting Stooped posture.
the mediastin um to the left. Scattered crackles on auscultation.
93
idf14-)�M'i-,;ii:i'U1" Ii).ij
I . Scan
(a) B lack airspaces in lung fields indicate
emphysema.
(b) 'double border' of diaphragm, indicating
breath lessness.
2. Analysis
Little venti latory reserve.
Previous fitness not regained since hospital
admission.
Inactive lifestyle.
Poor posture contributing to inefficiency of
breathing.
3. Problems and goals

Figure 3. 1 70 CT scan of Mr MB.
SOB.
Exercise tolerance.
4. Plan
Educate on breathlessness management.
Educate on posture correction.
Educate on relevance of exercise tolerance to
lifestyle and eligibility for lung transplant.
Assess exercise tolerance.
Negotiate daily exercise programme.
Check that chest clearance techniques are not
wasting energy; modify if necessary.
Follow up within a week to ensure motivation.
Adjust program me until optimum self-management.
Review 3-monthly.
Figure 3. 1 7b CT scan of Mr MB at a lower level The following study used lung inflation techni
ques to treat people with asthma. Has the
correct problem been identified?
Questions
The clinical usefulness of chest
I . CT scan: evidence of emphysema (Figure 3 . 1 7)?
plrysiotherapy techniques in bronchial
2. Analysis?
asthma is still being discussed. Lung
3. Problems and goals?
inflation techniques, such as incentive
4. Plan?
94 ------
RECOMMENDED READING
spirometry, voluntary deep breathing,

RECOMMENDED READING
intermittent positive pressure breathing and
continuous positive airways pressure, are Barnes, P. J. ( 1 995) Chronic obstructive pulmonary
used to increase lung volumes during acute disease. Update, 5 1 , 9 1 -97.
attacks and to reduce atelectasis, but British Thoracic Society ( 1 993) Guidelines for
published studies have failed to document management of asthma: a summary. Br. Med. J.,
306, 776-782.
their usefulness in the treatment of asthma.
Davis, P. B., Drumm, M. and Konstan, M. W. ( 1 996)
Eur. Respir. J. 1 993; 3 : 353-355 Cystic fibrosis. Am. J. Respir. Crit. Care Med. , 1 54,
1229-1256.
Demeter, S. L. ( 1 98 6) Hyperventilation syndrome and
asthma. Am. J. Med., 8 1,89-94.
RESPONSE TO LITERATURE APPRAISAL Fehrenbach, C. ( 1 998) Chronic obstructive pulmonary
disease. Prof Nurse, 1 3 , 771 -777.
Is the patient's problem:
Gibson, G. J. ( 1 996) Pulmonary hyperinflation. Eur.
• loss of lung volume? - no, acute asthma Respir. J., 9, 2640-2649.
causes hyperinflation and 'lung inflation Henderson, A. ( 1 994) Chronic respiratory failure.
techniques' would be counterproductive Practitioner, 238, 345-350.
Luce, P. J. ( 1 996) Asthma in the elderly. Br. J. Hosp.
• excess work of breathing? - yes, but the
Med., 55, 1 1 8 - 124.
methods described would increase the work
Parker, A. E. and Young, C. S. ( 1 9 9 1 ) The
of breathing physiotherapy management of cystic fibrosis in
• sputum retention? - maybe, but these children. Physiotherapy, 77, 584-5 86.
methods are not designed for sputum clear Partridge, M. R. (1 996) Self-management plans
ance. (asthma). Br. J. Ther. Rehab., 3, 271 -275.
This is the type of article that is interpreted as
meaning that 'physiotherapy' is unhelpful for
people with asthma.
------ 95
4 RESTRICTIVE AND OTHER DISORDERS
SUMMARY Pulmonary tuberculosis

Abscess
Introduction
Lung cancer
Interstitial lung disease
Sleep apnoea
Pleural effusion
Pulmonary manifestations of systemic disease
Pneumothorax
Chest infection
Neuromuscular disorders
Respiratory failure
Pneumonia
Mini case study
Pleurisy
Literature appraisal
HIV, AIDS and immunosuppression
Recommended reading
patchy fibrosis, thickened alveolar septa, remo

INTRODUCTION
delling of parenchyma and shrunken, stiff lungs.
Restrictive disorders are characterized by Smoking augments the damage. Stiff lungs mean
reduced lung volume, poor compliance and fewer functioning alveoli and often excess elastic
increased work of breathing (WOB). Restriction recoil. Involvement of alveoli means involvement
is caused by: of capillaries, and the term 'collagen vascular
disease' can overlap with interstitial lung disease.
• shrunken lung tissue, e.g. interstitial disease
The two main effects are:
• lung compressed from within the chest wall,
e.g. pleural effusion or pneumothorax
• i lung stiffness, which increases the work of
• lung compressed by the chest wall, e.g.
breathing
skeletal disorders
• 1 surface area of the alveolar-capillary
• reduced ability to expand the lung, e.g.
membrane, which impairs gas exchange.
neuromuscular disorders.
Other respiratory disorders covered in this Examples are described below.

chapter do not necessarily restrict the lung nor Fibrosing alveolitis is the commonest intersti
obstruct the airways but the respiratory system tial lung disease. Causes may be obscure, e.g. a
can be affected by infections, cancers and side effect of the drug amiodarone (Mathewson,
systemic disease. 1997), or obvious, e.g. occupational pollutants
such as metal and wood dust. If there is no
obvious cause it is known as cryptogenic or idio
INTERSTITIAL LUNG DISEASE
pathic fibrosing alveolitis. Progression is
Diseases that affect the supporting structures of variable, with average survival less than 3 years
the lung rather than the airspaces are covered by from diagnosis (Hubbard et al. , 1998). The term
the umbrella term 'interstitial lung disease'. Over fibrosing alveolitis may incorporate the end
200 disorders have been identified, usually result of other disorders, such as those described
related to immune disturbance or exposure to below, which mayor may not be classified sepa
toxic agents. Inflammatory changes lead to rately.
alveolitis, which may resolve or progress to Bird fancier's and farmer's lung cause
96
INTERSTITIAL LUNG DISEASE
pleurisy, pleural effusion and fibrosis (Leach,

1998). Patients are at risk of pneumonia because
treatment is with immunosuppressive agents.
Scleroderma is a connective tissue disorder
confined to the skin at first but often progressing
to internal organs, including the lung.
Rheumatoid disease is a systemic disease best
known for its inflamed joints, but in 10-15% of
patients also manifesting as 'rheumatoid lung'
(Jefferies and Turley, 1999, p. 201), which
incorporates pleural, vascular, airway and
fibrotic components (Hayakawa et at., 1996).
Sarcoidosis is a multisystem granulomatous
disorder of unknown cause with widespread
variation in severity, commonly presenting at
ages 20-40. A third of patients are symptom-free,
being identified by routine X-ray showing
bilateral lymphadenopathy and sometimes infil
trates. Skin, eyes and joints may be affected. Lung
involvement is common; it stabilizes or clears in
80% of patients, but the remainder suffer irrever
sible fibrosis, and most deaths from sarcoidosis
Figure 4.1 Ground-glass appearance of pneumoconiosis are due to lung damage (Judson 1998).
in a miner after working in the pit from age 13 to age 24,
Clinical features and diagnosis

The lungs have a large reserve capacity and
extrinsic allergic alveolitis, leading to fever and
the following only emerge after considerable
malaise 4-8 hours after exposure to the relevant
lllJury:
organic dust. Lung fibrosis may develop if
patients are reluctant to separate from their • shallow breathing to ease the elastic load,
birds or farming, but some protection can be and rapid breathing to sustain ventilation
provided by masks and antigen avoidance • dry cough (Lalloo, 1998)
(Bourke and Boyd, 1997). • on auscultation, fine end-inspiratory crackles
The pneumoconioses are slowly developing caused by popping open of peripheral
inhalation diseases. The body reacts to each airways, unchanged by deep breathing,
inhaled particle by creating an inflammatory wall coughing or position change
of cells around it. Miners' lung (Figure 4.1) and • progressive X-ray signs of 'ground glass'
silicosis are examples related to occupational (Figure 4.1), reticular patterning and honey
exposure. Asbestosis is an example characterized combing, as alveoli are pulled apart to form
by a 'shaggy heart' appearance on X-ray and a cystic spaces (see Figure 2.14), then an over
delay of up to 20 years between inhaling domed diaphragm as the lung shrinks
asbestos dust and developing the disease. Asbes • L Pa02 because of ValQ mismatch and L
tosis is less common than the pleural manifesta PaC02 because of rapid breathing
tions of asbestos exposure (p. 109). • hypoxaemia on exercise, not predicted by
Systemic lupus erythematosus (SLE) is charac resting Sa02
terized by exacerbations and renusslOns, • dyspnoea that becomes progressively incapa
including joint pain. Lung involvement is by citating
97
CHAPTER 4 REsTRICTIVE AND OTHER DISORDERS
• fatigue
PLEURAL EFFUSION
• digital clubbing in over half of patients
(Johnston et al., 1997). The pleural space normally contains less than
20 mL of fluid. Pleural effusion occurs when
Respiratory function tests show impaired gas there is excess fluid in the pleural cavity, caused
transfer and reduced lung volumes. Diagnosis is by disturbed osmotic or hydrostatic pressure in
by CT scan (Johnston et aI., 1997), but suspi the plasma, or changes in membrane permeabil
cions are raised by an exercise test that shows an ity. Malignancy causes 25% of pleural effusions
abnormal response of rapid shallow breathing, (Bartter, 1994). Other causes are heart, kidney
increased minute ventilation and high PA-a02 (de or liver failure, abdominal or cardiac surgery,
Lucas, 1996). pneumonia or TB.
Clinical features are a stony dull percussion
note and decreased breath sounds over the
Treatment affected area, with bronchial breathing and
Only 15% of patients respond to steroids aegophony just above the fluid level. A small
(MacNee, 1995), because fibrosis is often estab effusion of less than 500 mL creates few or no
lished and irreversible, but in combination with symptoms. A large effusion displaces the medias
interferon, substantial improvement is possible tinum (see Figure 2.10) and causes breathless
(Britton, 2000). Collagen-inhibitors also show ness. Radiologically there is a fluid line, often
promIse (Nagler, 1996). Symptoms are tracking up the pleura laterally (Figure 4.2). A
sometimes alleviated by immunosuppressive loculated effusion occurs when fluid accumulates
drugs and breathlessness temporarily relieved by in pockets.
nebulized local anaesthetic. Oxygen is needed in Medical treatment is directed at the cause,
the later stages, especially on exercise. Lung plus symptomatic relief of breathlessness by
transplantation offers hope for some patients. needle aspiration (thoracocentesis), performed
Physiotherapy to change the breathing pattern slowly to avoid ere-expansion pulmonary
is often unhelpful because the rapid shallow
breathing adopted by patients reduces the effect
of excessive lung recoil and is probably the most
efficient for them. Patients who find relief by
deep breathing might also have hyperventilation
syndrome caused by the rapid breathing asso
ciated with interstitial disease.
Patients may respond to some measures to
reduce WOB (Chapter 7), including judicious
use of non-invasive ventilation for those who
find it brings relief. Advice and encouragement
help to maintain functional activities within the
limits of dyspnoea, desaturation and fatigue.
Help with positioning is appreciated in the late
stages, following the patient's need, usually
avoiding the forward-lean positions which might
restrict the lung further.
In the unlikely event of a patient being
Figure 4.2 Bilateral pleural effusions. The right side
mechanically ventilated, manual hyperinflation shows a dense opacity with a smooth horizontal border and
should be used minimally because the non meniscal edge. The left shows a small effusion obliterating
compliant lungs are at risk of pneumothorax. the costophrenic angle.
98
PNEUMOTHORAX
oedema' (Kam et al., 1993). Surgery may be

PNEUMOTHORAX
needed for a thickened restrictive pleura. The
symptoms of malignant invasion of the pleura When the pneumothorax happened I was
can be palliated for a few days at a time by totally conscious of the puncturing of the
aspiration. Other options are a pleuroperitoneal thorax, the unbearable pain, the cold sweat,
shunt, pleurodesis (Reid and Rudd, 1993) or, for being afraid that the final moment would
loculated effusions, instillation of streptokinase come quicker than the help that you could
(Davies, 1999). give me.'
Physiotherapy is limited. Deep breathing Ruiz, 1993
exercises cannot expand lungs under pressure
If either pleural layer is ruptured, air rushes into
from fluid (Dechman, 1993). Positioning can be
the pleural space, causing a pneumothorax. The
used to optimize gas exchange. People with
lung shrinks towards the hilum, not always
moderate unilateral effusion may benefit from
symmetrically, in proportion to the amount of
side-lying with the affected side uppermost
pleural air. Air continues to escape into the
because both ventilation and perfusion are
pleura until pressure is equalized or the collap
greater in the lower lung. Large effusions are
sing lung seals the hole.
more likely to show improved Pa02 with the
Clinical features are diminished breath
effusion downwards to minimize compression of
sounds, breathlessness due to a reflex arc with
the unaffected lung (Chang et al., 1989). Some
afferents carried in the vagi, and pain in 75% of
patients require assistance with mobilization.
patients (Light, 1993). Radiographic signs are
Transudates are clear, low-protein, straw
shown in Figures 2.13 and 4.3.
coloured pleural fluids characteristic of simple
For a large pneumothorax, the collapsed lung
effusions caused by liver or kidney problems,
is seen shrivelled around the hilum, sometimes
heart failure, malnutrition or fluid imbalance.
with the mediastinum shifted away from the
Exudates are cloudy, high-protein effusions
affected side, especially if the pneumothorax is
containing cells that pass through a damaged
under tension (see below). A small pneu-
pleura, and are associated with malignancy,
trauma and infection. Haemothorax is blood in
the pleura as a result of malignancy or trauma,
and is managed by treating the cause, plus tube
drainage if necessary.
Empyema is pus in the pleural cavity
following localized infection. It can complicate
pneumonia, bronchiectasis, chronic aspiration,
abscess or chest surgery, especially oesophageal
surgery. The patient may be asymptomatic or
toxic, depending on the organism and volume of
pus. Treatment is by local and systemic antibio
tics. Other options are needle aspiration, tube
drainage either into a bag or with strong suction
using an underwater seal system, lavage, debride
ment via thoracoscopy, open drainage with rib
resection, or thoracotomy with decortication.
Surgery is required if pus fills more than 40% of
the hemithorax (Ferguson et al., 1996). Surgical
patients are debilitated and need attention to Figure 4.3 Large bilateral pneumothoraces in a patient
mobility. with emphysema.
99
CHAPTER 4 RESTRJCTIVE AND OTHER DISORDERS
mothorax can be identified more easily when the itself. A moderate first pneumothorax can be
film is taken on expiration and the lung IS managed by needle aspiration without
smaller. CT signs are shown in Figure 15. 1 1. admission to hospital. For hospitalized patients,
high concentrations of inspired oxygen speed
resolution by increasing the absorption of
Types of pneumothorax pleural air fourfold, the inert nitrogen being
displaced by absorbable oxygen (Light, 1993). A
Spontaneous pneumothorax larger pneumothorax can be treated with a
The beehive shape of the lungs means that the Heimlich valve, which enables air to escape but
apex of the upright lung is subject to greater not to re-enter.
mechanical stress than the base because the A chest drain (p. 269) is used if simpler
weight of the lung pulls down on it. A sponta methods are not adequate or the patient is on a
neous pneumothorax usually occurs in this ventilator. Once the air leak has ceased, i.e.
region, especially in tall, thin young men who when there is no more bubbling in the drainage
are thought to grow faster than their pleura is bottle, the drain is clamped for some hours and
able to keep up with. Although 'spontaneous', then removed if the X-ray shows no recurrence.
many patients are smokers and have blebs on x Sclerosing agents may be instilled through the
ray (Light, 1993). The recurrence rate is 23- chest drain to encourage adherence of the pleura
50% (Tschopp, 2000). to the chest wall. Surgical intervention (p. 268)
is necessary if these measures fail or if the
Secondary pneumothorax condition is recurrent or bilateral.
A pneumothorax may occur secondary to Physiotherapy is based on education in chest
puncture from a fractured rib, inaccurate drain management and positioning if necessary.
insertion of a cannula, high-volume positive Lying on the good side is often the most
pressure ventilation, rupture of an emphysema comfortable and is usually best for VAfQ
tous bulla or drug abuse leading to prolonged matching, but lying on the affected side may
Valsalva breath-holds or attempted central speed absorption of air (Zidulka et at., 1982).
venous injection. A pneumothorax secondary to Patients may require assistance with mobiliza
diseased lungs causes more severe symptoms and tion, vigorously if the cause is traumatic, e.g.
takes longer to heal. stab wound (Senekal, 1994), but gently if
recurrence is likely, e.g. immediately after
surgery, in case the pleura becomes unstuck.
Tension pneumothorax
Shortwave diathermy to increase the absorp
A pleural tear sometimes works as a valve so
tion of air has been suggested (Ma et al.,
that air enters the pleural space but cannot
1997).
escape, causing a pneumothorax under tension,
Precautions include avoidance of positive
usually in mechanically ventilated patients.
pressure techniques (CPAP, IPPB and other non
Progressive posltIve pressure displaces the
invasive ventilation strategies, or manual hyper
mediastinum and impairs venous return, causing
inflation) if there is no functioning chest drain.
respiratory distress and circulatory collapse.
Patients should be advised to avoid paroxysms
Recognition and management are discussed on
of coughing.
page 383.
Treatment NEUROMUSCULAR DISORDERS

To drain or not to drain? This depends on the Weak inspiratory muscles restrict expansion.
size of the pneumothorax and medical opinion. Sputum clearance may also be impaired because
If small and asymptomatic, it can be left to heal weak expiratory muscles impair cough and
100
NEUROMUSCULAR DISORDERS
reduced mechanical movement of the lung slows Post-polio respiratory insufficiency may occur
mucociliary clearance (Mier et al. , 1990). decades after the acute illness. Chronic overuse
of weak muscles, and ageing, lead to fatigue,
Pathophysiology and clinical features chronic pain and respiratory distress. Patients
If a patient has generalized muscle weakness, the may need advice on energy conservation,
respiratory muscles are usually included. balanced functional activities and NIV.
Respiratory muscle weakness may go undetected
if limb weakness reduces mobility, and ventila Physiotherapy
tory failure may arrive unexpectedly. Fatigue is Patients may need advice on balancing rest and
common and sleep apnoea may further impair exercise, including avoiding overuse of compen
quality of life. Assessment of the respiratory satory muscles. Some require treatment for
muscles is described on page 61. Some aspects of excess work of breathing or sputum retention.
specific disorders are discussed below. Upright positioning to facilitate breathing is
Respiratory complications are the major cause advised for patients with muscle weakness.
of morbidity and mortality in multiple sclerosis, Manual support can assist coughing (p. 202).
as a result of aspiration and pneumonia Regular position change and incentive spirome
secondary to bulbar weakness and immobility. try help to prevent atelectasis. If abdominal
Coughing is a particular problem because expira muscles show hypertonicity, full inspiration may
tory muscles lack the usual stimulus of strenuous be hampered, which further reduces lung
aCtlVlty and are disproportionately weak volume. Postures that encourage inhibitory
compared to the inspiratory muscles. There is control over spasticity can modify this.
evidence of some ability to strengthen the Monitoring is required once vital capacity falls
expiratory muscles but whether this ameliorates below 50% predicted, because ventilatory failure
the symptoms is unknown (Gosselink et al., is inevitable when VC is less than 30% and
1999). PaC02 starts to rise (Anzueto, 1999). The patient
A weak cough is also the main respiratory needs to make a decision on NIV before an acute
problem for people with motor neurone disease, episode precipitates action. If deterioration is
50% of whom die from complications such as progressive, the patient needs to understand that
aspiration and pneumonia within 3 years of weaning from NN may be impossible. However,
diagnosis (Sykes and Young, 1999, p. 95). If temporary relapse can be eased by ventilatory
there is bilateral diaphragmatic paralysis out of support, and overnight NIV is beneficial if
proportion to weakness of other muscles, non nocturnal hypoventilation is causing debilitating
invasive ventilation (NN) is indicated. If there is symptoms. There is some evidence that NIV can
bulbar weakness, swallowing assistance (p. 102) prolong life (Aboussouan, 1997) but generally it
or PEG feeding (p. 265) is required. If there is is symptom management that is the aim.
intermittent adduction of the vocal cords Patients with assisted peak cough flows of less
(signalled by episodic stridor in the day and than 160 Llmin require tracheostomy to clear
snoring at night), some patients are willing to secretions (Bio, 1998). Impaired communication,
accept tracheostomy (Shneerson, 1996a). The due to disease or mechanical devices, can be the
main fears of patients in late-stage disease are most difficult aspect for the patient and family,
breathlessness and choking. Breathlessness may and a reliable communications system IS
be controlled by some of the methods in essential.
Chapter 7 and can be relieved with an injection Inspiratory muscle training has been suggested
of combined diamorphine/chlorpromazine/ (McCool and Tzelepis, 1995), alternating with
hyoscine, or rectal diazepam. Excess salivation NIV for the more severely impaired (Klefbeck,
can be reduced by an anticholinergic such as 1999). Oxygen therapy is not advisable for
atropine or hyoscine. Death by choking is rare. people in ventilatory failure and can exacerbate
10 1
CHAPTER 4 RESTRICTIVE AND OTHER DISORDERS
nocturnal hypoventilation (Bach and Haas, speech-language therapist, but the physiothera
1996, p. 423), especially in post-polio patients pist may be required to stand by with suction
whose respiratory centres may have been equipment. Cervical auscultation is used by
damaged by the primary viral infection (Bach speech-language therapists to assess swallowing
and Haas, 1996, p. 371). (Cichero and Murdoch, 1998).
Prevention is by:
Management of chronic aspiration
Chronic aspiration is common in neuromuscular • head and chest elevation
disease because of its association with dysphagia • periodic turning from side to side
and poor gag reflex. A certain amount can be • avoidance of neck extension
tolerated if clearance mechanisms are normal • when eating, upright sitting with chin tucked
but, if symptoms are present, teamwork with the in, neck slightly flexed and the patient able
speech-language therapist, nursing staff and to see the food
carers is required. • avoidance of eating when tired
Dysphagia is suspected if there is excess saliva • little-and-often feeding
tion, deterioration after meals or lack of • use of finger foods to avoid utensils
elevation of the larynx on swallowing. A • avoidance of straws for drinking
tracheostomy with inflated cuff exacerbates • keeping the drinking glass full to prevent the
dysphagia but may reduce the risk of aspiration. patient tilting his/her head back
Swallowing problems often develop insidiously • if there is too little saliva, extra stimulation
but dysphagia usually parallels or shortly follows with the tongue
the development of speech problems. Patients • if there is too much saliva, advice to
are fearful of choking and suffocation swallow, and/or reduce dairy intake (p. 132)
(Jacobsson, 2000). • avoidance of distractions while eating
Aspiration is suspected in patients with • maintenance of the upright position for 30-
recurrent right lower lobe pneumonia, spiking 60 minutes after eating
temperatures, excess oral secretions, reluctance • keeping suction equipment to hand.
to eat or drink, weight loss, dehydration, gastro
oesophageal reflux or feeding that is associated Further advice on management is given by
with coughing or crackles on auscultation over Odderson (1995) and patients' organizations
the right main bronchus. Silent aspiration occurs (Appendix C).
without coughing and is present in 40% of Gauwitz (1995) advises chopped food rather
people with dysphagia (Gauwitz, 1995) but is then purees, placing the food in the unaffected
also common during sleep in elderly people side of the mouth, leisurely meals and avoidance
(Kikuchi et at., 1994). A quarter of patients with of food that is too hot or cold, bland, dry, sticky
stroke aspirate (Odderson, 1995) and half of or mucus-forming. Other tips are small
long-term tracheostornized patients aspirate mouthfuls, restriction of clear liquids, encour
during feeding (Nava 1998a). Aspiration can agement of regular gentle coughs and swallowing
cause bronchospasm, bronchitis, atelectasis, several times for each bolus. The speech
pneumonia and abscess (Bach and Haas, 1996, language therapist provides further advice on
p. 392). dietary texture and administration. If assisted
Radiological signs are regional or dissemi feeding is not adequate, a nasogastric tube itself
nated nodular shadows (see Figure 2.26), which can cause feelings of choking, and PEG feeding
may progress to interstitial scarring and is preferable (Norton, 1996).
honeycomb lung. Videofluoroscopy confirms Swallowing involves virtually all levels of the
delayed swallowing and reduced peristalsis. This central nervous system and about 50 paired
procedure is carried out by a radiologist and muscles of the mouth, pharynx and oesophagus
102
PNEUMONIA
(Bach and Haas, 1996, p. 392). Logemann spine. Chest wall compliance is impaired but
(1986) claims that the risk of aspiration can be lung compliance and diaphragmatic movement
reduced by muscle strengthening. Pharyngeal are preserved. Occasionally, fibrosis and bullous
function may be helped by isometric neck disease affect the lung. The chest X-ray shows
exercises to encourage laryngeal elevation. apparent hyperinflation because the chest wall
Dysphagia may lead to dehydration, which becomes fixed in an inspiratory posltIon.
limits secretion clearance, and weight loss, which Attention to posture, thoracic mobility and
limits mobility. Nutrition is often neglected and exercise training are advocated (Leite, 1995).
the physiotherapist may need to initiate multidis Severe cases of neuromuscular and skeletal
ciplinary management. disorders may lead to type II respiratory failure
The management of acute aspiration IS (p. 117), with hypercapnia and sometimes cor
discussed on page 105. The management of pulmonale.
neurological patients III intensive care IS
discussed on page 393.
PNEUMONIA
Pneumonia is the commonest cause of death

SKELETAL DISORDERS
from infection in the West because of its predi
lection for the elderly and immunosuppressed.
Kyphoscoliosis Infective or chemical agents breach lung
A distorted spine increases the work of breathing defences, inflame lung parenchyma and smallest
because of reduced chest wall compliance, bronchioles, then fill and consolidate alveoli
microatelectasis and altered alveolar surface with fibrous exudate. Risk factors are acute
tension (Elliott, 1995). The configuration of the stroke, poor nutrition, smoking, alcoholism,
chest wall forces the diaphragm to work ineffi winter and infancy. The changing pattern is
ciently. Surgery is sometimes undertaken to shown in Figure 4.4.
prevent progression of scoliosis or improve body Clinical features include fever, breathlessness,
image, but is unlikely to improve pulmonary tachycardia, myalgia and often dehydration. If
function (Wong et aI., 1996). localized, the affected area demonstrates a dull
percussion note, bronchial breath sounds or fine
Ankylosing spondylitis crackles, sometimes decreased expansion and a
This is a systemic disease that affects breathing pleural rub. The X-ray often lags behind clinical
because of the rigid thoracic cage and kyphotic presentation (Ferdinand, 1998) but tends to
Ageing population
patients �
Salvage of debilitated
PNEUMONIA
1 /
Antibiotic resistance
Intensive care / t '" Immunosuppression due to
I
HIV and transplantatuion
Foreign travel
Figure 4.4 How the causes of pneumonia are changing.
103
Physiotherapy is based on hydration and early

mobility. Other measures may be needed to
increase lung volume (Chapter 6). If excess
secretions develop and cannot be cleared inde
pendently, assistance is required (Chapter 8).
Lobar pneumonia
When pneumonia is confined to a lobe, localized
pleuritic pain is often a prominent feature.
Organisms include Streptococcus, for which
smoking is the main risk factor (Nuorti, 2000)
and the less common but more aggressive Kleb
siella, which may show cavitating consolidation
on X-ray. Pain limits breathing and mobility,
and, if not controlled by analgesia, may respond
to transcutaneous electrical nerve stimulation
(TENS).
Figure 4.5 Consolidation of right upper lobe,
Pneumocystis carinii pneumonia
People whose defence mechanisms are weakened
show a patchy opacity with ill-defined margms by HIV, post-transplant medication or severe
(Figure 4.5). debility are vulnerable to opportunist infection
There may be a dry cough at first, which can by organisms that are not normally pathogenic.
become productive of purulent and sometimes Pneumocystis carinii pneumonia (PCP) is a mani
rusty blood-stained sputum as the consolidation festation of this and is the common first AIDS
resolves. The structure of the lung is preserved defining illness in people with HIV who are not
and complete resolution is possible, although taking prophylactic medication, especially
sensitized nerve endings may leave a dry irritat smokers.
ing cough for some time. Invading fungal organisms damage the
Treatment is by oral or intravenous fluids, alveolar lining and a foamy exudate interferes
antiviral or antibacterial drugs, and oxygen if with gas exchange. Clinical features include dry
indicated. In the acute stage, physiotherapy is cough, breathlessness, chills, sweats and hypox
limited to positioning for VA1Q matching and aemia. Some patients are wasted from diarrhoea,
CPAP if hypoxaemia persists despite 40% oxygen malabsorption, dysphagia or mouth ulcers which
(Brett and Sinclair, 1993). Other patients may restrict food intake. They may or may not be
need assistance with mobility or simply advice to pyrexial because immunocompromised people
get dressed and walk around when ready. cannot always mount a fever in response to
There is overlap between different types of infection. Patients may be reluctant to take a full
pneumonia but the common classifications, with inspiration because of pleuritic pain or coughing
details of how physiotherapy is modified when fits. Auscultation may be normal or show fine
appropriate. scattered crackles. The X-ray may be normal at
first if immune deficiency delays the appearance
Bronchopneumonia of an inflammatory response, but later signs are
Bronchopneumonia is patchy and diffuse, often a perihilar haze, progressing to diffuse symmetri
favouring the lower lobes. It is common in the cal shadowing and air bronchograms (see Figure
immobile and elderly. Early signs are fine 2. 16). Sudden deterioration raises suspicions of a
crackles that persist despite deep breathing. pneumothorax.
104
PNEUMONIA
Non-invasive diagnosis is by X-ray, a low while antimicrobial drugs have time to work.
TLCO (p. 60), or exercise-induced oxygen desa Ventilated patients with PCP rarely have a
turation below 90% (Vilar, 1998). Arterial blood problem with bronchial secretions and
gases show hypoxaemia and a low PaC02 due to physiotherapy is based on positioning for VAl
breathlessness. Lung biopsy results are variable Q matching and maintenance of the muscu
because of the patchy nature of the disease loskeletal system.
(Vilar, 1998) but induced sputum, bronchoscopy
or bronc�oalveolar lavage can assist diagnosis. Other measures for people with AIDS and
Drug prophylaxis is by monthly nebulized immunocompromise are discussed on page 107.
pentamidine for patients at risk. Treatment is by
early use of a combination of antiviral and other Nosocomial pneumonia
drugs (Vilar,1998). Pneumonia that develops after hospitalization
Physiotherapists are involved in the following for more than 48 hours is considered to be
ways: hospital-acquired or nosocomial pneumonia. It
occurs in 1% of hospitalized patients, including
• Diagnostic assistance by sputum induction 10% of intensive care patients Guniper, 1999b),
(p. 36) or oxygen desaturation during exer and is the leading cause of hospital-related
cise (Chouaid et ai., 1993). mortality (Niederman, 1998). The disease may
• Administration of nebulized pentamidine to be caused by cross-infection between patients,
the lung parenchyma, using a filter and usually carried by staff, or acquired from other
special nebulizer that produces particles colonized sites such as a nasogastric tube
which reach lung tissue without creating side (Guerin, 1997), tracheostomy or the gut. A
effects in the upper airways. To limit envir major cause is misuse of broad-spectrum antibio
onmental contamination, a separate room is tics (Fiorentini, 1992). Nosocomial pneumonia
required, preferably with an air extraction involves different pathogens from community
system. Prior bronchodilator inhalation acquired pneumonia.
reduces the side effects of coughing and
bronchospasm, and patients are advised to
Legionella pneumonia
change position regularly to ensure delivery
to all parts of the lung. Legionnaires' disease is one of the 'atypical'
• Patients need support when in the grip of pneumonias. It occurs in local outbreaks, espe
acute breathlessness because they are inten cially in connection with cooling systems or
sely frightened and often think that they are inadequately cleaned small-volume nebulizers
dying. Physical assistance is described on (Mastro et al., 1991). Mortality is 5-10%.
page 169. Positioning depends on the
patient's choice, but when breathlessness is Aspiration pneumonia
severe, minimal handling is preferred. Reas Pulmonary aspiration is the spilling of gastric
surance can be given because although contents or foreign matter below the vocal cords.
people with AIDS know that they have an People who have inhaled unfriendly substances
eventually fatal disease, death rarely occurs such as vomit or gastric acid can develop aspira
during episodes of acute breathlessness. tion pneumonia within 2 hours, although post
• CPAP (p. 156) at pressures of 5-10 cmH20 anaesthetic patients do not develop the signs and
improves gas exchange in patients with symptoms for some hours (Beards and Nightin
severe disease (Miller and Semple, 1991) and gale, 1994). A vicious pneumonitis corrodes the
buys time for discussion with the patient alveolar-capillary membrane and leaves a legacy
about further treatment. If required, some of pulmonary oedema, haemorrhage and necrosis.
patients may choose mechanical ventilation Aspiration pneumonia should be suspected in
105
CHAPTER 4 RESTRICTIVE AND OTHER DISORDERS
anyone who has experienced a period of unex • stress, anxiety and pain
pected unconsciousness. • children, because of their low gastric pH
Signs of acute aspiration include crackles and • endotracheal tube, tracheostomy or nasogas
wheezes on auscultation, tachypnoea, tachycar tric tube.
dia, fever and sometimes cyanosis. Unless aspira
Patients require immediate physiotherapy by
tion is silent, coughing or choking may occur. X
postural drainage, percussion, vibrations,
ray signs of consolidation are evident within a
shaking and cough or suction. If the patient is
few hours, increase over 24-48 hours, then clear
able, other techniques to clear secretions can be
up within 1-2 weeks in uncomplicated cases.
used (Chapter 8). Associated trauma should be
The location of these infiltrates helps to identify
checked because any person found on the floor
which lobe is affected,
must first have got there. Once consolidation has
Material aspirated in the supine position tends
set in, as indicated by bronchial breathing, these
to collect in the posterior segments of the upper
manual techniques may be less effective, but
lobes or apical segments of the lower lobes.
CPAP may be beneficial, or PEEP for ventilated
Other targets are shown in Figure 4.6.
patients (Behera et ai., 1995).
Risk factors (Beards and Nightingale, 1994)
Medical intervention by intubation and
are:
suction may be indicated, with fluid replacement
• altered conscious level, e.g. head injury, to compensate for fluid sequestration in the
alcohol intoxication, seizure, stroke lungs and systemic tissues. Routine antibiotics
• pregnancy, because of increased abdominal are not indicated and tend to encourage
pressure and a high incidence of gastro-oeso secondary infection by resistant organIsms
phageal reflux (Beards and Nightingale, 1994).
• obesity Outcome depends on the volume and type of
Apical segment If on side, axillary subsegments

of lower lobe of upper lobe
If upright,
basal segments
of lower lobes
Figure 4.6 Aspiration in varying positions causing pneumonia in different lobes.
106
PULMONARY TUBERCULOSIS
aspirate and the immune status of the patient. • hand washing, sterilization of equipment and
Severe aspiration contributes to 25% of cases of use of a mask by any health worker with a
acute respiratory distress syndrome (Oh, 1997, cold, because of the patient's susceptibility
p. 319). Chronic aspiration is discussed on page to infection
102. • for HIV patients, autonomy because the
syndrome is long-standing and prone to
misconceptions
• the patient's many individual requirements,
PLEURISY
because of the effects of undernourishment,
Pleurisy IS inflammation of the pleural dehydration and, in the later stages of AIDS,
membranes, sometimes associated with lobar the discomforts of terminal disease and its
pneumonia. It causes a pleural friction rub and a treatment.
wicked localized pain because of the sensitivity
of the parietal pleura. This results in rapid Any patient may be HIV-positive and precau
shallow breathing. The pain may be eased by tions should be universal. Body fluids known to
heat or TENS. Dry pleurisy sometimes develops contain the HIV are blood, semen, vaginal secre
into a pleural effusion. This brings relief from tions and urine. The virus has not been found in
symptoms as the raw pleural membranes are normal sputum, but any sputum may contain
separated by fluid. blood. Precautions against transmission include
covering cuts or abrasions with waterproof
plasters, wearing gloves during contact with
body fluids and using visors to cover eyes, nose
HIV, AIDS AND IMMUNOSUPPRESSION
and mouth during suction. Masks give some
Respiratory complications affect the majority of protection.
people with the acquired immunodeficiency
syndrome (AIDS). These complications manifest
PULMONARY TUBERCULOSIS
as PCP (p. 104), Kaposi's sarcoma (p. 109), lung
abscess, tuberculosis or pleural effusion. Pulmonary tuberculosis (TB) is not a disease of
Necrotic lung tissue may rupture and cause a the past. The incidence is increasing in Europe
pneumothorax, which is notoriously difficult to and the USA, and new drug-resistant strains are
treat in this group of patients (Light, 1993). Oral emerging. One-third of the world's population is
herpes or a sore mouth can make eating difficult infected by the TB bacillus, which may become
and oxygen therapy intolerable. active if the host's defence mechanisms are
In the West, where powerful drugs are compromised by poor living conditions, drug
available, AIDS is, like COPD, a chronic and dependency or HIV infection. TB in an HIV
treatable disease which is ultimately fatal. The infected person is an AIDS-defining illness,
physiotherapist's role is to provide assistance creating a cruel duet as the two infections
with respiratory problems, mobilization, relaxa exacerbate each other. TB is the only disease
tion, exercise to improve immune function likely to be transmitted from AIDS patients to
(Lang, 1991), and massage to relieve neuropathic the community.
pain. TB of the lung is the commonest form of the
Other immunocompromised patients are disease, causing 3 million deaths a year, more
those who are very young, very old, malnour than any other infection (Empey, 1993).
ished, addicted to drugs or alcohol, taking Coughing disseminates infected aerosol, which
steroids or suffering malignancy. can remain suspended in the air for hours.
When working with immunocompromised Symptoms are fever, night sweats, cough, chest
people, specific attention should be given to: wall pain, weight loss, haemoptysis and breath-
107
CHAPTER 4 REsTRlCfIVE AND OTHER DISORDERS
lessness. The X-ray shows cavitating lesions in line (see Figures 2.8 and 2.17). Medical
the most stretched and poorly perfused areas of treatment is by antibiotics. Physiotherapy is
lung, which are the apices in humans and the effective if the abscess is open, postural drainage
bases in bats. Miliary TB shows evenly scattered being safe so long as the correct antibiotic is
nodules. given and positioning is accurate and thorough
The tubercle bacillus is slow growing and to avoid dissemination of infection.
tough, responding only to 6 months of treatment
with a combination of powerful antibacterial
LUNG CANCER
drugs. The patient is no longer infectious after 2
weeks' treatment, providing sputum is clear of Carcinoma of the lung is the commonest cancer
the bacillus. The physiotherapist's role is usually in the UK and the commonest cause of death
confined to eliciting sputum specimens in a from cancer (Simmonds, 1999). It is increasing
negative pressure room and devising ways to alarmingly in women as they catch up with men
encourage exercise in an isolation cubicle. A in smoking habits. Mean survival is less than 6
high-efficiency particulate air-filtering mask must months (Falk, 1997), depending on the type of
be used throughout. Patients in isolation need a tumour (Figure 4.7). Most tumours arise in the
window, a telephone and reassurance that they large bronchi, whose bifurcations are first to be
are not stigmatized. bombarded with tobacco smoke (Figure 4.8).
Tobacco causes at least 87% of deaths (Dresler,
1996).
ABSCESS
Clinical features are a diffuse or aching chest
Lung abscess is a focal collection of pus within pain, haemoptysis, clubbing, cough, unresolving
the lung parenchyma, caused by a virulent event pneumonia and breathlessness. Breathlessness is
such as inhalation of septic material. It leads to caused by the tumour, the treatment, e.g. radio
cavitation and necrosis. Patients may have a therapy, or the effect of having cancer, e.g.
swinging pyrexia, and the X-ray shows an cachexia. Systemic symptoms include loss of
opaque lesion until communication with the energy, appetite and weight. Recurrent
airways is established, when drainage of the pneumonia in a smoker is a suspicious sign. A
necrotic debris shows a ring shadow with fluid large tumour in a main bronchus may produce
Death
Usual diagnosis
First diagnosis
(/) Small-cell carcinoma Squamous cell carcinoma Adenocarcinoma
.� 40
:c
:::J
o
1:l
OJ
E
:::J
20
�
;;
o
E
� 4 6 8 10 12 14 16
Years
Figure 4.7 Lung cancer growth rates. A tumour usually becomes evident on X-ray when I cm in diameter, followed by
symptoms, then diagnosis (Redrawn from Bourke, S. J. and Brewis, R. A. L. ( 1998) Lecture Notes on Respiratory Medicine,
Blackwell, Oxford.)
108
LUNG CANCER
Other cancers
Kaposi's sarcoma
= This is a proliferative process that affects the
skin, gut and connective tissue of immunocom
promised people. Pulmonary Kaposi's sarcoma
(KS) is the commonest malignancy associated
with AIDS (Miller, 1 996) and affects the
Figure 4.8 Turbulence of airflow at branching of parenchyma, lymph nodes or pleura, manifesting
airways. as progressive dyspnoea and cough, hypoxaemia
and sometimes respiratory failure. CT findings
include nodules, masses and pleural effusions.
KS represents late-stage disease and a poor
prognosis. Treatment is by radiotherapy or
no radiological change until obstruction causes
chemotherapy (Antman and Chang, 2000).
lung collapse, but stridor or a monophonic
wheeze may be heard. Hoarseness indicates
Mesothelioma
involvement of the recurrent laryngeal nerve,
This arises in the mesothelial cells of the perito
which may impair speech and cough.
neum, pericardium or, most commonly, the
Lung and other cancers can cause a pleural
pleura, and is caused by asbestos exposure. In
effusion without tumour growth in the pleura,
the pleura it is associated with malignant pleural
and this is a poor prognostic indicator
effusion, chest pain and clubbing. Mesothelioma
(Martinez-Moragon, 1 998). An early sign that
may not develop until 50 years after exposure
sometimes appears before diagnosis is hyper
(Jefferies and Turley 1 999, p. 2 1 4), and is
trophic pulmonary osteoarthropathy, manifest as
usually fatal within 2 years. Palliation is by chest
pain and swelling of the wrists and ankles
drainage. Asbestos-related deaths are expected to
(Penson and Rudd, 1 997).
peak in about 20 1 5 (Boylan, 2000) .
The common cancers Bronchoalveolar carcinoma

This represents 30/0 of primary lung malignancies
A quarter of people with lung cancer suffer from
(Jefferies and Turley 1 999, p. 208 ) , developing
small-cell lung cancer, the most vicious and
in peripheral lung, manifesting as local or diffuse
rapidly spreading of the cancers. Other lung
infiltrates on X-ray and causing breathlessness,
cancers are squamous-cell, large-cell and adeno
cough and sometimes extreme quantities of
carcinoma, which are more likely to be
watery sputum. It is not caused by smoking.
localized. Medical treatment is aimed at inflict
ing the greatest damage to the cancer with the Metastases and spreading tumours
least damage to the patient, but the disease is
Metastatic disease carries a poor prognosis but
usually disseminated at presentation. Radiother
occasionally responds to surgery if the primary
apy and/or chemotherapy may ease symptoms or
tumour is controlled (Kandioler, 1 9 9 8 ).
reverse obstructive atelectasis. Multiple medica
Spreading tumours can cause various compli
tion may cause 'chemotherapy lung', leading to
cations:
diffuse infiltrates on X-ray and breathlessness.
Surgery (p. 265 ) is occasionally curative. Most • Upper airway obstruction leads to breathless
people with lung cancer have COPD and need ness and sometimes lung collapse. It can be
attention to this. palliated and sometimes a lung temporarily
re-expanded by cryotherapy, laser resection,
109
CHAPTER 4 REsTRlCrIVE AND OTHER DISORDERS
localized radiotherapy or stenting to splint oxygen saturation may drop to 75%, which
open the airway (Mehta, 1999). Stenting stimulates the cortex, and the subsequent arousal
may cause an irritating cough. may be accompanied by spectacular snoring.
• Superior vena caval obstruction causes The patient is affected by daytime sleepiness,
oedema, headache, difficulty in breathing, poor concentration, morning headaches due to
stridor and faintness on bending down. It CO2 retention, memory loss and a disgruntled
may be eased by radiotherapy and raising the spouse. Ironically, the more severe the sleep
head of the bed. fragmentation, the deeper the sleep and the less
• Pancoast's syndrome is invasion of anato likely the patient is to report sleep problems
mical structures such as the chest wall, (Wilkins et aI., 1995, p. 358).
lymphatics and sympathetic chain (Musco Risk of sleep apnoea is increased by smoking
lino, 1997). Consequences include: (Wetter et aI. , 1994) and high alcohol intake
- loss of sympathetic tone because of reduced muscle tone Oalleh et aI. ,
- if the upper rib is involved, shoulder 1993). It is doubled by being male, possibly
pam because progesterone is a respiratory stimulant.
if the inferior brachial plexus is Sleep apnoea often goes unrecognized because
involved, ulnar nerve pain and small patients make adjustments to their lifestyle, may
muscle wasting in the hand. not realize the severity of the problem and
misinterpret sleepiness as fatigue. Nearly half of
Physiotherapy people referred for chronic fatigue syndrome
Physiotherapists may be involved at any stage, have been found to have sleep disorders (Strollo,
including exercise programmes to aid prevention 1998). Physiotherapists may be the first to
(Francis, 1996), sputum induction (Khajotia, suspect the condition.
1991), relaxation (Sims, 1987), postoperative
management and terminal care. Weakness and Types of sleep apnoea
fatigue are frequent accompaniments to the
disease and its various treatments. Depression is Obstructive sleep apnoea
common and relates to prognosis (Buccheri, Obstructive sleep apnoea (OSA) is caused by
1998), which may be why the encouragement of nocturnal upper airway obstruction despite
independence and self-esteem appears to respiratory effort, and worsens as the night
improve survival (Zimmerman et aI. , 1997). progresses (Charbonneau, 1994). It affects 1-4%
of the population (Kiely, 1999) and 10% of
patients also have COPD, usually with the blue
SLEEP APNOEA
bloater pattern (Noureddine, 1996).
Falling asleep at the wheel is the cause of a OSA may be associated with obesity because
quarter of fatal car accidents (Cassel et aI. , the thick neck virtually chokes patients in their
1996). Sleeping at the wheel occurs 70 times own fat when muscle tone wanes at night.
more often in people with sleep apnoea than in Children are not immune (p. 430). OSA should
normal subjects (Haraldsson, 1990), and one be suspected in COPD patients whose nocturnal
study found that 100% of people with sleep desaturation is disproportionate to their spiro
apnoea have experienced near-miss car accidents metry.
(yamamoto, 2000). Sleep apnoea has been It takes on average 10 years of snoring before
blamed for oil-tanker spills, nuclear contamina OSA is detected, during which the ongoing
tions and the space shuttle explosion (Smith and vibration appears to disturb the complex muscu
Mayer, 1998). lature of the upper airway, which has to juggle
Sleep apnoea exists when breathing stops for breathing, swallowing, talking, laughing, crying
more than 10 seconds during sleep. Nocturnal and singing (Strollo, 1998). Diagnosis may not
1 10
SLEEP APNOEA
spondylitis or diaphragmatic paralysis, apnoea

can occur because of inhibition of accessory
muscle action during sleep.
TH A Nf( yo u
fo r
Conditions associated with sleep apnoea
The Pickwickian or obesity-hypoventilation
rv O T SNO R I N G . syndrome is a severe form of OSA seen in
markedly obese people. They may require non
invasive ventilation to unload the respiratory
muscles (Pankow, 1 997). The Prader-Willi
syndrome is a congenital disorder of obesity,
hypotonia and impaired cognition (Smith et aI. ,
1 99 8 ) . Nocturnal hypoventilation is an exaggera
tion of the normal reduction in respiratory drive
at night.
Management
Diagnosis is made from symptoms, history and a
sleep study to evaluate airflow, effort, Sa02,
ECG, positioning and limb movements. Sleep
apnoea can worsen in hospital because of
sedative drugs, the supine position and sleep
deprivation.
be forthcoming until unexpected right heart Management of OSA is firstly by weight loss
failure develops because of recurrent hypoxae and smoking cessation if relevant, avoidance of
mia. Pulmonary and systemic hypertension, evening alcohol or sedatives and strategies to
arrhythmias and death from cerebral and cardiac avoid sleeping supine (Strollo, 1 998), e.g. a
events cause significant mortality. Some 50% of strategic pillow or backpack at night.
people with OSA are hypertensive in the daytime CPAP (p. 1 5 6 ) can be used to pneumatically
(Wilkins et al. , 1 995, p. 3 5 8 ) . splint open the upper airway at night. Pressures
of 5 - 1 5 cmH20 are advised, and a reduction is
Central sleep apnoea often possible after a fortnight Gokic, 1 998), but
This is associated with neuromuscular disorders, smart machines are able to titrate the pressure
heart failure and abnormal control of breathing, for each individual (Strollo, 1 99 8 ) . CPAP
possibly as a result of depressed response to CO2 relieves symptoms, lowers mortality and can
during sleep. Snoring is not a characteristic and, reverse problems such as road accidents Ganson,
in contrast to OSA, there is a lack of respiratory 2000), heartburn, bedwetting (Kiely, 1 999),
effort. Pure central sleep apnoea is rare and most impotence and Cheyne-Stokes breathing, as well
people with sleep apnoea have both obstructive as acting as a catalyst to weight loss, which itself
and central components (Wilkins et aI., 1 995, p. may allow discontinuation of CPAP (Bradley,
359). 1 99 3 ) . Figure 4 . 9 shows how CPAP reduces
sleep-related fatigue and road accidents.
Restrictive sleep apnoea Problems with domiciliary CPAP are:
For those who have little respiratory reserve
because of disorders such as scoliosis, ankylosing • noise, in which case the machine can be put
111
CHAPTER 4 RESTRICTNE AND OTHER DISORDERS
Always E 1.2
�
Fre-
0
0 1 .0
0
quently 0
Q)
0 0.8
:::>
Some- OJ
Ol
a. 0.6
� times Q)
� 0.4
Seldom C
Q)
'0
'(3
0.2
u
«
Never �-----,-----.- 0
Untreated 1 year Untreated 1 year
CPAP CPAP
Figure 4.9 Reduction in fatigue and number of accidents in people with sleep-disordered breathing after a year of using
CPAP. (From Cassel, W. ( 1 99 6) Risk of traffic accidents in patients with sleep-disordered breathing. Eur. Resp. , 9, 2606-26 1 1 .)
in another room and the tubing extended, so increases minute volume, anaemIa hinders
long as pressures are re-checked oxygen delivery, acid-base imbalance affects
• dryness, in which case a humidifier can be breathing and malnutrition predisposes to chest
added, which also requires subsequent infection. Breathing itself affects heart rate and
rechecking of pressures BP (Fried, 1993). Specific disorders are discussed
• coldness, which can be lessened by keeping below.
the tubing under the bedclothes.
Cardiovascular disease
BiPAP (p. 179) is useful for people who
Neighbourly relations between heart and lung
cannot tolerate CPAP or for those with hypoven
are reflected in their integrated response to each
tilation (Strollo, 1998).
other's disorders, especially when intravascular
Other strategies are various contraptions such
pressures are involved.
as a nasopharyngeal airway, tongue retainer or
mandibular device (Stradling et aI. , 1998).
Pulmonary oedema
Severe disease may require surgery such as
Pulmonary oedema is extravascular water in the
tongue reduction, uvulopalatopharyngoplasty,
lungs, usually caused by back pressure from a
which is as complicated as it sounds, or recon
failing left heart. The main symptom is breath
struction to advance the mandible.
lessness, leading occasionally to a misdiagnosis
Central sleep apnoea may be helped by drugs
of asthma, from which the confusing term
to reduce REM sleep or stimulate respiration,
'cardiac asthma' arises. Breathlessness caused by
CO2 therapy (Badr et at., 1994) or nocturnal
pulmonary oedema is distinguished by orthop
nasal ventilation (Bott et at., 1992). Nocturnal
noea and paroxysmal nocturnal dyspnoea (p.
oxygen therapy may be helpful (Wilkins et at.,
3 1). Fatigue is caused by reduced cardiac output.
1995, p. 361), but if there is COPD overlap it
Radiographic signs are enlarged heart, upper
may suppress the respiratory drive (Bach and
lobe diversion and bilateral fleecy opacities
Haas, 1996).
spreading from the hila, which are known as
batswing or butterfly-wing shadows (see Figure
2. 14). Crackles on auscultation, more evident in
PULMONARY MANIFESTAnONS OF SYSTEMIC
dependent lung, are due to the popping open of
DISEASE
dependent alveoli compressed by peribronchial
The respiratory system is influenced by most oedema.
systemic disturbances; for example, fever Non-cardiogenic pulmonary oedema, distin-
1 12 ------
PULMONARY MANIFESTATIONS OF SYSTEMIC DISEASE
guished by a normal-sized heart on X-ray, can be pists, is particularly unhelpful for patients with
caused by fluid overload, systemic vasoconstric an enlarged heart because of compression of the
tion, oncotic pressure changes (e.g. cirrhosis, left mid and lower lung zones (Wiener et aI. ,
malnutrition, nephrotic syndrome) or increased 1990). CPAP can improve gas exchange
capillary permeability due to toxins or inflamma (Takeda, 1997). If mechanical ventilation is
tory damage. necessary, patients rarely require physiotherapy
Interstitial pulmonary oedema bare!y affects other than monitoring, positioning and muscu
lung function but, if the lymphatics become loskeletal care.
overloaded, fluid squeezes into alveoli, causing Right ventricular failure is caused by L VF,
alveolar oedema, a widened PA-a02 gradient and valvular disease of the left heart or chronic
hypoxaemia. If alveolar fluid moves into the pulmonary hypertension caused by hypoxic
airway, it mixes with air and is coughed up as conditions such as COPD. The term congestive
frothy sputum. cardiac failure (CCF) means both right and left
heart failure with congestion in the pulmonary
Heart failure and systemic circulations, often associated with
If the heart is unable to pump all the blood COPD.
returned to it, it is said to have failed. Heart
failure may be acute or chronic and is a response Pulmonary embolism
to heart or lung disease or heart surgery. Pulmonary embolism (PE) is blockage of the
Compensation for reduced oxygen delivery is by pulmonary vasculature, usually by a blood clot.
increased sympathetic drive. Decreased oxygen A small embolus enables secondary blood supply
delivery to the kidney leads to salt and water from the bronchial circulation to keep lung
retention. tissue viable, but this blood exudes into alveoli,
Heart failure is suspected if a patient with causmg haemoptysis and an inflammatory
predisposing factors develops oedema, fatigue reaction that manifests as sharp localized
and breathlessness due to pulmonary oedema. pleuritic pain, breathlessness, pallor and
Survival rates are lower than for many cancers sometimes pleural rub. Massive embolism causes
(Dargie, 1994), but people can live with chronic circulatory collapse, and occlusion of more than
heart failure for some years. Indeed, 1% of the 50% of the pulmonary vascular bed is fatal
population is considered to have heart failure Gefferies and Turley, 1999, p. 176). PE has been
(Cleland, 1996). It is helpful to explain the term found at autopsy to contribute to death in up to
to patients because of its misinterpretation in the 70% of patients (Wood and Spiro, 2000).
media as a heart attack or cardiac arrest. PE is difficult to diagnose clinically, but 70%
Left ventricular failure (LVF) IS the of patients have evidence of deep vein thrombo
commonest reason for heart failure and is sis (Edmondson, 1994), 20% of patients show
usually caused by coronary heart disease. The the classic triad of chest pain, dyspnoea and
failing left ventricle forces up pressure in the left haemoptysis (Reed, 1996), and 10% are asymp
atrium and the pulmonary vascular system tomatic (Wood and Spiro, 2000). The X-ray
behind it, leading to pulmonary oedema. may show a small pleural effusion or a periph
Treatment of LVF is by dealing with the cause eral wedge-shaped shadow indicating infarcted
where possible, plus oxygen, venodilator drugs lung. A V/Q scan is 50% conclusive (see Figure
to reduce filling pressures, and diuretics (p. 138). 2.21) and a spiral CT with intravenous contrast
The role of the physiotherapist is limited to medium is 90% conclusive (Hansell, 1998).
giving symptomatic relief by positioning the Recognition of PE in ventilated patients is
patient upright, with support of the feet to discussed on page 384.
prevent the inexorable slide down the bed. The Prevention of PE is by avoidance of DVT (p.
supine posture, that anathema for physiothera- 262). Immediate management of PE is by giving
113
oxygen and placing the patient supine, thus with portal hypertension, in case the catheter
boosting venous return to the left heart, which is enters the oesophagus.
deprived of pulmonary artery flow (Gray, 1992). • Impaired manufacture of albumin may
Treatment is by thrombolytic therapy to dissolve disturb fluid balance, especially in advanced
the clot, followed by heparin infusion and liver disease when the kidneys are also
sometimes insertion of caval filters. Embolect involved.
omy is rarely performed. • Lung expansion is restricted if the
It is possible that manual chest techniques or diaphragm is splinted by hepatomegaly or
mobilization could dislodge the clot. Theoreti ascites due to portal hypertension and
cally this might be beneficial if the clot moves reduced albumin, and some patients with
into a smaller blood vessel, but any active grossly enlarged livers are immobile and may
physiotherapy is considered risky until anticoa not be able to roll.
gulation therapy is established. • Encephalopathy is caused by circulating
toxins and reduces the patient's ability to co
Kidney disease operate.
Late-stage hypoxaemic respiratory disease • Cerebral oedema causes hyperventilation,
impairs perfusion to the kidneys (Howes et ai., which may be severe enough to require
1995). Kidney disease and its treatment affect mechanical ventilation (Cowley, 1993).
most body systems, the respiratory system being • Asterixis (p. 34) may be associated with liver
influenced by: disease rather than hypercapnia.
• Bilirubin in the plasma of jaundiced patients
• fluid overload due to kidney dysfunction, limits the accuracy of oximetry.
leading to pulmonary oedema and sometimes
pleural effusion For management of patients in liver failure,
• breathlessness due to either pulmonary see page 408.
oedema or metabolic acidosis if the kidney is
Sickle cell disease and thalassaemia
unable to maintain acid-base balance
• muscle wasting due to steroid treatment or Sickle cell disease is a common genetic disorder
uraemIa characterized by the sickling phenomenon, in
• following transplantation, OPPOrtUlllstlC which red blood cells crystallize into a sickle
chest infection due to immunosuppressive shape. The sickled cells become rigid, suffer
drugs accelerated haemolysis and are unable to squeeze
• sleep apnoea associated with end stage renal through small vessels. Morbidity and mortality
disease (Kimmel et at., 1989). result from haemolytic anaemia, vaso-occlusion
of the microvasculature in multiple organ
Renal support systems are discussed on page systems and infections due to a disturbed
408. immune system. Intermittent vaso-occlusive
crises are precipitated by:
Liver disease
• exercise
The liver boasts over 500 functions and is served
• fatigue
by two blood supplies. For the physiotherapist,
• dehydration
precautions when treating people with liver
• infection
disorders include the following:
• cold
• Tracheal suction is performed with caution • extreme temperature change
if clotting factors are abnormal. • damp housing
• Before nasopharyngeal suction, it is advisable • poor diet
to check for oesophageal varices associated • smoking.
1 14
PULMONARY MANIFESTATIONS OF SYSTEMJC DISEASE
When sickling occurs in the pulmonary vascu GOR often occurs at night when sleep-related
lature, an acute chest syndrome of chest pain, reduction in oesophageal motility slows
breathlessness, atelectasis and infiltrates clearance, allowing refluxed material more time
develops. The symptoms may be reduced by 2- to harm the mucosa. Other risk factors are
hourly incentive spirometry (Bellet, 1995). smoking, alcohol, the extremes of age, chronic
Patients may need assistance with gentle mobili aspiration, obesity (Locke et at., 1999) and
zation because of anaemia and fatigue. Surgery is raised abdominal pressure as occurs in coughing
often needed for gallstones or avascular femoral and wheezing. GOR increases the risk of oeso
necrosis, and physiotherapy is needed postopera phageal cancer (Lagergren et aI., 1999).
tively to reinforce pain relief and encourage Symptoms include heartburn, discomfort on
activity. Diaphragmatic splinting due to pain can swallowing, nocturnal cough, morning hoarse
lead to atelectasis and cause acute chest ness and regurgitation with a bitter taste in the
syndrome (Area, 1994). Patients need advice on mouth after recumbence, stooping or large
joint protection. Ice treatment is contraindicated. meals. There may be recurrent pulmonary infil
Sickle-call disease is commonest in black trates on X-ray. Symptomatic children feed
people, but Mediterranean and occasionally poorly and vomit. Vomiting may be the only
white people can be affected. The excruciating indication of GOR in people with CF. Confirma
ischaemic pain of vaso-occlusion mandates that tion of the diagnosis is by endoscopy, barium
these patients are under the care of a specialist swallow or oesophageal pH monitoring.
unit, where epidural analgesia (Yaster et aI., Management is by encouragement of side
1994) or other potent pain relief is available. lying (Dean, 1997), raising the head of the bed
Non-specialist staff sometimes suspect narcotic at night, weight reduction if appropriate, and
abuse in this group of patients, although the risk drug review. Patients should avoid late evening
is less than 1% (Lancet, 1995a). Some patients meals, large meals, stooping, smoking, alcohol,
carry a note from their specialist defining the caffeine and aminophylline, which relaxes the
required analgesia in case of admission to an cardiac sphincter. Anti-reflux Hz-antagonist
unfamiliar hospital. drugs, or occasionally surgery (Hogan, 2000),
Thalassaemia is an inherited disorder of may be indicated.
haemoglobin production leading to anaemia. The head-down postural drainage position is
Patients require lifelong blood transfusions. Iron to be avoided (Button et at. , 1994) but the effect
overload is common and causes an obstructive of different positions is variable, and slumped
and/or restrictive lung defect (Dimopoulou, sitting may be worse because of increased
1999). abdominal pressure. No physiotherapy should be
given immediately after meals. GOR in children
Castro-oesophageal reflux is covered on page 427.
Gastro-oesophageal reflux (GOR) is the involun
tary passage of gastric contents, with its pH of Diabetes
only 1.0, into the oesophagus. It is often asso Over 15% of the world's population has
ciated with cystic fibrosis, asthma or obstructive diabetes (Roizen, 1997), 2% in the UK
sleep apnoea (lng et aI., 2000). In adults it is (Marshall, 1996). Some develop pulmonary
related to chest disease as cause or effect, complications due to collagen and elastin
possibly because the oesophagus and bronchial changes (Ljubic et at. , 1998). Surgical patients
tree share vagal innervation. In children it is also are at risk because lack of insulin leads to unrest
associated with cough, recurrent croup (Yellon rained catabolism and raised circulating glucose,
et aI., 2000) or spastic cerebral palsy. In infants so that insulin is required to avoid dehydration
it is common and usually asymptomatic (Dodge, and acid-base disturbance.
1999). Complications of diabetes include fluid upset,
115
hypotension and pressure sores. In relation to reaction times and forgetfulness (Sharpe, 2000).
exercise, people with stable diabetes benefit so Long-term use can cause memory loss
long as they maintain hydration, look after their (Campbell, 1999a), bullae (Johnson, 2000) and
feet and when necessary increase their insulin problems related to the tobacco with which it is
and carbohydrates to avoid hypoglycaemic usually mixed. Non-psychoactive preparations
events. Warning signs of hypoglycaemia include have been used beneficially for bronchospasm,
light-headedness, weakness and fatigue, and a pain, nausea, poor appetite (Campbell, 1999a)
sugar source must be available during exercise and multiple sclerosis (Consroe et aI. , 1997).
sessions. Haemodynamic responses to exercise Patients report a beneficial effect for glaucoma
may be attenuated by autonomic neuropathy. and other visual problems, fatigue, tremor,
imbalance, sexual dysfunction and bowel and
Drug-induced lung disease bladder problems (Campbell, 1999a).
Immunological or cytotoxic lung damage can be Damage caused by the administration of illicit
caused by medication. Examples are interstitial drugs include the following:
pneumonitis caused by amiodarone and asthma
• Intravenous drug users risk septic throm
caused by aspirin. Reactions to illicit drug use
bophlebitis and pulmonary emboli.
depend on the substance, contaminants, route of
• As sites for peripheral venous access
administration and use of shared equipment.
diminish, venepuncture of neck veins creates
Narcotics and other drugs that depress
a risk of pneumothorax, and bullae may
consciousness can promote basal atelectasis and
occur in those who also smoke tobacco
aspiration, increasing the likelihood of
(Heffner, 1990).
pneumonia and lung abscess. Narcotics also
• Injecting crushed tablets can damage lung
increase membrane permeability, and heroin can
tissue.
cause non-cardiogenic pulmonary oedema (Sykes
• Paint inhalation provokes airway obstruction
and Young, 1999, p. 106), either immediately or
and alveolitis.
up to 24 hours later. The antidote to narcotic
• Glue sniffing increases pulmonary artery
poisoning is naloxone, which can itself induce
pressure and decreases gas transfer (Heffner,
pulmonary oedema (Heffner, 1990).
1990).
Cocaine can damage any major body organ,
but two-thirds of deaths from cocaine use are
due to homicide, suicide, traffic accidents and
CHEST INFECTION
falls (Boghdadi, 1997). Crack cocaine causes
respiratory symptoms in 25% of users, including Infection from viruses, bacteria or fungi can
necrosis of the nasal septum and alveolar occur anywhere from the upper respiratory tract
haemorrhage (Heffner, 1990). to the lung parenchyma. Chest infection includes
Reactions to Ecstasy are unpredictable, anything from acute bronchitis, a common and
depending on contaminants and the degree of usually self-limiting viral infection of the upper
associated exercise. Frequent use diminishes the bronchial tree, to life-threatening pneumonia.
positive effects and increases the negative effects. Influenza is particularly unpredictable, occurring
Dangerous effects include arrhythmias, in periodic pandemics including the 1918
hyperthermia (Dobbs and Coad, 1999), ARDS Spanish flu, which caused more deaths than the
(p. 411), renal failure, psychosis, convulsions First World War (Wiselka, 1994). Viruses and
and barotrauma (Rezvani, 1996). bacteria damage cilia and slow mucus clearance
Cannabis smoking appears to be relatively (Wills and Cole, 1996).
benign (Lancet, 1995b) in the short term Predisposing factors are being young, old,
because of its brief duration of action, but acute immunocompromised, stressed (Cobb, 1996)
central nervous system effects include reduced and having chronic lung disease. Symptoms
1 16
REsPIRATORY FAILURE
include fever, malaise and cough. Chest infec the breathing mechanism. It is sometimes a sign
tions are a common cause of exacerbation of of impending respiratory failure.
lung disease (Wilson, 1988). Most patients do
not benefit from antibiotics (Kuyvenhoven,
2000) but these drugs are still widely used (Liu
and Douglas, 1998). Physiotherapy is required if
patients are unable to clear secretions, and to
I;ii�iliMIiIi)ttl;�jiI
ensure full rehabilitation. Identify the problems of this 24-year-old woman
who has been admitted with pneumonia. then
answer the questions.
RESPIRATORY FAILURE
Background
Failure of the respiratory system to provide
S H : unemployed. mobile. independent.
adequate gas exchange for metabolic require
H PC: heroin user.
ments is known as respiratory failure (RF). This
is divided into the following: Subjective
• Type I (hypoxaemic) RF is failed oxygena Well.
tion, represented by Pa02 below 8 kPa

Objective
(60 mrnHg). It is caused by failure of the gas
exchanging function of the respiratory Patient in nightie. tucked up in bed.
system and can be acute (e.g. pneumonia) or Apyrexial.
chronic (e.g. pink puffer type of COPD). Fluid balance normal.
• Type II (hypoxaemic and hypercapnic) RF is Sa02 normal.
failed ventilation, represented by PaC02 Auscultation - bronchial breathing left lower lobe.
over 6.7 kPa (50 mmHg) as well as hypox no crackles.
aemia. It is caused by failure of the respira Respi ratory rate normal.
tory pump and can be acute (e.g. severe Breathing pattern normal.
acute asthma) or chronic (blue bloater type

Questions
of COPD, severe restrictive disease, Pick
wickian syndrome). Type II RF is also I . Identify the consolidation in Figure 4. 1 0
known as ventilatory failure and is a clinical

manifestation of impaired central respira
tory drive, muscle weakness or fatigue,
reflected by respiratory muscle strength
falling below 30% of normal (Simonds,
1996, p. 9). It is accompanied by a fall in
pH until renal compensation takes effect,
which allows assessment of the relative
degrees of acute and chronic hypoventila
tion (Curtis, 1994).
The process of respiration includes more than

gas exchange in the lung, but the term respira
tory failure is reserved for disorders that result
in a disturbance of arterial blood gases only.
Respiratory insufficiency occurs when adequate
gas exchange is maintained but at great cost to Figure 4.1 0 Ms TP.
117
2. Analysis?
RECOMMENDED READING
3. Problems?
4. Goals? Antman, K. and Chang, Y. (2000) Kaposi's sarcoma.
5. Plan? N. Eng/. J. Med. , 342, 1 027- 1 03 8 .
Cleland, ]. G. F . ( 1 996) Heart failure. Update, 52,
6 5 8 -663 .
Daniels, S. K. ( 1 99 8 ) Aspiration in patients with acute
stroke. Arch. Phys. Med. Rehab., 79, 14- 1 9 .
Douglas, N . ( 1 995) The sleep apnoea/hypopnoea
I . Location of consolidation syndrome. Practitioner, 239, 1 94- 1 97.

Edmondson, R. ( 1 994) The causes and management
Area of consolidation seen behind left pierced of pulmonary embolism. Care Crit. Ill, 1 0, 26-30.
nipple. Henderson, A. ( 1 994) Chronic respiratory failure.
Practitioner, 238, 345-350.
2. Analysis Horner, ]. ( 1 98 8 ) Aspiration following stroke.
No accessible secretions. No atelectasis. No Neurology, 3 8 , 1 3 5 9 - 1 3 62.
desatu ration . Johns, C. ]. and Michele, T. M. ( 1 999) The clinical
Bronchial breathing may l inger but is not causing management of sarcoidosis. Medicine, 78, 65 - 1 1 1 .
problems. Johnston, I. D. A., Prescott, R. ]. and Chalmers, ]. C.

( 1 997) British Thoracic Society study of
It is not necessary to 'treat the X-ray'.
cryptogenic fibrosing alveolitis. Thorax, 52, 3 8 -
3. Problems 44 .
MacFarlane, ]. ( 1 995) Acute pneumonia in the
No physiotherapy problems at present. hospital patient. Hosp. Update, 2 1 , 1 9 -24.
McClure, ]. ( 1 993) The role of physiotherapy in HIV
4. Goals
and AIDS. Physiotherapy, 79, 3 8 8 - 3 9 3 .
Self-rehabilitation. Michie, ]. ( 1 994) An introduction to lung cancer.
Physiotherapy, 80, 844-847.
5. Plan Miller, R. F. ( 1 995) Pneumocystis carinii pneumonia.
Advise patient to get dressed and mobilize. Thorax, 50, 1 9 1 -200.
Discharge. Mills, N. (2000) Does Tai Chi/Qi Gong help patients

with multiple sclerosis? ]. Bodywork Movement
Ther. , 4, 3 9-48.
Nollet, F., Reelen, R. and Prins, M. ( 1 999) Disability
LITERATURE APPRAISAL and functional assessment in former polio patients.
Arch. Phys. Med. Rehab., 80, 1 3 6- 143.
Bars of soap, if used, should be kept dry. Thistlethwaite, ]. E. ( 1 9 98) Respiratory tract
Br. ]. Nurs. 1995; 4: 926-932. infections. Update, 56, 1 0 8 - 1 1 2.
That's a good idea.
1 18
5 GENERAL MANAGEMENT
SUMMARY
Introduction Drug therapy

Oxygen therapy • Definitions
• Indications • Drugs to prevent inflammation
• Limitations • Drugs to treat inflammation
• Complications • Drugs to treat bronchospasm
• Delivery devices • Drugs to treat breathlessness
• Prescription and monitoring • Drugs to treat infection
• Acute oxygen therapy • Drugs to help clear secretions
• Long-term oxygen therapy • Drugs to inhibit coughing
• Portable oxygen • Drugs to improve ventilation
• Hyperbaric oxygen therapy • Drugs to relieve oedema
• Heliox therapy • Delivery devices
Nutrition Bronchoscopy and lavage
• Causes of poor nutrition Mini case study
• Effects of poor nutrition Literature appraisal
• Management Recommended reading
INTRODUCTION anything other than hypoxaemia. It should be

prescribed if resting Pa02 is below 8 kPa
Respiratory medicine has been transformed in (60 mmHg) or Sa02 below 90%. Potential or
the past 20 years by technical advances and an temporary hypoxaemia is included, e.g.:
understanding that, for these advances to be
effective, patients must become central players in • before and after suction
their own care. This chapter looks at current • first-time administration of bronchodilator
knowledge in the medical management of drugs in case of adverse effects
respiratory disorders. • after premedication for patients at risk, e.g.
prior to heart surgery (Royse, 1 997)
• during exercise, if demonstrable benefit has
OXYGEN THERAPY been shown.
For over 200 years, oxygen has been much used Hypoxaemia plays a limited part 10 the
and sometimes abused. It is an odourless, colour mechanism of breathlessness Oanssens, 2000),
less drug that has side effects and specific risks, and contrary to tradition, oxygen is not
but, with rational prescription, precision of indicated for shortness of breath (Stewart and
administration and objective monitoring, it is a Howard, 1 992). Breathlessness and hypoxaemia
potent therapy for the respiratory patient. may well coexist but they are caused by different
mechanisms and require different management.
Indications Oxygen is considered an expensive placebo if
Supplementary oxygen IS rarely indicated for used as a routine tonic for breathlesness (Leach
1 19
CHAPTER 5 GENERAL MANAGEMENT
and Bateman, 1 9 94). The following may be

exceptions : Complications
• High concentrations of inspired oxygen may
• Terminally ill patients who are breathless impair the respiratory drive in people with
may find some relief with oxygen therapy hypercapnic COPD (p. 1 25).
(Bruera et ai., 1 993). • Excess oxygen depletes protective antioxi
• Breathlessness on exercise may or may not dants. This causes oxygen toxicity, an
be relieved by supplementary oxygen (Dean inflammatory response of lung tissue
et at., 1 992; McDonald, 1 995) and patients following exposure to 1 00% oxygen for
should be assessed individually. Before or between 40 hours and 7 days (Heulitt,
after exercise, oxygen appears unhelpful 1 995). Any organ can be harmed but the
(Williamson, 1 993). For people with intersti lung is exposed to the highest P02. Oxygen
tial lung disease, oxygen is likely to improve toxicity impairs the actions of cilia, macro
exercise performance (Harris-Eze, 1 996). phages and surfactant, and the patient
experiences substernal pam, cough and
Prescription 'as required' is never appropriate
dyspnoea. The risk of oxygen tOXICIty is
(Hodgkin et at., 2000, p. 1 42). It makes no
increased by high-volume ventilation and
physiological sense because chemoreceptor
malnutrition, but pre-existing lung disease
signals are not consciously appreciated and
affords some protection (Durbin, 1 9 93). If
people do not feel a physical need for oxygen.
oxygen toxicity is suspected, monitoring by
Education is more beneficial than the psychologi
Pa02 is advisable because the shape of the
cal crutch of an expensive drug.
oxygen dissociation curve means that
Assessment for acute and long-term oxygen
measurements of Sa02 at high levels of
therapy includes nocturnal monitoring by
oxygenation are less sensitive.
oximetry, because day and night requirements
• Blindness may be caused if neonates are
are poorly related (Schenkel, 1 996). This is
given high concentrations of oxygen (p.
particularly important for patients who have a
43 6).
poor hypercapnic ventilatory response and run a
• 'Absorption atelectasis' can occur if absorp
greater risk of nocturnal hypoxaemia (Vos et at.,
tion of oxygen from alveoli exceeds replen
1 995).
ishment of alveolar gas, so that the alveoli
are no longer held open by a cushion of inert
Limitations nitrogen. This can occur in mechanically
• Directing oxygen into the throat does not ventilated patients receiving more than 70%
guarantee its arrival at the mitochondria. oxygen at low tidal volumes (Pilbeam, 1 998,
Tissue oxygenation also depends on lung p. 1 60). Absorption atelectasis is exploited
perfusion, haemoglobin levels, cardiac when oxygen is used to increase absorption
output, vascular sufficiency and tissue perfu of air from a pneumothorax (p. 1 00).
SlOn. • Discomfort can be caused by dry mucous
• Oxygen does not Improve ventilation membranes, eye irritation, a sense of being
directly, although ventilation may be smothered or excess work of breathing
enhanced by oxygen delivery to components caused by inadequate flow. A patient 'oxyge
of ventilation such as the respiratory nating' his/her forehead is a familiar sign of
muscles. this problem.
• If hypoxaemia is due to a large shunt (p. 1 3), • Oxygen is not addictive, but dependency
benefit is limited because shunted blood does occurs when patients rely on it unnecessarily.
not 'see' the added oxygen. • Oxygen creates a fire hazard by supporting
combustion. Smoking is banned.
120
OXYCEN THERAPY
Delivery devices High-flow (fixed performance) mask

These masks, also known as Venturi masks,
CTi nasal specs cat/sed so many problems; deliver a prescribed gas mixture at flows
th". kept falling out or were too tight. They intended to be greater than demand, i.e. higher
were one of the most uncomfortable than the patient's PIF (Figure 5.2). This
appliances, yet better than the mask which minimizes rebreathing expired air from the
seemed to suffocate you.' mask, even if it is loosely fitted, and delivers an
Ludwig, 1984 accurate FI02 as specified on the device. Oxygen
rushes from a nozzle and entrains a proportion
Low-flow (variable performance) mask of room air through a fixed-size entrainment
These simple masks (Figure 5 . 1) provide only a port, so that a specific concentration is
proportion of the patient's inspired gas. They delivered. This concentration depends on the
deliver a flow rate that is less than the patient's size of the entrainment ports, not the patient's
peak inspiratory flow (PIF) so that room air is PIF, and is reasonably accurate.
sucked in through holes in the mask to dilute the The flow indicated on the colour-coded
oxygen. The fractional inspired oxygen concen Venturi valve is the minimum, and can be
tration (FI02) therefore varies with the patient's increased as high as the patient requires for
own flow. The more rapid the patient's ventila comfort.
tion, the more room air is entrained and the lower H humidification is required, large-volume
the FI02• This provides inaccurate and uncon nebulizing humidifiers are available that can
trolled oxygen but is adequate for certain patients. deliver a specific FI02 (p. 1 8 8). Venturi masks
Flows of 6-8 Umin provide approximately cannot be humidified effectively because
40-500/0 oxygen, i.e. an FI02 of 0.4-0.5 moisture is condensed on reaching the Venturi
(Gribbin, 1 993). The flow should be maintained mechanism and can upset the delicate balance of
above 5 Umin to avoid rebreathing CO2, (Leach entraining the correct proportion of air. Details
and Bateman, 1 993). of humidifiers are on page 1 85.
Simple masks are suitable when accurate High-flow systems are used for:
concentrations are not necessary, e.g. after
routine surgery. FI02 is altered by changing the • patients needing an accurate FIOl. e.g.
oxygen flow rate at the flow meter. hypercapnic COPD patients who are depen-
Figure 5.1 Oxygen delivery systems. From left: simple mask, nasal cannula, transtracheal catheter (From Haas, F. and
Haas, S. S. (1990) The Chronic Bronchitis and Emphysema Handbook, John Wiley, Chichester, With permission.)
12 1
(a)
(b)
Roomair
� �=======i P atient
Oxygen - ---�
'--' •
, 7�0======�
Roomair
Figure S.2 (a) High-flow fixed performance 'venturi' mask with colour-coded valves to entrain room air and produce
different oxygen percentages (Intersurgical with permission). (b) Interaction of oxygen flow and entrained air.
dent on their hypoxic drive and need litre reservoir bag and deliver high-percentage
controlled oxygen therapy (Figure 5.4) oxygen. During exhalation, oxygen fills the
• breathless patients whose PIF is too high to bag instead of being wasted, then during inha
tolerate a low-flow system. lation this oxygen enriches the inspired gas
(Branson, 1 993).
High- and low-flow masks relate to high and A non-rebreathing system has valves at the
low accuracy, not to high and low FI02• reservoir bag and side vents to prevent expired
CO2 mixing on exhalation and room air mixing
High-concentration reservoir mask on inhalation. It delivers 5 5-90% oxygen at 6-
Reservoir systems (Figure 5.3) incorporate a 1 1 5 L/min. A partial-rebreathing system has no
122
OXYGEN THERAPY
• 3 L/min delivers 32% oxygen

• 4 L/min delivers 36% oxygen.
Flows above 4 L/min may cause untation

and damage the nasal septum. In theory, 8 L/
min can deliver 50% oxygen, but high flows
provide little additional oxygen because the
anatomical reservoir of the nasopharynx is
already filled with oxygen (Wissing, 1 98 8).
Mouth-breathers are partly accommodated by
entrainment of oxygen into this reservoir
during exhalation, but PI02 is higher with the
mouth closed (Dunlevy and Tyl, 1 992). Drying
of mucus membranes is not helped by humidifi
cation (Campbell et at., 1 9 8 8), but lanolin gives
some relief (not petroleum jelly or Vaseline,
whICh are petrol-based and react with oxygen).
The flow rate can be marked on the flow meter
with tape to remind patients and others of the
Figure 5.3 High-concentration reservoir mask correct setting.
(Intersurgical, with permission). Indications for nasal cannulae are:
• long-term oxygen therapy

valve and about one-third of the expired CO2
• patients who find masks uncomfortable
enters the bag, delivering 3 5 -600/0 oxygen at 6-
• confused patients, especially if a high
1 5 L/min (Bolgiano, 1 990).
concentration is needed, when cannulae can
The system provides a fixed PI02 if flow is
be used with a mask in case the mask is
s�fficient to keep the bag inflated during inspira
pulled off
tion. For breathless patients this may require up
�o 12 L/min to prevent extra WOB being • hypoxaemic patients using an incentive
spirometer, inspiratory muscle trainer, ultra
Imposed. The bag must be allowed to fill with
sonic nebulizer and for certain patients using
oxygen before fitting to the patient, and must be
a jet nebulizer (p. 1 4 1 ).
kept inflated throughout the respiratory cycle,
otherwise the patient is at risk from the combi
Nasal catheter
nation of a sealed system and inadequate flow.
These devices are inserted, after lubrication, into
Reservoir masks cannot be humidified.
one nostril to reach just behind the uvula and
are then taped to the face. They have several
Nasal cannula
holes near the tip so that the force of the oxygen
Cannulae, or prongs, deliver oxygen directly
flow is diffused, but patients often complain of a
into the nostrils so that the patient can talk,
sore throat. Catheters are impractical in infants
cough, eat and drink unhindered (Figure 5 . 1 ).
because they occlude most of the nasal airway,
80% of the oxygen is wasted (Tiep, 1 99 1 ). They
and are often not tolerated by children. They are
are low-flow systems but Branson ( 1 9 93 ) gives
sometimes used for short periods when a device
rough guidelines on the percentage delivered to
is needed that must not become dislodged. A
stable awake patients at rest:
flow of 3 -4 L/min usually delivers inspired
• 1 L/min delivers 24% oxygen concentrations of 3 0-40% (Sykes and Young,
• 2 L/min delivers 28% oxygen 1 999, p. 1 00).
123
Transtracheal catheter greater than the patient's PIF, it acts as a high

Small plastic transtracheal catheters can be surgi flow device.
cally introduced into the trachea, percutaneously
or through a tunnelled route, for long-term Prescription and monitoring
oxygen therapy (Figure 5.1 ). They are suited to Oxygen must be medically prescribed in writing,
patients who are sufficiently motivated to follow but all team members need to be involved
a protocol of self-care including irrigation with because it is notoriously mismanaged. Studies
saline. Advantages are: have shown 2 1 % inappropriate prescription,
8 6% inadequate monitoring, 56% inaccurate
• halving the flow rate required, leading to
administration (Leach and Bateman, 1 993) and
extended portable use (Simonds et at., 1 996,
8 8 % termination without assessment (Fitzgerald,
p. 1 3 1 )
1 98 8). One postoperative survey showed the
• high patient adherence because of its unob
mask staying in place in one out of 20 patients
trusive presence and a comfortable nose
(Baxter et at., 1 993).
(Kampelmacher et aI., 1 997).
PIF is affected by respiratory drive, inspira
A major disadvantage is the need for surgical tory muscles and the mechanical properties of
placement, with accompanying risks of infection, the lungs and chest wall. On average it is 40-
surgical emphysema, haemoptysis, displacement 50 Umin, but breathless or exercising patients
and dermatitis. may reach 1 20 or even 200 Umin. Extra energy
is then required to entrain room air, so that
reversal of hypoxaemia is at the expense of
Tent
increased WOB, inspiratory muscle fatigue and
Humidified oxygen is still occasionally delivered
sometimes hypercapnia (Dodd et at., 1 998).
to children via tents, but these are isolating, wet
Prescription should take account of patient
and deliver fluctuating levels of oxygen. Oxygen
comfort, including a high enough flow rate for
escapes each time the edges are untucked. If
breathless patients with a high PIF, in the same
undisturbed, levels of 50% oxygen can be
way as with CPAP (p. 158). Venturi masks can
achieved but CO2 retention then becomes a
be accurately titrated, as shown in Table 5.1 .
problem.
Head box Table 5.1 Oxygen concentrations delivered t o the

Clear plastic boxes over the heads of babies patient from high-flow systems; flow from the oxygen
source can be altered to provide different total flows to the
control the delivery of humidified oxygen. High
patient according to need, while maintaining control of the
flows are required and care should be taken to concentration (adapted from Dodd et 0/" 1998)
direct the gas flow away from the baby's face
and to ensure that the edges of the box do not Concentration Oxygen flow Total flow
rub the skin. Alternatives are oxygen chairs,
24% 2 Llmin 50Llmin
which incorporate a plastic canopy or hood to 3Llmin 75Llmin
deliver oxygen to an upright baby. 4L1min IOOLImin
28% 4L1min 44L1min
6Llmin 66L1min
T-piece circuit 8Llmin 88Llmin
A T-piece delivers oxygen to an intubated spon 35% 8Llmin 45Llmin
taneously breathing patient. It is a large-bore 12L1min 67 Llmin
16Llmin 90Llmin
non-rebreathing circuit that attaches to the 40% 10LImin 41Llmin
tracheal tube. Humidified oxygen is delivered 15Llmin 62L1min
through one end and exhaled gases leave 20 Llmin 82L1min
60% 15Llmin 30Llmin
through the other. So long as the flow rate is
124
OXYGEN THERAPY
For patients requmng a flow rate above 1 00 LI Medical prescription should therefore specify:
min, a high-flow generator can be used, i.e. a
• method of delivery
CPAP (p. 1 5 6) system without a pressure valve.
• flow rate and/or FI02
Oximetry is required to monitor response,
• nocturnal modifications.
and astute budget holders find it cheaper to
supply all their relevant beds with oximeters
rather than waste unnecessary oxygen. For Acute oxygen therapy
breathless patients, monitoring respiratory rate In the acute setting, oxygen should be adminis
indicates if fatigue is severe, but the most tered continuously unless hypoxaemia has been
sensitive monitor is the patient, who may demonstrated only in specific situations such as
demonstrate excess WOB subjectively or objec sleep, eating or exercise (AARC, 1 992).
tively (p. 3 6), or, if asked, say that they are not People with hypercapnic COPD vary in their
receiving enough flow. response to oxygen. Sustained hypercapnia has
PIF is reduced at night. A simple mask left a small proportion (Singer and Webb, 1 997,
delivers a higher FI02 for the lower PIP, which p. 2) dependent on hypoxia as a ventilatory
could tip some patients into respiratory failure stimulus (p. 7 1 ). Uncontrolled oxygen may
(Dodd et at., 1 998). For those using a Venturi deliver excess FI02, leading to gradual hypoven
mask, a lower flow rate may need to be tilation, drowsiness and respiratory acidosis,
prescribed. which can be lethal. Normocapnic COPD
P a02 on air<6 kPa 4

( P a020n air>6 kPa
I I
24%°2 2 8%°2
ABGs
after
t I
3 0 mins
P a02<6 kPa P a02 >6kPa P a02>6 kPa P a02<6 kPa
PaC02 unstable P aC02 unstable P aC02 stable P aC02 stable
pH <72. 6 pH <72 . 6 pH>72 . 6 pH>72 . 6
I I
ito2 8% 02 cont. cont.24% 02 ito2 8% 02
+ +
support support
ventilation ventilation
ABGs
t WithNI V�
after
3 0 mins
P a02<6 kPa. P a02<6kPa. Observe
P aC OipH unstable P aC OipH stable
I I
Consider IPPV Increase to 3 5% 02'
continue NIV
Figure 5.4 Flow chart of controlled oxygen therapy for exacerbations of hypercapnic COPD. showing the levels of Pa02
and PaC02 that indicate the need for supplementary oxygen and ventilatory support respectively. Arterial blood gases are taken
30 min after each change in treatment. and treatment is adjusted accordingly. A more detailed flow chart is illustrated in Gribbin
(1993). ABGs arterial blood gases; IPPV intermittent positive pressure ventilation; NIV non-invasive ventilation.
= = =
125
patients are not at risk (Fulmer and Snider, must be titrated to keep Sa02 at 90-92% (Oh,
1 9 84), nor are people with other disorders, 1 997, p. 232). Some physicians are happy for
except occasionally those with acute severe patients with COPD to be given high levels of
asthma (Wissing, 1 9 8 8) or restrictive disorder oxygen so long as they are kept under observa
(Bach and Haas, 1 996, p. 228). tion in a high-dependency area.
Patents with a limited response to high PaC02 Intermittent oxygen therapy given in the acute
require controlled oxygen therapy titrated to phase of COPD (Figure 5.5), especially for
their individual response in order to preserve hypercapnic patients, is like intermittent
their respiratory drive. Simple low-flow systems drowning (Hanning, 1 995). Oxygen stores in the
are inadequate. Nasal cannulae are unsatisfactory body are < 1 .5% of CO2 stores (Chin et at.,
in acute disease because exhausted patients may 1 997) because CO2 is needed for acid-base
hypoventilate and entrain little room air, thus balance, so if F102 is allowed to fall, CO2
receiving dangerously high F102 levels (Davies crowds out oxygen (Collins, 1 976).
and Hopkin, 1 9 8 9). If nasal cannulae are Patients with acute problems other than
necessary for patient comfort, monitoring of hypercapnic COPD, e.g. those with pneumonia
blood gases is required. or acute asthma, may need a generous F[02 of
Controlled oxygen is best delivered by a high 004-0.6 or more, delivered at high flow rates if
flow Venturi mask. Arterial blood gases are first they are breathless.
taken on air, and patients with the lowest Pa02, Postoperatively, oxygen prescription depends
who are most at risk, are given a low F[02 to avoid on the patient and type of surgery. Hypoxaemia
the possibility of upsetting the respiratory drive. may be transient, and low-risk patients usually
This must only be temporary while the patient is require only a few hours' oxygen after surgery,
monitored. After 30 minutes, if the PaC02 is but for people with lung disease or those under
stable or rises by no more than 1 .3 kPa going heart or lung surgery, several days and
( 1 0 mmHg), the F102 can be increased if nights of supplementary oxygen may be required
indicated. If the PaC02 rises excessively, ventila (p. 250).
tory support is needed, preferably by non-invasive Patients on acute oxygen therapy should
means, in order to reduce the WOB. At the same only have their mask removed for expectora
time, F102 is increased if indicated (Figure 504). tion or other brief reasons. Oximetry is
Several arterial stabs may be required, for required for prescription, morutoring and with
which local anaesthesia is specified in both UK drawal of oxygen. All patients should have an
and American guidelines (Lightowler, 1 996). An oxygen saturation chart, which also encourages
alternative is arterialized capillary blood taken reluctant patients to accept the need for initia
almost painlessly from the earlobe (Dar, 1 995). tion and withdrawal of their oxygen.
Small amounts of oxygen can relieve hypoxae
mia in these patients because reactions take Long-term oxygen therapy
place on the steep part of the oxygen dissocia
Only smoking cessation and long-term oxygen
tion curve. In practice, the danger of giving too
therapy (LTOT) can increase survival in COPD
much oxygen is commonly overestimated and
patients with severe hypoxaemia (Scalvini et at.,
patients can be deprived of much-needed
1 999). Accurately prescribed domiciliary oxygen
oxygen. Most COPD patients do not develop
has also shown the following benefits:
CO2 retention (Oh, 1 997, p. 232), and acute
hypercapnia should not be interpreted as a • 1 cor pulmonale
response to high F102 as it may be due to a dete • i quality of life
riorating condition. Hypoxaemia is more • i sleep
dangerous than hypercapnia, and if the guide • 1 exacerbations and hospital admissions
lines in Figure 5 A are not followed, oxygen (Leach and Bateman, 1 994)
126 ------
OXYGEN THERAPY
No oxygen
PaC027. L--------------
Pa 026 .
Uncontrolled oxygen
Pa C0 27. 3
Pa°26 . 1-----
(b
Intermittent oxygen
On Off
(c)
Controlled oxygen
Pa C O27 . 3 t========----=========
Pa 0267.
(d
Figure 5.5 Potential effects of different methods of oxygen administration on arterial blood gases (in kPa) for COPD
patients in acute hypercapnic respiratory failure: (a) continued deterioration; (b) uncontrolled oxygen - in this case delivering
excessive oxygen, leading to reduced respiratory drive, hypoventilation and further PaC02 retention; (c) gradual hypercapnia
and rapid hypoxaemia; (d) normalization of blood gases.
12 7
100
• improvement or stabilization of disease
progression (Simonds et al. , 1 996, p. 1 1 7).
Improvement stems mainly from higher ;;g

� 95
'"
nocturnal oxygen saturation, which relieves 0
'"
pulmonary hypertension. People with chronic CJ)
c
'" 90
hypoxaemia due to other diseases may also OJ
E
benefit (Petty and O'Donohue, 1 994). en
c
0
LTOT must not be prescribed on hospital :i'
(ij 85
discharge, although a temporary cylinder can be � 0
supplied for severe hypoxaemia (RCP, 1 999). 0
Patients should be assessed for LTOT at least a

80
month later, when blood gases are stable.
80 85 90 95 100
Monitoring of oxygen saturation is required
( Resting mean Sa02 (%)
during sleep, rest and exercise. Nocturnal desa
turation is likely if daytime 5a02 is below 93%
40
(Little et al. , 1 999), but Figure 5.6 shows the :;
0
limited relationship between day and night .c 35
Qj
oxygen requirements. 0.
'" 30
The following criteria for prescription apply c
0
in the UK (RCP, 1 99 9) : �:l 25
7ii 20
chronic stable hypoxaemia with Pa02 < '"
• OJ
"0
7.3 kPa (55 mmHg) breathing air, on two '" 15
0
samples taken at least 3 weeks apart, or up '"
CJ) 10
to 8 kPa (60 mmHg) if there is nocturnal OJ
E
hypoxaemia or pulmonary hypertension �
0
5
• disabling dyspnoea in terminal respiratory
disease. 5 10 15 20 25 3 0 35 40
(b Night-time Sa02desatur
ations
Ongoing need for LTOT should be verified
annually by a physician (Bach and Haas, 1 996).
Prescription also depends on the patient being Figure 5.6 Comparison of oxygen needs of people with
COPO during exercise and sleep. (a) Linear relationship
willing to use it. Education is essential. Rudkin between requirements during rest and exercise. (b) Non
and White ( 1 995) showed that less than 500/0 of linear relationship between requirements during rest and
patients understood why they were using sleep. (Modified from Schenkel, S. (1996) Oxygen saturation
oxygen, which means that they tend to underuse during daily activities in COPO. Eur. Resp. j. , 9, 2584--2589)
it (Make, 1 994) or misuse it in short bursts for
'relief of breathlessness' (Simonds et aI. , 1 996, p.
1 28). Many unnecessarily restrict their activity.
Cylinders and concentrators must be kept Patients are advised that oxygen should be
away from heaters, and tubing must be posi used for as long as they can manage without
tioned to avoid falls. Prescribers, too, must unnecessary disruption to their lifestyle (Luce et
educate themselves, as shown by studies indicat al. , 1 993). 'The more the merrier' is their
ing that only seven out of 60 eligible patients maxim. The minimum effective prescription is
were prescribed LTOT and, conversely, only for nocturnal oxygen therapy, but over 1 5 hours
3 3 % of patients receiving LTOT fulfilled the per 24 hours is preferable, and near-continuous
criteria (Simonds et al. , 1 996, p. 1 27). oxygen is ideal (Hodgkin et al. , 2000, p. 135).
128
OXYGEN THERAPY
Figure 5.7 Home oxygen systems. From left: cylinder, portable liquid oxygen, concentrator. (From Haas, F. and Haas, S.
S. (1990) The Chronic Bronchitis and Emphysema Handbook, John Wiley, Chichester, with permission.)
The goal is to achieve a PaOZ at least 8.7 kPa zero in thermos containers. Advantages are
(65 mmHg) without a rise in PaCOZ by more that electricity is not required, and easy port
than 1.3 kPa ( 1 0 mmHg). The flow rate for this ability means that re-employment is more
is generally 1 .5 -2.5 L/min, which can be viable (Lock, 1 992). Disadvantages are that
increased by 1 -2 L/min during sleep or exercise it evaporates over time, is twice as expensive
if indicated. Ongoing patient support IS as a concentrator and is rarely available on
mandatory. the British NHS.
Three systems are available (Figure 5.7):
Nasal cannulae are useful for convenience,
• Oxygen cylinders contain compressed except for mouth-breathers and those with a
oxygen delivered through a regulator valve. heavy cold. They cannot be humidified and
They are cumbersome, require repeat systemic hydration should be optimized, with a
prescriptions and regulator changes, are recommended fluid intake of about 2.5-3 litres
dangerous if not secured carefully, run out over 24 hours (Heslop and Shannon, 1 995).
of oxygen rapidly, provide a limited pressure Domiciliary oxygen means that the disease is
that is inadequate for driving a nebulizer and visible and can no longer be denied. Veteran
may not cope with long tubing. They deliver patients on long-term oxygen are often willing
cold, dry oxygen. to talk to new patients and their carers, who
• Oxygen concentrators separate ambient may feel dismayed at the prospect of a life spent
oxygen from nitrogen and are cheaper if tethered to bulky equipment by the nose.
more than four cylinders a week are needed
(Dodd et at., 1 99 8). They are noisy, cannot Portable oxygen
be modified for portable use and do not have If oxygen is required at rest, it is needed on
enough pressure to power a nebulizer unless exercise, and sometimes during eating or lengthy
two are used in parallel. The oxygen is at talking (Sliwinski, 1 9 94). Transient hypoxaemia
room temperature and humidity. sustained during routine activities is unlikely to
• Liquid oxygen is stored at nearly absolute be damaging, but prolonged or profound hypox-
129
aemia is harmful. Hypoxaemia on exercise may patients are advised to arrange for oxygen to be
occur within the first minute and then stabilize, provided if their Pa02 is below 9.4 kPa
or it may be progressive. (70 mmHg) on F,02 of 0. 15 (Dodd et at., 1 998).
A quarter of COPD patients who desaturate Charges vary widely and some airlines do not
on exercise show improved exercise tolerance provide masks or cannulae.
with ambulatory oxygen (Simonds et ai., 1 996,
p. 1 27). Leach (1 992) suggests that portable Hyperbaric oxygen therapy
oxygen be considered if it improves exercise
Hyperbaric oxygen is 1 00% oxygen delivered at
capacity by over 50%. Oxygen flow should be
pressures greater than atmospheric. High
sufficient to prevent desaturation or maintain
pressure oxygen does not improve tissue oxyge
saturation above 90%, and is usually about 4 L/
nation under normal circumstances, but benefi
mill.
cial effects have been claimed for gas gangrene
Portable cylinders are problematic because at
(when hyperbaric oxygen creates a high P02
low flows any improved exercise capacity may
environment to inhibit anaerobic organisms),
be cancelled out by the work of carrying the
crush injuries, ischaemia, burns, decompression
2.3 kg cylinder, and they are best wheeled on a
illness, post-radiation damage, compromised
shopping trolley or custom-built walker. At high
skin grafts (Slotman, 1 998) and severe cerebral
flows, the cylinder can empty before the patient
air emboli after heart surgery (Dexter and
has even settled into the car, especially as it has
Hindman, 1 997).
often not been completely filled because this
Hyperbaric oxygen is no longer used for
needs a full F-size cylinder. Patients describe the
people suffering from carbon monoxide
anxiety of using portable cylinders as like
poisoning because it has not been proved to
driving with the fuel gauge on red, and
increase the transport of dissolved oxygen, and
adherence is therefore poor.
may be detrimental (Scheinkestel et at., 1 999).
Duration of oxygen supply is increased by
Hyperbaric chambers can accommodate either
oxygen-conserving devices such as light-weight
one patient or a patient and attendants. Precau
demand-valve cylinders and pulsed dose oxygen
tions in this high pressure environment are:
(Garrod et at., 1 9 9 9). Some facilities offer a loan
or refilling service. Patients have to pay for • awareness that pulse oximetry is inaccurate
portable cylinders in the UK, but semi-portable • avoidance of glass vials and bottles
300 L cylinders can be prescribed on the NHS • for patients with an underwater chest drain,
(Table 5.2). checking that fluid does not get sucked back
For air travel, commercial airline cabins into the pleural cavity
contain the equivalent of 1 5 % oxygen, so • for intubated patients, filling the tracheal
tube cuff with liquid rather than air
• for patients on a ventilator, modification of
Table 5.2 Characteristics of domiciliary and portable
oxygen systems (adapted from Dodd et 01., 1998 and Rep, pressures to protect against barotrauma.
1999)
Hyperbaric oxygen is contraindicated if there
Source Capacity Flow Duration is an undrained pneumothorax (Pitkin, 1 997).
(L) (L/min) at 2L/min
'F' cylinder 1360 2 or 4 I Ih

Heliox therapy
Concentrator (continuous) 0.5-5 (continuous) Helium is an inert gas with one-eighth the
Liquid O2:
tank 25800 0.25-10
density of nitrogen. When blended with oxygen
8 days
portable 1032 0.25-10 8h it is called heliox, and a mixture with 2 1 %
PD 300 300 2 or 4 2.5h oxygen i s one-third a s dense a s air. This can
Portable 230 2 or 4 2h
more easily bypass obstructed airways.
130
NUTRITION
Heliox is used for people with acute asthma, Tuck, 1 997) and drains motivation (Powell
in whom it can reduce airflow resistance by 40% Tuck, 2000)
and increase peak flow by 35% (Manthous et ai., • well-nourished patients with stable COPD
1 995). This buys time while awaiting the effects show no evidence of chronic fatigue (Simi
of medication, or it can be used for those lowski, 1 9 9 1 ).
refusing intubation (Austan, 1 996).
Heliox can also relieve stridor, or swelling Causes of poor nutrition
from tumours or burns (Marino et ai., 1 995). It • Eating becomes a chore rather than a plea
can be used with non-invasive ventilation in sure for breathless people because the
severe COPD Golliet, 1 999) and a 70:30 combined actions of eating and breathing are
mixture can facilitate weaning by reducing WOB in competition.
(Harrison, 1995). When delivering heliox • A normal-sized meal can interfere with
through a ventilator, the delivered tidal volume diaphragmatic mechanics, especially when
may be greater than that set (Lee et ai., 1 999). accompanied by the air-swallowing asso
ciated with breathlessness.
• Appetite is reduced by smoking, depression,
NUTRITION the taste of sputum and some drugs.
• Exercise limitation and fatigue discourage
Breathing and eating are basic life processes that
the preparation of healthy food.
are intimately related in their mechanics,
• Desaturation during meals can be caused by
emotive associations and physiology. Air and
the breath-holding required for swallowing
food share common pathways during ingestion,
and the metabolic activity required for diges
separate briefly for processing and then blend in
tion and assimilation.
the blood for distribution and the production of
• Increased WOB raises calorie requirements.
energy.
People with emphysema have shown a 25%
Despite this interdependence, nutrition is still
increase in energy expenditure (Mowatt
a neglected area of respiratory medicine and the
Larssen, 1 993).
poor relation in medical and nursing undergrad
• Salbutamol Increases energy demand
uate curricula. This 'skeleton in the hospital
(Burdet, 1 997).
closet' was identified in 1 974 (Edington et ai.,
• Oxygen therapy or mouth breathing can dry
1 997) but still only a third of UK hospitals have
the mouth.
nutrition teams (Hindle et al. , 1 99 6), and most
• Nutrition is impaired by hypoxaemia
cases of malnutrition are not recognized (Powell
(Donahoe et ai., 1 992), alcoholism (Bridges
Tuck, 1 997). Malnutrition often reaches
et ai., 1 999) and being ill (Lennie, 1 999).
'marasmic proportions' in COPD (Donner and
• 'Hospital malnutrition' is exacerbated by
Howard, 1 992); for example, 47% of stable
unappetizing food, missed meals because of
patients have shown nutritional abnormalities
tests or procedures, the low priority given to
(Sahebjami, 1 993) and this can exceed 500/0 in
nutritional support and, for patients on ster
hospitalized patients (Fitting, 1 992).
oids, exacerbation of muscle wasting
Physiotherapists treating malnourished
(Saudny, 1 997). The nutrition of most
patients are working uphill. The following facts
patients deteriorates over an average 2-week
are directly related to physiotherapy and will
admission (Powell-Tuck, 1 997).
assist liaison with the health care team:
• malnourished people are unable to improve Effects of poor nutrition

muscle function and exercise tolerance Nutritional depletion impairs ciliary motility,
(Fitting, 1 992) aggravates the emphysematous process, erodes
• malnourishment impedes mobility (Powell- muscle (Bach and Haas, 1 99 6), depletes surfac-
13 1
CHAPTER 5 GENERAL MANAGH1El'-lT
tant, increases WOB, impairs tissue elasticity because these can increase the viscosity of
(DeMeo, 1 992), hinders fluid balance, can preci mucus (Enderby, 1 995)
pitate hypercapnic respiratory failure (Bach and • caffeine, which potentiates peptic ulceration,
Moldover, 1 99 6), decreases exercise capacity to which people with COPD are susceptible
(Palange et aI. , 1 9 9 8), causes depression and (Bach and Haas, 1 996, p. 253)
apathy (Powell-Tuck, 1 997), increases infection • additives and spicy food (Hodgkin et al.,
risk and mortality (Powell-Tuck, 2000) and rein 1 993)
forces the whole unhappy process by blunting • alcohol, which increases pulmonary hyper
hunger. tension and hypercapnia in COPD Oalleh et
Surprisingly, the diaphragm fails to enjoy al., 1 993), encourages snoring in normal
preferential status, and both inspiratory and people and sleep apnoea in snorers (Chan,
expiratory muscle strength are disproportio 1 9 90), and, for everyone else, impairs ciliary
nately reduced in malnutrition (DeMeo, 1 992), action and immune function (Hodgkin et aI.,
as shown by decreased spirometry and cough 1 993, p. 1 1 3).
pressures.
Supplementary feeds provide concentrated
Management nutrition orally or nasogastrically but can cause
bloating, and pulmonary aspiration if a nasogas
Attention to nutrition should be a routine
tric tube is used. They have proved laborious in
preventive measure for all people with COPD,
practice, especially in the home. They are
and indeed for many others. This should not be
sometimes successful for people with exacerba
left until debilitated patients have cannibalized
tion of disease, and occasionally for those with
the protein from their own respiratory muscles.
advanced chronic disease in (Figure 5.8).
Education includes the following suggestions:
Oral feeds should be taken with a glass rather
• Eat multiple small meals, preferably six times than through a straw to avoid excess WOB.
a day. Enteral feeds are best given at night to
• If breakfast is difficult, try liquidizing it. encourage daytime eating, and nasojejunal tubes
• Ensure adequate intake of vitamin E (Dow, improve tolerance (Whittaker, 1 990). Slow
1 9 9 6) and vitamin C, which help prevent
infection, reduce inflammation and mop up
oxidants in tobacco smoke (Sridhar, 1 995). 70
• Make use of high energy drinks such as Usual
6 8 COPO
we ig ht
-
home-made milk shakes and fresh fruit juice. exacerbations

• Take liquids separately from meals. OJ 66
• Avoid hard or dry food, or add sauces such � 6 4

1:
as gravy or custard. �62
• Avoid gas-forming foods.
3: 60
• Clean teeth or use a mouthwash before
58
meals if inhaled drugs or sputum have left a
bad taste. 5
6�-,.-.-�-.�.-��-,�
A 0 1 2 3 456 7 8 9101 11 2
• Meals should be leisurely, enjoyable and
Tm
i e
taken sitting up with elbows on the table to
stabilize the accessory muscles. Figure 5.8 Weight of a patient with severe COPD,
showing beneficial effects of nutritional support and
Patients can experiment with reducing or detrimental effects of exacerbations. A
= admission; D
=
abstaining from: discharge. (From Donahoe, M. and Rogers, R. M. (1990)

Nutritional assessment and support in COPD. Clinics in
• dairy foods, if secretions are a problem, Chest Medicine, 11, 487-504., with permission)
132
DRUG THERAPY
continuous infusion prevents excess metabolic such as COPD tend to be subjected to blind
activity which can lead to desaturation (Ryan et polypharmacy, even though effectiveness is
al., 1 993). limited in irreversible conditions. Physiothera
High-fat, low-carbohydrate formulae should pists need to discriminate and understand the
be used for patients with a tendency for hyper indications, side effects and delivery systems of
capnia because the carbohydrate loading of different drugs. Adherence rates are classically
normal supplementary feeds can increase CO2 around 5 0%, especially with multiple dosing,
production, oxygen consumption and breathless but patients are responsive to education about
ness for up to 1 V2 hours (Kuo et aI., 1 993). It is drugs and devices (Wright, 1 993), and it must be
not known if normal eating with high-carbohy clarified in each workplace whether this is the
drate food has a similar effect, and patients role of the pharmacist, nurse or physiotherapist.
should not be discouraged from eating any food This chapter will use the generic name (e.g.
that they enjoy. However, it is possible that salbutamol) or trade name (e.g. Ventolin)
excess consumption of the 'empty calories' of according to which is commonly used. Some
high-sugar, high-additive drinks such as British generic names will shortly become
Lucozade may affect a respiratory patient who redundant as international terminology is to
already retains CO2. become universal. Table 5.3 clarifies the names
Both obesity (p. 1 9) and malnutrition impair used in the UK at present.
lung function (Chen et aI., 1 993). Physiothera
pists may be the first to identify the need for Definitions
nutritional guidance and give basic advice, but a • Agonists activate a receptor response.
dietician is required for accurate assessment and • Antagonists block a receptor response.
treatment. Respiratory patients can show a • 'Half-life' measures the rate of elimination of
complicated pattern of weight loss, fluid a drug by indicating the time for plasma
retention, obesity and masked malnourishment. levels to drop to 50%. A drug is said to be
Body water can be altered by oxygen therapy completely eliminated after about five half
(Donahoe et al., 1 992), and body weight is not lives (Baterman and McLay, 1 99 9).
an adequate measuring tool. • Drug metabolism is determined by patient
For budget holders and bed managers, the fact age, size and the drug's route of excretion.
that nutritional support can reduce the length of The very young and very old are slower to
hospital stay by 5 - 1 6 days (Lennard-Jones, metabolize drugs. Drugs excreted by the
1 992) might give this aspect of patient care a kidney or metabolized by the liver are
higher priority. affected by kidney or liver failure.
A hospital is a meaningless edifice if even Drugs to prevent inflammation

one patient we are caring for has pain
The mechanism of allergic asthma can be influ
which is not eased, has a sleepless night, is
enced by the chromones (Intal or Tilade), which
given an unwholesome meal, is in
inhibit the release of inflammatory mediators
unaesthetic surroundings or is treated
such as neutrophils and eosinophils from mast
without basic human dignity.
cells. They protect against allergic and exercise
Khadra, 1998
induced asthma but do not reverse an established
attack. They can only be inhaled, and are parti
DRUG THERAPY
cularly effective in children, for whom they
Medication is normally prescribed by doctors should be the first-line preventive medication
and administered by nurses, but physiotherapists (Korhonen et aI., 1 99 9). They can be used
are involved in requesting and sometimes admin prophylactically before exercise or allergen
istering respiratory drugs. People with diseases exposure (Spooner, 2000).
133
Table 5.3 Medication for airways obstruction (trade names in parentheses)
Drug Delivery Side effects
Chromones Inhalation
Sodium cromoglycate (I ntal)
Nedocromil sodium (Tilade)
Corticosteroids Inhalation Hoarse voice (inhalation)

Beclomethasone (Becotide, Becloforte) Oropharyngeal candidiasis (inhalation)
Budesonide (Pulmicort) Osteoporosis
Fluticasone (Flixotide) Fluid retention
Prednisone Weight gain
Prednisolone Intravenous/oral Muscle atrophy
Hydrocortisone I nfection risk
Peptic ulceration
Fragile skin
Bruising
Hyperglycaemia
Diabetes
Hypertension
Cataract
Mood change
Adrenal suppression
Delayed healing
Retarded growth
Bronchodilators Inhalation Tremor

f3ragonists Oral Tachycardia
Salbutamol (Ventolin) Intravenous Agitation
T erbutaline (Bricanyl) Subcutaneous Atrial fibrillation
Slow-release f3ragonists Oral or inhalation
Bambuterol
Salmeterol (Serevent)
Eformoterol (Foradil)
Anticholinergics Inhalation Dry mouth
I pratropium (Atrovent) Constipation
Oxitropium (Oxivent) Urine retention
Glaucoma
Xanthines Oral or intravenous Headache
Theophylline Gastric ulcer
Aminophylline I nsomnia
Nausea and vomiting
Arrhythmias
Nasty taste
The only discernible side effect is a taste of

burning tyres, which can be reduced by a mint Drugs to treat inflammation
flavoured preparation. Because of their low Corticosteroids are hormone-based agents that
toxicity, chromones should be tried before reduce the inflammatory reactions that set off
steroids but, although they are effective in 70% bronchospasm, oedema and mucus hypersecre
of asthmatics (Holgate, 1 99 6), they take 4 weeks tion. For accurate prescription, a home trial with
to show an effect in 3 3 % of patients, and 1 2 serial peak flow measurements (Figure 3.10) is
weeks in 84% of patients (Corsico, 1 993). necessary because of spontaneous fluctuations in
134
DRUG THERAPY
aIrway calibre (Wiggins, 1 9 9 1 ). Maximum oids with the anabolic steroids abused by some
benefit may not be felt by the patient for 2 athletes.
months (Irwin et ai. , 1 99 8). Side effects are
listed in Table 5.3 and details are explained Drugs to treat bronchospasm
below. Response to bronchodilators is usual in asthma,
less frequent in chronic bronchitis and rare in
• Systemic side effects are reduced by using
emphysema. All acute patients on bronchodila
the inhaled route. Local side effects from
tors should use a peak flow chart until response
inhalation can be minimized by using a
is confirmed, and patients with chronic disease
spacer (p. 140), inhaling slowly and after
need a drug trial (Spence, 1 9 9 1 ) with peak flow
wards rinsing the mouth, gargling or
and symptom monitoring. These will identify
cleaning the teeth. Toothbrushes should be
reversible bronchospasm, defined as improve
renewed frequently. If using a mask, the face
ment in peak flow or FEV 1 by at least 1 5 % or
should be wiped afterwards.
1 5 0 mL (Dekker et ai. , 1 992). Measurements are
• In children, high-dose inhaled steroids retard
taken 20 minutes after Ventolin and 3 0 minutes
growth rate but not ultimate stature
after Atrovent. A drug trial also pinpoints which
(McCowan et ai. , 1 998).
drug, combination of drugs, dosage and route of
• Inhaled steroids can reduce bone density
administration are optimal.
(Boulet et ai. , 1 999) and oral steroids can
Both sympathetic (adrenergic) and parasympa
double the risk of hip fracture (Cooper,
thetic (cholinergic) receptors have been identified
1 995). Patients at risk should have preven
in bronchial smooth muscle. Sympathomimetics
tive treatment and should have their bone
are versatile drugs that mimic the action of the
mineral density regularly monitored (Cowan,
sympathetic nervous system. Those which
1 998). Doses of inhaled steroids below
stimulate �2-receptors in bronchial smooth
I OOO Ilm/day in adults and 400 Ilm/day in
muscle are known as �2-stimulants, �radrenergics
children show no significant effect on bones
or �2-agonists. Examples are:
or growth (Efthimiou and Barnes, 1998).
• High-dose steroids upset sleep and mood, • Ventolin or Bricanyl: onset of action 7 min,
with 20-50% of patients suffering depres peak effect 20 min, duration of action 3-5
sion (Mitchell, 1 998). hours
• Even at low doses, oral steroids can weaken • Serevent: onset 15 min, peak effect 1 hour,
systemic and respiratory muscles, which duration 1 2 hours.
reduces exercise tolerance and can manifest
Short-acting drugs such as Ventolin should be
as increased breathlessness. This may be
taken symptomatically rather than regularly.
ascribed mistakenly to deterioration of the
Regular use should be confined to those with
disease and lead to increased steroid dosage
acute asthma, severe chronic asthma, or as
(Decramer, 1 994).
prophylaxis before exercise-induced bronchos
Concern about side effects tempts prescribers pasm or allergen exposure. Most COPD patients
to nibble at the problem with low-dose do not show objective improvement with �r
therapy. Both undertreatment and side effects stimulants but some find symptomatic relief,
can be minimized by high dosage and early either as placebo or by reducing hyperinflation
weaning (acute disease) or alternate-day dosing (Gibson, 1 996).
(chronic disease). To minimize adrenal suppres Long-acting �rstimulants such as Serevent are
sion, a course of steroids lasting over 3 weeks not for use as symptomatic or rescue medication.
should be phased out gradually. Patients and These slow-release bronchodilators are
health workers are prone to 'steroid phobia', prescribed regularly for controlling nocturnal
especially as patients may confuse corticoster- asthma and some of the effects of brittle asthma.
135
Disadvantages of regular �rstimulants are system, and these effects can be achieved at
that they can reduce sensitivity to Ventolin itself lower dosage than required for bronchodilation,
(Giannini and Bacci, 1 9 9 9), may counterbalance thereby reducing the side effects that have
the benefits of steroids (Taylor, 2000) and, for hitherto limited their use (Barnes and Pauweis,
people with arrhythmias and hypoxaemia, they 1 994). If given over months, steroid dosage can
can have an adverse effect on the myocardium sometimes be reduced.
(Cazzola, 1 9 98). In severe COPD, the side effect The theophyllines are too insoluble to be
of trembling hands can impair ADL, and extra given by inhalation, and precise dosage is
energy expenditure due to a thermogenic effect required because of their narrow therapeutic
can be significant in malnourished people window. Slow-release preparations are used to
(Burdet, 1 997). �rstimulants tend to be control nocturnal asthma, and continuous intra
prescribed freely, and patients may overuse them venous therapy can be used for brittle asthma.
if not educated adequately. Unnecessary and Clearance rates are increased in smokers and
frequent use can worsen the course of COPD children, thus lowering blood levels, and
(Postma, 1 99 1 ) and asthma (Barrett, 1 995). decreased in elderly people and those with viral
Anticholinergic (antimuscarinic) bronchodila infection or heart failure.
tors, such as Atrovent, block the effect of acetyl If both �rstimulants and anticholinergics are
choline on autonomic nerve endings. They prescribed, the anticholinergic is taken first to
primarily affect the larger airways, have a slow open up the large airways and provide better
onset of 30-45 minutes and are most effective in access for the �rstimulant (Mathewson, 1 993).
infants and older people. They take second place If bronchodilator and preventive drug
as bronchodilators in asthma unless the side (chromones or steroids) are prescribed, the
effects of �2-stimulants are troublesome, but bronchodilator should be taken first to ensure
they may be more effective in COPD (Allen, maximum penetration of the preventive drug.
1 996). They can be used sequentially or in However, complicated instructions can demoti
combination with �rstimulants because of their vate patients and it is more important that the
additive effect (Dorinsky et al. , 1 999), e.g. drugs are taken than the exact sequence is
Combivent. Individuals show different response adhered to.
patterns and may react better to �rstimulants,
anticholinergics or both. There is an association Drugs to treat breathlessness
between glaucoma and nebulized Atrovent, so a Breathlessness in chronic lung disease becomes
mouthpiece should be used and eyes should be significant to the patient when roughly half the
kept shut. In contrast to �rstimulants, the ventilatory capacity is lost. Little of this function
recommended dose of two puffs is often subopti is recoverable, which often leads to an attitude
mal and some doctors are happy for patients to of therapeutic defeatism.
double or triple their intake. Sometimes the cause of breathlessness can be
Theophylline and its derivatives, such as treated, e.g. by diuretics, bronchodilators or
aminophylline, are part of the xanthine group of steroids. For a direct effect on breathlessness,
drugs, which have an interesting variety of the options are limited. Bronchodilators may
effects. They appear to bronchodilate, promote reduce breathlessness in some patients indepen
gas exchange, reduce breathlessness and improve dent of their bronchodilating effect, possibly by
exercise capacity (Cahalin and Sadowsky, 1 995), improving the efficiency of the diaphragm
reduce cough and sleep disturbance (Luce, (Hatipoglu et at. , 1 999). Morphine increases the
1 996), promote mucociliary clearance and exercise tolerance that is limited by breathless
reduce pulmonary hypertension (Banner, 1 994). ness (young, 1 98 9), reduces respiratory drive
Their anti-asthma properties are also related to and oxygen consumption, lessens anxiety and, in
reducing inflammation and boosting the immune a proportion of patients, reduces breathlessness
136
DRUG THERAPY
directly. The risk of morphine-induced respira overuse globally, mis-selling to the developing
tory depression is reduced by a slow-release world, their use as growth promoters in agricul
preparation and titration to the individual's need ture and the virtual shrouding of hospitals in an
(Light, 1 989). Dihydrocodeine has shown a 20% antibiotic blanket. Those who anticipate a post
reduction in exercise breathlessness (Burdon, antibiotic era are no longer considered doom
1 994) but constipation is a problem. mongers, and Arnyes ( 1 995) has predicted that
Buspirone is particularly useful because it is an we will run out of effective antibiotics by 2020.
anxiolytic which reduces breathlessness and There is increasing interest in Chinese herbal
increases exercise tolerance without sedative medicines, which show benefit in some lower
effect (Argyropoulou, 1 993). Inhaled lignocaine respiratory tract infections (Liu and Douglas,
ameliorates breathlessness associated with 1 99 8 ), and serious consideration is now given to
bronchoconstriction (Manning, 1 995), but maggot therapy for antibiotic-resistant wound
patients should not eat or drink for an hour infections (Thomas et al. , 1 999).
afterwards.
Drugs to help clear secretions
Drugs to treat infection Primary agents to clear secretions are systemic
hydration, effective humidification or drinkjng a
An antibiotic is indicated if a patient's condition
steamy cup of tea. If drugs are needed, they
is caused by bacterial infection and if the
should be aimed at improving mucus transport
organism responsible is sensitive to the antibiotic
rather than irritating the airways so that more
prescribed. Antibiotics often have to be given
secretions are created.
blind at first because 24 hours are needed for
Mucus transport may be enhanced by vitamin
microbiological results. Antibiotics show only a
C (Silver and Foster, 1 990), dry-powder
small benefit in exacerbations of COPD, but
mannitol (Daviskas, 1 997) and certain broncho
those most likely to benefit show all three of the
dilators such as bamiphylline (Todisco, 1 995)
following symptoms:
and Serevent (Rusznak, 1 9 9 1 ). The volume of
• i dyspnoea sputum expectorated can be reduced by inhaled
• i sputum volume oxitropium (Tamaoki, 1 994), inhaled indometha
• i sputum purulence (Smith et ai. , 1 999). cin (Tamaokj, 1 992) or inhaled steroids (Elborn
et ai. , 1 992).
Antibiotics should be specific and time Cilia are made to transport a viscoelastic gel.
limited. Prophylactic use is reserved for people They have difficulty propelling either liquids or
with chronic sepsis such as cystic fibrosis. Unne thick mucus. Acetylcysteine is a mucolytic that
cessary antibiotics simply select for resistant can reduce the viscosity of thick mucus but at
bacteria (Man et al. , 2000), leading to superin the expense of riskjng bronchospasm (Eng,
fection. Despite 65% of respiratory tract infec 1 998), so it needs to be accompanied by a
tions being viral, 75% of patients are prescribed bronchodilator. There is no evidence that it
antibiotics (Carroll, 1 989). offers any advantage over humidification or
Antibiotics are admjnistered orally, intrave saline instillation, and it is not available on the
nously or by nebulizers with powerful compres NHS except for palliation and sometimes for
sors designed for viscous solutions and which people with cystic fibrosis. If used, it can be
have an exhalation filter. Side effects of antibio nebulized or 1 -2 mL can be instilled down a
tics include skjn reactions and the emergence of tracheal tube (AHFS, 1 999).
resistant organisms, partly because of interference Surfactant has mucokinetic properties and is
with the friendly flora of the respiratory tract. showing some promise in aiding mucociliary
Bacteria are becoming resistant to antibiotics clearance (Wills and Cole, 1 9 9 6). The surface
faster than new drugs are invented because of tension of mucus can also be reduced by
137
iodinated glycerol (Petty, 1 990). Drugs such as improve diaphragm contractility (Roussos,
rhDNase for CF are described on page 89. 1 996). Other pharmacological possibilities are
reviewed by Heijden et al. (1 996).
Drugs to inhibit coughing
To suppress a non-productive and irritating Drugs to relieve oedema
cough, medication is available if physical means Salt and water excretion can be promoted by
(p. 204) are to no avail. Antitussive agents diuretics, either loop diuretics such as frusemide
include baclofen (Dicpinigaitis, 1 9 9 8), pholcodine or osmotic diuretics such as mannitol. They are
and dextromethorphan (Parvez et aI. , 1 996). potent and non-selective, and over-enthusiastic
Nebulized local anaesthetics block sensory nerve use can lead to volume depletion, dizziness on
traffic and provide temporary relief at night standing, loss of calcium and potassium,
(Trochtenberg, 1 994). A cough caused by asthma anorexia and vomiting (Weill et al. , 1 998).
or ACE-inhibitors can be reduced by Tilade Diuretics are the commonest cause of adverse
(Hargreaves, 1 995), and a post-infection cough drug reactions in old age (Rhodes, 1 993).
by Atrovent (Holmes et aI. , 1 992). Diuretics are useful to reduce cardiac
Non-specific cough suppressants are best workload in pulmonary oedema associated with
avoided (Irwin et al. , 1 99 8). 'Cough mixtures' chronic heart failure but they do not prevent
may contain both expectorant and suppressant progression of the disease (Cleland, 1 996) nor
but are strong placebos and the sugar content is affect survival (Kramer et al. , 1 999) and the asso
thought to briefly soothe irritated airways. ciated activation of the sympathetic nervous
system can exacerbate tachycardia and vasocon
Drugs to improve ventilation
striction while hindering stroke volume and
Respiratory stimulants should be used with tissue perfusion (Northridge, 1 996). Diuretics
caution if the respiratory muscles are already are not advised for acute heart failure (North
working maximally, because further stimulation ridge, 1 996) or oedema associated with immobi
will override the protective function of fatigue lity, venous insufficiency or premenstruation
(Barnes, 1 995). Respiratory stimulants do not (Rhodes, 1 993). Some patients taking diuretics
reverse the underlying cause of ventilatory restrict their fluid intake, especially if they have
failure. stress incontinence or poor mobility. However,
Doxapram drives ventilation via chemorecep diuretics can usually be taken at a time of day to
tors and the respiratory centre but at the cost of minimize disruption from the obligatory trips to
central nervous system stimulation, agitation the toilet (Gordon & Child, 2000).
(Simonds 1 996, p. 1 70), hallucinations, Drugs specifically for asthma are discussed on
increased WOB, breathlessness and sometimes page 8 1 , for CF on page 8 9, for primary heart
panic attacks (Abelson, 1 996). An infusion is disorders on page 333 and for palliative care on
sometimes tolerated by drowsy patients with page 3 1 1 .
post-anaesthesia hypoventilation or to avoid the
need for mechanical ventilation (Hirschberg, Delivery devices
1 994). Doxapram is widely used for ventilatory
Are respiratory drugs best ingested or inhaled?
failure, especially with acute oxygen therapy for
Inhaled therapy delivers an aerosolized drug,
COPD patients who cannot reach satisfactory
suspended as fine liquid or solid particles in air,
oxygen saturations without excessive hypercap
directly to the respiratory tract. It brings the
nia. This practice is not evidence-based and both
following advantages:
Gribbin ( 1 993) and Angus ( 1 996) advise against
it except as a temporary holding measure. If • rapid onset of action
non-invasive ventilation is not available to rest • local delivery to maximize the positive
the inspiratory muscles, the theophyllines may effects and minimize adverse effects
138
DRUG THERAPY
• delivery of drugs that are not active by other Inhalers

routes (Manthous, 1 994). Pressurized inhalers deliver an aerosol by
suspending an active drug in a propellant. The
Disadvantages are: traditional metered dose inhaler is portable and
cheap but the device will shortly be outlawed
• less effective lung deposition with increased because of its ozone-unfriendly propellant. Poor
airflow obstruction, leading to patchy and inhaler technique is common; 60% of COPD
less peripheral distribution in people with patients use them incorrectly (Reina
advanced COPD or acute severe asthma Rosenbaum et al. , 1 997). Other inhalers such
(Lipworth, 1 995) as the breath-actuated Autohaler or Easi
• reduced effectiveness in breathless people Breathe (Figure 5.1 O) co-ordinate drug release
whose rapid airflow favours deposition to with inhalation.
the central airways Slow inhalation and end-inspiratory pause are
• loss of much of the drug to the atmosphere, advised with pressurized inhalers (Pedersen,
stomach and pharynx, although high doses 1 99 6). Details of technique are available from
compensate for this. pharmacists and supplied with the inhaler.
Instructions for the Easi-Breathe are as follows:
Large particles more than 5 f.!m diameter are
• Shake inhaler.
lost in the upper airways. Small particles less
• Fold down cap from over mouthpiece.
than 2 f.!m are deposited in the alveoli and are
• Hold inhaler upright.
used for antibiotic delivery. Tiny particles less
• Breathe out.
than 0.5 f.!m are inhaled and exhaled untouched
• Place mouthpiece in mouth, close lips firmly.
(Figure 5.9).
• Ensure fingers are not blocking airholes.
Particles from 2-5 f.!m target the bronchi and
• Inhale slowly and deeply through mouth
bronchioles and are used for bronchodilators
piece, continue as inhaler puffs dose into
and steroids (Manthous, 1 994). The task of
mouth, continue until end of deep breath.
assessment for delivery systems may fall to the
• Take inhaler out of mouth, hold breath for
physiotherapist.
1 0 seconds or as long as comfortable.
• Breathe out slowly.
• Close cap.
• If taking a second puff, wait one minute to
re-prime inhaler.
Deposition in pharynx, Dry powder inhalers draw air through dry

larynx and upper powder to create an aerosol, which is released
respiratory airways
on inspiration. They require minimal co-ordina
tion and no breath-hold. Disadvantages are that
children under 6 years, breathless people and
those with bronchospasm may not be able to
release the drug if they are unable to generate
the required flow, i.e. 3 0-120 Umin (Dhand and
Fink, 1 999). The powder is sensltlve to
moisture, so it is either stored in foil blisters or
patients advised not to exhale into the device.
Devices have their own characteristics; for
Figure 5.9 Aerosol deposition at varying particle sizes example, the Turbohaler is efficient but requires
(Intersurgical, with permission), a forceful inspiration and does not indicate when
139
Easi-breathe Autohaler
Pressurized
inhalers
Tu rbohaler
Accuhaler
Dry powder
inhalers
Diskhaler
o 0
0
��
Nebuhaler Volumatic
Large volume
spacers
Aerochamber
Spacers for adult

and child
Figure 5. ' 0 Inhaler devices.
the dose has been delivered. Instructions for the • Close mouthpiece cover.
Clickhaler are as follows:
A spacer is a chamber between patient and
• Shake inhaler- inhaler that forms a reservoir from which the
• Remove mouthpiece cover- patient can inhale the aerosol. Advantages are
• Hold upright_ the following:
• Press button until click heard.
• Breathe out_ • Propellants and large particles drop out in
• Close lips around mouthpiece. the chamber, thus reducing the local side
• Inhale deeply_ effects of steroids (Everard et at- , 1 992).
• Remove device from lips, close lips_ • Aerosol momentum is slowed so that less is
• Hold breath for 1 0 seconds_ lost by impaction on the back of the throat.
140
DRUG THERAPY
• Less co-ordination is required because the • confusion about when to use which inhaler,
drug remains suspended in the spacer until e.g. mistaken use of steroids on a symptom
the patient breaths in, although early inhala related basis
tion is advised because the half-life of drug • difficulty in understanding instructions, e.g.
aerosol within the spacer is often less than mistaken spraying of the drug up the nose,
1 0 seconds (Thorax, 1 9 97). on to the chest or into the armpits!
• High doses can be delivered during acute
episodes. Small-volume nebulizers
A jet nebulizer uses the Venturi principle to
Spacers should always be used for children transform a drug in solution into a mist of
taking steroids (Barry, 1 994). Infants can use a droplets. A high-pressure system such as oxygen
soft face mask attached to the spacer (Everard et from a wall supply or air from a compressor
aI., 1 992). The large pear-shaped spacers such as forces the gas at high velocity through a narrow
the Nebuhaler or Volumatic are cumbersome but hole known as a Venturi. This creates an area of
most efficient (Barry, 1 996), simulating the low pressure, which draws the drug solution into
aerosol cloud from an inhaler. Slow quiet tidal the fast-moving gas stream and produces a flow
breathing is advised (Pedersen, 1 996). One dose of droplets. Large droplets are impacted on a
at a time should be fired into the spacer because baffle and fall back into the reservoir (Figure
multiple dosing is inefficient (Pedersen, 1 996). 5.1 1 ).
Large spacers should be washed with detergent
once a week, without rinsing, and then air-dried, Technique
in order to reduce static charge, which attracts • If the patient does not need oxygen, an air
the drug to the walls of the spacer rather than compressor is advisable as the driving force
the lungs (Pierart et aI. , 1 999). because the relative humidity of ambient air
Problems for patients with inhalers are: stabilizes particle size (Hodgkin et ai., 2000,
p. 1 23 ).
• the need for co-ordination and/or manual • Select a mouthpiece if possible, unless
dexterity patient preference or excessive breathlessness
Inspiration Expi ation

r
.
.
�
'
. .
. e . . . . .
. . .
. . . . . . .....-- - . . .
. . . . .
. . .
. . . .
.
Baffle -��r!f
Feeding
tube
Air from Air from

compressor compressor
Figure 5.1 1 Small-volume jet nebulizer for delivery of saline or aerosolized drugs in droplet form. (From O'Caliaghan, C.
and Barry, P. W. (1997) The science of nebulised drug delivery. Thorax, suppl. 2, 531-544, with permission.)
14 1
precludes this. Nose breathing filters the Some nebulizer solutions should not be
drug and reduces lung deposition by a mixed, and the hospital pharmacy can be
quarter (Salmon et at. , 1 990) and aerosol consulted for up-to-date information. Tapping
escaping from a mask can affect the eyes. the nebulizer when the liquid is beginning to fizz
• If possible, have the patient sitting upright in increases the delivered dose by 3 8 % (Everard et
a chair or side-lying to maximize basal at. , 1 994); this is unnecessary with the high
deposition. Some nebulizers do not function doses used for bronchodilation and simply
when angled. Ensure breathless patients have extends treatment time, but is useful for exact
support for their elbows. drugs such as antibiotics. Demand nebulizers
• Fill to between 2.5 and 6 mL, depending on increase efficiency by delivering the drug on
the nebulizer. Dilute with normal saline if inspiration only. Ultrasonic nebulizers (p. 1 8 8)
required. Set the flow rate to 8 L/min, unless are popular with patients because the density of
a compressor is used, which has a preset flow the mist facilitates more rapid completion of the
rate. process, but they do not suit all drug suspen
• Advise the patient: sions, e.g. budesonide or antibiotics.
to mouth-breathe if possible For patients who remain symptomatic
to intersperse tidal breaths with some despite inhaler use, a 3 -week home nebulizer
deep breaths and some end-inspiratory trial is more accurate than laboratory measure
holds to improve deposition (Hess, ments (Hosker, 1 995). A typical home trial
1 994) comprises nebulized saline, nebulized Ventolin
- if using a mouthpiece, not to obstruct and then a nebulized Ventolin!Atrovent mixture
the excess air port 6-hourly, each for 1 week. Symptoms and
- to allow 1 0 minutes for completion twice-daily peak flows are monitored and a
- after each use to empty and dry the positive result is defined as producing a 15%
nebulizer with a paper towel rather than increase in peak flow during a week on active
a tissue, which can clog the system (or treatment compared to the week on saline
when in hospital, or follow infection (Goldman et at. , 1 992). The first dose is best
control protocol) administered in hospital in case of side effects
- once a day to wash in hot soapy water, such as cardiac arrhythmias. Trials can also
rinse and dry with air from the compare bronchodilators with steroids and
compressor or oxygen supply, or follow nebulizers with inhalers. If patients use nebuli
hospital protocol. zers at home, they must be given adequate
Drying is the most important aspect of assessment, advice (BTS, 1 997) and back-up
the cleaning process (Dodd ( 1 996). servicing. Drug trials for home use are invalid
during acute illness.
For domiciliary use, patients must understand
the importance of cleaning, since one-third of Disadvantages and precautions.
nebulizers have been found to be contaminated • Drug availability between different nebuli
with bacteria Oones, 1 9 85). Regular servicing is zers varies fourfold (MacNeish, 1997).
required, otherwise the compressor becomes Breath-synchronized devices reduce some of
progressively less effective, even though continu the wastage (Nikander, 2000).
ing to produce a mist. Family education is • Nebulization cools the inspired gas, causing
advisable in order to improve a reported 44% a risk of bronchospasm in some patients.
adherence rate (Cochrane, 1 997) and to ensure • Angina or hypoxaemia occasionally occurs
that patients do not interpret '4-hourly nebs' as with nebulized Ventolin (Simpson, 1993).
requiring them to interrupt an already disrupted • ' Horrifying tales' of bacterial contamination
night. and inadequate servicing have been reported
142 ------
BRONCHOSCOPY AND LAVAGE
with domiciliary nebulizers (Lane, 1 9 9 1 ). �rreceptors. Even so, individual assessment is

For hospital nebulizers, Botman ( 1 9 8 7) required.
found one-third to be contaminated.
• Patient adherence may be hindered by the
BRONCHOSCOPY AND LAVAGE
long time required to complete nebulization.
• People with severe acute asthma may be Access to the bronchial tree for diagnostic or
over-reliant on repeated use when their therapeutic purposes is achieved with a fibreop
airways are dangerously obstructed and tic bronchoscope, a thin flexible instrument
nebulization is ineffective, with possibly passed through the nose and into the subsegmen
lethal results (Lane, 1 9 9 1 ). tal bronchi, using local, nebulized or general
• The inspired gas must be suited to the anaesthesia.
patient. ' Acutely hypoxaemic asthmatic Diagnostically, bronchoscopy can be used for:
patients require high PIOl levels and acute
hypercapnic COPD patients may require • observation
air, sometimes with oxygen via a nasal • biopsy, e.g. to identify malignant lesions
cannula. • brushings, e.g. to obtain lower airway micro
biology samples in patients with pneumonia
Indications or exacerbations of COPD, or to identify
The following may be suited to nebulizers: parenchymal lung disease, using a protected
specimen brush to prevent contamination by
• people who are too breathless to use an upper airway flora (Wilson, 1 999)
inhaler, such as during an asthma attack, so • washings or lavage.
long as over-reliance does not prevent
medical assistance being sought when indi Bronchoalveolar lavage involves wedging the
cated bronchoscope into a bronchus, washing 1 20-
• people who need large doses rapidly 200 mL of saline through it, then aspirating this
• antibiotic, antifungal and local anaesthetic along with fluid and cells from the lower respira
drug delivery tory tract and alveoli for diagnosing parenchy
• patients in whom assessment has shown mal lung disease. Complications include
improved outcome compared to inhalers. hypoxaemia and inflammation, which are
lessened by using less saline and a telescopic or
Inhaler or nebulizer ? standard catheter rather than a bronchoscope
Patients love nebulizers. They prefer them to (Fabregas, 1 996).
inhalers even when they contain placebo saline Therapeutically, bronchoscopy can be used
Genkins et ai. , 1 9 8 7), perhaps because patients for removing foreign bodies, placing stents
are automatically changed to nebulized drug (Cowling, 2000) and laser-resecting tumours
delivery when admitted to hospital so nebulizers (Todisco, 1 996). Bronchoscopy is rarely
'must be best', or perhaps because nebulizers justified as a substitute for physiotherapy in
create an impressive mist and do not demand clearing secretions (Brooks-Brunn, 1 995) and
respiratory gymnastics for co-ordination. can be complicated by bronchospasm, haemor
However, less drug reaches the lung by nebulizer rhage, pneumothorax, discomfort, subcutaneous
and ten times the dose needs to be prescribed. emphysema, arrhythmias or the transport of
According to Hess ( 1 994), nebulizers are less microorganisms from the upper airway to the
efficient, less convenient and twice as expensive sterile lower airways. However, bronchoscopy
as inhalers. According to Sahn and Heffner may be appropriate if there is intractable
(1 994, p. 1 62), their inefficiency can reach 'stag sputum retention with no air bronchogram on
gering proportions', with only 3 -9% reaching X-ray, i.e. with blocked central airways. To re-
143
expand atelectatic areas, it can be combined

with selective insufflation of air (Brooks-Brunn,
1 995) or followed by physiotherapy.
Rigid bronchoscopy can be used for removal
of large foreign bodies. This requires a general
anaesthetic and does not have the flexibility of
fibreoptic bronchoscopy, which allows rotation
in every direction. Virtual bronchoscopy can be
used for patients at high risk of complications
(Haponik et at., 1 999).
Patients are usually told the 'why' of the
procedure, but not always the 'how'.
Physiotherapists can check that patients under
stand to procedure to avoid disproportionate
fear (Poi et ai., 1 9 9 8). Figure 5. 120 Mr FJ.
I;ii�iIM1IiIi).tl;iit"
How would you treat this 32-year-old father who
has been referred for twice-weekly percussion and
postural drainage? He has polychondritis (chronic
inflammation of the cartilage), which has led to
collapse of his tracheal and bronchial cartilages.
Background
H PC: surgery on deformed chest and formation of
tracheostomy 1 5 years ago, discharged with
instructions to change and clean tracheostomy tube
twice-weekly.
Drugs: prednisolone.
SH: lives with wife and three children, started
office job 2 months ago, non-smoker.
Subjective
Occasional chest infections, last one 6 weeks ago Figure 5. 12b Mr FJ.
which never quite resolved.
Always have a bit of phlegm, usually no problem
clearing it but slightly more difficult over the last
6 weeks.
Change trachy tube 9-monthly. Objective
Slight SOBOE but not bothersome. Abnormal chest shape (Figure 5. 1 2).
Trachy sometimes causes a dry cough. RR normal.
144
RECOMMENDED READING
Breathing pattern slightly laboured. is safer than the infection-prone hospital

Clinically well hydrated. atmosphere). Advise Mr JF that a clean tube
Posture: round shoulders. might reduce his dry cough.
Auscultation: scattered crackles. • Negotiate lifetime programme to prevent chest
infections and maintain exercise tolerance,
Questions preferably based on enjoyable exercise, e.g.
football with children, but offer variety of
I . Why might Mr FJ have chest infections?
techniques for mucus clearance (Chapter 8).
2. What could have prevented the last chest
• Discuss possible effects of office atmosphere.
infection from being fully resolved?
• Assess whether postural correction is possible.
3. What could be causing the slight difficulty in
• Advise patient to ask GP's advice on bone
clearing his chest?
mineral density scan to check for steroid
4. Is the SOBOE a problem?
induced osteoporosis.
5. Is the dry cough a problem?
• Review 6-monthly by phone and yearly face to
6. Analysis?
face.
7. Problems?
8. Goals?
9. Plan?
RR respiratory rate; SH social history; SOBOE
= = =
shortness of breath on exertion.

The following study investigated chest
physiotherapy (CPT) for people with
pneumonia, as identified by infiltrates on X-ray.
Does the physiotherapy fit the pathophysiology ?
I . Tracheostomy bypassing upper airway defences,
And what do you make of the complications of
infrequent tube changes.
CPT?
2. and 3.
Change in lifestyle 2 months ago: inactivity, dry Inclusion criteria for group 1 comprised the
office atmosphere, possibly smokers at work. presence of unilateral pneumonic infiltrates
4. It is not bothersome at present but may become on chest X-ray . . . we found no statistically
so as Mr FJ ages and loses respiratory reserve. significant short-term therapeutic benefit
5. It depends on whether it worries the patient. from percussion or vibration.
6. No major disruption to lifestyle at present but CPT can cause . . . barotrauma, bended
potential for deterioration over time. Percussion endotracheal or ventilation tubing.
unsuitable because of long-term steroids.
Acta Anaesthesia!. Belg. 199 1 ; 4 2 : 1 6 5 - 1 70.
Postural drainage unlikely to suit patient's
lifestyle.
7. Risk of chest infections.
Some sputum retention.
Mild increase in work of breathing, probably
because of chest shape. Potential for reduced A passing acquaintance with the pathophysiology
exercise tolerance. of pneumonia would have saved the researchers
8. Reduce risk of infection. the trouble of beginning the study. Physical
Develop exercise tolerance. treatment cannot influence a lung that is solid
9. with inflammatory consolidation.
• Negotiate more frequent tube changes. Twice Imagination boggles at the image of CPT
weekly changes are unlikely to be adhered to causing barotrauma and bending an endotracheal
and are probably not necessary at home (which tube. . . .
145
CHAPTER 5 GENERAL MA AGEMENT
Kacmarek, R. M. (2000) Delivery systems for long-term

RECOMMENDED READING oxygen therapy. Eur. Respir. Care, 45, 84-92.
Baterman, D. and McLay, J. S. ( 1 9 99) Clinical Knoch, M. and Sommer, E. (2000) Jet mobilizer design
pharmacology: the basics. Medicine, 27(3 ), 1 -4. and function. Eur. Respir. Care, 45, 95-1 03 .
British Thoracic Society ( 1 997) Guidelines for Niederman, M. S. ( 1 9 98) Update in pulmonary
nebulizers. Thorax, 52 (suppl. 2), S4-S 1 6 . medicine. Ann. Intern. Med. , 128, 208 - 2 1 5 .
Cahalin, L. P . and Sadowsky, H. S. ( 1 995) Pulmonary Paton, J. ( 1 994) The safety of inhaled steroids in
medications. Phys. Ther., 75, 3 97-4 14. childhood asthma. Practitioner, 238, 322-
Dodd, M. E., Kellet, F., and Davis, A. (2000) Audit of 324.
oxygen prescribing before and after the Pedersen, S. ( 1 996) Inhalers and nebulizers : which to
introduction of a prescription chart. Br. Med. j., choose and why. Respir. Med., 90, 69-77.
3 2 1 , 864-865. Powell-Tuck, J. (2000) Nutrition. Best Pract. Res.
Emad, A. ( 1 997) Bronchoalveolar lavage. Respir. Care, Clin. Anaesth. , 1 3 , 4 1 1 -425 .
42, 765-780. Schols, A. M. W. J. (2000) Nutrition in chronic
Heslop, K. and Harkawat, R. (2000) Nebulizer obstructure pulmonary disease. Curro Opin. Pulm.
therapy from a practical perspective. Eur. Respir. Med. , 6, 1 1 0- 1 1 5 .
j. , 1 0, 2 1 3-2 1 5 . Spring, C. and McCrirrick, A. ( 1 999) The fibreoptic
Hess, D . R. (2000) Nebulizers: principles and bronchoscope in the ICU. Br. j. Intens. Care, 9 ( 1 ),
performance. Respir. Care, 45, 609-622. 14-22.
Hobbs, J. ( 1 995) On patients and inhalers. Respir. Dis.
Pract., 1 2 ( 1 ) , 8 - 1 2 .
146
6 PHYSIOTHERAPY TO INCREASE LUNG VOLUME
S UMMARY
Introduction to repiratory physiotherapy • Neurophysiological facilitation

What is loss of lung volume, and does it • Rib springing
matter? Mechanical aids to increase lung volume
Controlled mobilization • Incentive spirometry
Positioning • Continuous positive airway pressure
Breathing exercises • Intermittent positive pressure breathing
• Deep breathing Outcomes

• End-inspiratory hold Mini case study
• Abdominal breathing Literature appraisal
• Sniff Recommended reading
I NTRODUCTION TO RESPIRATORY • negotiate goals

PHYSIOTHERAPY • agree on a management plan and time frame
• treat the patient
What is respiratory physiotherapy? And does it
• re-assess
work ?
• discuss and modify the plan according to
Respiratory physiotherapy, to be effective,
ongoing assessment
includes education, pain relief, accurately
• check if goals are met.
targeted mobilization, manual and mechanical
techniques, and response to patients in distress. Goals should be specific, meaningful to the
It is ineffective to intervene with a process as patient and challenging but achievable.
personal as breathing without attention to the Patients who have difficulty communicating or
person as a whole. who are on a ventilator can still be involved with
Other aids to effectiveness are to avoid the decisions on treatment. For helpless patients, a
routine and to ensure that any improvement degree of autonomy is particularly important.
achieved is maintained. Ongoing management Physiotherapy usually includes advice, which
includes a negotiated plan of self-care and should be explicit, short, clear, written down
liaison with nursing staff or relatives. Brief and copied for the physiotherapy notes.
follow-up checks during the day may be appro The next three chapters will relate techniques
priate, rather than ticking off the patient's name to the available evidence, using the three main
in a notebook. One of a physiotherapist's most respiratory problems of reduced lung volume,
useful skills is in motivating patients, especially increased work of breathing and sputum
by providing positive feedback and encouraging retention.
patients' own ideas (Kerr, 1999).
A suggested approach is to : WHAT IS LOSS OF LUNG VOLUME, AND DOES IT
MATTER?
• assess the patient
• identify problems Loss of lung volume takes a variety of forms.
• clarify the patient's expectations • Atelectasis is collapse of anything from a few
147
CHAPTER 6 PHYSIOTHFRAPY TO INCREASF LUNC, VOLUl\lE
alveoli to the whole lung. Segmental, lobar

CONTROLLED MOBILIZATION
and lung collapse are visible radiographi
cally, but microatelectasis is not obviously The most fruitful technique for increasing lung
detectable. Causes include shallow breathing, volume is exercise (Dean, 1994). When accu
bronchial obstruction, absorption of trapped rately targeted, this combines upright posture,
gas, surfactant depletion and compreSSIOn which reduces pressure on the diaphragm and
from abdominal distension or pleural encourages basal distribution of air, with natural
disorder. Atelectasis has been reported in deep breathing. It is the first-line treatment for
74% of patients with acute spinal cord patients who can get out of bed.
injury, 85% with neuromuscular disease, up To ensure accuracy, the level of activity is
to 900/0 of patients after cardiac surgery and controlled so that the patient becomes just
25% of patients after upper abdominal slightly breathless but avoids muscle tension, then
surgery (Raoof et al., 1999). Physiotherapy s/he is asked to lean back against a wall to get his/
is indicated to treat or prevent atelectasis if her breath back, while being discouraged from
it is caused or anticipated by immobility, talking, which would upset the breathing rhythm.
poor positioning, mucous plug, shallow Relaxing against a wall minimizes postural
breathing and/or postoperative pain, espe activity of the abdominal muscles, allowing the
cially in non-alert patients. diaphragm to descend more freely. The
• Consolidation causes loss of functioning lung controlled 'slight breathlessness' then becomes
volume. It is not directly responsive to therapeutic as deep breathing, rather than wasted
physiotherapy but in a dehydrated patient it as shallow apical breathing. For patients who
is responsive to hydration, and further have not just had surgery, some find that holding
complications may be prevented by posi their hands behind their backs while leaning
tioning or mobilization. against the wall further frees their breathing.
• Pleural effusion, pneumothorax and abdom Patients who are not able to walk can use
inal distension compress the lung but are controlled activity by simply transferring from
inaccessible directly to physiotherapy. Posi bed to chair, then they 'get their breath back' by
tioning may assist comfort and gas exchange, relaxing against the back of the chair. Even less
and sometimes re-expansion of the lung may ambitiously, when bed-bound patients have
need assistance, e.g. after a pleural effusion simply rolled into side-lying, they can be encour
has been drained. aged to relax in the appropriate position while
• Restrictive disorders of the lung or chest wall returning to normal tidal breathing.
reduce lung volume but are less responSIve Once patients understand these principles and
to physical treatment. can identify the feeling of 'slight breathlessness'
and 'getting their breath back', they can practise
Even when the condition is not directly
on their own, using walking and their normal
responsive to physiotherapy, the patient may still
functional activities as a medium for improving
need attention.
lung volume. Regular graded exercise can then
When increasing lung volume, the distribution
be encouraged and monitored by the
of the extra air should be directed to poorly
physiotherapist.
ventilated lung regions. In postoperative or
Principles of safety when mobilizing patients
immobile patients this is usually the lower lobes.
are the following :
Loss of lung volume is a problem when it
causes a significant degree of:
• Check brakes on beds, chairs and wheel
• 1 surface area for gas exchange chairs.
• 1 lung compliance (Figure. I.3) • Place chairs strategically 10 advance,
• i work of breathing. supported against a wall.
148
POSITIONING
• Place chairs on stair landings if there IS (a)

space. Mean height 1.68 m
• Watch intravenous lines. (j)
• Ensure that patients dangle their legs over � �.3000S>--' 30� 600\
� 3.5
the edge of the bed for a period before
standing.
=
• Avoid holding a patient's arm if it is being .?;-
used for a walking aid. .�c. 3.0
• Ensure that patients keep their hands out of <1l
u
their pockets. Cii
-5 2. 5
• For the first 24 hours after surgery, watch .(jj
the patient's face for colour change that �

Cii
might indicate postural hypotension caused c
o 2.0 Bars indicate
by preoperative fluid restriction and perio U
C
±1 standard deviation
::J
perative fluid shifts. u..
• Discourage breath-holding; encourage steady 1.5 '------------------.....
relaxed breathing. Figure 6.1 (a) Functional residual capacity (FRC) in

• When sitting a patient in a chair or wheel different positions. (From Lumb, A. B. (2000) Nunn's Applied
chair, add extra stability by tucking a foot Respiratory PhYSiology, 5th edn, p. 52, with permission.)
behind a chair leg or wheel.
(b)
• Stand below the patient when going up or
FRC
down stairs.
• If a patient falls, hospital manual handling
protocol should be followed, but it is the
patient's head that is vulnerable and it can
sometimes be held against the physiothera
Ol Ol Ol Ol
pist for protection during the fall. C C C
Ol
C C
(J)
c
"B .>' :?- :?- "B .0.
U5 :z .(jj ::J
Cii
(J)
"0
(J)
"0 "0 en
I .(jj .(jj (J)
c.
.L I
POSrTrONING .<: -=
(J)
E
::J
Ol ...J
0: US
Changing a patient's posItIon may not seem a
dramatic procedure but this simple action often Figure 6.1 (b) FRC as a percentage of the sitting value.
prevents recourse to more time-consuming tech 'Sitting' means sitting upright with legs dependent. (From
niques that can be tiring for the patient. Posi Jenkins et 01., (I 988) The effect of posture on lung volumes.
Physiother., 74, 492-496. )
tioning should be an integral part of all
respiratory care, especially when prophylaxis is
6.1). Macnaughton (1995) found that FRC
the aim. It is used in its own right or in conjunc
can drop by up to 1 litre from the standing
tion with other techniques. No physiotherapy
to the supine position.
treatment should be carried out without consid
• Lung compliance decreases and work of
eration of the position in which it is performed.
breathing (WOB) increases progressively from
Positioning affects several aspects of lung
standing, to sitting, to supine. In supine, lung
function:
volume is restricted by (1) the load of the
• Lung volume is related to displacement of viscera, (2) increased thoracic blood volume
the diaphragm and abdominal contents. and (3) small airway closure. Wahba ( 1991)
Functional residual capacity (FRC) decreases found that WOB was 40% higher in supine
from standing to slumped sitting (Figure than in sitting.
149
CHAPTER 6 PHYSIOTHERAPY TO INCREASE LUNG VOLUME
• Despite compensatory hypoxic vasoconstric pressure against the diaphragm from the
tion (p. 13), a degree of perfusion persists in abdominal contents.
areas of low volume, which increases shunt. The following principles apply to immobile or
• Arterial oxygenation is usually higher in relatively immobile patients with atelectasis or
side-lying than supine. With bilateral or potential atelectasis:
diffuse pathology, this tends to be slightly
• Time should be spent in side-lying, well
greater lying on the right than the left
forward so that the diaphragm is free from
because of reduced compression of the heart
abdominal pressure (Figure 6.2). Side-lying
(Frownfelter and Dean, 1996, p. 312).
can also be encouraged for sleeping. A 2-
• Recumbency impairs fluid-regulating
hourly position change has been recom
mechanisms, leading to orthostatic intoler
mended (Brooks-Brunn, 1995).
ance and reduced motivation to mobilize
• Half-lying in bed rapidly becomes the
because of light-headedness.
slumped position for most patients as they
Supine is unhelpful for lung volume because slide down the bed (Figure 6.3). Time in
the diaphragm is inefficient and less co-ordinated half-lying should be limited for patients with
with chest wall mechanics (Wahba, 1991). The loss of lung volume, unless necessary for a
slumped position IS unhelpful because of specific medical reason or to minimize pain.
I -. " .
Figure 6.2 Side-lying position. The patient has an acutely distended abdomen, but the diaphragm is relieved of pressure by
the patient being rolled well forward.
150 ------
POSITIONING
Figure 6.3 The slumped position.
Manoeuvres to increase volume, such as side overrides the physiological ventilation

deep breathing, are relatively ineffective in gradient. Lying with the affected lung uppermost
half-lying because of pressure from abdom means that the better ventilation of the
inal viscera. dependent normal lung is matched with better
• When sitting out a patient after treatment, a perfusion (Figure 6.4). Perfusion is always
footstool may be inadvisable unless the greater in dependent areas, and VAiQ match is
patient has ankle oedema or a recent vein therefore enhanced in the 'bad lung up' position,
graft, or finds this position more comfor sometimes resulting in a dramatic improvement
table. in gas exchange. VA/Q is usually mismatched if
• Lengthy positioning in supine is best avoided the affected lung is dependent (Gillespie and
for those who have a high closing volume, Rehder, 1987).
e.g. people who are elderly, obese or smoke As well as optimizing gas exchange, the 'bad
heavily. lung up' rule suits other situations. It promotes
comfort following thoracotomy or chest drain
Positioning also affects the VA/Q ratio. Venti placement, facilitates postural drainage, and
lation and perfusion are usually matched because helps improve lung volume when atelectatic lung
the better-ventilated dependent lung is also is positioned uppermost to encourage expansion.
better perfused. For people with one-sided With atelectasis, the uppermost areas are
pneumonia, reduced ventilation on the affected stretched and better expanded, even though the
15 1
(a) (b)
C7
v
1j ~
Figure 6.4 Effect of positioning with one-sided pathology, e.g. thoracotomy, unilateral pneumonia. (a) With the affected
lung dependent, the better-ventilated uppermost lung is not matching the better-perfused lower lung. (b) With the affected lung
uppermost, the lower lung is better-ventilated and better-perfused, thus matching VrJQ and improving gas exchange. V =
ventilation; Q = perfusion.
dependent lung may be better ventilated because

BREATHING EXERCISES
of the compressed alveoli having greater
potential to expand and take in fresh gas. Breathing exercises to increase lung volume
Exceptions to the 'bad lung up' rule are : should be performed in cycles of no more than
three or four breaths so that :
• recent pneumonectomy (p. 268)
• large pleural effusion (p. 99) • maximum effort is put into each breath
• bronchopleural fistula, in case any unsavoury • dizziness from overbreathing is avoided
substances drain into the unaffected depen • shoulder tension is discouraged.
dent lung Once inflated, alveoli stay open for about an
• occasionally if there is a large tumour in a hour at normal tidal breaths, so it is advisable
main stem bronchus, when positioning the to do at least 10 deep breaths every waking
patient with the affected side uppermost may hour to maintain lung volume (Bartlett et ai.,
obstruct the bronchus and cause breathless 1973). This is a tall order for those who are
ness distracted by the events and uncertainties of
• any situation in which the oximeter or hospital life, and patients can use reminders
patient comfort indicates otherwise. such as food and drink trolleys or nurses'
hourly observations.
The above are guidelines only and patients
need individual assessment. After treatment, the Deep breathing
physiotherapist should explain to nursing staff
Optimum conditions are needed to ensure that
why the patient has been left in a specific
deep breaths reach peripheral regions. The
position, and that this should be maintained
following will facilitate this :
until the patient wants to move or it is time to
turn. Night staff should be included in training • relief of pain, nausea, dry mouth, discom
on positioning. Oximetry is useful to demon fort, fatigue, anxiety or tension
strate the effectiveness of positioning to both • avoidance of distractions
patient and staff. Accurate positioning and • minimum breathlessness, e.g. patients need
regular position change should be incorporated time to get their breath back after turning
into a patient's management plan 24 hours a • accurate pOSitIOning, usually side-lying
day. inclined-towards-prone, to facilitate maxi-
152
BREATHING EXERCISES
mum expansion of the base of the uppermost patients are more relaxed and breathe more
lung. effectively between a cycle of breaths than
during the deep breathing itself, in which case
If side-lying is impossible, upright sitting is attention should be paid to minimizing tension
the next option. Long-sitting might be necessary during the next cycle. Patients should not be
in some circumstances but allows limited engaged in conversation between cycles.
expansion only. Leaning-forward-long-sitting is Deep breathing has shown the following
useless for increasing lung volume because the benefits :
diaphragm is compressed up into the chest, even
• i lung volume Oones et at., 1997)
though the thorax may be expanding. The effec
• i ventilation and 1 airways resistance
tiveness of the side-lying-inclined-towards-prone
(Menkes and Britt, 1980)
position can be confirmed by auscultation.
• i surfactant secretion, thereby improving
When ready, patients are asked to breathe in
lung compliance (Melendez, 1992)
deeply and slowly through the nose, then sigh
• i VA/Q matching
out through the mouth. A demonstration is often
• 1 dead space ratio
the best way of explaining an action that is
• i diffusion (Prabhu et at., 1990)
normally automatic. Breathing through the nose
• i oxygen saturation (Ruggier et at., 1994;
warms and humidifies the air but doubles resis
Dallimore et at., 1998)
tance to airflow, and patients may prefer to
• with slow breathing, improved basal ventila
mouth-breathe if they are breathless or have a
tion as a result of reduced airway turbulence
nasogastric tube. Some respond better when
and preferential distribution of air to depen
asked to take a long breath rather than a deep
dent regions (Reid and Loveridge, 1983).
breath, or when asked to 'breathe in your
favourite smell'. Shallow breathing is inefficient because more
Distribution of ventilation is related to tidal volume is lost to dead space as the same air
position, flow and pathology (Menkes and Britt, is inhaled and exhaled more often. Breathless
1980). The physiotherapist's hands may be people require a special approach and should
placed over the basal area for monitoring not be asked to breathe slowly (p. 174).
purposes and for patient reassurance, but not The term 'thoracic expansion exercises' is
with any assumption that this magically redistri synonymous with deep breathing. Thoracic
butes ventilation to the underlying lung. expansion can be readily observed but does not
'Localized' breathing exercises do not make guarantee a deep breath. Literal interpretation of
physiological sense because humans are unable the terminology, or the patient's position, may
to deform individual portions of the chest wall inhibit the more subtle abdominal excursion.
(Martin et aI., 1976). But patients can still be
found obediently performing 'unilateral End-inspiratory hold
breathing' and 'basal costal breathing'. Even if Air can be coaxed into poorly ventilated regions
localized breathing were physically possible, as by interspersing every few deep breaths with
in some yoga masters, the way in which the two breath-holds for a few seconds at full inspira
layers of pleura slide on each other means that tion. This distributes air more evenly between
the lung responds generally rather than locally to lung segments and boosts collateral ventilation
a deep breath. (Cormier et at., 1991). Ideally, inflating
After every few breaths, the patient should pressures of 30-50 cmH20 should be held for 5
relax and regain his/her rhythm. Breathing rate seconds at 2-6 times tidal volume (Brooks
and pattern should be observed at this time, and Brunn, 1995) but many postoperative patients
the patient may need praise or a change in cannot achieve this. Observation will identify if
instruction before proceeding. Sometimes the end-inspiratory hold is effective, comforta-
153
CHAPTER 6 PHYSIOTHERAPY TO fNCREASE LUNG VOLUME
ble or, conversely, disturbs the breathing chest to compare it with movement of the
pattern. Accurate instruction is needed to abdomen
prevent shoulder girdle tension. The end • reminding patients that, when filling a kettle,
inspiratory hold is unsuitable for breathless they don't fill the top half first
people, who should not be asked to hold their • imagining a piece of elastic round the waist
breath. It should be used with caution in stretching during inhalation
patients with a tendency to bronchospasm • if supine, placing a box of tissues on the
(Mutatkar, 1999). abdomen to visually reinforce the movement
• incorporating incentive spirometry (p. 156)
Abdominal breathing to encourage a slow flow rate and give feed
Emphasis on abdominal movement during back on the larger volume inhaled (Peper,
inspiration leads to slower, deeper breathing, 1992)
less turbulence, reduced dead space and shoulder • some non-surgical patients find that other
girdle relaxation. The term 'diaphragmatic positions facilitate abdominal movement,
breathing' is sometimes understood by patients, e.g. prone lying, four-point kneeling or
although abdominal movement does not ensure standing with hands on the back of the hips
greater diaphragmatic contribution to breathing and elbows pushed backwards.
(Gosselink, 1995). The term 'breathing control'
Abdominal breathing usually increases the
is synonymous with abdominal breathing at tidal
lung volume but is not thought to alter the
volume.
distribution of ventilation (Martin et aI., 1976).
The patient is asked to get comfortable in a
However, the slow deep breathing that it incor
symmetrical position such as upright sitting. The
porates favours peripheral distribution (Fixley,
manoeuvre is first explained and demonstrated
1978).
unhurriedly, avoiding words like 'push', 'pull',
'try' and 'harder'. If relaxed abdominal
Sniff
breathing has not started naturally, then the
patient is taken through the following steps : Even after a full inspiration, it is often possible
to squeeze in a wee bit more air and further
• Rest the dominant hand on your abdomen, augment collateral ventilation by taking a sharp
with elbows supported, and, keeping your sniff at end-inspiration. Sceptical patients can be
shoulders relaxed, allow your hand to rise won over by a reminder that however packed a
gently while visualizing air filling your rush-hour underground train is, an extra person
abdomen like a balloon. can always be crammed in.
• Sigh the air out.
• Check that shoulders remain relaxed and Neurophysiological facilitation
heavy. Although positioning is the most cost-effective
• Gradually increase the depth of breathing way of maintaining lung volume, neurophysiolo
while maintaining relaxation. (If the aim is gical facilitation (NPF) is useful for some non
increased lung volume.) alert patients such as those who are drowsy
• If appropriate, progress to side-lying and postoperatively, those with neurological condi
relaxed standing. tions or those partially breathing on a ventilator,
Many patients respond to the physiothera especially if they are unable to turn. It is
pist's hands placed on the lower abdomen to thought that cutaneous and proprioceptive
encourage breathing 'in and down'. stimulation reflexly increases the depth of
Variations include: breathing Gones, 1998), albeit in the short term.
The perioral technique (Figure 6.5) is thought
• putting the other hand on the quiet upper to relate to the suckling reflex, and may facili-
154
MECHA ICAl AIDS TO INCREASE lUNG VOLUME
(b)
(a)
i�
: "
�,� �s
: ��
� '\
Therapist's finger on top
lip between tip and nose. j1....... �
INTERCOSTAL
MUSCLES :::::: :::g:J
� S:::: ./
.... -�
RiBS
direction of
pressure down
towards next rib
- not "In" towards
patient's back
(c)
(Aff��
IL
RIBS (d)
direction of
pressure
I
.
( /·�I.rG,-4\ �
: �c:::::
�
direction of
pressure � ....
PELVIS: �(\
\
.!�� "E;:..
I
I
Figure 6.5 (a) Perioral stimulation: moderate finger pressure is maintained inwards and downwards, just above the lip, as
long as the patient is required to deep-breathe. The effect may continue for some minutes afterwards. (b) Intercostal stretch:
pressure is downwards towards toes, on the upper border of the rib at end-expiration. Unilateral or bilateral. Not for floating
ribs. (c) Co-contraction of abdominal muscles: pressure laterally over lower ribs and pelvis, at right angles to patient, altemating
right and left sides and maintaining pressure for up to 2 minutes or until desired effect. (d) Vertebral pressure: finger pressure
against thoracic vertebrae between T2 and T I 0 (D. D. Bethune, 1975, Phys;other. Can. 27, 242-245).
tate slow as well as deep breathing. Other then a quick release at end-expiration. This may
effects seen with NPF are yawning, coughing, cause a deeper subsequent inspiration, especially
swallowing, abdominal contraction and occa when performed slowly and smoothly. It is
sionally change in consciousness Gones, 1998). sometimes used with paralysed patients but is
Some patients vary in their response from less effective, less comfortable and less safe than
breath to breath and day to day. It is worth NPF.
trying slightly different finger positions and
pressures, and sometimes finger vibrations.
MECHANICAL AIDS TO INCREASE LUNG
Effects may be cumulative.
VOLUME
Rib springing If previous measures are ineffective, a variety of
Rib springing is chest compression on expira mechanical aids are available to increase lung
tion, with overpressure downwards and inwards volume. Physiotherapists are ideally suited to
in the bucket-handle direction of rib movement, match people to machines because of their
155
patient-handling skills and understanding of Throughout the procedure the patient

physiology. watches the incentive spirometer while the
physiotherapist monitors the patient's
Incentive spirometry breathing pattern.
A sustained deep breath can be facilitated by an 4. An end-inspiratory hold is sustained.
incentive spirometer, which gives visual feedback 5. After exhalation, shoulder girdle relaxation is
on flow and volume. The Coach (Figure 6.6) and rechecked.
Voldyne devices encourage slow and controlled
inhalation by maintaining a marker (indicating Those on oxygen can use nasal cannulae or an
flow) between two arrows, and encourage an incentive spirometer which entrains oxygen.
end-inspiratory hold while a disc (indicating People with tracheostomies can use a connecting
volume) descends. In the Triflo device, two out tube. Once technique is faultless, patients are
of three plastic balls should be raised and the asked to take 10 incentive spirometry breaths per
breath sustained for some seconds while they are waking hour. Most devices are labelled for single
suspended. The third ball is a control and should patient use but a filter in the circuit and discussion
not be raised because this indicates high flow with the infection control department has enabled
and turbulence. The Triflo is less encouraging some hospitals to reuse the main component
for sustaining an end-inspiratory-hold and it is while disposing of the tubing and filter.
possible to cheat by taking short sharp breaths. The same effect can be obtained without the
The suggested technique is the following: incentive spirometer but the incentive of using a
device often causes greater inhaled volume, a
1. A demonstration is given using a separate
more controlled flow and more enthusiasm to
device.
practise. However, individuals vary, and obser
2. Patients should be relaxed and positioned as
vation of expansion and breathing pattern shows
for deep breathing, either side-lying or sitting
whether the patient breathes more effectively
upright, preferably in a chair.
with or without the device. Incentive spirometry
3. With lips sealed around the mouthpiece, the
is also suited to children and those with learning
patient inhales slowly and deeply.
difficulties because it can be learnt by demonstra
tion. It is not suitable for breathless patients.
Mini literature appraisal
Literature:
COACH BETWEEN 'There is little evidence to support the use

ARROWS
of incentive spirometry in airway
clearance.... '
Eur. Respir. J. 1999; 14: 1418-1424

LARGE BLUE DISC
RISES MEASURING
Appraisal: Incentive spirometry IS not
THE INSPIRED VOLUME intended for airway clearance.
Continuous positive airway pressure

For spontaneously breathing patients who
cannot muster the breath for incentive spirome
Figure 6.6 Incentive spirometer try, resting lung volume and gas exchange can be
156
Air entrainment
at 85 Umin
Oxygen at 15 Umin
I
------,.
OUTFLOW
Inspiration:
..
On/off
50 Umin
Expiration:
Flow CPAP 130 Umin
WHISPERFLOW VALVE
..
GENERATOR
Oxygen
adjustment
SAFETY CPAP VALVE

Inspiration:
5 em H20 150 Umin
above CPAP to patient
O
pressure
° PATIENT
g j
Expiration:
30 Umin
from patient
137.01 °
HUMIDIFIER
100 Umin a::

'"
n
:r
�
S
)-
8
Figure 6.7 CPAP circuit. The main CPAP valve is positioned on the opposite side of the rest of the
'"
circuit to prevent CO2 rebreathing, and a spare valve at -i
5 cmH20 above the threshold pressure acts as a pop-off safety valve (Medicaid, with permission). o
Z
n
�
'"
r
2
Cl
<
a
r
I-"
VI �'"
'-l
improved by pneumatically splinting open the 6. The patient assists with putting on the mask
airways and alveoli with continuous positive if possible in order to reduce anxiety. It is
airway pressure (CPAP). A CPAP device delivers best that the mask is not strapped on until
a constant flow of gas throughout inspiration the patient has felt the flow and is ready.
and expiration. This exceeds the flow rate of Flow should be at a level sufficient to
patients even when they are breathless. It is like maintain an open CPAP valve, even during a
a person putting their head out of the window of deep breath. Fine tuning trims it to just
a rapidly moving car. above the patient's peak inspiratory flow so
that there is outflow from the valve
The system throughout the cycle, while the mask has a
A flow generator connects to the oxygen supply, firm but comfortable seal.
entrains room air through a filter to give 7. The outflow should be rechecked after the
between 30% and 100% oxygen and generates patient has settled. The oximeter should be
gas flows of up to 150 L/min. The components rechecked after changing the flow, and FI02
needed to generate and withstand high flows are adjusted if appropriate.
illustrated in Figure 6.7. 8. Regular checks are required on the comfort
The patient breathes through a face mask, and seal of the mask, the fluid level and
nasal mask, mouthpiece (for intermittent use) or temperature of the humidifier, and the
T-piece (if intubated). Positive pressure is main oximeter.
tained by a preset threshold resistor valve (CPAP 9. After use, the mask should be removed
valve), which is independent of flow and before turning off the flow.
provides a constant pressure of between 2.5 and
A nasal mask and domestic device are used
20 cmH20. An oxygen analyser monitors the
overnight for people with obstructive sleep
FI02 and an oximeter monitors the patient's
apnoea. This may allow some air to escape
response. To reduce the dryness of high gas
through the mouth, but the high flow means that
flows, a heat-moisture exchanger may be
some leak is acceptable. Excessive leak can be
adequate but, for patients with thick secretions
controlled by a chin strap or soft collar.
or who cannot acclimatize to the dryness, the
high flows of CPAP require an efficient humidi
Effects
fier (Wiest et ai., 1999), or two humidifiers in
When the above steps are followed and comfort is
series (Harrison, 1993). Modern systems incor
maintained, CPAP increases FRC (Figure 6.8),
porate a high-pressure alarm.
Technique
Suggested guidelines are the following: CPAP applied
1. Patients using a full face mask should be in a �
high dependency area or kept under constant
observation because of difficulty in
T VT
�
expectoration and danger of aspirating vomit.
2. A CPAP valve is chosen that provides
pressure low enough to be comfortable but
jt
1
FAC
high enough to maintain adequate gas FAC I
exchange, usually 5-10 cmH20.
3. The patient is introduced to the mask.
t L--
____ �
4. Oxygen is adjusted to the required F,02' Figure 6.8 Effect of CPAP on lung volumes. VT = tidal
5. The flow is turned on. volume: FRC = functional residual capacity.
158
MECHANICAL AIDS TO INCREASE LUNG VOLUME
improves gas exchange and may avoid the need • Coughing without removing the mask can
for intubation and mechanical ventilation (Keilty create high pressures, which may damage the
and Bott, 1992). Atelectasis may be prevented, but ears and, with emphysema or late-stage CF,
re-expansion of collapsed lung tissue requires risk causing a pneumothorax. Some proto
sustained pressures of > 15 cmH20 (Andersen et cols advise that positive pressure techniques
ai., 1980), which are usually intolerable for an should only be used on wards with access to
alert patient and bring significant complications. chest drain equipment.
CPAP can also be used for patients with • The system is noisy, which may be detri
pneumonia (p. 104) or increased WOB due to mental to the patient and neighbours.
obstructed airways (p. 84). It can assist gas • The haemodynamic effects of CPAP vary.
exchange for people with pulmonary oedema as Positive pressure may compress alveolar
an interim measure until medication takes effect vessels, redistribute blood from chest to
(Wysocki, 1999). abdomen and, at pressures above 10 cmH20,
increase right ventricular afterload. Although
Complications cardiac output normally depends on preload,
• Discomfort is common, and uncomfortable poor ventricular function renders it depen
patients restrict their depth of breathing. Indi dent on afterload (Romand and Donald,
vidual adjustment of the mask, or a change of 1995), in which case cardiac output may be
mask, may be needed to prevent chafed skin, impaired by CPAP, especially in hypovo
sore ears or dry eyes. The bridge of the nose laemic patients. For people with normal
should be protected before rather than after a heart function, pressures above 15 cmHzO
pressure sore develops, using a dressing such can impair cardiac output (Mayor, 1997).
as Granuflex (Callaghan, 1998) especially in • CO2 retention can occur if a hypercapnic
patients who are hypotensive, hypovolaemic patient breathes with a small tidal volume
or with thin skin because of ageing or long against a high pressure valve.
term steroids. The mask seal is assisted by
having the dentures in. Claustrophobic Precautions
patients need sensitive handling. CP AP should not normally be used III the
• WOB may be increased and Pa02 decreased presence of:
(Romand and Donald, 1995) because of
• an undrained pneumothorax
difficulty in exhalation against positive pres
• surgical emphysema
sure. If there is loss of lung or chest wall
• bullae
elasticity, patients might be forced to use
• facial trauma
even more active exhalation.
• excessive secretions.
• At high pressures, gas can be forced into the
stomach, causing discomfort and restricted It should be used with caution in the presence
breathing. The risk is reduced by using a of:
nasogastric tube, which is advisable at pres
sures over 10 cmH20. If girth is measured to • bronchopleural fistula
assess for abdominal distension, this should • a large tumour in the proximal airways,
be explained, as it has been interpreted as because inspired gas under pressure may be
measuring for a coffin (Waldmann and able to enter but not exit past the obstruc
Gaine, 1996). tion.
• Aspiration is a risk for patients unable to
Two conditions for which CPAP may be useful,
remove the mask rapidly by themselves. The with precautions, are the following:
mask must be removed for eating and
drinking. • following oesophageal surgery, CPAP assists
159
gas exchange, but a nasogastric tube is scrutinized mercilessly in the literature and
required to prevent positive pressure jeopar found wanting, usually because it has been used
dising the anastomosis in the wrong way for the wrong patients. IPPB is
• a flail chest can be stabilised with CPAP, so simply pressure-supported inspiration using a
long as there is no undrained pneumothorax. non-invasive ventilator such as the Bird (Figure
6.9) Inspiration is triggered by the patient,
Intermittent positive pressure breathing sustained by positive pressure, and followed by
The slings and arrows of fashion have not been passive expiration.
kind to intermittent positive pressure breathing
(IPPB) and attitudes have swung from hero Indications
worship to ostracism. This technique has been Patients with atelectasis who are drowsy, weak
Flowrate
Inspiratory __ ---.J'lI�--j f-L--� Inspiratory

sensitivity pressure
Manual ____ �
control
Pressure ----t---II-__\_�
gauge
Two channel tubing
Mouthpiece
/
Exhalation
valve
Figure 6.9 Bird ventilator. Inspiratory sensitivity regulates the ease with which the machine triggers into inspiration.
Manual control can override the patient-trigger and machine-cycling mechanisms. The pressure gauge indicates the airway
pressure. The flow rate controls the rate at which gas is delivered to the patient. The inspiratory pressure is the pressure
that should be reached before cycling into expiration. The air-mix .knob allows entrainment of room air. The apnoea knob
controls automatic function and should be off throughout.
160 ------
MECHANICAL AIDS TO INCREASE LUNG VOLUME
or fatigued may benefit from IPPB. Patients who according to patient comfort ('Is that blowing
are unwilling, restless or in pain do not. Pain is too hard?'). Starting pressure may be about 10.
not a contraindication in itself but, if atelectasis Collapsed lung is difficult to re-expand because
is caused by pain, it is best to deal first with the of low compliance, and positive pressures of
pain because muscle splinting will prevent the 20 cmH20 are considered necessary when using
patient from accepting the positive pressure. bronchoscopy (Spring et aI., 1999). The pressure
Sputum retention may be an indication for dial should show a smooth rise to the preset
drowsy, weak or exhausted patients, e.g. those pressure at each breath to indicate patient co
with neurological problems. Excess WOB can ordination.
also be eased by IPPB (p. 179). IPPB is not The patient takes a small breath and the
indicated for administration of drugs because it machine does the rest, without the patient
does not offer any advantage over a simple jet prematurely stopping inspiration by active exha
nebulizer and the positive pressure results in lation. When the patient's breathing pattern has
30% less aerosol delivery to the lungs than a settled, the pressure can be gradually increased
nebulizer alone (Fink and Dhand, 1999). until maximum expansion is obtained without
disturbance to the breathing pattern. The
Technique for the Bird ventilator physiotherapist's job is to:
The nebulizer is filled with saline and tested by
• adjust the pressure, and occasionally adjust
activating inspiration with the red manual
the flow rate to compensate, because flow
button.
governs the speed with which the preset
If the aim is to increase volume to the lung
pressure is reached
bases, patients are positioned comfortably in
• reassure and advise the patient to allow the
side-lying with the affected lung uppermost.
air to fill the lungs and not to blow out
After turning into this position, they are allowed
• observe the abdomen for unwanted active
to return to normal tidal breathing, then asked
expiration
to hold the mouthpiece firmly with their lips.
• observe the face for discomfort
They are advised that extra air will flow into
• observe rib cage excursion to ensure that
their lungs to help their breathing and reassured
expansion is improving
that the procedure can be stopped at any time,
• afterwards, wash and dry the nebulizer
either by request or, if using a mouthpiece, by
• liaise with nursing staff and leave written
inhaling through the nose so that the machine is
instructions to avoid the patient or family
not triggered.
altering the knobs.
The inspiratory sensitivity determines how
much negative pressure the patient must The air-mix knob is maintained in the 'out'
generate in order to trigger a breath, a low position by a clip, which ensures that air is
number indicating that little effort is required. entrained and 40-45% oxygen is delivered. For
For the Bird Mark 7 or 8, it is set usually at patients who require high levels of oxygen,
about 7, or so that the patient can trigger 100% is delivered by pushing the air-mix knob
inspiration with ease ('Is it easy to breathe in ?'). in. For 24% oxygen, the machine is run on air
The {low rate determines how fast the gas is with oxygen entrained at 2 L/min via a needle
delivered, a low number for a long breath and a (through the red bung if the reusable circuit is
high number for a short breath. It is set as low used). Finer adjustments are achieved with an
as comfortable, starting at about 7- 10, to ensure oxygen blender attachment. For Entonox, the
minimal turbulence and optimum distribution of air-mix knob is pushed in to ensure the patient
ventilation. Breathless patients need a high flow receives all of the gas. The flow rate may need to
for comfort ('Is that enough air?'). be increased with these modifications.
The inspiratory pressure should be set The apnoea switch should be turned fully
16 1
clockwise to the off position to prevent • If the machine repeatedly triggers during
operation as a conventional ventilator. The inspiration, the patient may need a greater
manual button is not used routinely. delivery of gas by increasing flow or pres
A retard cap can be used to create a slight sure. Check that servicing is up to date.
positive end-expiratory pressure, which the manu • If a reusable circuit does not nebulize, check
facturers claim may prevent recollapse of alveoli. that the red bung is uppermost.
A mouth flange can be used to assist the mouth
piece seal. A mask can be held on the face of semi
Effects and complications
conscious people, but is frightening, and patients
If the patient is relaxed, comfortable and well
need explanations and the freedom to say no.
positioned, with controls accurately adjusted,
IPPB can be used via tracheostomy or endo
IPPB should increase lung volume, this increase
tracheal tube with inflated cuff but barotrauma
lasting for about an hour (AARC 1993a), or
is a risk because of the sealed system.
longer with correct positioning. Compared to
For acute patients, the physiotherapist
CPAP, positive pressure is intermittent and
should be present throughout in order to make
typically reaches higher pressures, thus increas
the fine adjustments needed. Occasionally, well
ing tidal volume, whereas CPAP increases FRe.
practised and alert patients can use it indepen
In practical terms, IPPB is best for opening up
dently, e.g. those with asthma or fibrosis, who
collapsed alveoli and CPAP is best for maintain
are sometimes reassured by having it available
ing the increased lung volume.
by their beds at night. IPPB is best used for
IPPB can also improve ventilation and gas
short periods of time, after which other techni
exchange and, if the patient does not attempt to
ques such as positioning or, if necessary, CPAP
assist the machine, reduce WOB (Bott et ai.,
can be used to maintain the lung volume
1992). IPPB has certain disadvantages compared
achieved.
to other mechanical aids:
If secretion clearance is to be included,
measures that decrease lung volume, such as the • It is less effective than spontaneous deep
head-down tip or manual techniques, are usually breathing (Bynum et al., 1976), which is
inappropriate during IPPB, although percussion why IPPB is unnecessary for patients who
may be suitable during expiration if it does not can deep-breathe independently.
upset the breathing pattern. • The extra volume is distributed preferen
tially to areas already well ventilated,
Troubleshooting because of the passive nature of inspiration
• If there is prolonged inspiration and the and absence of normal diaphragmatic
preset pressure is not reached, check for activity (Celli et ai., 1984), hence the impor
leaks in the circuit, at the mouth or through tance of positioning the collapsed area
the nose. If these are not the cause, try redu uppermost.
cing pressure and/or increasing flow. • It is possible that hypercapnic COPD
• If the preset pressure is reached too quickly, patients may lose their hypoxic respiratory
·
check that the patient is not actively drive because of the 40% oxygen delivered.
breathing out, blocking the mouthpiece with Starke et al. (1979) claim that this is not a
the tongue or letting pressure generate in the problem if adequate tidal volumes are deliv
mouth only. If a semi-conscious patient ered, but it would be advisable for patients
blocks their airway, the head should be at risk to be kept under observation after
slightly extended and the jaw protracted. treatment. Alternatively, air can be used as
• If the machine triggers into inspiration too the driving gas instead of oxygen, with
early, turn up the sensitivity; check apnoea modest amounts of supplemental oxygen
knob is off. added, either via a nasal cannula (if a mouth-
162
OUTCOMES
piece is used) or entraining oxygen as Precautions

described above. These are similar to those for CPAP, although
• Air swallowing may occur, especially if there the risk is greater if higher pressures are used.
is cheek distension or the patient burps after Box 6. 1 compares the different devices.
wards. This may be relieved by left-side
lying. Mini literature appraisal
A side effect that can sometimes be used to
advantage is that techniques such as IPPB, Title: Efficacy of chest physiotherapy and
incentive spirometry and deep breathing can intermittent positive pressure breathing in
make patients slightly breathless, even though the resolution of pneumonia. N. Engl. J.
this is not the aim. These patients can be posi Med. 1978; 299: 624-627.
tioned for optimum distribution of ventilation, Question: Do we need to read further than
then allowed to return to normal tidal this ?
breathing. If undisturbed, this encourages Comment 1 : Neither 'chest physiotherapy'
comfortable deep breathing using the same nor IPPB could logically influence the
'slight breathlessness' principle as with pathology of pneumonia.
controlled mobilization. Comment 2: Two modalities were used
together. If one of the two variables had been
effective, it could not have been identified.
Box 6. 1 Characteristics of mechanical aids to increase
lung volume (FRC functional residual capacity)
=
OUTCOMES
Incentive spirometry
Success in the treatment of patients with reduced
Full patient participation
lung volume can be measured by the following :
End-inspiratory hold
Physiological distribution of ventilation • improved breath sounds
Minimal supervision • more resonant percussion note
Minimal infection risk • clearer X-ray
Quiet • greater chest expansion
Cheap • improved 5a02, so long as other variables
which affect this are excluded, e.g. i F102•
CPAP
Positive pressure continuous
Face or nasal mask
Can accommodate breathless patient I;ii�i'R41IiIi) .11;tj;i:1
Can accommodate tired patient
Identify the problems of this 72-year-old
Used for raising FRC
postoperative patient, then answer the questions.
IPPB
Background
Positive pressure on inspiration only
Mouthpiece or face mask SH: sheltered accommodation, walks with frame.
Used periodically H PC: OA knee.
Can accommodate breathless patient 1 4/ I 0/98 right total knee replacement.
Can accommodate tired patient 1 6/ 1 0/98 transferred to ICU due to respiratory
Can accommodate semiconscious patient distress, disorientation and sputum retention,
Used for raising tidal volume intubated and ventilated.
1 7/ 1 0/98 extubated and returned to ward.
163
CHAPTER 6 PHYS'OTHERAPY TO 'NCREASE LUNG VOLUME
Disorientation and immobility conducive to sputum

Subjective retention.
Sleepy, wakeful night.
Little pain. 2. Problems
Inability to fully co-operate.
Objective Atelectasis.
Sputum retention.
Apyrexial.
Poor gas exchange.
Good fluid balance.
Knee potentially weak and immobile.
Obese.
Slumped in bed. 3. Goals
Restless.
Short term: orientate, improve ventilation and
Rapid asymmetrical breathing pattern.
optimize gas exchange, mobilize.
Feeble non-productive coughs.
Long term: rehabilitate for sheltered
Frequently falls asleep -+ mask slips -+ Sa02 drops.
accommodation.
Percussion note: dull LLL.
Auscultation: bronchial breathing RLL and middle
lobe, 1 breath sounds LLL, scattered coarse
crackles.
Sa02: 52% on air, 60% on F,02 of 0.6.
When ABGs were taken, PaC02 was found to be

raised and a diagnosis of COPD was made. F,02
was reduced to 0.28.
Questions
I. Analysis?
2. Problems?
3. Goals?
4. Plan?
Figure 6. 1 0 Ms MB.
ABGs = arterial blood gases; leu =intensive care
unit; LLL = left lower lobe. OA = osteoarthritis; RLL
= right lower lobe.
4. Plan
• Liaise with ICU physiotherapist about previous
RESPONSE TO M I N I CASE STUDY management.
• Request ABGs after change in F,02
• Communicate with patient, family and health
I . Analysis team to assist orientation.
CXR indicates loss of lung volume bibasally (Figure • Optimize environment for autonomy, familiarity,
6. 1 0). rest and sleep.
Possible causes of disorientation: hypoxia, • Position for gas exchange, mobilization of
hypercapnia, experience of ICU environment, secretions, knee comfort and function.
lack of sleep. • IPPB with controlled oxygen, progressing to
I mmobility, poor position and shallow breathing incentive spirometry and deep breathing
conducive to 1 lung volume. exercises as patient becomes more alert.
164 ------
RECOMMENDED READING
• Percussion and vibrations, progressing to ACB/ The physiology defies logic. Deep breathing
AD. can increase tidal volume I O-fold (p. 56). A
• Daily programme of knee exercises. glance at a patient on IPPB shows only a minor
• Sit out, mobilize with walking frame, progress. increase in tidal volume.
The logic defies logic. The only way of
ACB/AD = active cycle of breathing/autogenic drainage. 'moving regions of the wall of the thoracic cage'
is to fracture the ribs.
RECOMMENDED READING
Comment on the logic and physiology of the
following: . Barnitt, R. and Fulton, C. ( 1 994) Patient agreement to
treatment: a framework for therapists. Br. J. Ther.
[IJn p atients with suspected pulmon ary Rehabil. , 1, 1 2 1 - 1 27.
em boli there is no evidence that IPPB would Bott, J., Keilty, S. E. J. and Noone, L. ( 1 992)
incre ase alveolar ventil ation mo re th an Intermittent positive pressure breathing - a dying
deep bre athing.... art? Physiotherapy, 78, 656-660.
Macnaughton, P. D . ( 1 995) Posture and lung function
From the te rm 'd eep bre athing', it is
in health and disease. Br. J. Intens. Care, 1 (4),
unde rstood th at by volunt arily moving
1 3 3 - 1 3 7.
regions of the w all of the tho racic c age ,
Ntoumenopoulos, G. ( 1 995) Topical issues in
unde rlying lung tissue i s app rop ri ately
cardiopulmonary physiotherapy. Physiotherapy,
ae rated. 8 1 , 92-94.
S. Afr. J. Physiother. 1991; 4 1 : 63-67 Sully, P. ( 1 9 9 6) The impact of power in therapeutic
relationships. Nurs. Times, 92, 40-4 1 .
The premise defies logic. To increase alveolar

ventilation would not assist a patient with a
pulmonary embolus.
165
7 PHYSIOTHERAPY TO REDUCE THE WORK OF BREATHING
SUMMARY
Introduction Mechanical aids

Breathlessness • Effects for people with acute disorders
• Mechanism • Effects for people with chronic disorders
• Effects on the patient • Complications
Handling breathless people • Equipment
Sleep and rest • Technique
Positioning • Modes
Relaxation • Negative pressure ventilation
Breathing re-education • Other ventilators
• Overview • Tracheostomy ventilation
• Abdominal breathing Outcomes
• Innocenti technique Mini case study
Tips on reducing breathlessness Literature appraisal
Pacing Recommended reading
Other respiratory problems
INTRODUCTION BREATHLESSNESS
Increased work of breathing (WOB) in sponta 'It's very difficult not to panic when you're
neously breathing patients is manifest subjec fighting for breath . .. you feel as if a
tively by breathlessness and objectively by a vacuum is sucking the air out of you ... it
distressed breathing pattern. Breathless patients threatens your very existence . . , you're
are caught in a pincer of decreased ventilatory quite literally fighting for your life.'
capacity and increased ventilatory requirements. Patienr quoted by Williams, 1993
The basic principle of reducing WOB is

Breathlessness is the major link between lung
therefore to balance supply and demand, as
disease and disability (Wilson and Jones, 1989).
summarized in Table 7.1.
It is the commonest respiratory symptom and
considered one of the most frightening and
distressing symptoms that a patient can experi
Table 7.1 Measures to optimize the balance between
ence (Molen, 1995). Like pain, it is subjective
energy supply and demand
and shows wide variation between Individuals
Measures to increase Measures to decrease because it includes reactions to the symptom as
energy supply energy demand well as the symptom itself. Unlike pain, it
usually goes untreated, and the experience is
I
Nutrition Stress reduction
Oxygen therapy Sleep and rest
difficult for others to fully understand because
Fluid and electrolyte balance Positioning 'normal' breathlessness such as running for a bus
O2 delivery to inspiratory muscles Relaxation is of known duration and under control.
(e.g. haemoglobin, cardiac output) Breathing re-education
Mechanical support
Breathing normally occurs subconsciously.
Breathlessness is defined as awareness of the
166
BREATHLESSNESS
stimulus, whereas breathlessness arises from a

variety of interlinked processes.
Three components contribute to the
mechanism of breathlessness.
First, breathlessness relates to the work of
breathing. Without lung disease, respiratory drive
and respiratory load are balanced, e.g. when
exercise increases the respiratory drive in order to
increase ventilation. The breathlessness of disease
occurs when either drive or load is increased and
the balance is upset by mechanical abnormalities.
Figure 7.1 . Breathlessness. (From Leboeuf, C. (2000) A Examples of this mechanical component of
Practical Approach to the Late Effects of Polio, British Polio
breathlessness are:
Fellowship, Middlesex)
• i resistive load, e.g. i airflow resistance

caused by obstructive airways disease
intensity of breathing (Figure 7.1). Dyspnoea is
• i elastic load e.g. 1 compliance caused by
difficult breathing occurring at a level of activity
rigid chest, distended abdomen, fibrotic lungs
where it would not normally be expected. In
• 1 energy supply, e.g. malnutrition, shock
practice the words breathlessness and dyspnoea
states in which perfusion to the diaphragm is
tend to be used interchangeably. They should be
impaired
distinguished from the objective terms:
• i drive to breathe, e.g. parenchymal lung
• tachypnoea: rapid breathing disorders such as pulmonary oedema, inter
• hyperpnoea: increased ventilation 10
stitial disease or pneumonia (which stimulate
response to increased metabolism nerve impulses from interstitial receptors),
• hyperventilation: ventilation 10 excess of acidosis, anaemia, thyrotoxicosis
metabolic requirements. • i alveolar surface tension, e.g. pulmonary
oedema, ARDS (p. 411)
Mechanism • 1 power, which reduces the ability to cope
with excess drive or load, e.g. neuromuscular
A respiratory physiologist offering a unitary
deficiency, inoperative diaphragm due to
explanation for breathlessness should arouse
hyperinflated lungs, weakness, fatigue.
the same suspicion as a tattooed archbishop
offering a free ticket to heaven. Respiratory muscle fatigue increases the
Campbell and Howell, 1963 central motor command to the respiratory
muscles and magnifies the perception of effort in
Breathlessness is a private phenomenon, inacces the same way that a suitcase feels heavier the
sible through the traditional techniques of longer it is carried.
physiology. It incorporates both sensory physiol There is often overlap in the mechanical
ogy and the psychology of perception (Mahler, components of breathlessness e.g. increased
1990). The mechanics and the emotional experi airflow resistance causes a stronger drive to
ence are inseparable. breathe (Duranti, 1995).
Unlike pain, the precise stimulus that causes Second, there are cortical and subcortical
breathlessness has not been defined. Specialized inputs, as with any subjective sensation. Exacer
receptors have not been found, and the region of bating factors are uncertainty, distress, anxiety
the cerebral cortex that processes the informa (Muers, 1993), life experiences, frustration and
tion has not been mapped. If a person touches a lack of social support (Reardon, 1994). Hence
hot iron, pain arises from a quantifiable thermal the variation between breathlessness and the
167
CHAPTER 7 PHYSIOTHERAPY TO REDUCE THE WORK OF BREATHING
experience for each individual. Anxiety is parti Cardiorespiratory disease accounts for two
cularly detrimental because it creates a vicious thirds of cases of breathlessness (Pratter, 1989).
cycle of muscle tension and excess WOB. Other causes are neuromuscular or skeletal
Third, central chemoreceptors make some disorders, hyperthyroidism, anaemia, psycho
contribution to breathlessness by sensing a rise genic problems, obesity and pregnancy. As with
in PaC02, mediated through pH. Reduced Pa02 pain, the quality of breathlessness may help to
makes little contribution to breathlessness, identify its cause (Table 7.2).
which explains the limited effectiveness of
oxygen therapy on breathlessness (p. 119). A Effects on the patient
patient can be severely hypoxaemic without
'It's the worst feeling tn the world, the
feeling short of breath, and vice versa.
worst way to die, it's like smothering to
These mechanisms lead to a deluge of
death . . . to lose control of your breathing. '
impulses from the respiratory centres. The
DeVito, 1990
degree of breathlessness correlates with motor
output as reflected in the pressure generated by
The experience of breathlessness can vary from
the respiratory muscles, consciously perceived as
feeling that breathing is no longer automatic, to
a sense of effort (O'Donnell, 1994). Effort is
total preoccupation and unremitting fear. Fear
central to the concept of breathlessness, as
itself makes breathing more difficult. It is not
shown by a direct relationship with peak airway
easy for patients to communicate these feelings.
pressures and only an indirect relationship with
Lung disease is not blessed with high social
elastic or resistive loads (Burdon, 1994).
standing. Other conditions may elicit more
The result is an effort to breathe that is not
empathetic responses; for example, paraplegics
satisfied by the breath achieved, causing an inap
are seen as brave, heart attacks are assumed to
propriate relationship between ventilatory work
afflict high achievers, and a white cane elicits
and total body work.
instant sympathy. People labelled as 'only
Acute asthma shows how a combination of
bronchitic', however, are often elderly and
these factors causes breathlessness:
depressed, they spit and wheeze, and smokers
• Bronchial irritant receptors stimulate an are considered to have brought it on themselves.
abnormal drive to breathe. This attitude is shared by some health workers.
• Airway obstruction and inefficient breathing A degree of imaginative skill is needed when
at high lung volumes increase workload. working with people who are breathless in order
• Anxiety intensifies and perpetuates the to identify with the experience of, for example,
breathlessness. spending night after night in a chair unable to
Table 7.2 Some characteristics of breathlessness with different disorders; these are guidelines only, and
patients vary
Disorder Breathlessness Other symptoms
COPD Slow onset Productive cough

Asthma Episodic, on exhalation Chest tightness, wheeze
Interstitial lung disease Progressive, exertional Rapid shallow breathing, dry cough
Pneumonia Exertional Pleuritic pain, cough
Pneumothorax Moderate/severe Sudden pleuritic pain
Hyperventilation Air hunger, not relieved by rest Symptoms of ! PaC02
Pulmonary oedema Positional, on inhalation Bilateral fine crackles on auscultation
Neuromuscular Exertional, on inhalation Rapid breathing
Deconditioning Heavy
Obesity/pregnancy Exertional
168
POSITIONING
sleep, or dreading the effort of going to the

SLEEP AND REST
toilet, or anticipating the cruel slowness of
death. 'There's no peace, no let up with this thing,
you can't even escape when you go to bed,
it's with you 24 hours a day.'
HANDLING BREATHLESS PEOPLE
Patient quoted by Williams, 1993
Clare is a physiotherapist whose description of
The only treatment for fatigue is rest. This can
the bre�thlessness that she experienced during
be achieved most satisfactorily by sleep. One of
pneumonia indicates why some patients are not
the cruel ironies of breathlessness is its effect on
always pleased to see us:
sleep. Fragmentation of sleep impairs respiratory
performance, blunts response to hypercapnia
'At every breath I felt: was it going to be
and hypoxaemia, reduces inspiratory muscle
enough? I thought life was over, even
en�urance (Neilly, 1992) and is wretched. Many
though I knew that was irrational. I didn't
patlents say that sleep is what they need most in
want to have to be polite, I didn't want
order to recover.
the effort of please and thank you. I didn't
Sleep deprivation in respiratory patients is due
- mind how much phlegm was there, it could
to breathlessness, coughing and anxiety, aggra
just stay there. The thought of a physio
vated in hospital by noise, an unfamiliar environ
coming near me made me feel even more
ment and being woken for nebulizers.
ill. '
Physiotherapists should avoid waking patients
unnecessarily, ensure that their treatment does
Breathless people have lost control of their
not cause excess fatigue, and contribute to the
most basic physiological requirement. They
teamwork required to allow adequate sleep. It is
therefore need some control of their treatment.
a continuing puzzle that there is so little
They need to take their time and not be
emphasis in the health care system on facilitating
expected to talk unless they want to. They need
the healing effects of sleep.
acknowledgement of the reality of their experi
ence, not empty phrases like 'Don't be frigh
tened' or 'Try to get control'. . POSITIONING
Communication should be clear because
Many breathless people automatically assume a
anxiety increases oxygen consumption. With
posture that eases their breathing, but others
severely breathless people, questions should
need advice to find the position that best facili
require only a yes or no answer. It is best not to
tates their inspiratory muscles. Patients with a
pretend to understand if we do not, and patients
flat diaphragm may benefit from positions that
should not have their sentences finished for
use pressure from the abdominal contents to
them.
dome the muscle and provide some stretch to its
With long-term breathless patients, as with
fibres so that it can work with greater efficiency.
� nyone who is chronically disabled, it is
The arms are best supported, to optimize
Important to respect their knowledge. They
accessory muscle function, but without tension
know more than we do about the experience of
or active fixation. Positions to facilitate efficient
their disease and we learn much by listening to
breathing in breathless people include:
how they prefer to be handled.
The physical handling of acutely breathless • high side-lying (Figure 7.2).
patients requires maximum support, minimum • sitting upright in a chair with supported
speed and a rest between each manoeuvre. When arms; for many patients, it is easier to
patients are getting their breath back after breathe in this position than in bed. Some
moving, they should not be asked questions. like to lean back for support, others prefer
169
Figure 7.2 High side-lying to minimize the work of breathing in a breathless patient. The head rest is relatively low to
prevent the patient slipping down the bed and to avoid kinking the spine.
to lean slightly forward to put some stretch claustrophobic, others unpredictably desaturate
on the diaphragm in different positions. Oximetry is useful as
• sitting leaning forward from the waist, arms biofeedback. Some severely distressed people are
resting on pillows on a table, feet on the relieved by being held and rocked. The combina
floor tion of support and rhythmic movement soothes
• standing relaxed, leaning forwards with arms and relaxes them. Neck massage may help.
resting on a support such as a window sill. H breathlessness is due to pulmonary oedema,
• standing relaxed, leaning back against a wall the upright supported slttmg pOSitIOn IS
with legs slightly apart. preferred because hydrostatic pressure IS more
• standing relaxed leaning sideways against a relevant than diaphragmatic mechanics..
wall, arms in pockets if support is needed
for the accessory muscles.
• occasionally, lying flat is beneficial because RELAXATION
of pressure from the abdominal contents
Relaxation is facilitated by positioning, sensitive
against the diaphragm. A few patients even
handling and the provision of information to
find a slight head-down tip helpful.
reduce anxiety. Deeper relaxation may be
Individuals should experiment with different achieved by learning a relaxation technique.
positions. Some find the forward-lean positions Patients should be warm, comfortable and have
170
BREATHING RE·EDUCATION
Box 7.1 Patient handout on relaxation
Silence the phone, check that room temperature and ventilation are right for you.
Clear your chest if necessary to prevent disturbance by coughing.
Take up your preferred position.
Close your eyes. Notice any sounds, then release them from your attention.
Become aware of any thoughts, notice them, then let them go.
Imagine that you are in a place that you find peaceful, such as a beach or sunny field.
Breathe abdominally if comfortable. Let the stomach muscles soften, as if taking off a tight belt.
Feel the soft sensation of your abdomen rising and falling. Allow the breath to flow peacefully
throughout your body.
Focus your mind down your arms to your hands, allow the fingers to soften and arms to feel
heavy.
Focus your attention down your legs, let them feel heavy. (If sitting) feel your feet flat on the
floor.
Feel your head becoming heavier, let the muscles of your face soften, let your jaw loosen and
slacken, teeth parted.
Feel your neck a little longer and your shoulders heavier.
Feel the heaviness of your body on the bed or chair. Feel your body melt as if you are meat
without bone, feel warm energy spreading through your body.
Feel the rhythm and flow of your breathing, allow your body to relax more with each breath out.
Enjoy the sensation as long as you like.
When you are ready: slowly, in your own time, become aware of the sounds in the room once
more, begin to move gently, open your eyes, stretch.
When you are ready: get up very slowly.
Try to maintain the calmness for a while.
adequate fresh air. The physiotherapist's bleep state are:

should be re-routed. A technique should be
• 1 breathlessness, anxiety, airway obstruction
chosen, such as the physiological method (Payne
(Gift, 1992)
1995, p. 77), which does not entail breath
• 1 respiratory rate, oxygen consumption,
holding or strong muscle contraction. Other
heart rate and BP (Hodgkin and Petty,
methods can be used that incorporate breathing
1987).
itself, while maintaining rhythmic breathing and
an adequate breathing rate. Some suggestions are These benefits are maintained for varying
given in Box 7.l. lengths of time, but Renfroe (1988) found that
Patients should be reassured that relaxation the reduced respiratory rate was sustained the
is not difficult to learn, that there is no right longest. Many patients find that relaxation
or wrong way of doing it and that they can improves their breathing pattern without direct
follow what feels right for them. Although it breathing re-education.
does not matter if they fall asleep, the aim is
to stay awake to enjoy the experience of alert
BREATHING RE-EDUCATION
tranquillity so that they can re-create it as
desired and integrate aspects of it into their If patients have not adopted an efficient
daily activities. breathing pattern with the above measures, they
The effects of this hypometabolic conscious may benefit from smoothing their breathing into
171
a rhythmic pattern or they may find more struc This is not exactly anatomical but almost
tured breathing re-education helpful. The aims invariably facilitates relaxation.
are to reduce WOB and give patients confidence S. If patients are not yet breathing rhythmically,
in their ability to control breathless attacks. they can be encouraged directly, by demon
When intervening in a person's breathing stration and by suggestions to 'breathe
pattern, a minimalist approach is advised. smoothly with a nice steady rhythm, in your
Compensatory mechanisms such as dynamic own time'. A mirror may help.
hyperinflation should not be interfered with 6. Patients may then be able to develop gently
mindlessly. Even if a patient's breathing appears an abdominal pattern of breathing, and/or
unnatural, this may be the optimum for an indi raise the resting lung volume, as described on
vidual's pathology; for example, Hoover's sign the next page.
(p. 69) may be unavoidable and reliance on 7. Relaxation is rechecked.
shoulder girdle muscles may be making the best 8. Praise is given liberally!
of a bad job. If, however, breathing is irregular,
paradoxical or unnecessarily tense, it is likely to During this sequence, breathing usually
respond to re-education to improve efficiency. becomes slower and deeper naturally. Shallow
breathing wastes energy because of ventilating
dead space, and rapid breathing wastes energy
Overview because of turbulence. However, encouraging
The following steps are best taken one at a time. slow deep breathing beyond that developed
Close observation will then determine whether naturally tends to be counterproductive. Breaths
this step has been helpful and/or if the next step that are too deep are working against elastic
should be initiated. recoil and can increase the WOB, a twice-normal
1. The position is chosen by the patient, but the tidal volume quadrupling elastic workload (Haas
physiotherapist might suggest sitting upright and Axen, 1991, p. 17). The following points
in a chair, forward-lean-sitting or other clarify this concept for different conditions:
resting position (p. 169). Rapid shallow breathing adopted by those
•
2. Awareness of breathing is encouraged by with restrictive lung disease is logical
bringing the patient's attention to their because of high elastic recoil and low lung
breathing pattern. Are they breathing compliance (Mador, 1991), i.e. the breathing
apically, abdominally, using pursed lips and pattern is usually optimal and should rarely
prolonged expiration, breathing through nose be changed.
or mouth ? • Rapid shallow breathing in 'pink puffer' (p.
3. Relaxation can be a full body technique or 71) patients should not be disturbed if it is
simply raising awareness of tense areas, e.g. steady, but will need correcting if it is irre
jaw or hands, and advising on localized gular.
relaxation. Patients will not be able to relax • Hypercapnic 'blue bloater' patients are
the shoulder girdle if they depend on conserving energy wisely and their breathing
accessory muscles to breathe. The pattern may be best left undisturbed
physiotherapist's own relaxed posture, calm (Roussos 1996).
voice and steady breathing pattern will help
reduce the patient's tension. Slow, deep breathing may benefit people with
4. Relaxed breathing can be facilitated by a moderate obstructive lung disease but this is best
modified yoga technique: patients sit with encouraged indirectly by the methods described
their feet flat on the floor and visualize that above; if imposed directly it can disrupt the
they are breathing air 'in through your head breathing pattern (Faling, 1986) and tire the
and out through your feet into the floor'. inspiratory muscles (Begin, 1991).
172
TIPS ON REDUCING BREATHLESSNESS
Pursed lip breathing is often adopted volunta muscle contraction begins, i.e. when active
rily by breathless people because it can relieve expiration takes over from passive expiration.
breathlessness by acting as a form of PEP (p. The following steps are suggested:
189) to prevent airway closure. It may be ineffi
• posItIOning, relaxation and rhythmic
cient (Spahija, 1996), but can help some patients
breathing as described on the previous page
subjectively in time of need.
• observation of the patient's breathing
Abdominal breathing pattern
• at each breath, instruction to the patient to
Relaxation may be facilitated by abdominal
inhale just before abdominal muscle recruit
breathing, as described on page 154, but without
ment, then allow a smooth transition from
progression to side-lying or increased depth of
inspiration to expiration
breathing. Abdominal breathing may visibly
• practice in this, at first with the physiothera
break through a patient's wall of tension, but for
pist's voice, then without.
others it can be counterproductive, especially if
they have severe disease with a finely balanced Patients should avoid holding their breath or
breathing pattern that is readily upset. making other changes in their breathing pattern.
Positive outcomes include: Any rise in the JVP, or a flicker of the abdominal
muscles, indicates active expiration, in which
• 1 BP (Fried, 1993, p. 177)
case the technique must be modified. Ongoing
• 1 breathlessness (Breslin et at., 1990)
reinforcement is needed, but it is a pleasure to
• i inspiratory muscle strength (McConnochie
see the relief that it can then bring.
and Chatham, 1991).
Much encouragement is needed to alter a
Negative outcomes include: familiar breathing pattern, but the earlier in the
disease process these techniques are learnt, the
• disruption of breathing pattern (Gosselink,
more easily patients can incorporate them into
1995)
their lifestyle. There is no clear evidence that a
• i WOB (Vitacca, 1998).
voluntary act can become automatic but, if
Patients vary greatly in how they respond. repeated regularly, learning can occur by a
change in the process underpinning its control
Innocenti technique (Gallego and Perruchet, 1991). If not, practice
Forced expiration consumes excess energy and can enable it to be used when required.
does not improve expiratory airflow (Tobin,
1988). If patients continue to use forced expira
TIPS ON REDUCING BREATHLESSNESS
tion despite the previous manoeuvres, they can
be helped by a simple technique that raises Patients can be advised that breathlessness is
resting lung volume above the level at which affected by talking, eating, posture and muscle
abdominal recruitment occurs (Innocenti, 1966). tension. Many know this but it is difficult for
This technique acts like CPAP to hold airways some to adapt to, and reinforcement by regular
open and occurs naturally with exercise training reminders helps raise awareness.
(Pellegrino et at., 1999). It helps to prevent
airways shutdown, consuming less energy than Avoidance of breath-holding
pursed lip breathing. Reported outcomes are A habit that is common in tense patients is
improved Pa02, exercise tolerance and quality of breath-holding, which increases tension and
life (Innocenti, 1997). breathlessness. Breath-holding can be observed
Patients should not change their rate or depth when patients are concentrating, making an
of breathing. They simply start inhalation just effort or listening to advice. If this is pointed out
before the point at which visible abdominal to them at each opportunity, with advice to
173
'keep the rhythm going', they are often able to 1994) and acupressure or self-acupressure to any
bring it under control. Patients find this habit of the breathless points (p. 84).
easier to change than altering a lifetime of rapid
talking or body tension. Physiotherapist, patient
PACING
and family members can compete to be the first
to notice each instance of breath-holding. Once breathing is controlled, through either
direct breathing re-education or other techni
Desensitization to breathlessness ques, it can be incorporated progressively into
To reduce the fear that inhibits activity, patients standing, eating, talking, walking, stair-climbing
can learn to desensitize themselves to breathless and ADL. Pacing assists this process of integra
ness. First and foremost, they are told that tion by allowing patients to maintain steadiness
breathlessness itself is not harmful. This is a and control during activities. Walking alongside
revelation to some patients, who feel that it is patients, steadily and sometimes more slowly
causing damage (Bellamy, 1997) and that every than they are used to, teaches patients to achieve
breathless attack further progresses their control and understand the relevance of energy
disease. They are reminded that smoking, lack conservation. Recreating and managing situa
of oxygen and the disease process are harmful, tions that typically increase breathlessness for
but breathlessness is a symptom and not each individual will improve confidence.
damaging in itself.
Once this is understood, patients are free to
OTHER RESPIRATORY PROBLEMS
attempt activities that increase breathlessness in
a way that they control, and then gently regain If a breathless person has a problem of reduced
their own breath. Patient and physiotherapist lung volume (Chapter 6), e.g. postoperative
start by walking together, the patient being atelectasis, positioning is the first-line treatment
reminded to maintain relaxed rhythmic because it is least disruptive to the breathing
movement, relaxed rhythmic breathing, a good pattern. So long as patients are relaxed and pain
posture and to stop to get their breath back free, lung expansion will be facilitated as they
whenever they want. Patients who are decondi get their breath back after turning to the appro
tioned and fearful might simply walk round the priate position.
bed and sit down. They are then praised for If further measures such as deep breathing are
their success in increasing and controlling their necessary, the breathing rate should be main
breathlessness and encouraged to switch their tained throughout. When asked to take a deep
attitude from fear of breathlessness to confidence breath, breathless patients sometimes respond by
in their own ability to control it. holding their breath instead. This can be avoided
Desensitization is progressed by the patient by advising them to 'keep breathing in and out',
being exposed to graduated increases in breath or telling them when to breathe in and out, until
lessness, then integrating this with other activ they find their own rhythm. No more than two
ities, using the same rhythmic breathing and deep breaths should be taken at a. time, then
steady movement. For those who rush at activ they are advised to breathe comfortably.
ities, a slower pace is advised. Breathing rate and pattern are observed while
they return to normal tidal volume.
Other tips If a breathless person has a problem of
A fan reduces breathlessness by influencing sputum retention (Chapter 8), vibrations may
receptors in the trigeminal nerve distribution sometimes disturb the breathing pattern. Percus
that provides information to the sensory cortex sion may be better tolerated and can even be
(Manning, 1995). Other tips are mechanical relaxing if a slow, rhythmic technique is used.
vibration over the chest wall (Sibuya et ai., The head-down postural drainage position is
174
MECHANlCAL AIDS
usually contraindicated for breathless people.

Very occasionally it is beneficial for emphysema
tous patients because their flat diaphragm is
pushed into a more functional dome shape.
However, this must be done slowly and only if
comfortable. Oximetry can be reassuring for
both patient and clinician.
MECHANICAL AIDS
'From our very first night she made a quite

startling difference to my life. Just one night
converted me to the joys and thrills of home
ventilation. '
Brooks, 1990
Non-invasive ventilation (NIV) provides

inspiratory muscle rest for people who are
burdened with ventilatory failure due to
excessive WOB. This can be due to obstructive
or restrictive disorder in either the acute or
chronic state.
NIV delivers a predetermined volume or
pressure either automatically or, more usually, in
response to patient effort. Positive pressure is
delivered via mask or mouthpiece, or less
commonly via the natural airway using negative
pressure. Compared to invasive mechanical
ventilation, NIV carries less risk of infection Figure 7.3 Non-invasive ventilation by nasal mask
(Guerin, 1997), is more comfortable, easier for (Medicaid).
speech and swallowing, safer and more conveni
ent (Bach, 1994). Intensive care is not required
and patients can participate in their own without loss of respiratory drive, better
management. NIV does not protect the airway outcomes are shown with NIV than with the
and provides no direct access to the trachea for respiratory stimulant doxapram (Angus, 1996).
suction. Patient handling skills are required to talk
Nasal mask positive pressure ventilation is the frightened patients through the process and
commonest system (Figure 7.3), but other venti encourage them to allow the machine to do its
lators are discussed at the end of this section. job.
Patients who most benefit include those with:
Effects for people with acute disorders • exacerbation of COPD or CF with rising
For acutely ill patients, NIV unloads the inspira PaC02 and falling pH
tory muscles, reduces breathlessness and corrects • acute asthma, to reduce the effort of main
respiratory acidosis. In COPD, this has resulted taining dynamic hyperinflation
in reduced need for intubation, ICU length of • acute restrictive disorders such as pneu
stay and deaths (Wysocki, 1999). monia, postoperative atelectasis or ARDS
For patients unable to tolerate oxygen therapy • severe pulmonary oedema, for which intuba-
175
tion may be avoided by using NIV (Hoff mandatory breaths irrespective of respiratory
mann and Welte, 1999) drive.
• patients weaning from mechanical ventila NIV is contraindicated in patients with some
tion unstable medical conditions such as shock,
• those declining mechanical ventilation. arrhythmias or upper GI bleeding. Before initiat
• in tandem with controlled oxygen therapy ing NIV, a decision must be reached with the
when Pa02 above 7 kPa (52 mmHg) cannot medical team and patient about whether intuba
be maintained without PaC02 rising above tion or palliation is appropriate if NIV fails.
10 kPa (75 mmHg) and pH falling below Success is likely if pH and PaC02 respond within
7.34 an hour (Figure 7.4).
Patients with acute respiratory failure have
shown improved breathing patterns (Girault, Effects for people with chronic disorders
1997), survival rates (Keenan, 1997), and a 70%
(For the first time in months I felt
success rate in correcting gas exchange abnorm
reasonably clear-headed, my thinking felt
alities and avoiding intubation (Meduri, 1996).
keener, I no longer fell asleep in mid
Outcomes are most positive in patients who
sentence, my headaches disappeared. . ..
have some pump failure, e.g. inspiratory muscle
Over the following months, as my strength
fatigue, rather than solely airway or parenchymal
slowly returned, my posture and balance
disease. High concentrations of oxygen can be
noticeably improved.'
entrained if necessary, even with hypercapnic
COPD patients if there is a safety backup of Brooks 1990
There is often a reluctance to take full advantage

of home ventilation because:
11 • ventilator use has traditionally been asso
ciated with institutionalization
10
• doctors tend to assume that ventilator users
9 have a poor quality of life and the patient's
view is not always sought.
8
Arterial NIV should be considered if there is daytime

blood 7
gases hypercapnia and symptoms of nocturnal hypo
6 ventilation (morning headache, daytime sleepi
ness, breathlessness and often anorexia),
5
confirmed by a sleep study. Patient and family
4 need to be motivated to manage a ventilator at
0
home, after acclimatization in hospital.
Home NIV has shown an 87% positive
Time from admission
response (Goldstein, 1995), with sustained
improvement in gas exchange and reduced
Figure 7.4 Arterial blood gases of a 60-year-old woman hospitalization (Leger, 1994). The mechanisms
with acute COPD, ventilatory failure and respiratory for improvement are thought to relate to respira
acidosis. On admission, 5.02 was 57% and pH 7.21. CPAP
tory control, i.e. increased response to hypercap
raised 5.02 to 82% but hypercapnia and acidosis persisted.
NIV corrected acidosis to pH 7.39 and improved
nia by lowering bicarbonate in the cerebrospinal
hypercapnia within an hour. (From Keilty, S. E. J. and fluid in response to reduced PaC02, and reversal
Moxham, J. (1995) Noninvasive ventilation in acute-on of hypoxic depression of the respiratory centres
chronic airways disease. Hospital Update, 21, 165-171). (Shneerson, 1996b). Relief from symptoms of
176
MECHANICAL AIDS
hypoventilation is rapid, especially improved

quality of sleep (Shneerson, 1996b), and patients Complications
often fall asleep as soon as the machine is set up. Problems of positive-pressure ventilation are
For people with chronic disorders, NIV has described on page 159. Pressure sores can be
shown: avoided with forehead spacers supplied with
• early hospital discharge with cost savings of some masks. Discomfort and mask leaks are
200% a year (Bach, 1994) modified by trying different sizes and types of
• improved arterial blood gases (ABGs), mask. Other options are customized masks or
reversed pulmonary hypertension and cor different masks used in rotation. Bubble masks
pulmonale (Simonds, 1998) contain an inner lining that improves the seal by
• tolerance of oxygen therapy when used at inflating on inspiration and lessens skin pressure
night and during daytime naps (Sivasothy et by deflating on expiration.
aI., 1998) Gastric distension sometimes occurs with
• increased vital capacity (Pehrsson, 1994) volume-controlled machines or in patients with
• prolonged life (Muir, 1993). low chest wall compliance. Options are:
Patients use the ventilator until ABGs are • adopting the left-side-lying position
optimal, then regularly according to symptoms. • using the lowest effective pressures
Patients who benefit include: • waiting to see if it eases with time
• trying a different ventilator.
• those with advanced hypercapnic COPD,
scoliosis, neuromuscular disease, especially Nasal dryness may be helped by nasal drops.
those with daytime PaC02 above 6 kPa Mouth dryness usually responds to reducing air
(45 mmHg) leaks through the mouth. Skin irritation may be
• those awaiting transplantation solved by daily washing of mask, spacer and the
• those wanting to come off invasive ventila patient's skin, and using minimal strap tension.
tion. If the straps feel too tight, a smaller mask may
Patients have to fulfil the following criteria: allow them to be loosened, or a skull cap can be
used.
• Pa02 > 8.0 kPa (60 mmHg) Patients may pull off the mask if they are
• glottic control adequate to prevent recurrent suffering hypoxic confusion, anxiety or adminis
aspiration tration of doxapram. They need explanations
• maintenance of unassisted or assisted peak and observation.
cough flows greater than 3 Llsec (Bach and
Haas, 1996, p. 373). Equipment
Most patients require at least 6 hours of venti Advantages of pressure-controlled (p. 343)
latory support per night, but improvements have machines are the comfort of a limited peak
been found with periods of rest from 8 hours a pressure, reduced risk of pneumothorax in
week to 10 hours a night (Axen, 1991). advanced emphysema and compensation for
Nocturnal ventilation is used when possible leaks. Volume-controlled machines are more
because this compensates for loss of accessory suited to people with high or fluctuating airway
muscle activity during sleep, but daytime NIV resistance or lung compliance. However, there
can be effective for patients who prefer this are differences in the 'feel' of individual
(Schonhofer et aI., 1997). Patients may well be machines, and patients have their own prefer
up and about in the daytime, but live in a precar ences.
ious balance that leaves them unable to respond Machines should have a sensitive trigger,
to increased energy demand such as a chest short response time, variable flow, be capable of
infection. delivering an adequate tidal volume (VT) or
177
pressure, and be quiet and portable. Some For the spontaneous/timed option, RR is set
machines have a PEEP (p. 351) option which at 2-5 less than the patient's spontaneous rate.
reduces the risk of atelectasis in neuromuscular Parameters are set according to ABGs and
disease and gas trapping in patients with hyper comfort. Alternatives to ABGs are capillary
inflated chests. Occasionally PEEP may reduce blood gases or transcutaneous monitoring
cardiac output and oxygen delivery in patients Ganssens, 1998). The machine should match the
with obstructive disease (Ambrosino et at., patient rather than the patient being obliged to
1993). conform to the machine. If inspiratory and
Nasal masks should be comfortable and small expiratory times are used, they are set to
enough to fit from half-way down the bridge of synchronize with chest wall movement. For
the nose to just below the nares. Full face masks volume-controlled machines, COz can be blown
double deadspace and increase the likelihood of off by increasing VT or I:E ratio in order to raise
complications, but they are suited to people who minute volume. For pressure-controlled
mouth-breathe. For patients with glasses or those machines, a typical starting pressure 1S
who find nasal masks claustrophobic, nasal 10 cmHzO, building up to 15-20cmHzO.
'pillows' avoid contact with the bridge of the The machine is turned on before applying the
nose or cheeks. Mouthpieces are best if pressures mask. Anxiety is minimized by allowing patients
above 25 cmHzO are needed, or for mobility to feel the air blowing against their hand. When
when using a wheelchair. Some ventilator strapping the mask on, the top straps are
dependent people prefer a mouthpiece in the tightened first, and straps need to be equally
daytime and lipseal device or customized mask at tight on both sides. If oxygen is· added, an
night. oxygen analyser and oximeter are used as for
A bacterial filter or heat-moisture exchanger CPAP. For machines with pressure alarms, the
can be added to the circuit, after checking the low pressure alarm is set 8-10 cmHzO below the
handbook to ensure that it does not upset the lowest working pressure, and the upper pressure
pressures. Patients requiring humidification will limit is set at about 40 cmHzO. Exhalation ports
need a high-efficiency humidifier. are designed to exhaust COz and must not be
blocked, except initially to test that flow is
Technique present. They should be directed away from the
patient's face.
For acute patients, NIV should be set up at an
Patients are asked to keep their mouths shut.
early stage when the pH falls below 7.35 and
Some may voluntarily keep it closed once they
respiratory rate (RR) nses above 30/min
feel relief but others are committed mouth
(Baldwin, 1997). Patients with chronic disease
breathers. If they do not want a chin strap or
must be fully rehabilitated, and a maintenance
collar, side-lying with a pillow supporting the
service operational. For all patients, medical
chin may help prevent mouth leaks. Small leaks
management must be optimal.
may be acceptable so long as they do not
One of the following can be chosen:
interfere with triggering into inspiration or
• a spontaneous option, which superimposes cycling into expiration, and so long as VT and
inspiratory and, usually, expiratory pressures ABGs are adequate. Patients may find that slight
on the patient's own breathing neck extension helps to optimize airflow. The
• a spontaneous/timed option, which adds mask should be removed before turning the
mandatory breaths if the patient does not machine off. If a full face mask is used, it is best
breathe after a set time interval for the patient to avoid eating or drinking 2
• a timed option, usually used by the physi hours beforehand.
cian, which is fully controlled ventilation for Improvement in RR and pH in the first hour
patients who are unable to breathe at all. is a predictor of success. PaCOZ should not be
178
MECHANICAL AIDS
forced down too quickly if there is high bicarbo reduce WOB so long as the patient is relaxed
nate, otherwise metabolic alkalosis may and does not attempt to assist or resist. For the
supervene. Acutely ill patients may be given Bird, the instructions on page 161 are followed,
continuous NIV for 24 hours, removing the with the following modifications:
mask only to talk, drink and eat, or they may
• the most comfortable resting position is used
use it for a couple of hours morning and
(p. 169)
afternoon, plus overnight. Intermittent support
• the flow is turned up to match breathlessness
may then be appropriate, with longer periods of
• the pressure need not be progressively
spontaneous breathing as weaning progresses.
increased because the aim is not to increase
The mask is removed for administration of nebu
lung volume but to ease WOB.
lizers, which should be delivered through normal
nebulizer devices. Treatment by the Bird may be needed two
hourly in the acute phase, unless the patient is
Modes asleep. Very occasionally an exhausted patient is
unable to initiate a pressure-triggered breath, in
Continuous positive airways pressure
which case a flow-triggered machine is required
CPAP (p.156) does not support ventilation
(see below).
directly, and respiratory muscle unloading is
limited (Wysocki, 1999). However, in hyperin
Bilevel positive airway pressure
flation conditions, CPAP takes over the work of
'BiPAP' is the trade name for a specific machine
sustained muscle activity during inspiration and
but, like Biro and Hoover, the word has become
keeps the airways open to allow greater gas
synonymous with the generic and the term
emptying during expiration (Greenwald, 1993).
BiPAP is commonly used to describe the BiPAP
Pressures of 4-5 cmH20 may be adequate to
mode on any machine. This mode delivers
counteract the inspiratory threshold load caused
continuous positive pressure with independent
by gas trapping (O'Donnell, 1994). The instruc
control of inspiratory and expiratory pressures.
tions on page 158 are followed but, instead of
Bilevel pressures are more comfortable than
the goal being to increase Sa02, pressures are
CPAP and more flexible than IPPB. BiPAP is the
titrated to the individual's comfort to ensure
non-invasive equivalent of pressure support with
that hyperinflation is not increased.
PEEP (Chapter 13).
Many people with an exacerbation of COPD
Inspiratory positive airway pressure is usually
find CPAP frightening and claustrophobic, and
started at about 10-14 cmH20 and increased in
outcomes are patchy:
increments of 2 cmH20 until there is least effort
• even when ameliorating the WOB induced during inspiration and optimum ABGs. Expira
by hyperinflation, CPAP does not necessarily tory positive airway pressure is started at 2-
ease breathlessness (Fessler, 1995) 4 cmH20 and increased to achieve optimum
• desaturation can occur (Elliott et aI., 1994) comfort and Sa02, but levels over 6 cmH20 tend
• CPAP is less successful than inspiratory pres to impose an unacceptable expiratory load and
sure support (Gibson, 1996) or bilevel posi interfere with sleep. A minimum 2 cmH20 is
tive pressure. required to prevent CO2 building up in the circuit.
• it is contraindicated in Typell respiratory A plateau valve extubation port may be available
failure )p. 1 17) because of the risk of CO2 to prevent CO2 retention. If inspiratory and
retention expiratory pressures are equal, CPAP is delivered.
BiPAP can improve sleep, reduce breathless
Inspiratory pressure support ness and increase exercise capacity (Renston,
Positive pressure on inspiration is provided by 1994). For acute patients, the need for intuba
IPPB (p. 159) or a multimode machine. This can tion was reduced to zero in one study of severe
179
exacerbations of COPD, using an average pressure and mask

inspiratory pressure of 14 and expiratory • normal physiological distribution of ventila
pressure of 4 (Confalonieri, 1994). tion
BiPAP is usually flow-triggered, pressure • for patients unable to bring their hands to
controlled and flow-cycled (p. 203). It adjusts to their face to manoeuvre a nasal mask, easier
compensate for minor leaks, which do not have communication.
to be eliminated by ruthless tightening of
Disadvantages are:
headgear.
To summarize: • awkward machinery
• CPAP may be useful for hyperinflation or • risk of sleep apnoea due to upper aIrway
type I respiratory failure. collapse (Thomson, 1997), especially 1ll
• IPPB is useful when the problem is exhaus ventilator-triggered modes.
tion, hypercapnia or type II respiratory
The tank ventilator encloses all the patient
failure.
except the head in an airtight iron lung. Disad
• BiPAP is ideal and can be individually
vantages are size, noise, discomfort from the
titrated to each of these problems.
neck seal, immobility, fear of suffocation and
Non-invasive ventilation is now well-estab inaccessibility of the patient. Jackets and the
lished as an evidence-based practice that can rigid cuirass, which apply negative pressure over
reduce morbidity and mortality, but it is still the the chest and abdomen, are less efficient but
exception rather than the rule in many UK more convenient (Bach, 1994), but may restrict
hospitals. Physiotherapists are well placed to sleep or have air leaks.
initiate and co-ordinate the teamwork required Patients in tanks may require physiotherapy
to set up a service. Whether it is doctor-led or because of immobility and ineffective cough. If
physiotherapist-led, all relevant staff need to be secretions are a problem, vibrations and percus
trained, including the medical team to provide sion through the portholes may be helpful.
timely ABGs, and on-call physiotherapists to Coughing is assisted manually (p. 203).
understand the teamwork, indications and prac Treatment in prone requires a person to sit by
ticalities. the patient's head to watch his or her colour. If
the patient vomits, pressure must be equalized
Negative pressure ventilation immediately by opening a porthole because of
Negative pressure is applied externally via a the danger of aspiration.
machine that encloses part of the patient's body, Motivated patients can be taught to master
sucking air into the lungs through the patient's the art of glossopharyngeal breathing (Bach,
natural airway. Negative pressure ventilators are 1994). Using the lips, soft palate and tongue, 6-
more time-consuming and difficult to adjust than 9 mouthfuls of 60-100 mL of air are collected in
positive pressure ventilators, but they suit some the mouth and throat, then gulped into the lungs
individuals, especially those with: using the tongue, pharynx and larynx, creating a
respectable VT. Success provides the following
• nocturnal hypoventilation and restrictive
advantages for those with no measurable vital
disorders such as post-polio syndrome, who
capacity:
require long-term support
• severe right heart overload or haemody • the independence of a few hours' ventilator
namic instability free time
• hypercapnic coma (Corrado, 1996). • the ability to call for help
Advantages are: • a safety margin in case of ventilator failure.
• avoidance of the complications of positive Using a mirror and an upright or other
180
OUTCOMES
symmetrical pOSItIOn, traInIng requires much ventilator failure

concentration, with short daily sessions to avoid • with full mechanical ventilation if the
fatigue. A video is available (Appendix C). machine is volume cycled and can deliver
three times the volume of air that would be
Other ventilators required using a cuffed tube
• to permit speech, if there is a speaking valve
High-frequency oscillators deliver high-flow
attachment.
bursts of gas either through a mouthpiece or
externally by generating an oscillating pressure Invasive ventilation can be managed at home
through a cuirass device such as the Hayek, if the patient or carer is educated to deflate and
which conforms to the surface of the body from inflate the cuff, change and clean the tracheost
neck to hips (Hardinge, 1995). It is expensive, omy tube and suction aseptically.
comfortable · and reduces WOB by overriding
spontaneous ventilation. It may assist clearance
OUTCOMES
of secretions.
The rocking bed uses gravity-assisted displace Reduced work of breathing can be judged by the
ment of abdominal contents to augment following:
diaphragm excursion, usually for people with
• ! breathlessness (see p. 216 for assessment)
isolated bilateral diaphragm weakness. It is most
• ! fatigue
effective and comfortable with some degree of
• ! RR
head elevation throughout the rocking cycle. For
• more synchronous breathing pattern
immobile patients, the variation in pressure
• i exercise tolerance and ADL, if the limiting
reduces the risk of skin breakdown.
factor for these is breathlessness.
The pneumobelt is used in sitting and
standing only. For expiration, it inflates a
bladder at 50 cmH20 around the abdomen to
push up the diaphragm. For passive inspiration,
it deflates to allow diaphragmatic descent. I;ii�i«RiMIi'i)ItI;kj'i'
You are called i n to see a 69-year-old woman with
Tracheostomy ventilation an exacerbation of COPO. Identify her problems
The kind of life lived by a patient under from the selected details and answer the questions.
conditions of vigorous response to a
challenge is infinitely preferable to a Background
crunching, desperate winding down. S H : lives alone, manages stairs, i ndependent,
Cousins, 198 1 supportive son.
Medical notes: not for I PPY.
Long-term invasive ventilation may be needed
for some people with bulbar weakness or venti Subjective
lator-dependency for over 16 hours/day, such as
Can't breathe.
those with high spinal cord lesions, or occasion
Dry mouth.
ally for those with COPD who have been unable
to wean from mechanical ventilation (Muir et Objective
al. , 1994). A cuffed tracheostomy tube is
Pa02 9.5, PaC02 1 1 . 3 , pH 7. 2 1 , HCO] 32, BE 1 04.
necessary if airtight ventilation is required.
5a02 85% but varying.
Uncuffed or deflated cuffs can be used for the
On 24% d ry oxygen.
following:
Temperature 36°C.
• to allow spontaneous breathing In case of On infusion of salbutamol and doxapram.
181
Propped up in bed. Explanations to patient, including information on

Rapid shallow breathing. the fact that doxapram causes shaking, which
Body shaking continuously. might reduce her fear.
Difficulty speaking. BiPAP.
Appears fearfu l + + . Humidify oxygen.
Liaise with nursing staff or relatives on mouth care
Questions and assistance with oral fluids.
I . Is the goal of medical treatment pall iative or Liaise with medical staff over common goals.
cu rative? Fan, positioning, other techniques to reduce WOB.
2. Analysis?
3. Problems? DNR = do not resuscitate.
4. Goals?
S . Plan?
IPPV = intermittent positive pressure ventilation. LITERATURE APPRAISAL
Comment on the connection between the

RESPONSE TO M I N I CASE STUDY following two statements. Does the conclusion
fit ?
I . Medical treatment [PJerceived quality of life appears to be

The fact that Ms IU is not for i nvasive ventilation linked with peripheral muscle force in
suggests that palliation is the goal. However, the COPD patients. . . .
doxapram infusion is not palliative. Consequently, peripheral muscle
training may be an important tool in
2. Analysis improving quality of life in COPD patients.
Teamwork is required before decisions can be Eur. Respir. J. 1 996; 9(23 ) : 1445
made on goals of physiotherapy.
Patient is severely acidotic, but is normally
independent. However, decisions on qual ity of
life are best made by the patient rather than the
health team. RESPONSE TO LITERATURE APPRAISAL
Auscultation and X-ray are irrelevant at present Chickens and eggs. The second statement may
because they would not supply any further be a correct conclusion, but the first statement
i nformation that would d i rect treatment. does not prove that weak peripheral muscles
cause impaired quality of life. Peripheral muscles
3. Problems
may weaken as a result of exercise limitation or
Type II venti latory fai lure and respiratory acidosis. malnutrition. Both are common in COPD, as is
Distress. impaired quality of life.
4. Goals
Support ventilation non-i nvasively. This could fu lfil RECOMMENDED READING
palliative or cu rative criteria.
Adam, K. and Oswald, I. ( 1 984) Sleep helps healing.
Liaise with medical team about goals of treatment
Br. Med. j. , 289, 1400- 1 40 1 .
and whether patient has given previous opinion Barberger-Gateau, P . ( 1 9 97) Dyspnoea and disability.
on DNR status. Crit. Rev. Phys. Rehabil. Med., 9, 265-299.
Carrieri-Kohlman, V. ( 1 99 3 ) Desensitization and
5. Plan
182
RECOMMENDED READING
guided mastery. Heart Lung, 22, 226-234. Roland, M. and Peper, E. ( 1 9 8 7) Inhalation volume
Jobst, K., McPherson, K. and Brown, V. ( 1 9 8 6 ) changes with inspirometer feedback and
Controlled trial of acupuncture for disabling diaphragmatic breathing coaching. Clin.
breathlessness. Lancet, ii, 1 4 1 6 - 1 4 1 8 . Biofeedback Health, 10, 8 9-97.
Nisell, O . ( 1 992) Causes and mechanisms of Wolkove, N . and Kreisman, H. ( 1 9 8 4) Effect of
breathlessness. Clin. Physiol. , 12 , 1 - 1 7 . transcendental meditation on breathing and
Olivier, F. 1. ( 1 998) Suggested guidelines for the use respiratory control. J. Appl. Physiol. , 56, 607-6 1 2.
of exercise with adults in acute care settings. Phys.
Canaaa, 50, 1 2 7- 1 3 5 .
183
8 PHYSIOTHERAPY TO CLEAR SECRETIONS
SUMMARY
Sputum in perspective �echanical aids

Hydration and humidification • Positive expiratory pressure
• Classification • Flutter
• Effects • Cornet
• Complications • Percussors, vibrators and oscillators
• Indications • Intermittent positive pressure breathing
• Technique Cough
Exercise • Cough facilitation
Postural drainage • Precautions
• Technique • Cough suppression
• Effects Pharyngeal suction
• Indications • Indications
• Precautions • Catheters
�anual techniques • Technique
• Technique • Complications
• Effects • Precautions
• Indications Nasopharyngeal airway
• Precautions �nitracheostomy
• �ni literature appraisal Outcomes
Breathing techniques �ini case study
• Active cycle of breathing Literature appraisal
• Autogenic drainage Recommended reading
SPUTUM IN PERSPECTIVE distress and airflow limitation, they do matter and

need to be cleared, with or without assistance.
It may be gob to you but it's my bread and
In the medium term, secretions in people with
butter.
COPD do not correlate with airflow obstruction
Cole, physician, 1999
(Baldwin, 1994; Bateman et aI., 1979; Peto et aI.,
Question 1 1983) or mortality (Wiles and Hnizdo, 1991).
People with non-acute COPD complain little
Do bronchial secretions matter? In the short
about sputum or its effect on their quality of life.
term, can they obstruct breathing? In the
The evidence that sputum clearance improves
medium term, do they correlate with lung
lung function in stable COPD is underwhelming.
function or quality of life? In the long term,
But in patients with excess secretions and
are they implicated in the natural history of
chronic infection, the following must be consid
disease?
ered:
In the short term, if superficial secretions are
seen or heard to obstruct breathing, causing • uncleared secretions augment infection
184 ------
HYDRATION AND HUMI DIFICATION
• chronic infection damages airways by preci 1991). For secretion clearance from the large
pitating the inflammatory cascade. airways, where total cross-section is narrower,
FEV 1 measurements may be helpful in long-term
People with diseases such as cystic fibrosis
studies if airway obstruction has been affected
(CF) or bronchiectasis still show little relation
by progressive damage caused by excess secre
ship between expectorated sputum and
tions. However, the procedure itself alters the
pulmonary function (Rubin, 1997), but Williams
bronchial status quo by shearing secretions off
(1995) suggests that secretion clearance slows
the airway wall.
the deterioration in lung function over time. At
A more sensitive test is specific airways conduc
present we must assume that secretions do
tance, which measures airflow obstruction
matter for these patients, especially as few
without a forced expiration. For this we have one
researchers would care to investigate the effects
aged study to rely on, which suggests that conven
of depriving, say, a sample of children with CF
tional chest physiotherapy reduces airflow
of their physiotherapy for a lifetime.
obstruction in the short term (Cochrane et ai.,
Therefore, on balance:
1977).
• for patients with sputum retention: secre
tions do matter Question 3
• for patients with excess secretions: secretions How do we identify the problem?
do matter if their presence augments
progression of the disease or compromises • Is mucociliary clearance the problem,
oxygenation, but appear not to matter for impaired by hypoxia, infection, damaged
people with stable COPD if they do not airways, dehydration, cigarette smoke,
complain of this and are capable of clearing immobility, anaesthetic agent or pollution
their own secretions. (Houtmeyers, 1999)?
• Is coughing the problem, impaired by weak
Question 2 ness or pain?
When secretions do matter, how do we evaluate • Is expectoration the problem, impaired by a
our clearance techniques? The literature is a dry mouth or embarrassment?
minefield when trying to assess secretion This section assumes that patients need
clearance. Studies in vitro or in people with physiotherapy if they have sputum retention, or
normal lungs bear limited relation to clinical if excess secretions are detrimental.
practice. Studies that do not correct for cough
alone are suspect because most physiotherapy
techniques to clear secretions include coughing. HYDRATION AND HUMIDIFICATION
Studies that do not follow up secretion clearance Humidity: water content of a gas, expressed as
for several hours after treatment are of limited absolute or relative.
usefulness (Mortensen et ai., 1991). Studies that Absolute humidity: water in a given volume of
measure sputum volume or sputum weight do gas (mglL), which increases or decreases with
not compensate for saliva or swallowed secre temperature.
tions (Hasani et ai., 1994). Sputum volume is Relative humidity: water expressed as a
adequate for outcome measurement in clinical percentage of that which would fully saturate
practice but is not valid for research. the volume of gas at a given temperature (%).
Research is most useful when secretion
clearance is measured by labelling inhaled radio The major determinants of mucociliary clearance
active aerosol, whose particles become are the quality and quantity of mucus and the
entrapped in airway mucus, then scanning mucus health of the cilia (King, 1998), all of which
clearance by gamma camera (Mortensen et ai., depend on systemic hydration. The mucociliary
185
CHAPTER 8 PHYSIOTHERAPY TO CLEAR SECRETIONS
Optimum range
Max MTV
c:
Adequate range
� Mucus thick
c:
.2
OJ MTV stopped
'"
o Cilia stopped
U
:::J
::2:
Humidity
Figure 8.1 Variation of inspired humidity from core

temperature and 100% relative humidity, and how this
might affect mucosal function. MTV mucociliary transport
=
velocity. (From Williams, R. , Rankin, N., Smith, T. et 01.

( 1 996) Relationship between the humidity and temperature
of inspired gas and the function of the airway mucosa. Figure 8 2 Systemic hydration. (From Ries, A. L. and
Critical Care Medicine, 24, II) Moser, K. M. ( 1 996) Shortness of Breath: A Guide to Better
Uving and Breathing, C. V. Mosby, St Louis, MO)
escalator provides a frontier against the

onslaught of 10 billion inhaled particles a day, transport by 25% (Luce et ai., 1993, p. 136).
but this depends on the sol layer of watery fluid Systemic fluid intake is cheap, safe and not
in which the cilia must be able to move freely. baffled out in the upper airways as is much
Dehydration immobilizes cilia more than death inhaled moisture. Systemic hydration should be
(Clarke, 1989) and causes mucosal drying, the priority (Figure 8.2).
inflammation and ulceration (Figure 8. 1). Some patients restrict their fluid intake. They
At body temperature, a small increase in may have stress incontinence due to chronic
temperature causes a relatively large increase in cough. They may have frequency due to
water content (Joynt and Lipman, 1994), and the diuretics. Hospitalized patients may not be near
bronchial tree is normally fully saturated with the toilet. They may reduce their drinking
water vapour from just below the carina onwards. because of the change in environment and daily
From here to the alveoli, with the temperature at routine. Blower (1997) found that over a third
37°C, water content at 43.9 mglL maintains of hospitalized patients were unable to drink as
relative humidity at 100% (Branson, 1999). often as needed, and over half were thirsty.
To maintain this and prevent secretions thick Causes were inability to reach their drink and
ening, the following can be administered: unwillingness to bother busy staff.
For hospitalized patients it is recommended
• systemic hydration by oral or intravenous that daily fluid intake is 1.5 litres (DoH, 1995).
fluids Hot weather, fever and exacerbation of disease
• humidification by inhalation of a vapour markedly increase requirements. For 'patients at
• nebulization by inhalation of an aerosol home, a trial of increased fluid intake would
• heat-moisture exchange using a filter. indicate whether or not this helps expectoration,
in which case it can be incorporated into their
Classification routine, a jug of water being accessible as a
Hydration reminder. Liquid diets and blenderized meals do
There is no evidence that overhydration speeds not hydrate because of their osmotic load. Juices
mucociliary clearance, but dehydration is and canned drinks are adequate but not as
common (Blower, 1997) and reduces mucus efficient as water. Caffeine drinks such as tea,
186 ------
HYDRATION AND HUMIDIFICATION
Table 8.1 Comparison of systems
Hot water humidifier Nebulizer HME
Moisture output (g/m3) 35-50 20-1000 25-35

Infection risk Reservoir and circuit Reservoir, circuit and aerosol Low
Advantages Bacteria not transmitted with vapour For tenacious secretions Simple, cheap
Disadvantages Labour-intensive Labour-intensive May block with mucus
Bulky May be inadequate
coffee and cola have some diuretic action and are water humidifiers may assist in moistening a dry
less helpful but are preferred by some patients. throat, but a steamy cup of tea is more pleasur
Some disorders may be complicated by acid able.
base or electrolyte disturbance, kidney dysfunc To ensure safety, the humidifier should:
tion, pulmonary oedema or diuretic therapy, and
• incorporate an over-heating alarm
liaison with medical staff is then advisable.
• be kept heated continuously to mmlmlze
colonization with bacteria
Hot water humidification
• be kept below the patient to prevent
A hot water humidifier or hot water bath (Table
condensed water tipping into the airway.
8.1) creates a vapour by passing gas over or
through sterile liquid, which is maintained at Condensed water should be viewed as infec
4S-60°C. The vapour is allowed to cool along a tious waste. Tubing requires regular emptying,
specific length of tubing to reach the patient either manually (away from the patient) or by
with a relative humidity of 100% at 37°C. water traps in the circuit (Figure 8.3). Heated
When used with non-intubated patients, the wire circuits prevent condensation, but if these
nose and larynx cause the vapour to condense permit cooler temperatures in the hot water
into drops that are too large to navigate the chamber, there is increased risk of infection
airways. Hot water humidifiers are therefore best (Branson, 1996).
used for patients with endotracheal or tracheost A steam inhalation uses the same principle by
omy tubes, which allow passage of the vapour. delivering vapour from near-boiling water to the
They are also used for small children to keep patient via a mouthpiece. Some patients find it
their narrow upper airways clear, under supervi beneficial but the temperature of the water is not
sion. For adults with an intact upper airway, hot controlled and the container is easily knocked
Water trap
Figure 8.3 A water trap to collect condensed water in the tubing between humidifier and patient.
187
over. It is contraindicated for hospitalized

patients, and if patients at home want to use it
they need safery advice. Menthol or other
additives are found useful by some patients.
Cold water humidification

A cold water humidifier bubbles cold gas
through cold water, preferably via a diffuser
which breaks up air into small bubbles to
increase the gas-water interface. Gas passes too
quickly to pick up much moisture and the higher
the flow rate, the poorer the humidification
(Mason, 1993, p. 23 1). The system is thought to Figure 8.4 Humidification. (From Ries, A. L. and Moser,
be incapable of achieving a positive water K. M. (1996) Shortness of Breath: A Guide to Better Uving
and Breathing, C. V. Mosby, St Louis, MO)
balance in the airways (Darin, 1982), is insuffi
cient to prevent insensible water loss (Hodgkin
et al., 1993, p. 207), cools the system below which combine the advantages of both vapour
room temperature (Campbell et al., 1988) and and aerosol. Large-volume nebulizers incorpo
was condemned as 'dangerously inadequate' over rate a Venturi system which ensures delivery of a
three decades ago (Graff and Benson, 1969). fixed percentage of oxygen (Figure 8.5). Some
These 'bubble-through' humidifiers may be nebulizers collect the larger droplets and recycle
indicated for some patients on dry oxygen if them to be re-nebulized. Large-volume nebuli
they feel that this makes their mouths more zers are used continuously.
comfortable. Otherwise they simply increase Small-volume jet nebulizers, used periodically
airflow resistance (Mason, 1993, p. 231) and before physiotherapy, are the same as those used
grow bacteria, although this is rarely a problem for drug delivery and carry the same risk of
because so little infected humidiry reaches the infection (p. 142). These 'saline nebs' deliver
patient. Sceptical ward staff can be won over by rypically just 2 mL of fluid (Hodgkin et aI., 1993,
being invited to observe the time it takes for the p. 206). They have been shown to increase
water to be used up (if ever). The untiring enthu sputum 'yield' but create no significant increase in
siasm of sales representatives has kept most radioaerosol clearance (Sutton et al., 1988). This
hospitals stocked up with these humidifiers, and may be because they wet the throat and assist
we await research on any new devices. expectoration but are not adequate for loosening
secretions. It is therefore suggested that:
Nebulized humidification (Figure 8.4)
• if the problem is a dry mouth or throat,
Large-volume nebulizers use the same
mouth care is required
mechanism as the nebulizers used for delivering
• if the problem is thick secretions, a large
drugs (p. 14 1). Sterile liquid is converted into an
volume jet nebulizer is required
aerosol, whose droplets are small enough to
• if the patient finds a small-volume nebulizer
navigate the nasal passages and vocal cords, and
helpful, it can be used with appropriate
reach the airways. They pose a greater risk of
infection control measures.
infection than a hot-water humidifier because
organisms can be carried in droplets but not Small volume saline nebulizers may be more
vapour (Pilbeam, 1998, p. 161). helpful in the community, where bacteria are
Large-volume jet nebulizers commonly use a less vicious than in hospital, but patients must
cold liquid because heat is not necessary for this not leave them wet and untended after use.
mechanism, but heated nebulizers are available The ultrasonic nebulizer is a self-contained
188
I
(a) Oxygen supply
at flow specified
on collar
Entrainment
_____ collar with choice
of settings
OIl
Humidified
oxygen
to patient
_MAXIMUM_
Pickup tube
(inside jar) Jar
_MINIMUM_
Air supply
BUm
3 Um oxygen
35% setting
(b)
24% Humidified
oxygen to the
patient
Jar
Figure 8.5 (a) Large-volume nebuliser to deliver 28%

oxygen and above (Henleys). (b) Large-volume nebuliser
set up for 24% oxygen. The nebuliser is powered by air,
and oxygen is entrained with a Venturi adapter (Intersurgical).
F102 is checked with an oxygen analyser.
189
CHAPTER 8 PHYSIOTHERAPY TO CLEAR S ECRETIONS
electrical device that transmits vibrations • A condenser HME, sometimes known as a

through a liquid to atomize the particles, Swedish nose, traps expired water vapour
producing a 2-10-fold greater output than a jet and some body heat. It is 50% efficient and
nebulizer (Phillips and Millard, 1994). Oxygen fits over a tracheostomy tube.
can be added with a nasal cannula. Advantages • A hygroscopic HME is impregnated with a
are its silence and efficiency. Disadvantages are chemical that absorbs water and humidifies
expense and, sometimes, the less beneficial the subsequent inspiration. If used for over
effects of efficiency: 24 hours, it may become saturated and
increase airflow resistance. It is 700/0 effi
• Deeper penetration into the airways creates cient.
a greater risk of infection (Suda, 1995). If • A hydrophobic HME is water-repellent and
the device is not well maintained, a 'pseudo conducts heat poorly, thus causing a
monas soup' can be poured into the patient. temperature gradient, leading to evapora
• The dense aerosol increases airflow resis tion, cooling and conservation of water on
tance, which may be a problem with severe expiration. It is 60-70% efficient.
acute asthma.
• Fluid overload is a risk for people in renal HMEs are less effictive than the natural nasal
failure or for babies. Water intoxication can passages, which are 80-85% efficient (Lloyd,
inactivate surfactant, block airways, damage 1987). They become less efficient over time or
cilia and overwhelm the mucociliary esca when a patient breathes with high tidal volumes
lator (Shelly et aI., 1988). (Martin, 1990a). HMEs are not adequate for
patients with thick secretions (Branson, 1996)
When used in patients who have difficulty but are convenient for mobile patients, for
clearing their own secretions, a physiotherapist limited periods of mechanical ventilation or
should be on hand because of the increased when using devices such as CPAP or a manual
volume of secretions. inflation bag (p. 371). Some HMEs incorporate
a bacterial filter. HMEs show less colonization
with organisms than hot water humidifiers
Heat-moisture exchange
(Boots et aI., 1997) but have not been found to
Heat-moisture exchangers (HMEs; Figure 8.6)
reduce the incidence of nosocomial pneumonia
reproduce the humidification and filtration
(Misset, 1991).
functions of the upper airways. They comprise
Tents and head boxes are discussed on page
the following Qoynt and Lipman, 1994):
124.
Effects of humidification
The superficial gel layer of the mucus blanket
acts as a protective barrier between the body and
atmosphere, and is mostly waterproof, but it can
absorb some inhaled moisture (Conway, 1992b).
Complications of humidification
• Ubiquitous hospital bacteria enjoy nothing
more than stagnant humidifier water, espe
cially if it is lukewarm. Hot-water baths are
Figure 8.6 Heat-moisture exchanger used to retum less risky, partly because they are hot and
heat and moisture in exhaled gas to the patient's own partly because vapour cannot convey
airways. bacteria (Branson, 1996). Infection is also a
190
risk in home humidifiers (Patterson et al., oxygen, water may condense in the entrain
1998). ment ports and alter FI 02, and attempts to
• Bronchospasm can be caused in susceptible humidify the oxygen and/or entrained air
patients by: with a humidity adapter are rarely effective
- an unheated nebulizer (Gribbin, 1993); it is better to set up a
- dense ultrasonic mist venturi nebulizer.
- use of a liquid other than isotonic saline
in nebulizing systems (Church, 1991). Technique
• Hypercapnic COPD patients may suffer loss A mask or mouthpiece can be used, depending
of respiratory drive if uncontrolled oxygen is on patient comfort. Lung deposition is enhanced
used as the driving gas. Large-volume nebuli by the upright-sitting or side-lying position.
zers can be set up to run on 24% oxygen Condensation is minimized by wide-bore tubing,
(Figure 8. Sb). avoidance of lengthy convolutions of tubing, or
use of a heated wire circuit. When using a
Indications heated system, the manufacturer's safety instruc
tions should be followed; for example, use the
Humidification is necessary for:
correct length of tubing and ensure that, when
• people whose upper airway has been the heater is on, gas flow is maintained and the
bypassed with a tracheal tube reservoir is not dry.
• people with thick secretions When small nebulizers are used for drug
• babies at risk of airway blockage with secre delivery, they are diluted with isotonic saline.
tions Large, non-disposable nebulizers use sterile
• people on oxygen therapy who have hyper water because repeated filling leads to encrusta
reactive airways (heated system required) or tion. Water should not be used for people with
if using a mask for prolonged periods, with hyperreactive airways. Other fluids for nebuli
high flow rates (Fulmer and Snider, 1984), zation include hypertonic saline, which is
or who are mouth-breathing, nil-by-mouth usually used to induce sputum for diagnostic
or have a dry mouth and find expectoration purposes (p. 38) but has been shown to double
difficult, especially if they are on oxygen the mucociliary clearance rate in sputum from
therapy people with bronchiectasis and CF by increas
• patients using non-invasive mechanical aids ing the osmolality of secretions (Wills et al.,
such as CPAP, which deliver high-flow dry 1997).
gases (Conway, 1992b). If hypertonic saline is used, it should be
preceded by a bronchodilator in case of bronch
Humidification is not indicated for the ospasm and used preferably with an ultrasonic
following: nebulizer (Eng et aI., 1996).
Regular checks for a visible mist may show
• people using nasal cannulae, because at low that there is no blockage in the system, but
flow rates the patient's nose provides production of a mist does not indicate correct
adequate humidification, and any added droplet size because the therapeutic range of 2-
moisture is lost by condensation in the S !lm diameter is not visible.
narrow tubing (Campbell et al., 1988) Room humidifiers have no influence on the
• people with permanent tracheostomies, respiratory tract and can create a source of
because adaptation occurs (Shelly et al., infection (Wissing, 1988), but a well-main
1988) tained system may reduce the incidence of
• people using venturi masks, because the 'sick building syndrome' (Nordstrom et aI.,
entrained ambient air is not as dry as piped 1994).
191
EXERCISE Modifications include:
Exercise is an efficient way to assist clearance of • alternate-side-Iying, the most commonly

secretions. It creates a shearing force along the used position for patients with generalized
airway walls (Andersen et at., 1979) and leads to secretions
sympathetic stimulation of cilia by catechola • sleeping in a modified postural drainage
mine release and parasympathetic stimulation of position (Verboon et at., 1986), using tele
airway mucus glands (Bye et at., 1997). The phone directories to prop up the foot of the
benefits of exercise have been mostly documen bed, so long as this does not cause coughing
ted with CF patients and measured by FEV 1 during the night
(Thomas et at., 1995). In children with PCD (p. • bending forward over the toilet, or leaning
92), exercise has been found more beneficial over to clean the bath, which are positions
than drugs in aiding bronchodilation prior to reported by some patients to spontaneously
physiotherapy (Phillips et at., 1998). clear secretions.
POSTURAL DRAINAGE Effects

Postural drainage (PD) is thought to use gravity PD is effective if it provides symptomatic relief
to assist drainage of secretions, but the exact or long-term benefit. It is unhelpful if patients
mechanism is unclear. find it uncomfortable or unacceptably inconveni
ent. Long-term benefit is difficult to evaluate
Technique because most studies do not isolate it from other
Timing depends on the individual, but PD in the techniques.
early morning helps clear the night's accumu Wong et at. ( 1977) suggest that thin mucus is
lated secretions, and PD an hour before sleep more responsive to gravity than thick mucus,
reduces night coughing. PD should be avoided and that, while mucus in the large airways is
after meals. If bronchodilators are prescribed, responsive to gravity in CF patients, surface
these are best taken 15 minutes beforehand. forces may limit drainage in the smaller airways.
Patients are positioned with the area to be Mortensen et at. ( 1991) have shown that total
drained uppermost (Appendix B), bearing in clearance is unchanged several hours after
mind that these positions may need modification treatment. This suggests that it might be less
for patient comfort or if lung architecture has useful for the long-term effect of a disease
been distorted by surgery, fibrosis, a large process, e.g. the vicious cycle of CF, but may be
abscess or bullae. The most affected area is useful for symptomatic management so that time
drained first to prevent infected secretions at school is more amenable or time at the dentist
spilling into healthy lung. Patients on monitors more comfortable.
should be checked for arrhythmias or desatura The direct effect of gravity may not be the
tion before, during and after PD. only mechanism. Tannenbaum and Davids
Drainage times vary, but ideally each position ( 1995) cast doubt on the ability of gravity to
requires 10 minutes (Gumery et at., 2001). If the influence thick secretions, and Lannefors ( 1992)
disease affects the whole lung, each lobe requires found, surprisingly, that dependent lung showed
drainage, but a maximum of three positions at a greater clearance than non-dependent lung. The
session keeps it tolerable. People with localized rationale may be that the greater ventilation in
bronchiectasis or an abscess should be positioned dependent regions (p. 9) encourages movement
with the affected area upwards. The procedure of secretions by mechanical squeezing. It may
should be discontinued if the patient complains also be that the motion of changing into a
of headache, discomfort, dizziness, palpitations, postural drainage position has as much effect as
breathlessness or fatigue. the position itself, as shown by patients who
192 ------
MANUAL TECHNIQUES
expectorate immediately after changing • undrained pneumothorax

position. • bronchopleural fistula
Unhelpful effects are mainly related to the • risk of aspiration
head-down position, which increases the work • gastro-oesophageal reflux (Button et ai.,
of breathing (Marini et ai., 1984), tends to 1994).
reduce tidal volume (Olseni, 1994) and
decreases FRC in people with normal lungs
MANUAL TECHNIQUES
Oenkins et ai., 1988).
Percussion or vibrations are performed in a
Indications postural drainage position. They aim to jar loose
PD is used for people who find it preferable or secretions from the airway walls.
more effective than other means, especially if
they have diffi<mlty in using more active Technique
methods. PD assists people with lung abscess
Percussion consists of rhythmic clapping on the
usually, bronchiectasis often and CF sometimes.
chest with loose wrist and cupped hand, creating
If used for patients with acute problems,
an energy wave that is transmitted to the
modified positions are often required. For
airways. A sheet or pyjama top should cover the
people with chronic conditions, poor compliance
patient but thick covering dampens transmission
with this antisocial procedure is renowned
through the chest wall (Frownfelter and Dean,
(Currie et ai., 1986). A week's trial should
1996, p. 345), and correct cupping of the hand
include motivating patients to fit an individual
ensures that the procedure is completely comfor
programme into their daily routine so that
table. Indeed, performed correctly, it can soothe
results can be assessed accurately and decisions
children and sometimes give relief to people
can be made on whether this and/or other
who are acutely breathless. Patients may prefer a
measures are most suitable.
slow single-handed technique (Bastow, personal
Precautions communication, 1996) or rapid double-handed
technique, but the latter can cause breath
It is unwise to tip a patient head down in the
holding and occasionally bronchospasm
presence of:
(Wollmer et aI., 1985).
• cerebral oedema, e.g. acute head injury or Vibrations consist of a fine oscillation of the
recent stroke hands directed inwards against the chest,
• hypertension performed on exhalation after a deep inhalation.
• surgical emphysema Shaking is a coarser movement in which the
• trauma, burns or recent surgery to the head chest wall is rhythmically compressed. Both are
or neck less effective on a squashy mattress. Vibrations,
• recent pneumonectomy or surgery to the shaking and percussion should be interspersed
aorta, oesophagus or cardiac sphincter of the with relaxed deep breathing to prevent airway
stomach closure, desaturation or bronchospasm.
• headache
• breathlessness Effects
• symptomatic hiatus hernia
Many studies on these traditional techniques are
• history of seizures
old, unreliable or contradictory, but some claims
• epistaxis or recent haemoptysis
are the following:
• abdominal distension, pregnancy, obesity
• acute spinal cord lesion • When combined with postural drainage,
• pulmonary oedema, arrhythmias or cardio manual techniques accelerate clearance from
vascular instability peripheral lung regions (Bateman et ai.,
193
1981) and produce more sputum than exer patients without sputum production IS not
cise alone (Bilton et aI., 1992) but it is indicated' .
unclear which modality is the effective one Appraisal: Postural drainage and chest
• Percussion speeds mucociliary transport percussion in patients with mgrowmg
(Radford, 1982). toenails is not indicated either.
Self-percussion is objectively ineffective and

can cause oxygen desaturation in vulnerable
BREATHING TECHNIQUES
patients because of the physical effort (Carr et
al., 1995). Patients sometimes claim subjective Both of the following breathing techniques are
benefit, in which case those at risk of desatura flexible, efficient and effective when taught
tion are advised to include regular rests with correctly. They foster independence because
relaxed breathing. once taught they can be used without assistance.
They are particularly suited to people with
Indications chronic lung problems but are adaptable to those
Manual techniques reinforce patient dependency with acute disease, autogenic drainage being
but are suited to some people who find these preferable for fatigued patients. They are
methods helpful. Patients with chronic problems described separately but are based on the same
usually prefer to choose an independent principles and physiotherapists are advised to
technique. Manual techniques may benefit develop their own technique which incorporates
people who are exhausted, e.g. with an exacer both.
bation of disease, or weakened by neurological
disease, or young children, the very elderly or Active cycle of breathing
those with learning difficulties. The active cycle of breathing (ACB) consists of a
cycle of huffs from mid to low lung volume
Precautions interspersed with deep breathing and relaxed
Percussion and vibrations are to be avoided or abdominal breathing (Pryor and Webber, 1998,
modified in the presence of: p. 140).
• rib fracture, or potential rib fracture, e.g.

Mechanism
metastatic carcinoma or osteoporosis
During huffing or forced expiration, the pleural
• loss of skin integrity, e.g. surgery, burns or
pressure becomes posItIve and equals the
chest drains
alveolar pressure at a point along the airway
• pain, e.g. the above, pleurisy or post-herpetic
called the equal pressure point, usually in the
neuralgia
segmental bronchi. Towards the mouth from this
• recent or excessive haemoptysis, e.g. due to
point, the transmural pressure gradient is
abscess or lung contusion
reversed so that pressure outside the airway is
• severe clotting disorder, e.g. platelet count
higher than inside, thus squeezing the airway by
below 50 000 (see Glossary)
a process known as dynamic compression (p. 3).
• surgical emphysema
This limits airflow, but the squeezing of airways
• unstable angina or arrhythmias.
mouthwards of this point mobilizes secretions.
At high lung volumes, the equal pressure point is
more proximal because pleural pressure
Mini literature appraisal decreases and alveolar elastic recoil pressure
increases (Figure 8.7). It is thought that huffing
Literature: Connors et al. ( 1980) stated that at low lung volume mobilizes secretions from
'postural drainage and chest percussion in the more distal airways.
194
Upper
airway
Alveoli
++
Low lung
:E:P::
+
++
++
] volume
c-----....
+
..."".. .. ++ +
] FRC
EPP
+
++
++
+
+
High lung
++
volume
+
++
Figure B. 7 Greater pressures outside the airways (pleural pressure) than inside, caused by huffing. The equal pressure
point (EPP) at different lung volumes moves towards the mouth as lung volume increases. FRC = functional residual capacity.
To counteract airway closure, the huffing

phase of the cycle is interspersed with deep
breathing. Relaxed abdominal breathing is also
interspersed to reduce risks of bronchospasm,
paroxysms of coughing or desaturation (Steven
et ai., 1992).
Effects
The depth from which mucus is cleared has not
yet been validated (AARC, 1993b) and the effect
is still thought to be in the larger airways
(Conway, 1992b), but ACB may be working
quietly in the small airways by 'milking' the
mucus mouthwards.
Technique
Correct teaching is essential because huffing I em
alone can cause more airways obstruction than
Figure B.B A section of the bronchial tree (A) at FRC
coughing (Figure 8.8), worsen pulmonary ,
(B) at full inspiration, (C) at full expiration and (D) during

function (Boyd, 1994) and lmpaIr mucus coughing. (From Marshall, R. and Holden, W. S. (1963)
clearance (David, 1991). Patients at risk of Changes in calibre of the airways in man. Thorax, 18, 54-
bronchospasm need to control the airflow and 58)
195
give particular attention to relaxed breathing (deep breathing or abdominal breathing)

and rests. with the squeezing component (the huff)
Patients take up their position of choice. This • taking too sharp a deep breath, thus forcing
is often sitting but some find postural drainage the secretions back or stirring up bronchos
positions helpful, e.g. alternate side-lying. The pasm
following sequence is best demonstrated to • not relaxing between cycles
patients while sitting facing them: • coughing before secretions are accessible.
• relaxed abdominal breathing (breathing Patients with undiagnosed hyperventilation

control) to facilitate relaxation syndrome may develop symptoms (p. 295) when
• three or four deep breaths (thoracic expan they take the deep breath, in which case the
sion) to reverse airway closure and open technique needs to be modified. Huffing should
collateral channels be delayed or modified if it causes bronchos
• relaxed abdominal breathing, to maintain pasm, fatigue or spasms of coughing. Some
relaxation patients prefer to do several cycles of deep and
• one or two huffs, from low lung volume at abdominal breathing before the huff. Technique
first, to mobilize secretions must be checked regularly.
• relaxed abdominal breathing, etc. Many patients find it complicated to learn
three components and the principles can be
Cycles continue until the chest is subjectively applied using two components only. The deep
or objectively clear, or the patient tires. breath can be combined with the abdominal
Avoidance of high lung volumes is easier if breath by taking 'a nice big comfortable relaxed
patients are told to inhale only a 'half-breath' sigh'. This stretches the airways but maintains
before the huff, or to huff at the end of expira relaxation, and can be interspersed with the
tion only. Higher lung volumes can be used once huff.
secretions are mobilized from distal airways.
Many patients will be able to identify when
Autogenic drainage
secretions are shifting, or can be shown by the
technique used in autogenic drainage, below. Autogenic drainage (AD) shares a similar
Maintaining an open glottis may be facilitated by rationale to ACB, with special emphasis on
huffing through a paediatric peak flow mouth creating high airflow in different generations of
piece, so long as patients do not use it as if bronchi without allowing airway collapse.
taking a peak flow reading. Controlled breathing clears secretions from
Flexibility is encouraged to suit the individual. small to large airways by gradually increasing
The number of huffs can vary and the force of FRC. For people with CF or bronchiectasis, the
the huff can vary greatly. Rests between cycles full sequence can take up to 30-45 minutes to
can be momentary or, for those who are tense or complete, but it is less burdensome when
liable to bronchospasm, may be longer. The combined with activities such as nebulizing
sequence can vary so long as the principles of drugs or watching TV. For other patients, length
alternate stretching and squeezing of the airways of treatment is shorter and flexible. Control of
are followed and relaxation is maintained. the speed of inhalation and exhalation IS the
The patient will make spontaneous adapta key.
tions and the physiotherapist can check whether
these are helpful. Unhelpful examples include: Indications
AD is particularly suited to people with chronic
• huffing at too high a lung volume at first, by hypersecretory disease, but selected components
taking a deep breath before the huff can be used for the acute hospital patient, e.g.
• not alternating the stretching components postoperative patients who are anxious about
196 ------
pain and stitches, people with haemoptysis or glottis are kept open and the neck is maintained
asthma or for those at risk of panic attacks. For in slight extension because any obstruction
breathless people, short sessions are required, prevents free laminar flow of air (Figure 8.9).
with modifications as necessary to avoid Upper airway closure and air swallowing are less
upsetting the breathing pattern. Adolescents likely if there is little movement of the larynx.
appreciate that AD can reduce their hyperin The nose is blown if necessary, and the throat
flated chests so long as they do not start inhala cleared of secretions to reduce resistance to
tion before fully breathing out. airflow. The location of secretions is identified
by the patient exhaling until the rattle of secre
Effects tions is heard. The later the rattle on exhalation,
AD improves airflow in the small airways, the more peripheral are secretions. The AD cycle
clearing secretions that are not easily accessible, is then followed:
and is often preferred by patients (Butler and
1. Inhalation through the nose at 1.5-2 times
Sutherland, 1998). It is less likely to cause
tidal volume, slow enough for the breath not
oxygen desaturation than PD and percussion
to be heard, using an abdominal breathing
(Giles, 1995). Compared to ACB, it shows faster
pattern if possible. Slow inspiration prevents
mucus clearance (Miller et al., 1995), greater
secretions moving distally and encourages
increase in Sa02 and reduction in hypercapnia
equal filling of all areas of lung.
(Savci et al., 2000).
2. End-inspiratory pause for 1-3 seconds to
encourage air to get behind secretions by
Technique
collateral ventilation.
Patients choose their position. Most sit upright,
3. Exhalation at a steady rate, with the highest
although some prefer supine. For facilitation of
flow that does not cause airway collapse,
abdominal movement, some patients find prone
breathing out to a low enough volume to
helpful. During teaching, the physiotherapist's
locate and 'unstick' the mucus. Some patients
hands can be used to assess secretions and facili
exhale through the nose or through pursed
tate exhalation.
lips to utilize the extra resistance and create a
Face muscles, shoulders and arms remain
form of PEP (p. 198).
relaxed throughout. The mouth, throat and
If the mucus has been heard to rattle early on
exhalation, it is advisable to clear the upper
airways first at higher lung volumes. If not, the
breaths are started from residual volume (Figure
8.9).
When the patient feels the secretions moving
upwards, breaths are taken at a higher FRC to
'collect' the mucus. These two phases may need
to be repeated several times before the rattle of
secretions is felt more proximally. Breathing at
higher volumes can then be used to 'evacuate' the
mucus to the upper airways, from where they can
be expectorated by a huff or gentle cough.
The aim is a mucus rattle and not a wheeze.
Patients at risk of bronchospasm may need to
exhale 'as gently as a receding wave leaving
Figure 8.9 Disruption of airflow by upper airway foam on the beach'. The upper airway should
constriction, remain open throughout. Exhaling against a
197
Phase 2 3
UNSTICK COLLECT EVACUATE
n
(Low lung volume)
�
(Mid lung volume) (Higj1lung volume)
Mobilize peripheral Collect in middle Expec te
secretions airways
I RV
,..-,
,..-,
,..-,
�
" r--;
VT
"'-'r--lr-lr-"'1
E RV
----------- - -- - - - --- - c-
-- ---- -- --- --
RV
Figure 8.10 The three phases of autogenic drainage. (From Prasad, S. A. and Hussey, J. (1995) Paediatric Respiratory Core,
Nelson Thomes)
tissue held at arm's length, or exhaling to mist be incorporated into the chest clearance
up glasses or a mirror, encourages maximum sequence. A written handout is needed for rein
airflow and discourages noise in the throat, forcement. Box 8. 1 gives an example that
which indicates upper airway closure. Cupping a includes the principles of ACB and AD. Box 8.2
hand over one ear accentuates the sound of is a useful accompaniment.
airflow and enables the patient to minimize it.
Some patients with bronchiectasis can skip the
MECHANICAL AIDS
second phase if the unstick phase brings up
secretions quickly. Patients do not need to
follow three rigid sequences so long as they use Positive expiratory pressure
the principle of gradually increasing lung volume Positive expiratory pressure (PEP) is the applica
so that distal airways are cleared first. Patients tion of positive pressure at the mouth during
who find it difficult to breathe at low lung expiration. Breathing out against resistance is
volumes can vary the volumes (Prasad, 1993). thought to open up airways, even the distribu
Coughing is re-educated to ensure that it is tion of ventilation, force air through collateral
effective and not just noisy, and it may be channels and boost mucociliary clearance (Figure
avoided altogether if the huff is successful. Unne 8. 1 1). PEP also helps counteract airway closure
cessary huffing or coughing closes airways and caused by floppy airways or coughing.
stimulates the bronchospasm that has been
avoided with such care. Technique
AD is best interspersed with relaxation. If using a mask (Figure 8. 12), patients adjust the
Regular exercise is advised, and the PEP or air seal for the correct fit. Children need to accli
flutter device, described in the next section, may matize to the mask, or take it home to try out,
198
MECHANICAL AIDS
Box 8.1 Patient handout: breathing technique for clearing secretions
This technique squeezes and stretches your airways so that secretions can be brought up from deep
in your lungs and expectorated with the minimum of effort.
1. Sit comfortably, or use any position that makes it easiest to clear your lungs.
2. Take one or two or three deep slow comfortable relaxed breaths, like sighs, preferably
through your nose.
3. Relax for a few seconds to get your breathing steady again.
4. Take a very small breath in, then huff hard enough to move the secretions but not hard
enough to make you wheeze or cough. Keep your throat open as you huff, head slightly raised.
5. Relax for a few seconds.
6. Repeat no. 2.
7. Continue the cycle, and as you feel the secretions shift, allow yourself slightly deeper breaths
before the huff. This squeezes the airways higher up in your chest as the secretions move
mouthwards.
8. Take sips of water between cycles. Keep relaxed.
9. When the secretions are ready, huff them out, or if necessary cough them out. Do not cough
unnecessarily. When huffing or coughing, do your pelvic floor exercise before and during the
cough.
10. Continue the cycle until your lungs are clear. If you are not sure, breathe out until you feel a
rattle. The longer it takes to reach the rattle, the deeper are the secretions. If there is no rattle,
your lungs are clear.
Box 8.2 Patient handout: pelvic floor exercises Uane Goudge, Eastbourne DGH, with modifications)
Your pelvic floor can be strained by excessive coughing. Each cough is like a bounce on the pelvic
floor muscles, which form a sling between the base of the spine and the pubic bone. Strengthening
your pelvic floor muscles helps to prevent leaking.
Exercise
Feet slightly apart, close back passage (anal sphincter) and tighten front passages (urethra and
vagina), draw them up inside.
Hold for a count of up to 4.
Let go slowly.
Do not hold your breath.
Avoid tightening buttock or tummy muscles.
How, when, where

Practise in different positions, e.g. lying with knees up, sitting, standing.
Practise little and often!
Set a daily programme that you know you can achieve.
Practise on the telephone, at the sink, while waiting for the kettle to boil, at the bus stop, in the
supermarket queue, during TV advertisements.
Tighten pelvic floor muscles before any action causing a downward thrust, e.g. coughing, sneezing,
laughing, pushing.
199
Figure B.12 Mask PEP.
Figure B. I I Collateral ventilation. Ventilation (V) finds its

way behind the mucus plug through collateral channels.
resistance and an adult a 2.5-3.5 mm resistance.
With the PEP mask held firmly over nose and
before adding the resistance. If using a mouth mouth, patients inhale slowly at normal tidal
piece (Figure 8.13), a nose clip is used and the volume, hold their breath briefly at end-inspira
same principles applied. tion, then exhale actively but not fully or force
Patients then take up their position of choice fully. They should experience a comfortable
but, for those with advanced disease, sitting with effort, as if giving way to the resistance. As the
elbows resting on a table may protect the lungs secretions move centrally, breaths can be taken
from over-distension. The smallest diameter at higher tidal volumes. A manometer between
resistor is chosen which the patient can use the valve and resistor monitors the pressure.
comfortably for 2 minutes to achieve a pressure This is observed by the physiotherapist and not
of 12-15 cmH20 during mid-exhalation. As a the patient, who might otherwise try to reach
guideline, a child might start with a 1.5 mm the target pressure by altering their breathing
pattern.
Exhalation should last no more than 4
seconds. About 10 PEP breaths are alternated
with several relaxed breaths. When secretions
have been mobilized, they can be cleared by
ACB/AD. This continues until the lungs are
clear. During stable disease, most patients find
that two I S-minute or three 10-minute sessions
a day are adequate. Modifications of technique
for mouthpiece PEP are enclosed with the
device. The resistance should be checked
approximately fortnightly for 6 weeks, then
every month for 3 months.
'High pressure PEP' creates pressures of
60 cmH20 (Hardy, 1994), using a manometer
Figure B.13 Mouthpiece PEP (Medicaid). and flow volume curves to gain maximal homo-
200
MECHANICAL AIDS
geneity of expiration. It is not used regularly lations are caused by the vibrations of a steel ball
because of the equipment required. within a cone. The device encourages slow
·
breathing in order to keep up the oscillations
Indications and gives more feedback than PEP by its vibra
PEP is mostly used by people with CF, especially tions.
adolescents and those seeking freedom from PD, The flutter can be used for patients who find
but people with bronchiectasis, or those with it helpful subjectively. Rigorous research is
COPD who have difficulty clearing secretions, lacking, although claims have been made that it
also find it helpful (Christensen et al., 1990). It assists people with COPD (Callegari, 1994), CF
is suited to patients with moderate amounts of (Konstan, 1994) and productive asthma (Girard
sputum and can be used by children as young as and Terki, 1994). The oscillations may reduce
4. Those with large amounts of sputum need sputum viscosity (App et at., 1998) by rearran
extra emphasis on accompanying techniques ging crosslinks and reducing molecular size
such as ACB/AD. (King, 1997). Some patients find the flutter
PEP can reduce the incidence of chest helpful for a final clear-out after other techni
infection and improve lung function (Plebani, ques.
1997). There are claims that it is more effective
than PD (Mortensen et al., 1991), PD and Technique
percussion (McIlwaine et at., 1996) or the flutter Patients sit as if using the PEP mask, hold the
(McIlwaine et at., 1997). mouthpiece in the lips, inhale through the nose,
hold for 2-3 seconds, then exhale at twice
Flutter normal speed through the mouth. Patients must
The combined effects of PEP and oscillation are keep their cheeks taut and avoid blocking the
exploited by the flutter (Figure 8. 14), a device holes on the device.
resembling a short fat pipe and suited to anyone The aim is for maximum oscillation, which is
who can blow bubbles. By exhaling into the assessed subjectively by the patient and objec
flutter, the patient creates a positive oscillatory tively by the physiotherapist palpating for vibra
pressure of 10-20 cmH20 in the airways. Oscil- tions over the chest. The angle of the device
should be varied until maximum frequency of
oscillation is experienced. Mobilization of distal
secretions is emphasized by tilting the flutter
Perforated slightly upwards, and for more proximal secre
o
protective tions it is held more horizontal. The location
cover
from which secretions are mobilized, for both
0 flutter and PEP, can also be influenced by
0 breathing from different lung volumes, as with
Exhaled air ACB/AD. The flutter is used for between 5
minutes (e.g. in COPD) and 20 minutes (e.g. in
CF). Some devices break if dropped, and the
steel ball should be kept away from toddlers,
who might put it in their mouths.
The flutter is less evidence-based than PEP,
but patients vary in their preference and should
Mouthpiece use whichever they find most helpful. PEP can
High-density
steel ball be taught in two sessions and the flutter in one.
Videos for teaching PEP and the flutter are
Figure 8.14 Flutter device (VarioRaw). available (Appendix C).
------ 201
C HAPTER 8 PHYSIOTHERAPY TO CLEAR SECRETIONS
COUGH
Cough facilitation
Poor technique may be camouflaged by making
loud but ineffectual noises in the throat. Tips to
overcome problems are described below:
• Pain following surgery inhibits coughing.

Pain relief and manual support are covered
in Chapter 10.
• Thick secretions reduce the effectiveness of
Figure 8. 1 5 Cornet (RC cornet, wrth perrnission). coughing (King, 1985). Assistance is by
hydration if necessary, or a large volume
nebulizer or, for rapid effect, an ultrasonic
nebulizer.
Cornet • A dry mouth inhibits expectoration. This
Positive pressure and oscillations can be created can be helped by a hot steamy drink, semi
by actively breathing out through a curved frozen juice or gin and tonic (Reynard,
plastic tube called a cornet (Figure 8. 15). This 1997) mouthwash, sips of water or sucking
contains a flexible hose, which acts as a valve. Ice.
Feng et at. (1998) claim that this decreases • Inhibition may be caused by embarrass
sputum viscosity. ment, disgust or anxiety. Patients may be
anxious about 'stitches splitting', in which
case they can usually be reassured because
Percussors, vibrators and oscillators wound dehiscence is rare (see p. 251).
A variety of expensive devices are available to Anxiety about stress incontinence can
shake up the airways: inhibit coughing, especially In elderly
people. There may also be anxiety about
• mechanical percussors and vibrators (Bauer nausea or paroxysms of coughing.
et aI., 1994) • Weakness due to neuromuscular or terminal
• inflatable vests known as high-frequency disease demands a resourceful physiothera
chest wall compressors (Arens et at., 1994) pist. All measures should first be taken to
• oral high frequency oscillators or intrapul bring the secretions proximally, as described
monary percussors, described on page 181 previously. Good old IPPB, surprisingly, can
(Kluft et aI., 1996) sometimes be helpful. Physical assistance is
• small mechanical vibrators, which are then given by helping the patient sit over the
cheaper and may help clearance from the edge of the bed if possible. The abdomen is
lung periphery (Gross and King, 1984). compressed manually, inwards and upwards,
while either sitting beside (Figure 8. 16) or
kneeling behind the patient. Abdominal
Intermittent positive pressure breathing compression is co-ordinated with the patient
Some weak or drowsy patients with sputum making an expiratory effort, and if helpful,
retention may respond to IPPB. If other interven leaning forward. Some patients can assist
tions have been ineffective, mechanical assistance themselves by sitting with a pillow pressed
can promote deep breaths in order to mobilize against the abdomen, then, after a deep
secretions or to maintain ventilation while other breath, bending forward while exhaling
techniques are applied. sharply. Some patients can learn breath-
202
COUGH
Figure 8.16 Supported cough.
stacking or glossopharyngeal breathing (p. • Other tips are:

180) to increase the inhaled volume prior to - acupressure to CV1 7 (p. 84)
the cough (Irwin et ai., 1998). For the well - blowing out through a straw into a glass
resourced, Bach (1993) describes a mechan of water
ical positive pressure blower with expulsive - gentle stimulation in one or other ear
decompression that aids coughing. canal (Irwin et ai., 1998) to stimulate
• If the upper airway is narrowed by a tumour, Arnold's nerve response but without
obstruction is sometimes relieved by the using any instrument, which is risky.
patient leaning in different directions to shift
the position of the tumour, then coughing. Precautions
• Semiconscious people may respond to Coughing should be avoided immediately after
abdominal co-contraction (see Figure 6.Sc), eye or cranial surgery, or in the presence of an
or quick gentle pressure upwards and aneurysm. It is also best discouraged, when
inwards over the trachea just above the possible, if there is raised intracranial pressure,
suprasternal notch. Moderate or strong pres surgical emphysema, recent pneumonectomy or
sure should be avoided, especially in elderly (depending on the cause) haemoptysis. Huffing
people because of potentially brittle calcified can sometimes be substituted. Manually assisted
tracheal cartilages. coughing should be avoided after eating.
------ 203
after starting the drug. Other non-productive

and 'habit' coughs, such as those following viral
infection, usually disappear over time but can
perpetuate themselves by irritating the airways.
Coughs and throat-clearing due to hyperventila
tion syndrome will melt away once the
syndrome is treated. Factors that exacerbate
coughing include irritants such as strong smells
and cigarette smoke, or change in air tempera
ture, especially when breathing through the
l(
mouth.
Suggestions to facilitate cough suppression
include the following:
• ask the patient to identify whether the cough

Figure 8.17 The need for cough suppression. (From is 'wet or dry'
Milne, A. ( 1 998) Smo/Qng: The Inside Story, Woodside, • if it is dry, advise to voluntarily inhibit the
Stafford, with permission. Artist: James Northfield . ) cough
• swallow
• take sips of water, lemon juice or cold green
Cough suppression grape JUICe
• breathe through the nose
Coughing needs to be inhibited in the following
• take repeated short sniffs
situations:
• take slow or shallow breaths
• if one of the above precautions is present • breathe out through pursed lips
• during ACB/AD, before secretions are acces • use autogenic drainage techniques to control
sible airflow
• if the cough is dry and irritates the airways • suck lozenges, ice pops or frozen seedless
• if coughing brings on bronchospasm, parox green grapes
ysms of coughing or distress (Figure 8. 17). • paradoxically, one manual percussion given
once on the chest
Multiple or paroxysmal coughs can lead to
• inhaling the steam from hot water poured
impaired mucus transport, fatigue, airway
over root ginger, then drinking the warm
closure (Menkes and Britt, 1980) and occasion
solution
ally cough syncope from excessive intrathoracic
• 'imagine warm honey sliding down your
pressure.
throat'
Some patients inhibit their cough for social
• for patients with floppy airways, e.g. late
reasons or because of anxiety about stress incon
stage CF, using a PEP mask to stabilize
tinence. These are understandable but not
airways and reduce expiratory flow
healthy reasons to abstain, and patients will need
• drugs as described on page 138
advice and, if appropriate, referral.
• for nocturnal cough, avoidance of the supine
The first step when dealing with an unproduc
position, or, if intractable, use of CPAP
tive cough is to identify the cause (p. 3 1). A .
(Bonnet, 1995).
cough caused by asthma, post-nasal drip or
gastro-oesophageal reflux should disappear once Occasionally a dry cough may be helpful and
the inflammation is controlled. A quarter of need not be suppressed, e.g. if a patient finds
patients taking ACE inhibitor drugs develop a that one brief cough will settle it as if 'scratching
cough, which disappears on average 4 months an itch'.
204
PHARYNGEAL SUCTION
�----------------------� r------�
,--, /
PHARYNGEAL SUCTION
�------------�
'The worst part is the initial introduction of (a)
the catheter into the nostrils. Once past the
turn at the back of the nose, it is not too
unpleasant, until a cough is stimulated; � ______________ --J
�
then it feels like hours as the catheter is (b)
bro".ght back up. It felt as if I was choking.'
Ludwig, 1 984
These remarks come from a physiotherapist who �------�

found herself at the wrong end of a suction (c )
catheter, arid they illustrate why most clinicians
are, rightly, reluctant to put their patients
through the ordeal of pharyngeal suction, which
is usually distressing and sometimes painful. It is
L..-
(d)
__ ��
also dirty, risky and limited in effectiveness, but
there are occasions when it is necessary.
Indications "':-:--
(e)
_____ :1)
Suction is performed if all the following criteria
are met: I I I
7 6 5
• secretions are accessible to the catheter, as
(f)
indicated by crackles in the upper airway on
auscultation Figure 8.18 Different catheter tips.
• secretions are detrimental to the patient
• the patient is unable to clear secretions by
other means. to limit damage to the mucosa (Lomholt,
Patients who are semiconscious, weak or 1982a). The side-eyes should not be too large
neurologically impaired may require suction, but (Figure 8. 18c) or they reduce suction efficiency,
those who are fatigued rarely do, because unless and their total size should be less than that of
fatigue is extreme enough for the patient to need the end-hole so that they do not become suction
mechanical ventilation, coughing is usually still channels. Catheters with multiple side-eyes cause
possible. Risks are increased in a combative less invagination than those with one or two
patient, and those who need physical restraint eyes (Link et ai. , 1976).
for suction rarely need to undergo the procedure A beaded tip is designed to prevent the side
because they are usually strong enough to cough eyes grabbing the mucosa, but the bead makes it
effectively, even though they choose not to. unsuited to nasal suction because of the enlarged
Forcible suction is unethical, illegal in the UK tip (Figure 8.18d). The ideal catheter is flexible
and acceptable only in life-threatening situations. and has a smooth rounded tip and small,
multiple, countersunk side eyes.
Catheters
Technique
Catheters have an end-hole through which the
The following steps are suggested:
mucus is suctioned and side-eyes to relieve
vacuum if the end-hole becomes blocked. Both 1. Ensure that the resuscitation status of the
end-hole and side-eyes are best slightly depressed patient is known.
------ 205
CHAPTER 8 PHYSIOTHERAPY TO CLEAR SECRETIO S
2. A size 10 FG catheter is preferable, but is usually in the trachea if the patient

some patients may need size 12. coughs.
3. Ensure the patient is upright or side-lying in 10. When resistance is felt, this is probably the
case of vomiting. carina and the catheter should be withdrawn
4. Preoxygenate for a minimum 2 minutes if slightly before applying vacuum pressure in
this is not contraindicated. The oxygen mask order to limit trauma. Note roughly the
should then be kept close to the patient's length of catheter that has been inserted so
face throughout. that the carina can be avoided if further
5. Explain to the patient how it will feel, how suction is necessary.
long it will last and that s/he may ask for a 11. Apply suction and bring up the catheter
pause at any time, a request that must be slowly and smoothly, avoiding catheter
responded to. Unconscious patients need an rotation or sudden intermittent suction.
explanation. Slow withdrawal reduces the need for a
6. Set the suction pressure. High pressures can second attempt, but if the patient appears
be damaging but low pressures are less distressed, the catheter should be partially
effective and may prolong suction time withdrawn until distress stops, then the
(Lomholt, 1982b). Consensus suggests that vacuum should be removed and oxygen
the maximum safe pressure for adults is applied with the catheter still in situ, until
23 kPa (170 mmHg) (Donald et ai., 2000) the patient is ready to continue.
but original research is lacking and the
lowest effective pressure should be used. Rotation is unnecessary with multiple-eyed
7. Partially unpeel the catheter pack and attach catheters and ineffective with other catheters
the catheter to the suction tubing while (Emergency Care Research Institute, 1977)
keeping the rest of the catheter in the pack. because torsional stiffness prevents transmission
Put gloves on both hands. The dominant of rotation to the catheter tip in vivo.
hand needs a sterile glove and both gloves Intermittent suction involving the sudden on!
should be non-powdered in case the powder off application of vacuum pressure has two
finds its way into the lungs. Remove the disadvantages:
catheter from the pack and lubricate the tip • it reduces effectiveness by decreasing flow
with water-soluble jelly. Maintain sterility of from an average 19 to an average 8.5 L/min
catheter and sterile glove. (Brown, 1983), making further suction more
8. With the suction port open, slide the likely
catheter gently into the nostril, directing it • sudden release of pressure may damage
parallel to the floor of the nose. If resistance mucosa (Frownfelter and Dean, 1996, p.
is felt at the back of the pharynx, rotate the 768).
catheter slowly between the fingers and ease
very gently forwards. Czarnik et al. ( 1991) found that intermittent
9. To reduce the risk of entering the suction had no advantages over continuous
oesophagus, ask the patient to tilt the suction.
head back, stick the tongue out and Protection of mucosa is best maintained by
cough. If coughing is not possible, slide continuous withdrawal, without stopping to
the catheter down during inspiration, when change the position of the dominant hand on the
the glottis is more open. If the patient catheter. If suction pressure rises unacceptably,
swallows, the catheter has slipped into the the rocking thumb technique should be used,
oesophagus, in which case it should be which is the smooth and partial removal of the
slightly withdrawn, the head repositioned thumb from the control port of the catheter to
and the procedure continued. The catheter reduce pressure gently.
206
PHARYNGEAL SUCfION
Afterwards, remove the gloves inside out over 'breathe it in', then it is rotated and passed
the catheter and discard, rinse out suction gently into the throat, curve downwards. During
.
tubing, give the patient oxygen and comfort, insertion it should be held downwards so that it
check monitors. does not press on the soft palate and cause
If the nasal route is uncomfortable, the other gagging. Introducing the airway is not painful
nostril can be tried or the oral route used. but is often distressing, and patients should be
For oral suction, the catheter is inserted into reassured that it will not stop them breathing.
an oral Guedel airway, a plastic tube shaped to Passage of the catheter then proceeds through
conform to the palate with a flange to prevent it the airway, as described above.
slipping into the throat (Figure 8.19b). A size 6
is average, but the airway is best sized by Complications
holding it against the ear lobe and measuring it Untoward effects of suction may be subclinical
to the corner of the mouth. With the catheter tip and go unrecognized. Complications include the
protruding just beyond the end of the airway, following.
both airway and catheter are passed into the
mouth, curve upwards, the patient is advised to • Airway mucosa is exquisitely sensitive and is
damaged by both passage of the catheter
(a) (Swartz, 1996) and pull from the vacuum
(Kleiber et at., 1988), exacerbated by poor
technique. Damage can be tantamount to a
crude biopsy, leading to bleeding and up to
500/0 reduction in mucociliary transport
(Landa et aI., 1980), with short- and long
term effects.
• Infective organisms find an easy target once
the protective mucosa is damaged.
• The vacuum can cause atelectasis.
• Sustained hypoxia can result from atelec
tasis, removal of oxygen, enforced apnoea
(Petersen et at., 1979) and increased oxygen
demand.
• Hypoxaemia or irritation of the vagus nerve
can cause arrhythmias, bradycardia or
unstable BP. Stress can cause tachycardia.
• Laryngospasm is a rare but dangerous
complication. If the patient stops breathing
and the catheter feels stuck, the crash team
should be called. Laryngospasm may be
relieved by gentle positive pressure via a
mask and oxygen from the crash trolley, or
intubation may be necessary (Leisure et aI.,
1995).
Precautions
• Pharyngeal suction is contraindicated if
Figure 8.19 (a) N asopharyngeal airway and (b) oral stridor is present because of the risk of total
airway. airway obstruction.
------ 207
• Relative contraindications are an unstable and re-inserted. The tip rests behind the tongue
cardiovascular system, undrained pneu just above the epiglottis. A safety pin across the
mothorax, haemoptysis of unknown origin top prevents it disappearing into the patient. It
and acute face, neck or head injury. should not be used in patients who have polyps,
• If there is cerebrospinal fluid leak after basal congenital deformities or old fractures of the
skull fracture, an oral airway should be used nose, CSF leak or bleeding from the nose or ear
because there is a risk of infection if organ Genkin, 1996).
isms are dislodged and come into contact
with cerebrospinal fluid.
MINITRACHEOSTOMY
• Bleeding may occur in patients who have
clotting disorders or are receiving heparin or Minitracheostomy: small opening into the
thrombolytic drugs. trachea to facilitate suction.
• If the patient has pulmonary oedema, suction Minitracheotomy: procedure to create a
does not help the condition and will remove minitracheostomy.
surfactant if performed repeatedly.
A relief for both physiotherapist and patient has
• Suction aggravates bronchospasm but so too
been the advent of the minitracheostomy (Figure
does excess mucus.
8 . 20), which allows access for safe and comforta
• Following recent pneumonectomy or lung
ble suction and leaves minimal scarring. A mini
transplant, the catheter should not be taken
tracheostomy can prevent the need for
beyond the pharynx in case it impinges on
bronchoscopy or intubation (Preston et aI.,
the bronchial stump or anastomosis.
1986).
• After recent oesophagectomy with a high
A minitracheotomy is usually performed
anastomosis, or with a tracheo-oesophageal
under local anaesthesia on the ward. A 4 mm
fistula, the catheter may miss the trachea and
internal diameter cannula is inserted surgically
enter the oesophagus. Insertion should there
through the cricothyroid membrane into the
fore not be beyond the pharynx, or a mini
trachea, then left in place for as many days as
tracheostomy can be requested.
necessary. Suction with a size 10 catheter can
Clinicians should wear a visor (or mask and then be performed through the aperture, and the
goggles) to prevent cross-infection because the patient can breathe normally throughout. Some
patient may be infected with Pseudomonas,
MRSA (p. 320), TB, HIV or other invisible
bug.
NASOPHARYNGEAL AIRWAY
A nasopharyngeal airway (Figure 8.19a) can be

used for patients who need frequent suction, but
insertion is painful and sinus infection is a risk.
Size 6 mm is usually suited to women and 7 mm
to men. The size is correct if the airway can be
slightly rotated inside the nose. It is lubricated
with aqueous or lignocaine gel before insertion,
passed gently into the largest nostril, directed
along the floor of the nose parallel to the hard
palate, then left in place for a maximum 24
hours, after which if necessary it can be cleaned Figure B.20 Minitracheostomy.
208
OUTCOMES
secretions are too thick for a minitracheostomy,

although saline instillation may be helpful. A
spigot protects the airway when the tube is not
III use.
A minitracheostomy tube is uncuffed and

preserves the function of the glottis so that
natural humidification is maintained and the
patient can cough, speak, eat and breathe spon
taneously.
Minitracheotomy is often performed later
than optimal. The physiotherapist can act as
instigator .to ensure that it is used early
enough to be most effective. Prophylactic
placement during surgery is useful for patients
at high risk of postoperative sputum retention
(Kirk, 1996).
OUTCOMES
The following can be used to evaluate the effec

tiveness of techniques for sputum retention or
excess secretions:
Figure B.21 SP.
• the patient's opinion
• 1 crackles on auscultation Exercise mainly by biking to school, little exercise
• i volume of sputum
in holidays.
• i 5a02, so long as other variables are
Frequent admissions.
excluded
• greater independence of patients to manage
their own secretions. Subjective
Physiotherapists can evaluate their manual Bored.
techniques through a bronchoscope, if their Not clearing phlegm.
patient is to undergo this procedure. N ot hungry or thi rsty.
Objective
I;ii�i" +$1IiIi)••1a Hyperinflated chest.
Th in.
A 1 7-year-old is admitted with an exacerbation of Top-up feeding by gastrostomy at night.
his cystic fibrosis ( Figure 8.2 1 ). IV antibiotics.
Clin ically dehydrated.
Background FEV 1/FVC 67, F EV 1 1 .2 L, FVC 1 .8 L - not reversed
S H : lives with parents, about to start college. with bronchodilators.
Self-management by brief morning session and $a02 95%
longer evening session: ACB, PEP, flutter, Spiking temperature.
postural drai nage. Auscultation: Widespread crackles.
Regular reviews with domiciliary physiotherapist. Frequent small, non-productive coughs.
------ 209
1. 'Deep breathing exercises have been

Questions proposed to assist the tachypnoeic patient.'
I . Analysis? 2. 'IPPB is claimed to be useful in delivering
2. Problem? aerosolized bronchodilators.'
3. Goals? 3. 'Available evidence suggests that postural
4. Plan? drainage and controlled coughing or FET
may be the most effective components'.
Eur. Respir. J. 1 993 ; 3: 353-355
I;!f14.]�;1'g.j;ii�i141IiIi).A_ FEY
to ACE.
= forced expiration technique, predecessor
I. Analysis
X-ray (Figure 8.2 1 ) shows soft tissue densities and
multiple ring shadows, suggesting infection
superim posed on chronic lung damage. X-ray 1. A tachypnoeic patient's problem is increased
and RFTs indicate advanced disease. WOB, not loss of lung volume. Deep
Chest clearance may be hampered by weakness, breathing is counterproductive for breathless
exacerbated by poor nutrition, and thick patients.
secretions, exacerbated by dehydration. 2. The words 'claimed to be' are unreferenced.
IPPB is an expensive and inefficient way of
2. Problem delivering medication.
Sputum retention. 3. Where is the 'available evidence'?
3. Goals
Clear chest. RECOMMENDED READING
Motivate reo future self-management. Anstey, K. H. and Roskell, C. (2000) Hydrotherapy:
detrimental or beneficial to the respiratory system?
4. Plan Physiotherapy, 86, 5 - 1 3 .
Liaise with team re i ncreasing fluid intake through Atwood, C . W . ( 1 9 98) Positive pressure therapy.
IV. Respir. Care, 43, 3 07-3 1 7.
Check ACB tech nique. Bremner, H., Carriere, B. ( 1 999) Evaluation of
If patient is tired or weak, discuss with him which breathing mechanisms in patients with pelvic floor
techniq ues might suit, e.g. postural drainage,

dysfunction. WCPT Proc. , p. 5 7 8 .
Bye, P. T. P., Alison, J. A . a n d Regnis, J. A . ( 1 997)
percussion, vibrations, I P P B .
Exercise performance and rehabilitation in CF.
Re-educate cough: suppress ineffective coughs,
Crit. Rev. Phys. Rehabil. Med., 9, 1 -3 3 .
cough only when secretions accessible.
Houtmeyers, E. and Gosselink, R. ( 1 999) Regulation
As patient im proves, start daily gym sessions. of mucociliary clearance in health and disease.
Check effect of car fumes when biking. Consider Eur. Respir. ]., 1 3 , 1 1 77- 1 1 8 8 .
mask. Irwin, R . S . , Boulet, L.-P. and Cloutier, M. M . ( 1 998)
Liaise with domiciliary physiotherapist. Managing cough as a defense mechanism and as a
symptom. Chest, 1 14, 1 3 3 S- 1 79S.
Pryor, J. A. ( 1 999) Physiotherapy for airway clearance
in adults. Eur. Respir. ]., 14, 1 4 1 8 - 1 424.
LITERATURE APPRAISAL Sch6ni, M. H. ( 1 989) Autogenic drainage. ]. Roy. Soc.
Med., 1 6(suppl.), 32-37.
Are the following statements problem-based? Williams, M. T. ( 1 995) Chest physiotherapy and
Are they evidence-based? cystic fibrosis. Chest, 1 06, 1 8 72- 1 8 82.
2 10
9 PULMONARY REHABILITATION
SUMMARY
Introduction • Safety
• Participants • Technique
• The set up Inspiratory muscle training
Assessment • Rationale
• Background information • Effects
• Respiratory function tests • Indications and contraindications
• Breathlessness and quality of life • Technique
• Exercise testing Energy conservation

Education • Activities of daily living
• Motivation • Stress reduction
• Understanding reactions to the disease • Mechanical rest
• Smoking withdrawal Follow-up, home management and self-help

Reduction in breathlessness Outcomes
Exercise training Mini case study
• Effects Literature appraisal
• Mechanism of training Recommended reading
INTRODUCTION the management of people with chronic respira

tory disability (Griffiths et ai., 2000), not an
Pulmonary rehabilitation is the only optional extra, but its provision in the UK lags
approach to chronic lung disease short of behind the rest of Europe and the US (Steiner et
lung transplantation that improves the long ai. , 2000). The need is greater now that patients
term outlook for these patients. are being discharged from hospital 'quicker and
Tiep, 1 99 1
sicker'.
Rehabilitation for people disabled by breathless Rehabilitation does not reverse lung damage
ness is a neglected area of health care but one of but it modifies the disability that derives from it
the most rewarding aspects of physiotherapy. It and normally shows greater benefit than medica
is neglected because of a widespread attitude tion (Lacasse, 1 996). Participants report a sense
that patients have reached a dead end. It is of well-being due to gaining control over
rewarding because it can improve independence symptoms, especially the fear of breathlessness.
for people who have become entangled in a web Evidence of the benefits of pulmonary rehabi
of inactivity and helplessness. Physiotherapists litation are legion (Appendix E), with some
themselves may feel helpless when faced with outcomes summarized below:
someone who has uncontrolled breathlessness, • ! breathlessness by 65% (Votto, 1 996)
lungs like tissue paper, a pessimistic outlook, an • i exercise capacity and quality of life,
unglamorous disease and no nice straightforward according to 14 trials (Lacasse, 1 996), even
problem, such as excess secretions, which can be for severely impaired patients (Griffiths et
dealt with by time-honoured techniques. ai. , 1 996)
Pulmonary rehabilitation should be integral to • ! health care costs (Figure 9 . 1 ), with at least
------ 211
CHAPTER 9 PULMONARY REHABILITATION
20
--- Data for all patients

18
- - - - Data only for those patients surviving
eight years in programme
16
�
14 \
C \
Q)
� \
0.. 12 \
Q; \
0..
<n 10
>-
\
'"
"0
\
Ei \
8
'0. \
<n
0
I \
6
\
\
4
\
2
1 yr 1st yr 2nd yr 3rd yr 4th yr 8th yr

Before
Years before and during pulmonary rehabilitation programme
Figure 9. 1 Hospital admissions after initiation of pulmonary rehabilitation, (From Hodgkin, J , E" Connors, G, L, and Bell, C.
W, (1993) Pulmonary Rehabilitation: Guidelines to Success, J, B, Lippincott, Philadelphia, PA)
12 studies demonstrating reduced hospitali contribution o f the participant and family IS
zation (Reina-Rosenbaum et at. , 1 997) central.

• in modified form, i ability to wean from
mechanical ventilation (Kozu, 1 999). Participants
No patient is 'too sick' or 'too well' to
Quality of life shows the most sustained benefit from a pulmonary rehabilitation
improvement (Foglio et at., 1 999). Positive programme.
outcomes depend on realistic expectations, Menier, 1994
teamwork and follow-up.
A programme includes about eight to 10 partici
Chronic lung disease links physical and
pants, with stratification for mild, moderate and
psychological factors by a potent blend of
severe disease. Suggested selection criteria are
breathlessness and chronic disability, and the
the following:
attitude and encouragement of the rehabilitation
team play a major role. Potential team members • breathlessness limiting activity
should be involved at the planning stage so that • motivation towards self-help and lifestyle
they have a vested interest in its success. The change
team typically comprises physiotherapist, occu • stable condition
pational therapist, respiratory nurse, physician, • optimal medical management
dietician and clinical psychologist or social • adequate ability to hear or communicate
worker, one of whom is the co-ordinator. The • ability to attend the full programme.
212
INTRODUCTION
1400 not be excluded, because helping them to quit

'1?
� 1200 can be part of the programme. Patients who
C suffer depression should not be excluded
·E 1000
<0 because depression does not reduce attendance
.!: 800
1J (Garrod et ai., 1 996). Exclusion criteria are
Q)
-'"
(ii 600 discussed under the sections 'Background infor

;:
Q)
u
400 mation' and 'Safety'.
c
J!l
III
(5
200
0
1 The set up
Admission Discharge Admission Discharge
COPD
The options are:
non-COPO
Figure 9.2 · Distance walked in 6 minutes before and • an outpatient programme

after exercise training, showing comparable benefits for • an inpatient programme in a dedicated reha
people with and without COPD. (From Foster, S. and bilitation ward
Thomas, H. M. ( 1 990) Pulmonary rehabilitation in lung • a discharge programme after exacerbation,
disease other than COPD. American Review of Respiratory
Diseases, 141, 60 1 -604) either in a pre-discharge ward or at home
• a home-based programme, useful for severely
disabled people or as a cost-effective alterna
tive to hospitalization for mild exacerbations
COPD is the most common cause of disability in • a community-based programme in a day
the community (Allison, 1 995), but people also centre, physiotherapy practice (Cambach,
benefit if they have asthma (Didour, 1 997), 1 997) or other facility that has single-story
cystic fibrosis, interstitial or other restrictive access and a more upbeat atmosphere than
disease, neuromuscular disorders (ACCP/ hospital.
AACVPR, 1 997), or following surgery
(Chumillas et ai. , 1 998) or long-term institutio Resuscitation and safety training are necessary
nalization (Schleifer et aL, 1 994). Figure 9.2 for programmes held outside hospital.
shows the comparable benefits. Pre-discharge wards do not prolong hospital
People with restrictive lung disease show stay Games et ai. , 1 9 9 8 ) and are ideal for frail
benefit in the early stages (Novitch, 1 995), elderly patients who would otherwise remain in
although the following precautions are an acute medical ward becoming deconditioned
advisable: and prey to hospital bacteria.
Home-based programmes are becoming
• for interstitial disease, monitoring for hypox popular because, although they lack peer
aemia during exercise support, exercise and energy conservation can be
• for neuromuscular disease, preventing adapted to an individual's environment (Garrod,
overuse of compensating muscles. 1 99 8 ), involve the family, reduce hospitalization
(Allison and Yohannes, 1 999) and have shown a
Outcomes are unrelated to lung function, and tripling of the time that benefits are sustained
patients can benefit regardless of severity of compared to a hospital-based programme
disease, including those with chronic hypercap (Strijbos, 1 996).
nia (Celli, 1 994) or old age (Clark, 1 996).
Rehabilitation is especially needed after an Resources
acute episode when patients are at their most The following are needed for a programme
teachable, and particularly to prevent the based in a hospital or day centre:
stepwise loss of function that follows hospitaliza
tion (Peach and Pathy, 1 9 8 1 ) . Smokers should • large, warm room with easily opened
213
windows, cheerful atmosphere, wall space session might include a question-and-answer

and non-slip floor, free from dust-collecting discussion with all team members, and plans for
furniture, and with acoustics that can cope the future. The programme must be during
with choruses of coughing daylight hours and avoid early mornings or rush
• comfortable upright chairs hour travel.
• treadmill, exercise bike, trampoline, quoits,
weights, stretchy bands, springs and other
gym equipment ASSESSMENT
• steps Assessment should take account of:
• rolla tors and high walking frame
• full length mirror • respiratory impairment: 1 lung function, e.g.
• fan FEV}
• demonstration inhalers • respiratory disability: the effect of this
• oxygen impairment, e.g. anxiety or 1 exercise capa
• oximeter city
• nebulizer system and drugs • respiratory handicap: social and other disad
• sputum pots and tissues vantages.
• audiovisual teaching aids
• handouts, exercise booklets, diaries, writing There is much vanatIOn between degree of
materials impairment and an individual's disability or
• name labels to encourage group interaction handicap.
• refreshments Rehabilitation is aimed at symptoms rather
• crash trolley and team members trained III than the disease process.
life support Participants are assessed as described III
• individual transport arrangements such as Chapter 2, with factors relating specifically to
taxis or cars to avoid the stress and delays of rehabilitation described below.
public or ambulance transport.
Background information
Financial planning needs to take account of The case notes should be scrutinized to check
staffing, venue, equipment, stationary, photoco that exercise training is safe. Contraindications
pying, telephone and administration time. include acute disease, symptomatic angina,
recent embolism or myocardial infarct, second
Structure and timing or third-degree heart block, deep vein thrombo
Sessions are arranged typically twice weekly for sis and resting systolic BP above 240 mmHg or
6 - 1 2 weeks. Once a week tends to be less diastolic above 120 mmHg. Relative contraindi
successful in maintaining motivation between cations include disabling stroke or arthritis,
seSSIOns. The initial physiotherapy seSSIOn, haemoptysis (depending on the cause), meta
either on a one-to-one basis or with half the static cancer, unstable asthma, resting heart rate
group at a time, includes assessment, identifica (HR) below 1 00 and resting systolic pressure
tion of partICIpant needs, goal setting, above 1 8 0 mmHg or diastolic above 95 mmHg
breathing re-education and a suggested home (Bach and Haas, 1 996). Liaison with the
programme. physician is suggested if PaC02 is above 8 kPa
Thereafter, each session would typically be (60 mmHg).
based around an hour's education on a specified People with insulin-dependent diabetes benefit
topic, a break for socializing, an exercise session from exercise training, which can also improve
and relaxation. A half-way review helps partici glucose tolerance, but extra vigilance is required
pants to take stock and plan for the end. A final to identify hypoglycaemia (p. 1 1 6). Steroid-
214
AsSESSMENT
induced osteoporosis is not a contraindication tion, e.g. :

and indeed is an indication for sensible weight
• FEV 1 > 60% predicted indicates mild
bearing exercise (Inman et at., 1 999). People
COPD: aerobic programme suitable
with heart failure usually benefit from exercise
• FEV 1 40-60% predicted indicates moderate
training: those with mild disease may take
COPD: peripheral muscle strengthening and
longer to recover from activity and those with
use of multigym suitable
more advanced disease require a low-intensity
• FEV 1 < 40% predicted indicates severe
programme (Pifia, 1 996). People with intermit
COPD: isolated muscle group work and
tent claudication can improve their walking
range of movement suitable.
distance (Brandsma et at., 1 99 8 ) .
The following drug history is relevant: If oximetry is not available, RFTs may
provide information on gas transfer, which, if
• drugs such as beta-blockers render the BP
above 55% predicted, indicates that oxygen
and pulse unreliable for monitoring purposes
desaturation is unlikely during exercise (Mak et
(p. 334)
aI. , 1 993). This suggests that diffusion character
• if prescribed and indicated, bronchodilators
istics play a role in exercise-induced desatura
and anti-angina drugs should be taken before
tion.
exercise
• steroids should be at the lowest effective
dose to minimize muscle weakness. Breathlessness and quality of life
It is helpful to ask participants how breathless
Respiratory function tests ness affects their lives and why they think they
RFTs are generally unhelpful for outcome are breathless. Participants are often relieved to
measurements. FEV 1 does not relate to disability be asked if their breathlessness is frightening,
(Bestall et aI. , 1 999), but it helps distinguish because this may not have been acknowledged
COPD from asthma, and may assist stratifica- before. Breathlessness can only be interpreted
Box 9.1 Measurements of breathlessness. The activity scale reflects the amount of effort required to induce breathlessness.
The Borg scale (Box 9.7a) can also be used.
Visual analogue scale
Greatest breathlessness
�o breathlessness
Activity scale
1 . Breathlessness with strenuous activity
2. Breathlessness on stairs
3. Breathlessness forcing patient to give up at least one activity
4. Breathlessness forcing patient to abandon most activities or give up work
5. Breathlessness on dressing, or preventing patient leaving home.
215
and reported by the person experiencing it Participants often describe breathlessness in

(Molen, 1 995), and Box 9. 1 helps them to terms of the effect on their lifestyle, and this
quantify the symptom. Visual analogue scales are can be measured functionally. Health-related
easier for participants when they are vertical quality of life (QoL) scales characterize well
rather then horizontal (Molen, 1 995). Breath being and include the effect of deconditioning
lessness must be explained to participants so that caused by a lifestyle restricted to minimize
they distinguish it from sensations such as breathlessness (Figure 9.3). Also known as
fatigue or chest tightness. health status or functional status scales, QoL
Quality of life definition
Objective functioning Subjective wellbeing
£;
Cii
Q)
I
Figure 9.3 A classification scheme for quality of life measures. Physical well-being (top right) relates to the effect of
symptoms on vitality and physical health. Mental well-being (bottom right) involves subjective appraisal of factors such as
anxiety, depression and social support. Physical functioning (top left) reflects ability to perform specific tasks and includes
employment. Mental functioning (bottom left) indicates ability to rise to cognitive and social challenges. (From Muldoon, M. F.,
Barger, S. D., Flory, J . D. and Manuck, S. B. (1998) What are quality of life measurements measuring? British Medical Journal,
3 16, 542-545)
216 ------
AsSESSMENT
scales can be generic or disease-specific, and exercise under hypoxic conditions (Webb et al. ,
several examples are available (Harper et at. , 1991).
1 997; Muldoon, 1 998; Eakin et al. , 1 99 8 ; Oxygen prescription is based on the flow
Bestall et al. , 1 999). Figure 9 . 4 illustrates a required to maintain Sa02 at over 9 1 % during the
QoL scale that can be filled out by patients last 30 seconds of a 5-minute corridor walk
without assistance. (Hagarty, 1996). Participants are discouraged
Quality of life is described by deLateur from becoming obsessed with their oximeter and
(1 997): to maintain awareness of their subjective response
to exercise. Transient desaturation is acceptable.
Though difficult to study, it's not
For severely impaired patients, a brief test
impossible;
such as sit-to-stand or stand-up-and-go can be
Though qualitative, it can be quantified;
used. For patients who are able, the following
Though 'subjective, it can be observed;
are available.
Though theoretical, it's certainly not
Six-minute distance: For endurance testing,
impractical.
participants are asked to walk for 6 minutes as
QoL scales are useful if they take account of fast as reasonably possible along a measured flat
participants stopping 'wanting' to do what they corridor, following standardized instructions.
cannot do, and if they distinguish breathlesness Stopping to rest is allowed but included within
and distress (Wilson and Jones, 1 9 89). Causes the 6 minutes. Participants should feel at the end
of distress include difficulty with conversation that they have performed to their maximum
(Lee et at., 1 998), frustration, embarrassment, capacity. The physiotherapist can inform the
dependency, reduced capacity for spontaneity, participant when each minute is completed but
and the sensation of breathlessness itself. Indivi should not walk alongside because this might
dual stressors and coping strategies can be iden influence his/her speed.
tified. The data to record are the 6-minute distance,
symptoms, HR and Sa02' Modifications are
Exercise testing required if there are orthopaedic or neurological
Exercise testing can be measured objectively by problems. Three or four practice walks are
walking or stair-climbing. This gives an accurate needed, with 20 minute rests in between. Repeat
indication of progress so long as the patient is tests should be performed at the same time in
not suffering an acute illness, but is not for relation to any bronchodilator drugs. A 1 5 %
comparison between patients. Observation of the change i n distance i s said t o b e clinically mean
participant during activity gives information on ingful (Savci et al ., 2000).
tension and fatigue. Stair climbing: The stair climbing test is done
under the same conditions and involves counting
Tests by the physiotherapist the number of steps that can be climbed up and
Oximetry (p. 324) on exercise testing is down in 2 minutes.
advisable because resting S.02 is not a predictor Shuttle: The shuttle test (Revill et al. , 1 999) is
of exercise desaturation (Mak et al. , 1 993). If incremental, externally paced, needs only one
oxygen is required at rest, an increment of 1 - practice walk and is more reproducible and less
2 L/min i s often needed o n exercise. The dependent on motivation. Participants are asked
oximeter should be validated under exercise to walk around a 1 0-metre oval circuit, with two
conditions and is not considered reliable when cones at each end to prevent an abrupt turn
recording values below 90% on exercise (Figure 9.6).
(Carone, 1 997). Small oximeters can be attached The speed of walking is dictated by a taped
to a belt, the wrist or a finger (Figure 9.5). Ear bleep which increases in line with the participant
oximeters may not be valid during heavy raising their speed gradually from 1 to 5 miles
217
..-......
N n
,......
00
S;
::::j
'"
1. Because of my breathing problems, I walk on the ftat m
;<l
o as fast as normal
\D
I
just below normal
I
'"0
......
o slowly P
j
'"
o very slowly 3::
o
BREATHING PROBLEMS QUESTIONNAIRE
�
-.
;0
rn
:r:
:>
2. Because of my breathing problems, I can walk on the ftat without stopping for r
o less than 20 paces (less than 10 yards) �

(3
lick ....
only
o about 40 paces (about 20 yards) I z
o about 80 paces (about 40 yards)
j o I never need to stop because of my breathing
The purpose of this questionnaire is to find out how your breathing

problems affect your life.
For each sentence please choose the ending which best

3. When I wash ::lyself down I usually
describes yourself. Please tick the circle 0 to show your choice.
Do not spend too long over any one sentence, just tick the
o dry mysen wrthout any problems
ending which is most Uke you. PIe... o dry myself slowly

... one
only
o sit and dry off
,
Please make sure that you have ticked one box for every sentence o need assistance to dry mysen
J
4.
....
P sc.
lick"",,
only
J
If I wanted to, I could do light gardening or DIY
o
o
o
o
as much as I want so
for a short time as long as
I could not do these jobs
Don't know/not interested
long as I take it slowly
I can ta�e rt slowly
Figure 9.4 Breathing problems questionnaire (Michael Hyland and Julia Bott, with permission).
9. Mfbre8lh1ng problems
5. I �'6UlI1Iy feel that I have
_ . 0 nevetm� me depres8ed .
b more energy than other people ofmy age
-.. o es much energy as other people of mY age - '8 often Inake
- .... 0 �makeme·depresaed
-
b ....
o slightly less energy than other people of my age
o much less energy than other people ofmy age
J
me depresaed
nearly alw?ys make me d'!pl'essed
J
o no energy at all
�
-
10. My breathing problems
6. When I am with fam�y or friends am I

-.. never make me worried or anxious
P.....
o not embarrassed by my breathing
o occasionally embarrassed by my breathing
-
b ....
sometines make me worried or anxious
after. make me worried or anxious
licl<ono
only o often embarrassed by my breathing J nearty always make me worried or anxious
J o nearty always embarrassed by my breathing
7. When I am at social gatherings my breathing problems mean that
Plea••
o I go right in and enjoy myself
licl<ono o I go in but keep an eye on where the door or window is
only
o I stay on the edge or near a window or door
J o I never il'o to social gatherings
-
8. On a_age, my breathing problems usually ke"p me awake at night
P••• o hardly ever at all

ti_ o up to ha� an hour
only
o about one to two hours
J o f"ost ofthe night
�
V>
�
V>
N $:
� rn
\0 �
Figure 9.5 Portable oximeters (see Appendix C for manufacturers).
10m
Figure 9.6 Shuttle walking test.
220
EDUCATION
per hour. The tape (Appendix C) gives standar

dized instructions, and no verbal encouragement
is given. The physiotherapist walks alongside for
the first minute to discourage the participant
from exceeding the initial speed. Thereafter, if
the cone is reached early the participant waits
for the beep before continuing. The end point is
when symptoms prevent the participant complet
ing a circuit in the time allowed. Ideally the
maximum should be reached within 1 0-15
minutes. Half-an-hour's rest is needed after the
practice test. The shuttle is closely related to
maximum oxygen consumption (V02 max) (Singh
et aI. , 1 994). Some participants have trouble co
ordinating the cones with the beep.
Tests in the laboratory

Exercise testing based on treadmill-walking or
cycle ergometry is unfamiliar to participants,
unreliable in relation to everyday activity (Mak
et aI. , 1993) and less related to exercise capacity
than breathlessness (Wijkstra, 1 994). However, Education is the most cost-effective aspect of
measurable workloads can be imposed in the rehabilitation (Tougaard et aI., 1 992), and
laboratory while monitoring minute ventilation, underpins all other components. It increases
CO2 output, HR, BP, Sa02, blood gases and participants' confidence and reduces uncertainty
oxygen consumption (V02). This helps to and fear (Small and Graydon, 1 992), whereas
highlight the interaction between vanous ignorance can breed a catastrophizing of life
systems involved in oxygen delivery to the events. Most participants want to know as
tissues. An ECG stress test detects myocardial much as possible about their condition but are
ischaemia by identifying ST segment changes. often reluctant to ask questions in a clinical
Exercise testing can help determine the cause setting. A rehabilitation programme provides
of exercise limitation. Respiratory disease is time and a non-threatening atmosphere for
likely if breathlessness is the limiting factor. If a discussion.
person reaches the anaerobic threshold early, i.e. Age does not itself hinder intellectual ability,
at less than 40% predicted V02max, or if but elderly participants may need time for
maximum predicted HR is reached early, limita processing information, and hypoxaemia may
tion is probably due to cardiovascular disease. impair memory. Retention of information IS
A checklist can be made up from any of the optimal if:
suggestions in Box 9.2 and selected parts used • the room is free of distractions
for initial assessment, interim assessment and • the teaching plan is set out clearly
final outcome. • the most important points are made first
• teaching sessions are brief
EDUCATION • language is simple and jargon-free
Real education must entail emancipation: • advice is specific rather than general
liberating people to make their own • information is reinforced regularly
decisions on their own terms. throughout the programme
Fahrenfort, 1 987 • booklets and handouts are included
221
Box 9.2 Assessment for rehabilitation
Medical notes Stress incontinence • Loss of confidence

• Footwear
BP Appetite
• Other
HR
Diet Does breathlessness limit:
Sa02 on FI02 of
Pa02
-- onFI02 of - Daily activity level • bending
PaC 02--
-- • reaching over head
pH Use of transport • climbing stairs
HCOj" Understanding of the disease
• shopping
FEV 1 __% predicted • housework
FVC __% predicted Constipation YIN • sleeping
Hospital admissions • Action taken • dressing
• bath/shower
Steroids Cough YIN
• toilet
• Oral • Productive/dry
• conversation
• Inhaled • Pattern, e.g. am/pm
• sexual relations
• How long Sputum YIN • preparing meals
Other medication • Thick/thin • eating
• Easy to clear YIN • feeling angry
Relevant medical history • being angry
• Hypertension Smoker YIN
• playing with children
• Angina • How many
• going for a walk
• MI • Understanding of effects
• walking around at home
• Heart failure Ex-smoker YIN • walking with others on
• Peripheral vascular • How many the level
disease • When stopped
• Musculoskeletal disease Which of the above are most
• Neurological disease Self-management important for the patient?
• Diabetes • Symptoms
• Osteoporosis • When to call GP What would the patient
• Other most like to do but cannot
Home oxygen
because of breathlessness?
Social history • Hours per day
• Stairs • Cylinder/concentrator
Expectations
• Family support • Flow rate
• Social services • On exercise YIN Goals
• Employment, hobbies • When eating YIN
• When breathless YIN Objective
Subjective • At night YIN
SaOZ
Fatigue Factors limiting mobility • Rest
• Breathlessness Talking
Sleep •
• Fatigue • After walk or shuttle
Depression • Weakness FI02 to maintain Sa02
Anxiety
• Chest pain > 9 1 % during last 30 s of
• Other pain 5 min walk.
Panic • Imbalance
Frustration • Dizziness Breathing pattern
• Poor eyesight
Ability to relax • Use of oxygen
222
EDUCATION
Box 9.3 Topics for education and discussion
Figure 9.7 How we breathe. (From Ries, A. L. and

Moser, K. M. (1996) Shortness of Breath: A Guide to
Better Uving and Breathing, C. V. M osby, St Louis, MO)
How we breathe (Figure 9.7), the relation between symptoms and pathology, the nature of breath
lessness
Medical tests, procedures, interpretation of results
Oxygen therapy: effects, side effects, equipment, consequences of non-adherence
Drug therapy: effects, side effects, inhalers and nebulizers, consequences of non-adherence, records
and charts to aid memory
Fluids and nutrition
Smoking cessation
Relation between symptoms and interventions such as relaxation, breathing re-education, chest
clearance, exercise training and energy conservation
Self-assessment, symptom management, recognition and management of exacerbations, recognition
of the need for medical attention, e.g. change in symptoms or new symptoms
Prevention of infection, e.g. avoidance of people with respiratory infections, influenza vaccination
Management of the environment, e.g. indoor exercise if outside air is polluted, covering nose and
mouth when exercising in cold weather, bowls of water by radiators, prevention of dust
Community resources, benefits and entitlements (with corresponding advice to welfare agencies on
the needs of the 'invisible' respiratory patient)
Vocational guidance to improve self-esteem and social participation while avoiding jobs or hobbies
with respiratory irritants or excess energy expenditure
Tips such as a walking stick to advise motorists of a slow walking pace, advice to carers on simple
massage techniques
Advice for participants before visiting the doctor, e.g. write down questions to ask in advance,
clarify points that are not understood
Management of panic attacks (p. 3 04)
Home equipment
Travel tips, including use of nebulizers and oxygen abroad and while travelling (RCP, 1 999)
------ 223
• participants are reminded to check body to treatment (Mellins et aI. , 1 992), which may
tension, take medication and practise their be because of inadequate information or depres
breathing: suggestions include memory aids sion. Motivation is essential if participants are to
such as stickers on kettles, reminders on practise at home. A twice-a-week programme of
toothbrushes, use of dead time such as structured exercise is not enough by itself to
queues or TV advertisements. improve exercise tolerance (Ringbaek, 2000) .
Participants are unlikely to ignore their own
The respiratory nurse teaches the under
beliefs and goals in order to follow a prescriptive
standing and practical management of oxygen
approach, and education is not achieved by
and medication. The dietician identifies indivi
simply feeding information into an empty vessel
dual nutrition problems, suggests six-meal-a-day
and pressing the right buttons. The hierarchical
menus, advises on healthy eating and explains
hospital environment may encourage some
which foods are mucus-forming, gas-forming,
patients to take up the sick role and assume that
constipating or hard to digest. The physician
the experts know best. This apparent compliance
answers medical questions and discusses
is counterproductive in the rehabilitation
advance directives in relation to life-prolonging
process. Motivation is enhanced by participants
treatment (Heffner, 1 996). Participants are
taking responsibility for their own management.
reminded that rehabilitation is not a course of
Factors that increase motivation are:
treatment to make them better but more of a
lifeplan. Educational topics are suggested in • clear advance information (Box 9.4) in large
Box 9.3 . print
• realistic expectations
Motivation
• active participation, e.g. self-monitoring,
The therapist-patient relationship can invitations to question, comment, design
succeed or fail, depending on the care that programmes, contribute ideas
the therapist takes in understanding the • verbal commitment from participants
needs and circumstances of her patients. • praise, warmth, humour, honesty and
Walker, 1995 responsiveness from the rehabilitation team
• family involvement
• focus on health rather than disease
• short simple regimes (Mellins et at., 1 992)
• understanding the rationale of each compo-
nent
• early success, reinforced by progress charts
• access to notes (McLaren, 1 9 9 1 )
• continuity o f personnel
• certificate of completion.
Factors that decrease motivation are:
• fatigue
• fear of failure
• anxiety or depression
• advice that is inconvenient or difficult to
follow
Motivation is the best predictor of the success of • embarrassment
rehabilitation (Brannon et aI. , 1 998, p. 346). • boredom, e.g. repetitive exercise, 12-minute
Over 70% of patients with COPD do not adhere walking test, waiting for transport
224
EDLICATION
• coercIOn social isolation and low energy can sabotage

• lack of recognition of the individual as a rehabilitation. Anxiety is another frequent
whole. accompaniment to breathlessness and uncer
tainty. When depression and anxiety coexist,
Box 9.4 Suggested contents of a welcome booklet sent patient and physician often fail to recognize the
to prospective participants depression (Dudley et at., 1 9 8 0??).
Participants may not have considered the
• What is pulmonary rehabilitation for?
relevance of psychosocial factors to their disabil
• What does it entail?
ity, despite their myriad of feelings. Care should
• What clothes and shoes shall I wear?
be taken with language because the word
• Do I need my reading glasses or
'psychological' may be interpreted as a psychia
medic:ation?
tric disorder and the word 'disabled' is difficult
• How do I get there? What floor? Where
for people who have not thought of themselves
do I report?
in this context. To use emotionally charged
• Who will be there?
words without preparation is like using the word
• Can I bring someone with me?
'stump' to a new amputee.
It should be explained that feelings are closely
Most participants are enthusiastic learners, connected with breathing for all people,
and liberal use of teaching aids, using pictures including those with normal lungs, that it is
rather than graphs, can explain the disease natural for breathless people to feel depressed
process in a way that is enjoyable. A large-print and anxious, and that this is an expression of
diary is useful to log daily exercise, symptoms, humanity, not weakness.
feelings, diet, drugs and side effects, action taken Anxiety is exacerbated by fears, e.g. that death
and the results. The diary can include a nego will be by suffocation, a common misconception
tiated written contract stating achievable and that can contribute to panic attacks. Most respira
functional goals, the time to achieve them, and tory patients will die after lapsing into a coma.
obligations of the participant and the rehabilita Topics to discuss include:
tion team. Achievement of the first goal gives • identification of stressors
participants a motivating boost. • recognition and management of depression
The relationship between participants can (without taking comfort in smoking!)
facilitate motivation. They may share transport • living with limitations (Figure 9 . 8 )
to the sessions, swap ideas and exercise together
outside classes. Participant beliefs and individual
attitudes are central to motivation. One partici
pant, for example, did not use her oxygen until
she was told of the difficulty for her heart in
'pumping thick blood'.
Understanding reactions to the disease

Psychological dimensions carry a
remarkable weight in the way patients . . .
face rehabilitation.
Lera, 1 997
Depression is often accepted as a manifestation

Figure 9.8 Lifestyle adaptation (From Leboeuf, C .
of the disease and not addressed, even though (2000) A Practical Approach to the Late Effects o f Polio,
the symptoms of sleeplessness, poor appetite, British Polio Fellowship, Middlesex, with permission.)
225
• the importance of activity and maintaining a hypertensives, antiulcer and cardiac drugs, can
social life affect sexual function, in which case drug review
• relationships with partner and family, is indicated.
including concepts of guilt, dependence and Many physiotherapists are comfortable to
resentment listen to patients talking about feelings, but
• relationships with others: coping with referral to a an appropriate agency may be
embarrassment or perceived stigma, how to required because this can be a complicated area.
explain about using oxygen or walking Denial, for instance, has been shown to reduce
slowly, how to cope when the legitimacy of adherence (Borak et al. , 1 9 9 1 ) , but some level of
an invisible condition is doubted, how to denial may be necessary as a coping strategy
ensure that adequate time is allowed for (Bosley, 1 99 6 ) . The relevance of participants'
speaking. feelings is shown by evidence that attitudes and
beliefs bear more relation to exercise tolerance
Relationships may be affected by lack of spon than ventilatory capacity (Morgan et al. , 1 983).
taneity because breathless people often cannot
waste breath in expressing anxiety, anger, love Smoking withdrawal
or happiness. This emotional straightjacket can Tobacco .. . disturbeth the humors and
isolate partners from each other. Any family spirits, corrupteth the breath . . . exsiccateth
member can be welcomed to educational the windpipe, lungs and liver.
sessIOns. Tobias Venner, 17th century physician
(Bach and Haas, 1996)
It is natural for chronically disabled people to
harbour resentment at the loss of their dreams. Smoking cessation is the first priority in the
This may be projected on to their family or any management of people with COPD. Some 70%
of the rehabilitation team. Allowing patients to of smokers want to give up (Venables, 1 994) but
talk gives them an opportunity to understand their endeavours are hampered by the tena
this process. If there is no appropriate outlet, the ciously addictive properties of nicotine (Figure
resentment turns inward and augments depres 9 . 9), as well as less specific obstacles such as
sion. People who are depressed usually respond
to a receptive ear. Time is always needed when
working with troubled people, but this is time
well invested by a member of the team with
whom the participant feels comfortable, because
little progress can otherwise be made.
Self-esteem and sexuality are closely linked,
and loss of sexual expression reinforces low
confidence. Education can help discriminate
between the effects of myth, illness and drugs on
sexual activity. Myths perpetuated by society
include the expectation that elderly people
cannot have, do not want or should not want
sexual relations, and that disabled people are
sexually neutered. Illness causes decondition
ing, poor self-image, fatigue or breathlessness.
Alternative positions may be helpful, although
some men find the change to a passive position Figure 9.9 The killer weed. (From Ries. A. L. and
unsettling at first. Kissing may be difficult for Moser. K. M. ( 1 996) Shortness of Breath: A Guide to Better
breathless people. Drugs, such as certain anti- Uving and Breathing. C. V. Mosby. St Louis. MO)
226
EDUCATION
comradeship amongst smokers, stress or failure drains the will. A quit date should be
boredom. decided, preferably when something unusual is
Multiple reinforcements are more successful happening and with a reward for success at the
than a single intervention, and every strategy for end. Goals can be set, low priority cigarettes
encouragement should be employed because stopped, a diary (Figure 9. 1 0) initiated, habits
A smoking diary
Keep a smoking diary for two days - one at work and one at home.
When it is complete, start asking yourself some questions:
What sort of activities provoke me 'into having Which cigarettes could I easily have not
a cigarette? (eg having a cup of coffee, or smoked, and why?
answering the telephone).
Which cigarettes did I feel I could not have
Who provokes me Into having a cigarette? done without, and why?
Which cigarettes did I find most enjoyable,

and why?
Time What were you Who were you How were you How much did How much did
doing? with? feeling? you enjoy it? you need it?
Figure 9.10 Smoking diary, (From Quit, with permission; see Appendix C.)
227
linked with smoking can be changed, e.g. orange sleep disturbance. Side effects include skin irrita
juice instead of coffee and avoidance of passing tion, eased by changing the site daily, and mild
the cigarette shop. effects of quitting, which disappear after about
Alternative strategies can be devised for 1 0 days of patch-wearing. For rapid boluses in
difficult situations or in case of relapse. Although time of need, nicotine gum, inhalers or nasal
total cessation is best (Flaxman, 1 978), reduced sprays can be used in tandem with patches. Gum
levels of smoking can be an alternative (Klech, should not be chewed but compressed with the
1 99 8 ) so long as compensatory deep inhalation teeth and left in the mouth for 1 minute. Contra
is avoided. indications to nicotine replacement are:
Plenty of water is advised, and distraction
from cravings might include: • pregnancy and breast feeding
• acute MI, unstable angma, severe arrhyth-
• sucking mints, chewing gum or dried fruit, mIaS
eating an apple • recent stroke
• brushing teeth, taking a shower • for patches: some skin problems
• phoning a friend or helpline (e.g. Quitline, • for gum: peptic ulcers.
Appendix C).
A pre-planned phone call to the participant is A variety of drugs are available to assist with
helpful a few days after the quit date, when drawal (Covey, 2000), one or other of which
motivation, determination and support from may be helpful. Changing to 'light' cigarettes is
others might be waning. normally unhelpful because of altered smoking
Advice should not appear patronizing but patterns (Klech, 1 998). Herbal cigarettes contain
specific information can be given such as the no nicotine but produce tar and carbon
effects of tobacco on the smoker's family (p. 22), monoxide.
suggestions on alternative uses of the £1 000 per Other tips include posters (Figure 9 . 1 1),
year spent on the average British habit, and the acupuncture (Aiping, 1 994), hypnotherapy,
fact that, while smoking appears to help clear biofeedback by carbon monoxide monitoring
the chest, it only does so by irritating the Oarvis, 1 9 8 6), group counselling and role play,
airways and creating extra secretions. e.g. asking friends not to smoke around them.
Participants need to understand the physical Participants themselves provide ideas for each
and psychological difficulties of withdrawal but other and can set up a 'buddy system' by
also the pleasures of sweeter-smelling breath and swapping phone numbers. Positive support helps
clothes, improved appetite and bank balance, counteract patients' previous experience of being
reduced cough and even some recovery of lung treated as if they should be punished for
function (Hodgkin et aI. , 2000, p. 356). smoking (maybe some of this punitive energy
Weight gain can be a problem for up to a could be directed at the tobacco companies!).
year, and it is usually wiser to emphasize healthy But - would it not be preferable for a person
eating rather than trying to lose weight at the who is disabled and housebound to continue
same time. Temporary irritability can strain rela with one of life's few remaining pleasures? That
tionships but should be understood as the body is the patient's decision. The j ob of the rehabili
recovering rather than a reason to return to tation team is to educate, to explain that it is
smoking. never too late to stop and then to support
Nicotine replacement can double success rates patients after they have made their decision.
(Tonnesen, 1 999) but is not at present available
on the NHS, although it would be cost-effective There's nothing to giving up smoking. I've
(Stapleton et at., 1 9 99). Up to two patches can be done it hundreds of times.
used over 24 hours, or just in the daytime for less Mark Twain
228 ------
EDUCATION
Chang e s your body

go es through when you quit
2 0 minutes
Blood pressure and pulse rate return to
normal. C irculation improves in hands
and feet, making them warmer.
8 hours
Oxygen levels in the blood return to
normal. Chances of a heart attack start
to fall.
24 hours
Carbon monoxide is eliminated from
the body. The lungs start to clear out
mucus and other debris.
48 hours
N icotine is no longer detectable in the
body. The abil ity to taste and smell is
improved.
7 2 hours
Breathing becomes easier as the
bronchial tubes relax. Energy levels
increase.
2· 1 2 weeks
C irculation improves throughout the
body, making walking easier.
3·9 months
Breathing problems such as cough,
shortness of breath, and wheezing
improve. Overall. lung function is
increased by 5 - 10%.
5 years
Risk o f a heart attack falls to about half
that of a smoker.
10 years
Risk o f lung cancer falls to about half o f
that found in a s m o k e r . R i s k o f a heart
attack falls to about the same as
someone who has never smoked.
Basrd o n mformallon from t h e 1990 U S Surgeon
!Jenera/'s repor/.
Figure 9.11 Encouragement to quit. (From Quit, with permission; see Appendix C.)
229
Figure 9.12 Positioning for breathless people (From Haas, F. and Haas, S. S. ( 1 990) The Chronic Bronchitis and Emphysema
Handbook, John Wiley, Chichester, with permission.)
• sIttmg astride a chair to fix the pelvis:

REDUCTION IN BREATHLESSNESS
passive thoracic rotation
Any of the techniques discussed on page 1 73 can • half-lying with a roll under the thorax: thor
be taught to participants, including a variety of acic extension assisted by passive arm eleva
resting positions (Figure 9. 12). An addition for tion
people with chronic breathlessness is mobiliza • for some participants who have developed a
tion of the thorax. Some participants may need stiff hyperinflated chest: manual compression
individual attention at first, and thereafter they on exhalation in a bucket-handle direction
can choose from various self-management strate • stretches to muscles around the shoulder.
gIes.
Kolaczkowski ( 1 989) has developed a series
Thoracic mobility of 40 techniques, some of which have been
shown to increase Sa02' A video is available
Thoracic mobility may be impaired by chronic
(Appendix C).
muscle tension, shortening of anterior chest and
The normal precautions apply, . especially
shoulder muscles, abnormal mechanics of
steroid-induced osteoporosis. Handling and posi
breathing and a forward head posture. This can
tioning must not exacerbate breathlessness.
add a restrictive element to an obstructive
Participants are encouraged to do their own
condition and cause pain, sometimes misdiag
stretching exercises, including side-flexion,
nosed as pleurisy.
rotation and hand-over-head exercises. They are
Carr ( 1 993) claims beneficial effects from the
motivated by understanding that expansion of
following:
their lungs is hindered by a stiff rib cage.
• in forward-Iean-sitting: Maitland mobiliza Box 9.S shows how participants can mobilize
tions to vertebral and scapular joints their own thorax. Exercises such as these have
230 ------
REDUCTION IN BREATHLESSNESS
Box 9.5 Flexibility exercises, mostly in sitting
1 . Head movements
• While breathing in, look up to ceiling. While breathing out, slowly bring chin down to chest.
• Keeping shoulders still, move your head sideways to bring your ear towards your shoulder.
Repeat the other side.

• Turn your head to look over your shoulder. Repeat the other side. Maintain steady breathing
throughout.
2. Shoulder girdle circling
Circle shoulders slowly forward, upward, backward, downward. Relax. Repeat m opposite
direction..
3. Chest stretch
Hands behind back, breathe in, push chest forward and shoulders back. Breathe out and relax.
4. Back stretch
Lock hands, stretch hands forward at shoulder level, feel stretch between shoulder blades, relax.
5. Arm circling
Hold arm sideways at shoulder height, circle arm in progressively increasing circles for count of 4,
then decrease for count of 4. Repeat with other arm. Maintain relaxed breathing throughout.
6. Trunk rotation
With arms folded across chest, keeping pelvis still and knees forward, breathe in. While breathing
out, rotate trunk to look over shoulder. Repeat other side. Maintain steady breathing.
7. Trunk rotation
As above, with hands behind head.
8. Trunk extension
With hands behind head, lean over back of (low-backed) chair while breathing in. Return while
breathing out.
9. Trunk side-flexion
With hands across chest or behind head, and keeping buttocks flat on the chair, bend from side to
side.
1 0 . Trunk flexion
Breathe in gently. While breathing out, bend forward towards toes. Sit up slowly while breathing
m.
1 1 . Pelvic circling
Standing with hands on hips: rotate pelvis in slow circle.
12. Calf stretch
Standing with one foot in front of the other: lean forward and bend front leg, keeping back heel
down. Repeat with other leg.
1 3 . Pectoral stretch
Standing holding the inside of a door frame: while breathing in, step through frame with one foot
and feel stretch across front of chest. While breathing out, step back. Repeat with other foot.
14. Arms up
Standing with elbows straight: while breathing in, lift rolled-up newspaper above head in one
hand, pass to other hand. While breathing out, bring arms down.
------ 23 1
Fear of breathlessness
shown benefits such as reduced breathlessness
\
and increased vital capacity (Kakizaki et aI.,
1 999).
Participants should be reminded of the
following:
• avoid straining, pain or discomfort ('stretch

is good, pain is bad') ! Exercise
tolerance
• keep movements relaxed and fluid, allow
\
arms and legs to move independently of the
body
• maintain an efficient and relaxed breathing
pattern. Muscle
! Efficiency and
co-ordination weakness
EXERCISE TRAINING �
Mr Smith becomes short of breath when he
exerts himself. Mr Smith has lung disease
Figure 9.13 Vicious cycle that augments breathlessness
in patients with chronic lung disease.
and I know that lung disease causes
shortness of breath. Therefore Mr Smith's
exerctse limitation is due to his lung
disease. tion to breathlessness (Belman et aI., 1 9 9 1 ) ,
Quoted by Schwartzstein, 1 992 which might explain evidence that exercise
training causes a greater reduction in the
This myth that breathless people cannot benefit
distress associated with dyspnoea than in
from exercise training is at last eroding under
the intensity of dyspnoea itself (Carrieri,
the onslaught of evidence to the contrary. But
1 992).
exercise training is still not provided as an
• Pulmonary rehabilitation aims at endurance,
integral part of respiratory care for many
flexibility and some strength, which empha
patients, perhaps because of an assumption that
size factors such as nutrition and physical
patients cannot reach a training threshold if
fitness, rather than maximal capacity, which
exercise is limited by breathlessness. But:
depends on ventilation, gas exchange and
• Rampulla ( 1 992) has shown that more oxygen delivery to the respiratory muscles.
COPD patients stop exercising because of
The programme must be individually planned,
fatigue than breathlessness.
acceptable to the participant, accessible, safe,
• Donner and Howard ( 1 992) have shown that
show tangible benefits and be designed so that it
for people with moderate disease, cardiovas
can be maintained unsupervised at home. Long
cular or peripheral muscles are the main
term commitment is needed because de-training
limiting factors, especially when chronic
occurs faster than training.
hypoxia impairs muscle function (Wuyam et
aI. , 1 992). Effects
• A significant limiting factor is the patient's
The benefits of exercise for people with normal
fear of breathlessness rather than breathless
lungs are well-known (p. 23). Extra benefits are
ness itself. Success relies on desensitization
found in people who have respiratory disease:
to breathlessness so that patients can break
out of their vicious cycle of breathlessness • Respiratory patients who train have shown
and deconditioning (Figure 9. 1 3 ) . improved exercise tolerance (Figure 9.2),
• Exercise itself acts a s a form o f desensitiza- cardiovascular fitness and raised anaerobic
232
EXFRCISF TRAINING
threshold (Schwartzstein, 1 992). Maximal 1 994). This has been confirmed by Clark et al.
oxygen consumption (V02max) can be ( 1 996), who found major improvements in
increased in people with less severe disease, endurance with unchanged cardiorespiratory
and improved muscle strength can be fitness, and suggested a further mechanism of
comparable to that in healthy young people improved neuromuscular coupling.
(Simpson et al. , 1 992). Prior deconditioning People with COPD generate lactic acidosis at
means that modest exercise is likely to low exercise levels. Hypercapnic patients may
induce a physiological training effect, even find it particularly difficult to work above the
in elderly people (Casaburi, 1 992) . anaerobic threshold because CO2 is generated by
• Breathlessness is relieved by improved exer lactic acid buffering, and fatigue may be caused
cise tolerance, activity-related sensory input by the excess ventilation required to compensate
and reduced gas trapping because of freer for metabolic acidosis (Casaburi, 1 992) .
airflow, represented by a minor 70/0 improve
ment in FEV1 (O'Donnell, 1 995). The Safety
distress component of breathlessness
Breathlessness is not an adequate indicator to
decreases more than the intensity compo
limit exercise, because patients can drop their
nent, showing how desensitization and
oxygen saturation to 70% without increased
reduced anxiety have a direct effect on the
dyspnoea. Oximetry during assessment is
perception of breathlessness (Bach and Haas,
advisable, and can be used as biofeedback and
1 996, p. 348).
reassurance.
• A sense of well-being and confidence, along
For hypercapnic patients, PaC02 will show an
with reduced anxiety and depression, is
increase during exercise because of extra meta
consistently reported and is greater than
bolism, and if it does not fall back to normal
objective change (Hodgkin et al. , 1 993, p.
afterwards, training intensity must be reduced.
286).
Some 5 0% of COPD patients aged over 50
• Exercise reduces smoking (Russell e t al. ,
have cardiovascular disease (Haas and Haas,
1 9 8 8 ) , BP (Brannon et aI. , 1 998, p. 76) and
1 990, p. 1 3 3 ) . Breathlessness may prevent
risk of chest infection (Karper and Boschen,
exercise from stressing the cardiovascular
1 993). It promotes relaxation and sleep,
system, but the boundaries of safety should be
stabilizes blood sugar and reduces gut
defined. Guidelines for cardiovascular patients
problems (Hodgkin et al. , 1 993, p. 1 09).
are the following.
Mechanism of training • Exercise should be terminated if there is
The severity of disease dictates how training failure to increase heart rate (HR) or failure
improves exercise tolerance. People with to raise systolic BP at least 10 mmHg above
moderate COPD (FEVJ > 1 .2 L) can reach their the resting level
anaerobic threshold and develop lactic acidosis, • For participants on beta-blockers such as
which occurs at a higher percentage of V02 max propranolol, resting BP cannot be used as a
(e.g. 8 0-90% versus 60-70% in those with predictor of BP during exercise (Potempa et
normal lungs). al. , 1 9 9 1 )
In severe COPD (FEV 1 < 1 .2 L), exercise is
See also cardiac rehabilitation, p. 2 8 9 .
commonly limited by ventilatory function and
Practical safeguards for all participants are:
gas exchange abnormalities, and improved
exercise tolerance is thought to be due to greater • scrutiny of the notes following comprehen
mechanical skill, which reduces the oxygen cost sive medical screening
of exercise, a more efficient ventilatory pattern, • detailed explanations and education on self
and desensitization to breathlessness (Ries, monitoring, including identifying the appro-
233
priate balance of feeling 'breathless but not for respiratory patients than strength trallllllg.
speechless' Endurance training forestalls the onset of ineffi
• optimum nutrition to prevent depletion of cient anaerobic metabolism and enhances the use
muscle proteins and mllllmlze fatigue of oxygen.
(Rampulla, 1 992), a factor underscored by
the response to exercise training being Preliminaries
dependent on nutrition (Palange et aI. , Participants are reminded that exercise is not
1 99 8 ) synonymous with pumping iron. They set their
• optimum fluid and drug therapy own goals, such as being able to walk to the
• treatment of any anaemia pub. Inpatients should be dressed in their day
• isotonic rather than isometric exercise to clothes and all participants should have cleared
reduce the risk of hypertension, impaired their chests of secretions before exercising.
blood flow and fatigue Warming up in a group allows participants
• for participants who put their hands in their to enjoy movement for its own sake, distract
pockets to support the shoulder girdle, ing them from preoccupation with breathless
advice to maintain the support with hands ness and reducing the seriousness associated
outside their pockets with a therapeutic environment. Five minutes
• discouragement of competition may be sufficient for respiratory patients.
• steady exercise with no rushing at the start Stretching exercises can be chosen from those
or finish in Box 9.5.
• adequate rest, with placement of chairs at Music may be used for pleasure but not as a
intervals metronome, and participants can be invited to
• termination of exercise if there is angina, bring their own favourites. Participants should
cyanosis, pallor, cold clammy skin, fatigue, feel free to move at their own pace or not join in
confusion, headache, dizziness, nausea, desa if they wish. For severely breathless people, the
turation below 800/0 or BP rise to more than warm up period should be brief and may simply
250 mmHg systolic or more than 1 20 mean starting their modified exercise training
diastolic (AARC, 1 992). slowly.
During activity, participants are discouraged
Further details are given by Olivier ( 1 998) from rushing or breath-holding, which can
and comprehensive risk assessment by Pollock disturb the breathing pattern and increase BP
and Wilmore ( 1 990). . (Linsenbardt et aI. , 1 992). They are encouraged
to take comfortable strides and maintain a
rhythmic quality of movement.
Technique
Even when a conventional trallllllg response is Exercise prescription
not anticipated, the three principles of training Four components make up the exercise
are followed: prescription: mode, intensity, duration and
• overload, i.e. intensity must be greater than frequency.
the muscle's normal load The mode of exercise relates to the partICI
• reversibility, i.e. cessation of training loses pants' lifestyles. Many choose walking, stair
the benefit gained climbing or occupation-based exercise. Some
• specificity, i.e. only the specific activities prefer the stationary bike or treadmill because
practised will show improvement. they feel in control, can use oxygen easily and
have support for their shoulder girdle. About
Endurance trallllllg, comprising low-resis 85% of body weight is supported by a bike, and
tance, high-repetition exercise, is more suitable large muscle groups can be exercised with less
234
EXERCISE TRAINING
Box 9.6 Circuit exercises
Each exercise is continued for 1 minute. Repetitions are recorded by participants on individual
clipboards. Participants rest between each exercise at 'breathing control stations' until breathless
ness returns to baseline, usually in about 1 minute. Instructions are best pinned to the wall.
1. Knee tensing. Long-sitting on plinth, bed or sofa with knees on a pillow or coffee jar: tighten
thigh muscles, hold for count of 4, relax. Repeat with other leg. Maintain steady breathing
throughout.
2. Biceps curl. Sitting with elbows on table: lift weight or bag of sugar, lower slowly. Repeat with
other arm. Maintain steady breathing throughout.
3 . Heel-toe. In sitting, raise alternate heels and toes, in time with breathing.
4. Ball throwing and catching
5 . Quadriceps exercises. In sitting, straighten one knee, hold for count of 4, lower leg slowly.
Repeat with other leg.
6. Towel wringing. In sitting, wring towel tightly, hold for count of 4. Slowly untwist towel.
Keep breathing steadily throughout.
7. Lift ups. In sitting, inhale gently. While breathing out, push down with both hands and lift
pelvis off seat. While breathing in, let yourself down slowly.
8. Step ups. Breathe out, step up with one foot. Breathe in, bring up other foot. Step down with
one foot, then the other.
9. Walking sideways.
10. Wall press-ups. Stand with feet a comfortable distance from the wall, put hands on wall, bend
at elbow (keeping heels on floor), push arms straight again.
1 1 . Abdominal contractions. In sitting, pull in abdominal muscles, relax and breathe.
12. Static bike, hula-hoops, trampet.
1 3 . Bounce ball off wall.
14. Calf exercise. Holding back of chair, go up on toes, return heels to floor.
1 5 . High knee marching. Holding back of chair with one hand, march on the spot, lifting knees
high.
16. Arm raise. Sitting or standing, raise arm, with or without weight, above head. Lower slowly.
Repeat with other arm.
1 7. Bend down, stretch up. In time with breathing.
1 8 . Sit to stand. Using dining room chair, sit-stand-sit. Repeat, holding a ball.
23 5
strain than walking (Bach and Haas, 1 9 9 6, p. The intensity of exercise can vary from the
309). Treadmill-walking enables participants to use of precise physiological monitoring to a
learn the feel of different speeds, so that they laissez-faire approach. Some methods are
can structure their home programme. Other described below.
participants enjoy simple activities that can be 1 . The predicted maximum HR can either be
continued at home, such as chair exercises. Low estimated as 220 minus age or measured during
intensity individual limb exercises are well an incremental stress test. Exercise is tradition
tolerated and translate into improved whole ally maintained at 70% of maximum HR, but
body exercise capacity (Clark et al. , 1 99 6 ) . respiratory patients can achieve a training effect
Upper limb exercise needs to be included at 30-40% of maximum (Hellman, 1 994) . HR is
(ACCP/AACVPR, 1997), and hobbies such as linearly related to V02max, so the pulse can be
bowls are both enjoyable and useful for chest taken at, say, 50% of V02max and used as a
mobility. target. Multiples of V02max are expressed as
Circuit training can involve six to ten exercise METs (see Glossary) . These complicated
stations, choosing from examples in Box 9 . 6 . methods of monitoring exercise intensity are
Exercises are best alternated between upper/ widely described but may not be suitable
lower limb exercises, and easy/difficult exercises. because:
Gentle p rogressive arm exercises reduce the
• many respiratory patients are too breathless
breathlessness associated with upper limb activ
to reach true maximal HR or V02max (Mejia,
ities, with a carry-over effect on the respiratory
1999)
muscles that can be equivalent to inspiratory
• HR is affected by cardiorespiratory drugs
muscle training (Hodgkin et ai., 2000, p. 1 5 8 ) .
such as beta-blockers, digoxin and salbu
Unsupported arm exercise should b e included
tamol
unless this causes abdominal paradox (p. 37).
• even people with normal lungs show a wide
Loss of shoulder girdle support forces the inter
variation in HR (Belman et at. , 1 9 9 1 ) and
costal and accessory muscles to stabilize the
V02 max (Bach and Haas, 1 996).
arms and torso, which shifts the breathing load
to the diaphragm, creating a challenge for 2. Breathlessness scales can be kept on clip
people with COPD (Figure 9 . 14). boards for participants to assess their perception
of breathlessness (Box 9 . 7) . Exercise can be
increased gradually while maintaining breathless
ness at a constant tolerable level. Breathlessness
scales are reproducible, correlate with physiolo
gical measures of exercise intensity and even in
people with normal lungs have been shown to
result in greater improvement in endurance than
when using HR (Koltyn and Morgan, 1 992). It
is thought safer for the participant to choose the
level of breathlessness rather than the
physiotherapist (Myles and Maclean, 1 9 8 6) .
3 . Participants achieve a moderate training
response if they are able simply to exercise
enough to achieve an increase in breathlessness
at a constant tolerable level while avoiding
Figure 9.14 The effort of unsupported upper limb
activity (From Ries. A. L. and Moser, K. M . (1996) Shortness distress or desaturation. This allows for the
of Breath: A Guide to Better Uving and Breathing, C. V. variation in intensity that suits different indivi
Mosby, St Louis, MO) duals. Some exercise gently while others can
236
EXERCISE TRAINING
Box 9. 7 Breathlessness scales training sessions usually last for 3 0-60 minutes
but, for home practice, respiratory patients find
a) Borg shortness of breath scale, which it more acceptable to exercise for one or more
assigns numerical values to degrees of breath short sessions a day with brief warm up and cool
lessness. The level chosen by the participant down periods. Severely breathless people may
is maintained while the amount of exercise prefer interval training, which alternates 1 5 - to
gradually increases. 3 0-second episodes of exercise with rest.
o - Nothing at all People who tend to rush at their exercise in
0.5 - Very very slight an attempt to get it over quickly may find that
1 - Very slight counting breaths with their steps helps them to
2 - Slight pace themselves in the early stages, e.g.: in/one,
3 - Moderate out/one, or in/one, out/one/two. For others this
4 - Somewhat severe disturbs their rhythm and distracts them from
5 - Severe focusing on awareness of their breathing and
6 level of effort. Stair-climbing may be more
7 - Very severe efficient if performed by inhaling as one leg is
8 raised, exhaling as the body is raised and inter
9 - Very very severe spersing every few steps with a rest.
10 - Maximal
Cool down
b) Breathlessness rating scale. The partlcl Participants are asked to slow down their
pant chooses to work at rating 2,3 or 4. activity for a few minutes, e.g. by slow walking,
Rating 1 Comfortable breathing throughout to prevent sudden pooling of blood in the lower
Rating 2 During: deeper breathing extremities.
After: recovery 2-5 min
Day after: comfortable
Progression
Rating 3 During: harder breathing
Participants progress by increasing duration or
After: recovery 4-7 min frequency, usually in weekly increments.
Day after: comfortable Intensity usually stays the same but some partici
Rating 4 During: breathless but not
pants are happy to increase this. Improvement
speechless usually continues for 4-6 months and, when a
After: recovery 5-1 0 min plateau is reached, moderate exercise should be
Day after: not tired
maintained at a minimum 15 minutes a day. An
Rating 5 During: breathless and speechless
indoor programme is substituted when there is
After: recovery > 10 min air pollution, wind or rain. Urban patients are
Day after: tired advised to choose the least polluted times and
places for training. A fixed routine at a regular
time of day helps adherence to the programme.
exercise safely at over 8 00/0 of their maximum Progression includes adaptation to uneven
(Ries, 1 994). terrain and any anticipated problems identified
The balance of duration and frequency by the patient. Figures 9 . 1 5 and 9 . 1 6 are
depends on individual preference because the suggested documentation to record results and
result is similar if total work is the same. Low monitor progress.
intensity, unstructured programmes appear to be Once a week, participants should put them
as beneficial as high-intensity, highly structured selves back on the same programme as on the
programmes (Bach and Haas, 1 996). Supervised final day of their training. If this is difficult, they
--
-- 237
Stage 1 : Level 1 -2 on shuttle or recovering from exacerbation

Name:
�
Activity
Warm u p
Wa l k i n para l lel bars
B i ceps curls
B i ke without resistance
Quadriceps
S i t-to-sta nd
Cool down
Rest
5,0,
Borg
Stage 2: Level 3-6 on shuttle or able to bike for 15 min
�
Name:
e
Activity
Warm u p
Tread m i l l 2 m i n
Quadriceps + 1 kg
Wa l l press-ups
B i ke res istance 2 5
S ma l l step
Arms 50 reps
Cool down
Rest
5, 0,
Borg
Stage 3: Level 7 on shuttle or bike 15 min + arm exercises 50 reps
�
Name:
te
Activity
Warm up
B i ke resistance 50
B a l ls, sandbags, etc
M u ltigym
Stairs
Cool down
Rest
5,0,
Bo�g
Figure 9. 1 5 Circuit record sheet.
238
INSPIRATORY MUSCLE TRAINING
Name
Date Resting Distance or no. shuttles Completion of exercise 2 min after exercise
5.02 5.02 5.02

Borg Borg Borg
5.02 5.02 5.02
Borg Borg Borg
5.02 5.02 5.02

Borg Borg Borg
5.02 5.02 5a02
Borg Borg Borg
Figure 9. 1 6 ' Progress sheet, used as baseline and at 3 months, 6 months and 12 months
have lost fitness and will need to increase their • inadequate oxygen delivery to the muscles
maintenance exercise. If training is interrupted because of heart failure or blood gas
by illness or holiday, the programme is restarted abnormalities, which may respond to fluid,
at a lower level. The difficult task of maintaining drug and oxygen therapy
fitness needs follow-up encouragement from the • steroid-induced weakness, which should
rehabilitation team. respond to drug review
• mechanical disadvantage, which might
The condition of exercise is not a mere
respond to breathing re-education (Martinez
variant of the condition of rest, it is the
et al. , 1 9 9 1 ) or exercise training (O'Donnell,
essence of the machine.
1 99 5 ) .
Sir John Bancroft, quoted by Clark 1 9 9 6
Therefore, for strong inspiratory muscles, it is

INSPIRATORY MUSCLE TRAINING presumed inappropriate to add a further load.
For weak muscles, the cause should be
The concept that strengthening the respiratory
addressed.
muscles would allow a patient to sustain a higher
level of ventilation during exercise is an attrac
tive one if this increased exercise tolerance, but Question 2
does it work? Training can make the diaphragm either more or
less susceptible to fatigue (Braun et al. , 1 9 8 3 ) .
Rationale How?
A diaphragm that becomes more susceptible
Question 1
to fatigue after training is thought to have
Respiratory disease can make inspiratory muscles
reached maximum adaptability and can improve
either weaker or stronger than normal (Heijdra,
performance no further. It is already chronically
1 994). How?
fatigued and is more likely to benefit from
Strong muscles develop by working against
nutrition than training. Jederlinic et al. (1 984)
the resistance of obstructed airways or stiff lungs
claim that inspiratory muscle training (IMT) can
(Newell, 1 9 89). Weak muscles are due to:
override the protective mechanism of fatigue and
• poor nutntIOn, in which case dietary lead to exhaustion and desaturation. Fatigue
management is indicated, which can improve responds to rest.
inspiratory muscle strength by 40% A diaphragm that becomes less susceptible to
(Donahoe and Rogers, 1990) fatigue after training is in a fit state to adapt to
239
the training stimulus. This is when IMT may be muscle damage (Anzueto, 1 992). Patients with
appropriate, especially as people with COPD weak muscles may benefit from training, regard
show parallel decrements in strength of limb and less of how breathless they are, and are most
respiratory muscles, each contributing indepen likely to respond if:
dently to reduced exercise capacity (Simonds et
at. , 1 996, p. 27). • they are fearful of activity, because IMT can
be used to desensitize them to breathlessness
Effects prior to venturing into exercise training
Increased strength: ability to generate greater • they are unable to do exercise training for
force other reasons, in which case IMT can be a
Increased endurance: ability to generate the same substitute
work for a longer time. • they find breathing re-education difficult, in
which case using the device might famil
When used appropriately, IMT can improve iarize them to an altered breathing pattern,
inspiratory muscle strength and endurance before progressing to self-regulation of
(O'Kroy, 1 993) but there is limited evidence that breathing
this benefits the patient (ACCP/AACVPR, 1 997). • they enjoy it!
Results have been mixed but, in rested and
nourished patients, the following outcomes have Most studies have investigated people with
been reported: COPD, but benefits have been reported for
• 1 breathlessness and i exercise tolerance people with CF (Sawyer and Clanton, 1 993),
(Lisboa et aI. , 1 997) asthma (McConnell et at. , 1 998), restrictive
• i nocturnal saturation (Heijdra, 1 996) disease (Chatham, 2000) and those awaiting
• i motivation to exercise (McConnell et at. , heart transplantation (Cahalin, 1 997). Others
1 99 8 ) . include patients with steroid-induced respiratory
muscle weakness (Weiner, 1 995) and those in
One study found there was n o effect unless respiratory failure who fail to wean from
nutrition was providing 1 . 5 times the basal mechanical ventilation because of respiratory
metabolic needs (Rochester, 1 992). muscle atrophy (Aldrich, 1 985).
Some patients have shown reduced breathless For people with neurological disease,
ness by training the expiratory muscles (Suzuki damaged nerves must be respected and weak
and Sato, 1 995). Expiratory muscle training may muscles not overworked. However, exercise
benefit people with multiple sclerosis (Smeltzer, induced injury has not been reported, possibly
1 996) whose poor cough pressures are caused by because patients would not tolerate fatiguing
weak expiratory muscles, partly due to decondi loads. Disorders that leave the intact muscles
tioning because of inactivity. unaffected, such as quadriplegia, have shown
improvement with both inspiratory and expira
Indications and contraindications tory muscle training (p. 396). Progressive
How can we select those patients with weak disorders such as muscular dystrophy have
muscles for whom training might provide protec shown some benefit before the stage of advanced
tion against chronic fatigue, and avoid overbur disease when CO2 is retained (McCool and
dening those with fatigued muscles? The clinical Tzelepis, 1 995).
symptoms of fatigue and weakness are similar Some benefit has been shown for those
but the two states are distinguishable (p. 7-8) . without disease, e.g. the elderly (Copestake and
Fatigued muscles are unsuited t o training, and McConnell, 1 994) and sportsmen who want to
excessive exercise may split fibres, create maintain their fitness when injury prevents
'overuse atrophy' (Braun et aI. , 1 98 3 ) and cause training (Chatham, 2000).
240 -------
ENERGY CONSERVATION
Technique
Devices are cheap and simple. The principles of
training are followed:
• alternate exercise with rest
• avoid distressing levels of fatigue
• progress by time and/or resistance. (a)
For strength training, the target is generally

800/0 of MIP (p. 6 1 ) and for endurance training
it is 60%, but benefits have been found at 3 0%
of maximum (Nield, 1 999). If the aim is desensi
tization to breathlessness, resistance should be at
a level that leaves the patient more breathless
than normal but not speechless or distressed.
More simply, a resistance can be set that the
patient can tolerate for 10 minutes (Brannon et
al. , 1 998, p. 43 1 ) . Patients should be relaxed but
inhale with sufficient force to overcome the
resistance. They should work at different ranges
to prevent muscle fatigue, while avoiding excess
hyperinflation. If oxygen is needed, nasal
cannulae can be used. (b)
If progressing by time, this increases from
about 5 minutes twice a day to about 1 5 Figure 9. 1 7 (a) Flow-dependent inspiratory muscle
minutes three times a day. I f the patient prefers, trainer. (b) Pressure-threshold inspiratory muscle trainer.
the timing remains stable, e.g. five 2-minute
periods three times a day, with resistance
increased fortnightly for the first 6 weeks and A pressure-threshold device (Figure 9 . 1 7b)
then monthly. incorporates a spring-loaded one-way valve,
When patients have mastered the art, training which opens to permit airflow only when a
can be combined with watching TV or reading. preset inspiratory pressure has been reached
Adherence is reasonable when IMT fits into the (Gosselink, 1 996). The load is independent of
patient's schedule and the resistance is not airflow and can be set at a percentage of MIP.
uncomfortably high. Training diaries and further This obliges the patient to generate a set inspira
details of technique are provided by manufac tory force with every breath and is able to create
turers (Appendix C). a training effect.
A flow-dependent device (Figure 9. 1 7a) sets Incentive spirometry has been shown to
resistance by the size of various inspiratory provide sufficient resistance to create a training
orifices, but this load can be lessened by the response in some elderly people (Marinho et aI. ,
patient taking slow breaths to reduce turbulence. 1 999).
These devices are less likely to produce a
training effect and are best used for desensitiza
ENERGY CONSERVATION
tion to breathlessness. PEP masks can be used
as flow-dependent inspiratory muscle trainers One of my ambitions is to dissuade health
by attaching the resistance to the inspiratory professionals from saying 'there's nothing
port. more that can be done'. Apart from the
------ 241
devastating effect it has on people, it is • Organize chores by location to avoid

simply not true . .. there is always multiple trips.
something that can be done. • Co-ordinate breathing, e.g. inhale with
Clay, cited by Ahmedzai, 1 997 pulling and exhale with pushing, bending or
the strenuous part of an activity ('blow as
Strategies to conserve energy tend to be used in
you go').
the later stages of disease, but they are best
• Move smoothly, avoid extraneous move
taught early to give participants greater control
ments, use a rolla tor rather than a Zimmer
over how they achieve a balance of rest and
frame, which destabilizes the shoulder girdle
exercise. Energy conservation is compatible with
and requires twice the oxygen consumption
exercise training and indeed is integral to it.
(Foley et al. , 1 996).
Activities of daily living • Lean on shopping trolleys.
• Organize work space to reduce clutter and
Activities of daily living (ADL) training can
minimize reaching and bending.
improve breathlessness and Sa02 (Aronsson et
• Ensure that work surfaces are the correct
al. , 1 996). Occupational therapists are valuable
height.
allies in this, assisting participants to allocate
• Keep heavy items on top of the work
selectively their diminishing energy by work
surface.
simplification and aids such as trolleys, high
• Rest elbows on worktop for arm activities.
walking frames and household gadgets.
• Develop economic lifting methods using leg
If occupational therapy is not available, the
power rather than back and shoulders.
physiotherapist can advise participants, or make
• Slide pots and pans along the worktop rather
a handout with pictures (e.g. Figure 9. 1 8), based
than lifting them.
on the following:
• Prepare large one-dish meals such as casser
• Prioritize activities, eliminate non-essentials. oles, serve in baking dish, freeze leftovers.
• Plan in advance, allow time, alternate hard • Soak washing up.
and easy chores, spread energy-demanding • Use a stool for kitchen work and ironing, as
tasks over the week, pace activities and work this can save 24% of energy (Bach and Haas,
in stages. 1 996, p. 336).
• Sit to dress, put on two items at once e.g.
underwear with trousers or skirt.
• Reduce bending by crossing one leg over
the other to put on socks, trousers and
shoes.
• Avoid aerosols or strongly scented perfumes.
• For bed-making, have a raised bed on casters
away from walls, unfold sheets on the bed,
make only one trip round the bed.
• Use non-iron clothes, electric toothbrush,
long-handled sponge, soap-on-a-rope, towel
ling bathrobes, slip-on shoes or Velcro
closures.
• Plan ahead for socializing because the energy
Nicotine makes a useful pesticide
expenditure can equal that of walking Gette
Figure 9. 1 8 Activities of daily living. (From Milne, A. et al. , 1 997).
( 1 998) Smoking: The Inside Story, Woodside, Stafford, with
permission. Artist: James Northfield.) Participants can share their own strategies
242
ENERGY CONSERVAT10N
disease suffer muscle tension from breathless

ness, stress and the body positions needed to
ease their breathing. A rhythmically active
muscle such as the diaphragm is in particular
need of relaxation in order to return to its
resting position after contraction (Coirault,
1 999), especially when it is being overused to
maintain hyperinflation. Some have become
accustomed to muscle tension and forget how it
feels to be relaxed. Relaxation helps breathing
and breathing helps relaxation. It should be
taught early and reinforced throughout.
Relaxation
Relaxation can be taught by several methods,
e.g. page 1 70, or self-taught from books, tapes
or classes. Daily practice is needed until the
sensation is appreciated and the skill mastered,
Figure 9. 1 9 Energy conservation in the shower (From whereupon a degree of relaxation is integrated
Ries, A. L. and Moser, K. M. (1 996) Shortness of Breath: A into everyday life by identifying stressful situa
Guide to Better Uving and Breathing, C. V. Mosby, 5t Louis, tions and practising in different positions.
MO) Relaxed walking can be consciously maintained.
Spot checks during the day can identify body
tension.
such as finding inconspicuous 'puffing stations'
Relaxation can be achieved in other ways.
during shopping trips, e.g. window shopping.
Participants often have their own ideas, e.g.
Advice needs to be individualized. Some
sewing, jigsaws or, for insomniacs, watching a
people might find it more important to use their
lighted aquarium at night. Activities such as
energy to get to the shops than to be indepen
circle dancing or Tai Chi provide rhythmic
dent with dressing. Some prefer to sleep down
exercise with a meditative effect, which empha
stairs rather than suffer the 'stigma' of a stairlift.
sizes trunk rotation (Wolf et aI. , 1 997), and
Some find sitting in a shower easier than using a
improve balance, posture, immune function and
bath (Figure 9. 1 9), while others find that water
conditioning (Lan, 1 996).
on their face upsets their breathing. Some are
not happy to have their spouse bathe them.
Complementary therapies
Stress reduction The best way to still the mind is to move
Voluntary control of respiration is perhaps the body.
the oldest stress-reduction technique known. Roth, 1 99 0
It has been used for thousands of years to
Complementary therapies may help ease breath
reduce anxiety and promote a generalized
lessness and stress, depending on the practi
state of relaxation.
tioner. It is useful to have some knowledge of
Everly, 1 9 8 9
complementary therapies and local resources for
Stress is physiologically detrimental (p. 25) . participants who request this information.
Putting a tense person through a physical Yoga incorporates breathing techniques,
training programme without advice on stress meditation and postures that consume minimal
management is silly. People with chronic lung energy and induce physiological effects charac-
243
teristic of deep relaxation. One study demon Follow-up plans should be set at the start of the
strated improved lung function (Singh, 1 990) programme. It takes a minimum of 6 weeks, and
and another a reduced ventilatory response to often longer, for participants to see an improve
CO2 (Stanescu, 1 9 8 1 ) . Yogic breathing promotes ment. If expectations are not met, they may lose
breathing awareness, nose-breathing and heart. Some supervised training is best continued
'complete breathing', which begins with for a period after the initial programme, to
abdominal breathing, then expands the lower prevent detraining and demotivation (Swerts,
chest and finally the upper chest (Fried, 1 993, p. 1 9 90). Thereafter, follow-up in patients' homes
239). Meditation clears interfering thoughts or by telephone (Pal, 1 99 8 ), newsletter or
from the mind, reducing respiratory rate, HR further training sessions (Ojanen, 1 993) may be
and BP (Fried, 1 993, p. 23 5). needed, 3- and then 6-monthly.
The Alexander technique inhibits muscle The hospital may be able to provide a regular
tension, which reduces WOB and can improve venue, or a leisure centre may be appropriate.
objective measures such as peak flow and Transport to follow-up meetings and social get
respiratory muscle strength (Austin and Ausubel, togethers may be available through voluntary
1 992). The Feldenkrais method uses the organizations.
principle of least effort and is useful for energy Home visits are especially useful for people
conservation (Hannon, 2000). Massage can who are elderly, anxious, forgetful, using new
reduce BP (Hernandez-Reif, 2000). Biofeedback equipment or at the end-stage of disease. The
to reduce muscle tension allows the sensation to home environment is where people feel most in
be recognized and control gained over it control and are most responsive to advice.
(Hodgkin et al. , 2000, p. 12). Imagery uses Patients are now cared for at home when they
visualization of peaceful scenes, which can have relatively acute disease or when using intra
achieve a relaxed alpha brain-wave state (Haas venous therapy, tracheostomies or home ventila
and Axen, 1 9 9 1 , p. 285). Hypnotherapy reduces tors.
the metabolic rate through deep relaxation (Sato Home visits provide the opportunity to check
et at. , 1 9 8 6). Acupuncture works directly on for adequate heating, and health or safety
reducing the perception of breathlessness and hazards. They are also supportive for the family.
has shown increased exercise tolerance Gobst et Spouses may be stressed, neglect their own
al. , 1 98 6) . Patients contemplating aromatherapy health, feel guilty or be fearful of sleeping lest
need to be aware that different oils can affect their partner die in the night. Children may lack
breathing positively or negatively. attention and be caught up in conflicting
emotions. Between visits, patients and families
Mechanical rest need a contact telephone number.
For chronically fatigued patients, non-invasive Respiratory patients can withdraw into social
ventilation at home may be part of rehabilita isolation because of the nature of their
tion. symptoms, and the mutual support that develops
between participants during the rehabilitation
programme may become one of its most
FOLLOW-UP, HOME MANAGEMENT AND SELF
enduring assets. This support can be built into
HELP
self-help groups using the Internet, or Breathe
The increased exercise capacity, improved Easy, co-ordinated by the British Lung Founda
skills and sense of empowerment achieved in tion (Appendix C), or peer outreach programmes
rehabilitation do little good if the patient's in which patients are visited by volunteers with
sole exercise thereafter is pushing remote lung disease who have been selected for their
control buttons to change TV channels. ability to cope with their disabilities. Social
Thomas, 1 996b outings, monthly lunches and annual celebra-
244
OmcoMES
10
tions may develop, which are particularly
9
supportive for people who do not like to be seen OJ
<ii 8
in public with their oxygen. u
(J) 7
I
Ol
If I go and visit a Breathe Easy supporter 0 6
Ee. 5
who hasn't been to a group meeting for a cu
Cl> 4
while, I know what I'll find. Someone 0
c:
a. 3
sitting in an armchair, the TV in front, a (J)
>- 2
nebulizer on one side and the remote 0
control and telephone on the other. We all 0

know it - it's the siege situation.
Breathe Easy Newsletter, 1997 Figure 9.20 Pre- and post-rehabilitation scores for
dyspnoea, showing the effectiveness of breathing re
education, relaxation and exercise training. (From Strij bos, J .
OUTCOMES H . e t 01. ( 1 989) Objective and subjective performance
indicators in COPD. European Respiratory Journal, 2, 666)
Evaluation of rehabilitation can be by the
following:
• number of participants completing the

programme Western medicine has yet to make full adjust
• scales on breathlessness and QoL ment to the increasing prevalence of chronic
• diary review over acute disease, and tends to focus on illness
• hobbies, job (if wanted) rather than prevention and rehabilitation.
• GP visits, admissions to hospital, time In Physiotherapists can play a part in educating
hospital others on the effectiveness of pulmonary rehabi
• anxiety and depression scores litation by lecturing to medical and other
• smoking students, initiating meetings with physicians and
• medication e.g. 1 betaragonists providing proof of benefit to patients (Figure
• independence in ADL 9 .20) and cost-effectiveness to budget-holders
• video evidence of improved flexibility, (Figures 9 . 1 , 9 .20, 9.2 1 , Appendix E).
posture and gait
• weight i or 1 as appropriate
• specifically in relation to exercise training: i
walking distance, i shuttle test, i V02 max, 1 a: 1 80
« 161
exercise HR, 1 blood lactate levels (Mohse w
>- 1 50
nifar et al., 1 9 8 3 ) -
• improved well-being o f carers. en 1

>-
«
0
Changes in lung function are not anticipated. ..J
«
Boxes 9. 1 or 9.2 can be used to record the !:: 60
0-
relevant outcome measures. en
30
It is hoped that an abiding legacy of the 0
:I:
programme is the friendship and courage that 0
BEFORE AFTER
participants give each other. For those labouring
under the double burden of disease and ageing,
Figure 9.2 1 Pre- and postrehabilitation hospital days.
the outcome should be a more optlmlstlC
(From Make ( 1 994) Collaborative self-management
attitude towards a life that can be active and strategies for patients with respiratory disease. Respiratory
fulfilling. Core, 39, 566-577)
245
'I'm thankful that I have one leg,

To limp is no disgrace.
Although I can't be number one
l;ji1:.]��1" .';ii�i'$\11i'i)·A
I still can run the race. I. Analysis
It's not the things you cannot do
Loss of confidence and exercise tolerance since
That makes you what you are,
discharge.
It's doing good with what you've got
That lights the morning star.' 2. Problems
Hart, quoted by deLateur, 1 997
Breathlessness.
Inefficient breath ing pattern.
I;ii�i'$\1IiIi)·m;i;ii:I 1 exercise tolerance.

Depression .
Misuse of oxygen .
Identify the problems of this 66-year-old man with
emphysema who was referred as an outpatient 3. Goals
after disappointment following rejection for
Short term: daily walk to bandstand.
transplantation.
Medium term: return to pre-ad mission function
Background including steps up to flat.

Long-term : l ifelong programme.
SH: l ives with wife, fi rst floor flat with l ift.
Drugs: bronchod ilators, steroids, diuretics. 4. Plan
H PC : Recent admission for exacerbation,
• Obtain further information from patient on
discharged with home oxygen, making slow
fluids, nutrition, limitations to exercise tolerance
recovery.
(e.g. anxiety, SOB, deconditioning).
Subjective • Identify cause of poor sleep, liaise with

multidisciplinary team where appropriate.
Can't do much since leaving hospital.
• Educate, or refer to respiratory nu rse for
Able to look after self.
education, on oxygen therapy. Refer to d ietician
Able to drive.
for nutritional advice. Check knowledge of
Unable to walk any useful d istance.
medication.
Unable to help in house or with shopping.
• Following preliminaries (e.g. education for
Poor sleep since hospital.
anxiety and desensitization for breathlessness)
Not hungry.
retrain efficient breathing pattern and initiate
Don't use oxygen much .
written daily exercise programme.
No phlegm.
• Follow up in a week to maintain motivation,
Objective then monthly, then 6-monthly reviews.
Leaning forward with hands on knees.

Speaking in short sentences.
Pursed lip breath ing with active expiration. LITERATURE APPRAISAL
Comment on the logic of the following state

Questions
ments.
I . Analysis?
2. Problems? Pursed lip breathing should be employed
3. Goals? during and following exercise and during
4. Plan? any activity.
[TJhe authors concluded that the inability
246 ------
RECOMMENDED READING
of pursed lip breathing to decrease oxygen ( 1 99 3 ) Desensitisation and guided mastery:

consumption meant that this breathing treatment approaches for the management of
method failed to decrease the work of dyspnea. Heart Lung, 22, 226-234.
Celli, B . R. ( 1 994) Physical reconditioning of patients
breathing.
with respiratory diseases: legs, arms and breathing
. . . using a tilt board such as an ironing
retraining. Respir. Care, 39, 4 8 1 -499.
board. . . .
DeVito, A. J. ( 1 9 9 0) Dyspnea during hospitalization
Clin. Chest Med. 1 9 8 6 ; 7 : 5 9 9 - 6 1 8
for acute phase of illness as recalled by patients
with COPD. Heart Lung, 19, 1 8 6- 1 9 l .
Gaskin, L. and Thomas, J . ( 1 995) Pulse oximetry and
exercise. Physiotherapy, 8 1 , 254-2 6 l .
Janssens, J . P . (2000) Management o f dyspnea in
RESPONSE TO LITERATURE APPRAISAL severe COPD. J. Pain Symptom Man. , 19, 3 7 8 -

3 92 .
Pursed lip breathing is recommended even Kakizaki, F., Shibuya, M. a n d Yamazaki, T. ( 1 999)
though it is unable to decrease oxygen consump Preliminary report on the effects of respiratory
tion or decrease WOB. muscle stretch gymnastics on chest wall mobility
Discrepancy between findings and conclusion in patients with COPD. Respir. Care, 44, 409-
is not unusual, possibly because authors find it 4 14 .

Lan, c., Lai, J. S . a n d Chen, S . (2000) Tai C h i Chuan
difficult to accept what they had not anticipated.
to improve muscular strength and endurance in
It might have been more useful if the discussion
elderly individuals. Arch. Phys. Med. Rehab ., 8 1 ,
had looked at possible reasons why some
604-607.
patients find pursed lip breathing helpful even if Lareau, S. C. ( 1 996) Functional status instruments:
it does not reduce their WOB. Outcome measures in patients with COPD. Heart
And an ironing board is for ironing. . . . Lung, 25, 2 1 1 -224.
Molen, B . van der ( 1 995) Dyspnoea: a study of
measurement instruments for the assessment of
RECOMMENDED READING dyspnoea. J. Adv. Nurs., 22, 948-956.
Nicholls, D. (2000) Breathlessness. A qualitative
(See also appendix E) model of meaning. Physiotherapy, 86, 2 3 -27.
AARC Clinical Practice Guidelines ( 1 999) Suctioning O'Donnell, D . E. ( 1 994) Breathlessness in patients
of the patient in the home. Respir. Care, 44, 99- with chronic airflow limitation. Chest, 106, 904-
1 04. 9 1 2.
ACCP/AACVPR ( 1 997) Pulmonary rehabilitation: Peel, C. and Mossberg, K. A. ( 1 9 95 ) Effects o f
joint ACCP/AACVPR evidence-based guidelines. cardiovascular medications o n exercise responses.
Chest, 1 12, 1 3 63 - 1 3 9 6 . Phys. Ther., 75, 3 8 7-3 9 6 .
Ambrosino, N . and Clini, E. ( 1 996) Evaluation i n Steele, B. ( 1 992) The dyspnea experience: nociceptive
pulmonary rehabilitation. Respir. Med. , 9 0 , 3 9 5 - properties and a model for research and practice.
400. Adv. Nurs. Sci., 1 5 , 64-76.
Ambrosino, N. and Foglio, K. ( 1 996) Selection criteria Vickers, A. and Zollman, C. ( 1 99 9 ) Hypnosis and
for pulmonary rehabilitation. Respir. Med. , 90, relaxation therapies. Br. Med. j., 3 19, 1 3 4 6 - 1 349.
3 1 7-322.
Carrieri, V., Douglas, M. K. and Gormley, J. M.
247
10 PHYSIOTHERAPY FOR PEOPLE UNDERGOING SURGERY
SUMMARY
Introduction Heart surgery

Respiratory complications of surgery Transplantation
Other complications of surgery Repair of co-arctation of the aorta
Preoperative management Oesophagectomy
Pain management Breast surgery
Postoperative physiotherapy Head and neck surgery
Abdominal surgery Case study
Lung surgery Literature appraisal
Pleural surgery Recommended reading
Chest drains
INTRODUCTION However, complications related to pam and

bedrest have decreased.
Surgery is now available for those previously Physiotherapists working on a surgical ward
denied it because of disease or debility. Many need acumen in order to identify patients who
operations can now be performed via laparo need treatment, and empathy for the individual
scopy (keyhole incision through the abdominal because what is routine for physiotherapists is a
wall) or thoracoscopy (keyhole incision through unique event for patients. Patients antiCIpate
the chest wall), including aortic aneurysm repair surgery with their own mixture of hope and
(Cerveira et al., 1 999) and heart surgery (Burke, dread.
1998). Respiratory complications are the leading
Minimal access techniques use fibreoptic cause of postoperative morbidity and death
endoscopes, which provide illuminated fields of (Brooks-Brunn, 1 995). Most patients gain from
vision and allow keyhole surgery by instruments physiotherapy input to the team management of
inserted through several small stab incisions. pain, positioning and handling. All could
Video-assisted techniques enable the operative doubtless benefit from direct physiotherapy, but
field to be viewed by the team on a monitor most physiotherapists select for assessment only
displaying a magnified view from within the those at risk due to (Bluman et al., 1998):
patient's body. Major surgery is also possible at
the bedside or in the intensive care unit (ICU), • smoking history, especially current smokers
often under local anaesthesia (Dennison et ai. , who have a six-fold greater incidence of
1 996). Virtual surgery may become a reality postoperative complications
(Cregan, 1 999). • surgery to the upper abdomen or chest
These changes have altered requirements for • prolonged preoperative stay
physiotherapy. Sicker patients who are now able • prolonged anaesthesia
to have surgery require extra input, and policies • the presence of lung or heart disease
of early discharge demand rapid rehabilitation. • obesity or malnourishment
248 ------
REsPIRATORY COMPLICATIONS O F SURGERY
• advanced age ventilation causing intrathoracic pooling of

• excessive anxiety blood which further displaces air from the
• emergency surgery lung.
• Drowsiness and immobility obliterate the
regular oscillations in tidal volume that
RESPIRATORY COMPLICATIONS OF SURGERY
normally punctuate breathing and stimulate
Lung complications occur in 25-50% of patients surfactant production.
undergoing major surgery (Ferguson, 1 999). • Absorption atelectasis (p. 1 20) is due to
After abdominal or chest surgery these reach a supplemental oxygen during anaesthesia.
maximum within 48 hours. The following have This begins after about 40 min of 40% O2
been demonstrated after full-incision surgery. and 5 min of 1 00% O2 (Clarke et al., 1 998).
It is augmented by the closed gas pockets
Atelectasis created by reduced lung volume (He den
Atelectasis (collapsed alveoli) occurs in typically stierna, 1 999).
1 0-15% of the lung and lasts an average 2 days • Muscle tone is reduced.
postoperatively (Hedenstierna, 1 999). The left • Diaphragmatic function may be impaired by
lower lobe is the commonest site, possibly abdominal distension (Frost, 1 996).
because of compression from the heart (Raoof et • Sympathetic pleural effusion is a common,
al., 1 999). Causes are described below. though usually minor, reaction to fluid over
load.
• Pain is the major culprit (Simpson et al.,
1992), dull at rest and sharp on movement. Atelectasis creates a restrictive lung defect,
This leads to immobility and, after chest or reducing lung compliance, increasing airway
abdominal surgery, guarding spasm of the resistance (Wahba, 1 9 9 1 ) and depleting surfac
trunk muscles and inhibition of breathing tant (Brooks-Brunn, 1 995). Persistent atelectasis
(Figure 10. 1 ) so that tidal breathing falls into may be associated with chest infection but there
the closing volume range (Sutcliffe, 1 993). is little evidence of causality (Brooks-Brunn,
• Prolonged recumbency affects the amount of 1 995).
::7:��\ j
Anaesthetic ----. J,Mucus transport � Sputum retention
During
surgery
� Absorption
'telectaSiS
After
dy,""";oo
. �
� J, FRC � Airway closure -. Atelectasis
surgery
Pain ------.
J,Cough ___
Negative ---...
fluid balance • Sputum retention
Dry mouth --+- J, Expectoration

�
Figure 10.1 I nterrelation of factors affecting postoperative lung function.
--
-- 249
CHAPTER 1 0 PHYSIOTHERAPY FOR PEOPLE UNDERGOING SURGERY
Atelectasis can be reduced by measures to

increase lung volume (Chapter 6). Greater Other chest problems
efforts are needed to inflate collapsed alveoli Intubation can cause bronchospasm in suscepti
than to inflate those that are partially open. ble patients (Wong and Shier, 1997). Toxic
Prevention is therefore better than cure. levels of opioids can cause respiratory depres
sion. Vital capacity can drop by 40-50%
Hypoxaemia (Wahba, 1991) because of pain, leading to
There is a close correlation between atelectasis impaired cough.
and shunt. Hypoxaemia is caused by shunting of
blood through airless lung and inhibition of OTHER COMPLICATIONS OF SURGERY
hypoxic vasoconstriction (p. 1 1) by volatile
Fatigue is related to the degree of trauma during
anaesthetic agents. Hypoxaemia may not be
surgery and lack of nutrition after surgery
significant and many patients leave hospital
(Christensen and Kehlet, 1 984). It is more severe
happily ignorant of its existence. For others it
and prolonged than expected by most patients,
can impair healing, promote infection and
persisting for a month in two-thirds of people
contribute to postoperative confusion (Hanning,
and directly affecting exercise capacity
1 992). When present for a few hours it is
(Delaunay, 1 995). Frequent short walks should
related to the anaesthetic. When present for
be negotiated rather than infrequent long ones.
several days it is related to the surgery and post
Some drugs contribute to the 'big little
operative factors (Hudes, 1 98 9).
problem' of postoperative nausea. This is experi
Patients at risk may suffer nocturnal hypoxae
enced by 20-30% of patients (Diflorio, 1 999),
mia for up to five nights after surgery (Roberts et
some of whom find it a more wretched experi
at. , 1 993). They have missed out on their rapid
ence than pain (Watcha, 1996). It is commonest
eye-movement sleep due to disruption and medi
after lengthy surgery or in patients who are
cation, and as they catch up on this part of their
hypovolaemic, in pain, anxious, obese or female
sleep cycle, their oxygen requirements increase
(Broomhead, 1 995). Nausea inhibits deep
(p. 25) . Patients who have had major surgery, or
breathing, and vomiting can lead to complica
those with respiratory or cardiovascular disease,
tions such as fatigue, bleeding, dehiscence
should be monitored for nocturnal oxygen desa
(separation of the incision or rupture of the
turation to prevent premature cessation of
wound), aspiration of gastric contents, delayed
oxygen therapy. During surgery, the provision of
hospital discharge and increased readmissions
800/0 oxygen has been shown to halve the
(Watcha, 1 996). Rapid-onset analgesics such as
incidence of wound infection (Grief, 2000).
fentanyl cause less nausea than morphine
Chest infection (Claxton, 1 997). Nausea may be relieved by:
Intubation overrides defence mechanisms and • hydration, pain relief, drug review (Watcha,
anaesthetic agents impair ciliary action. After 1 996)
halothane-nitrous oxide anaesthesia, mucocili • midazolam (Diflorio, 1 999), dexamethasone
ary transport slows after 30 minutes and stops (Henzi, 2000), cannabis (Russo, 1998)
after 90 minutes (Houtmeyers, 1 999). This powdered ginger (Phillips, 1993)
predisposes to chest infection, especially in • hypnosis (Faymonville, 1 997), preoperative
smokers (Konrad, 1 993). Signs may emerge relaxation (Enqvist, 1 997)
some days after surgery, e.g. crackles on auscul • acupressure (Fan et at. , 1997) or TENS
tation, purulent bronchial secretions, malaise, (Frazer, 1 999) applied to P6 located two
fever and sometimes tachypnoea. If pneumonia thumbs' widths proximal to the distal wrist
develops, mortality can reach 30-40% (Brooks crease on the inner arm in line with the
Brunn, 1 995). middle finger (Ellis, 1 994, p. 157)
250
OTHER COMPLICATIONS OF SURGERY
• supplemental oxygen, which can halve the vasodilating anaesthetic drugs and prevention of
incidence of nausea and vomiting (Greif et shivering by paralysing drugs. Complications
al., 1 999). include wound infection, impaired coagulation
and delayed hospital discharge (Leslie and
Anxiety increases diaphragmatic splinting and Sessler, 1 999).
stimulates metabolic and hormonal stress Incessant hiccups, caused by irritation of the
responses which can delay healing and promote diaphragm, cause sharp pain at the wound site.
infection (Salmon, 1 992). Anxiety is reduced by They may be inhibited by baclofen (Walker,
giving' preoperative information and granting 1 99 8a), sugar, acupressure to CV1 7 (p. 84), an
postoperative autonomy. array of techniques to raise PaC02 (breath
Depression may occur, especially if surgery holding, rebreathing, drinking a glass of water
affects body image, e.g. colostomy, head and from the wrong side of the glass), dropping a
neck surgery or mastectomy. An understanding piece of ice down the back to hyperextend the
ear or referral to a self-help group (Appendix C) neck, or prayers to St Jude, the patron saint of
may prevent a sense of loss degenerating into lost causes.
long-term depression. Hypertension is most likely after abdominal
Fluid imbalance causes electrolyte disturbance aneurysm repair, carotid endarterectomy or
and can lead to desaturation even if gas intracranial surgery (Frost, 1 996).
exchange is adequate (Westbrook and Sykes, Neurological problems such as dementia or
1 992). Hypovolaemia is due to pre- and post stroke may follow apparently uncomplicated
operative fluid restriction, the drying effect of surgery (Sharpe and Hanning, 1 999).
premedication, unhumidified anaesthetic gases Postoperative haemorrhage, due to surgical
and tissue trauma (Rosenthal, 1 999). Postural complications or deficient clotting mechanisms,
hypotension may be a sign of unrecognized is suspected if there is:
hypovolaemia and is a reminder to avoid sudden
• obvious bleeding
motion or position change. Fluid overload may
• rapid filling of drainage bottles
be caused by over-enthusiastic fluid replacement.
• signs of hypovolaemic shock (p. 362).
Urine retention, flatulence or constipation
impairs excursion of the diaphragm. Urine Persistent bleeding that does not respond to
retention may be helped by acupressure to CV2 correction of haemostatic abnormalities may
on the midline of the upper border of the reqUlre electrocoagulation or exploratory
symphysis pubis (Ellis, 1 994, p. 1 04). Flatulence surgery.
may be relieved by pelvic tilting and knee rolling Deep vein thrombosis (DVT) is a blood clot
in crook-lying. that develops surreptitiously, usually during
Hypoxaemia increases the risk of wound surgery. Causes are calf compression, immobi
infection (Whitney, 1 989), which is suspected if lity, fluid loss, manipulation of blood vessels, the
there is fever, swelling, erythema or increased surgical stress response which upsets clotting
localized pain. Wound infection increases the (Edmondson, 1 994) and depression because of
risk of dehiscence, especially if the patient is the serotonin effect on platelet aggregation
malnourished, obese, immunocompromised or (Seiner, 1 999). DVT complicates one-fifth of
has malignant disease or a history of radiother major operations (Ashby, 1 995) but is under
apy or longterm steroid use. Wound infections diagnosed because it is clinically silent in 50% of
are not detected for several days postoperatively, patients (Bright, 1 995). Signs may include
but perioperative oxygen reduces their incidence tenderness, swelling and warmth of the calf, or
(Greif et aI., 2000). sometimes pain on dorsiflexion (Homan's sign),
Hypothermia occurs during surgery because of any of which must be reported. Diagnosis can be
exposure of internal organs, fluid administration, confirmed by ultrasound or Doppler imaging. A
------ 251
DVT becomes serious if it breaks free and causes 1 996). Stress lengthens hospital stay (Liu, 1994)
pulmonary embolism (p. 1 13) by lodging in the and can contribute to muscle breakdown,
pulmonary vascular bed. Patients most at risk are delayed healing and immunosuppression
those who: (Salmon, 1 992). Anxious patients should be seen
early if possible because anxiety at impending
• are elderly, obese, or have malignant,
surgery inhibits receptivity (Cupples, 1991). If
vascular or blood disorders
musculoskeletal problems are anticipated, e.g.
• are undergoing lengthy surgery, especially of
after lMA grafting (p. 270), liaising with
the knee, hip or pelvis, which involve distor
surgeons is advisable (EI-Ansary et al., 2000).
tion and traction of blood vessels
Some patients find it beneficial to have
• have had a previous history of DVT.
relatives present for the preoperative visit. The
Awareness during anaesthesia is a feared following can be included:
complication that occurs in one out of 500
• Assessment
operations. If patients speak of this, it should be
• Explanations, e.g. :
reported because it can lead to post-traumatic
- surgery leads to inadequate lung expan
stress disorder (Ghoneim, 2000).
sion, so that activity and sometimes
Postoperative recovery and shortened hospital
deep breathing are needed after the
stay is facilitated by adequate pain relief,
operation
intensive nutrition, early mobilization (Moniche
- if there is extra sputum, breathing exer
et al. , 1 995), a leafy view through the window
cises and coughing may be necessary
(Ulrich, 1 984), positive suggestions under anaes
- prevention is paramount
thesia (Williams et al. , 1 994) and the measures
• Advice to ask for adequate relief of pain or
described in the next section.
nausea.
• Information specific to the operation. Most
PREOPERATIVE MANAGEMENT patients like to know about the wound,
drips, drains and what it will feel like.
Is physiotherapy necessary preoperatively? Preo
People undergoing complex procedures may
perative physiotherapy consisting of information
benefit from visits by patients who have had
and advice on positioning, mobilization and
similar surgery.
chest clearance has shown a reduction in post
• Advice to keep active before surgery.
operative complications, increased Sa02 and
• For high-risk or anxious patients, informa
improved mobilization (Olsen et al. , 1 997).
tion on how to roll, deep breathe, use the
Preoperative exercise and education have shown
incentive spirometer, sit up and cough with
more speedy postoperative recovery (Athur et
mlmmum paIll.
al., 2000). Information alone has been shown to
• Any questions?
reduce complications (Cupples, 1991), increase
ability to deep breathe and cough (Lindeman, People with hypersecretory lung disease may
1971), reduce analgesic requirements by half and need assistance with sputum clearance. Those in
lead to discharge nearly 3 days earlier (Egbert et hospital for longer than a day preoperatively
aI. , 1 964). Some of these studies would not be need advice on a mobility regime. Those
current with today's surgery but illustrate the expecting to wake up on a ventilator need infor
power of information. This is especially mation on the endotracheal tube, the experience
important for children and those expecting to of positive pressure ventilation and suction
wake up in the ICU, where they will feel relieved Oablonski, 1 994), advice that they may hear
at the sight of a familiar face. before being able to respond, suggestions on
Information relieves anxiety, and anxiety is methods of communication, and reassurance that
related to postoperative complications (Gilbert, there will be a nurse watching over them. Visits
252
PAIN MANAGEMENT
to the lCU by the patient and family are often epidural analgesia (Cousins, 1 989), or local
helpful, after careful explanations. Patients are anaesthetic infused into the sciatic nerve (Pavy
advised to stop smoking, although this is best and Doyle, 1 996).
started months previously. However, last-minute
smoking cessation reduces carbon monoxide PAIN MANAGEMENT
levels and improves cardiovascular status
A visit to most postoperative wards will
(Munday et al., 1 993). Some of this information
show you the time-honoured ritual of
may be covered by other members of the team.
inadequate pain management. Like most
Anxious people benefit from relaxation
unpleasant things in life we have done our
(Mogan et al., 1985). Mindless and inaccurate
best to ignore the situation in the hope that
reassurance does not engender trust and can
it will disappear.
impair the· 'work of worry', which is a natural
Harmer, 1991
and necessary part of adjusting to the operation
and its outcome (Salmon, 1 992). Reassurance is Unnecessary postoperative pain still occurs
helpful if anxiety is unrealistic (Teasdale, 1 995). despite advances in medication, improved
Postoperative distress is related to lack of surgical technique and the advent of acute pain
knowledge (Salmon, 1992), and information can teams. These teams have reduced postoperative
be reinforced by written advice. morbidity (Hall and Bowden, 1 996) and surgical
The tradition of prolonged preoperative fluid patients now receive better pain management
and food restriction is now considered unjusti than medical patients (Gray, 1 999). However,
fied. Fluid restriction may lower stomach pH unnecessary pain still occurs because of:
because of reduced dilution of gastric secretions
• a wide variation in patients' perception of
(Greenfield, 1 997), and hypovolaemia causes
pam
more peri operative deaths than water in the
• a wide and unpredictable variation m
stomach (Thomas, 1 987). Clear oral fluids 2
response to analgesics
hours before surgery improves comfort, reduces
• rudimentary pain assessment
dehydration and makes it easier to expectorate
• inexperience, tradition and staff overwork
postoperatively without compromising safety
(Justins and Richardson, 1 99 1 )
(Phillips et aI., 1 993). For patients at risk of
• ignorance o f the difference between abuse
nutritional compromise, preoperative carbohy
and therapeutic use of opioids (Hanks,
drate-rich drinks can be beneficial and can pass
1 996)
safely through the stomach within 90 minutes
• ignorance of the fact that addiction occurs in
(Nygren et aI., 1996).
fewer than 1 in 3000 people who take
Drug dosage to prevent pain is significantly
analgesic drugs (Lavies, 1 992)
less than that required to abolish pain after it
• ignorance of the fact that post-opioid
has occurred (Katz et al., 1 994). Before surgery,
euphoria is not the same as respiratory
pre-emptive analgesia reduces postoperative pain
depression (Lindley, 1 990)
by preventing noxious impulses gaining entry
• an attitude that pain is unimportant, inevi
into the central nervous system, where they
table and to be borne with fortitude, espe
'wind up' the response to subsequent afferent
cially in cultures such as Britain's that see
inputs. Neural blockade of these stimuli is
stoicism as a virtue and distress as a weak
assisted by adding anti-inflammatory drugs or
ness
morphine to the premedication (Lascelles, 1 997)
• patients' low expectations of pain relief and
or using preoperative nerve blocks (Lindgren,
anxiety about side effects (Sutcliffe, 1 993).
1 997). Postoperative phantom pain is related to
the degree of pre-amputation pain (Nikolajsen, The concept of pain includes both the
1 997) and can be eliminated by preoperative sensation and the individual's reaction to that
253
sensation. Pain is a subjective experience, but (Sutcliffe, 1 993). Unrelieved pain is thought to
one study found that 50% of nurses doubt be the main factor limiting the expansion of day
patients' reports (McCaffery and Ferrell, 1 992). surgery (Rawal, 1 997).
It is not unusual to hear patients dismissed as Prolonged pain can become chronic pain by
having a 'low pain threshold' or even 'making a central sensitization (Anand, 1 998). Crombie
fuss'. (1998) found that at one pain clinic, long-term
postoperative pain was shown to be the cause of
Whose pain should the physician control:
referral in 22.5% of patients.
The patient's? That of the relatives? Or his
own, generated by his inability to help the Assessment
patient?
Problems arise when staff make decisions for
Szasz, 1968
patients, which can lead to one-quarter the
Effects of pain prescribed analgesia being given (Rosenberg,
1 992). Postoperative pain should be assessed and
The relationship between pain and atelectasis
graphed like any other vital sign (Sjostrom et al.,
(Figure 1 0.2) can be understood readily by
1 997), e.g. Figure 1 0.3, 1 0.4 or for computer
anyone trying to take a deep breath when in the
buffs, interactive computer animation
dentist's chair. Pain not only inhibits breathing,
(Swanston, 1 993). Pain on movement should be
it increases oxygen consumption and the risk of
included in the assessment (Hall and Bowden,
infection, delays healing and hospital discharge,
1 996).
and can increase morbidity and mortality
Pain assessment is a right for people who are
(Cheever, 1 999). It is associated with anxiety
cognitively impaired or do not speak English,
(McGrath and Frager, 1 996), causes hyperten
not just those who can complain in a way that is
sion and hyperglycaemia, upsets electrolytes,
easy to understand. For patients with confu
further increases pain by causing muscle spasm
sional states or intellectual impairment, pain
and can mask signs of hypovolaemia, which in
assessment needs to be modified in order to
severe cases predisposes to multiple organ failure
avoid problems that can themselves increase
medical complications (LaChapelle et aI., 1 999).
Elderly people are at particular risk of under
treatment and the majority of those with
60 o Atelectasis dementia have been found to suffer severe post-
50
(/)
C
Q) 40
.� Verbal Iatlng SCOIe fOI pain
0.
'0 30 Patients' feeling Score
(jj
.0
E 20 No pain on movement o
::>
z
Mild pain on movement
10
Moderate pain on movement 2
0 Severe pain on movement 3
pain pain
Figure 10.2 The effect of pain on atelectasis. (From Figure 10.3 Pain scale that incorporates movement and
Embling, S. A. ( 1 985) Incidence, Aetiology and Implications of is particularly helpful before physiotherapy. (From Hall, P. A.
Atelectasis follovving Cardiopulmonary Bypass Surgery. MSc and Bowden, M. I. ( 1 996) Introducing an acute pain service.
dissertation, University of Southampton, with permission.) British Joumal of Hospital Medicine, 55, 1 5-17)
254
PAIN MANAGEMENT
The worsl pain

I ever fell
• anxiety or fear
• physical discomfort
• physical tension
• lack of autonomy or privacy
• depression
• sleep fragmentation (McIntosh, 1989).
This is fertile ground for the physiotherapist.
Physical tension can be eased by posture change
or relaxation (Miller and Perry, 1 990). Anxiety
can be reduced by keeping patients informed.
Autonomy can be enhanced by including them in
decisions. During activity, patients need reassur
ance in words and actions that they will be
heard and responded to. 'Tell me if it hurts and
I'll stop' is music to their ears.
Handling patients in pain

pain works subversively, undermining
c. • •
one's self-confidence and self-control, worn

No pain at all dismayingly fragile. The sense of
Figure 10.4 Visual analogue scale.
anticipation is honed, to hysteria almost,
and one quickly learns to be thoroughly
suspicious of the well-meant: "this won't
operative pain (Morrison and Siu, 2000). The hurt".'
opinion of relatives may be helpful. Pain assess Brooks, 1990
ment for children and infants is on page 432. Physiotherapists should be seen as experts in the
If pain cannot be assessed by the patient, relief of pain rather than its perpetrators. The
objective signs are pallor, sweating, shallow essence of physiotherapy is skilful handling, and
breathing, breath-holding and increased pulse, there are few rewards greater than relief on the
BP and respiratory rate. Severe pain causes face of a patient whose pain we have eased.
nausea, vomiting and reduced pulse and BP. Handling and positioning have been found to be
as important in relieving acute pain as drugs
(Sutcliffe, 1 993).
Reduction in the perception of pain Guidelines are the following:
There are many things that make pain
• Patients must be assured that they are in
worse, such as the spirit in which it is
control.
inflicted. You are indeed acutely vulnerable
• Analgesia should be given automatically
to the attitude of people surrounding you.
before physiotherapy, instead of first
Donald, 1977
checking to see if treatment causes pain, a
Perception of pain varies with some factors that strategy known as shutting the stable door
physiotherapists cannot modify such as the after the horse has bolted.
operative technique and previous experience. • Unnecessary handling should be avoided.
However, physiotherapists can modify other • The patient should be informed of how and
factors: when each movement will take place. Words
255
to avoid are 'just relax', which signals to any doses of morphine depress respiration, but
seasoned patient that they are about to be sedation should not be interpreted as respiratory
hurt, or 'sorry' after an unexpected move depression (pasero, 1 994), and clinically signifi
ment instead of clear explanations before the cant respiratory depression is accompanied by
movement. The 'wince-sorry' scenario is signs such as somnolence, mental clouding
familiar to those who have witnessed (Cherny and Foley, 1 997), rapid shallow
patients being routinely hurt and then routi breathing and greater rib-cage contribution to
nely apologized to. tidal volume (Leino et ai. , 1 999). Depression of
respiration is reversible by the opiate antagonist
Manual handling for patients in pain incorpo naloxone (Narcan). Opioid addiction is rare
rates the principles of offering advice and unless administration is continuous in a patient
support but allowing patients to move them who has no pain (Aitkenhead, 1 989). Well
selves as much as possible. managed narcotic drugs improve ventilation and
F or rolling into side lying, patients can be gas exchange because breathing is made easier by
asked to bend their knees, shift away from the relief of pain (Harcus, 1 977).
direction in which they are to roll, hold onto the 'Balanced' analgesia combines drugs to
bed rail, push with their knees and roll in one influence different physiological processes, and
piece. If a bed rail is not available, physiothera can provide almost complete analgesia at rest and
pists can ensure that the bed is the right height, during mobilization (d'Amours, 1 996). Non
then press their own fist into the bed, to protect steroidal anti-inflammatory drugs (NSAIDs)
their back, and the patient holds on to their engage the peripheral nervous system and help
straight supported arm. Patients are encouraged reduce opioid-induced side effects (Ganea and
to emphasize pushing with their legs rather than Bogue, 1 999). The synergistic effect of epidural
pulling with their arms, in order to inhibit opioids and local anaesthetic is particularly useful
abdominal muscle work. for pain on movement (Cook, 1 997). Balanced
For any manoeuvre that entails abdominal analgesia is necessary for opioid addicts, who
muscle work, e.g. eccentric contraction when have a high tolerance to the drug and may need a
lying back against the pillows, laparotomy pain combination of epidural, PCA and infusion
can be reduced by facilitating active back (Connor and Muir, 1998).
extension and thus reciprocal abdominal relaxa Analgesia can be delivered systemically (oral,
tion. intramuscular, intravenous), or regionally.
Regional analgesia blocks transmission within
Medication and routes of administration. the peripheral nervous system, does not befuddle
the entire central nervous system and causes
Freedom from pain should be a basic
little nausea.
human right.
Liebeskind and Melzack, 1987
Intramuscular route
If an acute pain team is not available, The time-honoured 'p.r.n.' Injection is unjok
physiotherapists need to be involved in the team ingly referred to as 'pain relief never'. It is
management of pain. Analgesics are based on the delivered as required, has no rational basis,
medication being titrated to effect rather than on produces wide fluctuations in serum levels,
a per-kilogram basis (Tobias, 1 994). leaves pain unrelieved in half the recipients
Morphine remains the favourite opioid (Jacox et ai. , 1 992) and augments a vicious cycle
analgesic, with a half-life of several hours. Side of anxiety and pain. Patients in pain also require
effects include nausea, constipation, abdominal more staff time. P.r.n. analgesia is berated in the
distension, elimination of spontaneous sighs and, literature but still used in some hospitals.
in hypovolaemic patients, hypotension. Large Regular intermittent dosage is more effective,
256
PAIN MANAGEMENT
because it takes less drug to prevent pain than to depressed, but pneumothorax is a risk and the
subdue it, but dosage may still be inadequate X-ray should be scrutinized if positive pressure
because of wide variations in uptake, distribution techniques are anticipated.
and elimination, especially in patients who are
cold, dehydrated (d'Amours, 1 996) or elderly. Epidural
Blood concentration varies by at least a factor of The epidural route alters spinal processing by
5 and the concentration at which each individual delivering drugs to the epidural space, the
becomes pain-free varies by a factor of 3 or 4 catheter being inserted in the operating theatre
Gustins and Richardson, 1991}. and left in situ. Morphine works directly on the
opiate receptors along the spinal cord, and can
Intravenous route control pain originating anywhere below the
The IV route works immediately and can be cranial nerves. Analgesics are usually combined
delivered continuously or in boluses. Morphine with local anaesthetic drugs such as bupivacaine
is commonly used. Fentanyl is a synthetic opioid (Berti et al., 2000). Patients should be told that
that is 100 times as potent as morphine and postoperative epidurals are not the same as the
useful prior to physiotherapy because of its rapid well-known anaesthetic epidurals given during
onset, short duration of action and lack of childbirth and they will not be completely numb
disturbance to hypovolaemic or haemodynami below the catheter. In increasing order of
cally compromised patients (Oh, 1 997, p. 680). efficacy, administration is by intermittent
Patient-controlled analgesia (PCA) delivers a blockade, continuous infusion (Cook, 1 997) or
preset dose of drug, usually intravenously, by PCA (Mann et ai. , 2000).
syringe pump when the patient presses a button. Advantages of epidurals are legion: 1
This accommodates to individual need, reduces pulmonary complications and intubation time
anxiety, encourages mobility, reduces sleep (Frost, 1 996), 1 opioid side effects, (Massard
disturbance, is preferred by patients for the and Wihlm, 1 998), 1 stress response and
autonomy it allows, requires less drug to paralytic ileus, i diaphragmatic function and
achieve the same pain control and can lead to mobilization (Cook, 1 997), 1 oxygen consump
earlier discharge (Thomas, 1 995). A tion, 1 incidence of DVT and wound infection,
programmed lock-out interval of, say, 5-10 hospital stay shortened by an average of a week
minutes, ensures that each dose achieves peak (Smedstad, 1 992), and i graft blood flow after
effect before the next dose is released. Patients vascular surgery (Cousins, 1 989).
must be reassured that they can use the device Disadvantages of epidurals are local infection
freely, although their relatives should not press risk, especially with repeated top-ups, partial
the button. Respiratory depression is rare, sensory or motor loss and blockade of sympa
although oximetry is advisable if the patient has thetic outflow which is especially noticeable in
limited understanding and staffing levels are hypovolaemic patients. Patients receiving inter
low. PCA is more effective for dull pain than mittent dosage should lie flat for 30 minutes
the sharp pain of coughing. It does not reduce after a top-up to avoid hypotension. High
the incidence of nausea, and anti emetics must blocks are mainly associated with hypotension,
be given separately if required. while low blocks may cause urine retention.
Respiratory depression is found in less than 10/0
Intercostal route of patients, usually occurring within V2- 1 hour
Blocks to intercostal nerve transmission are used of a top-up or 6-12 hours later Gacques, 1 994},
for rib fractures. They are administered by and is reversible with naloxone. Other side
repeated injections into multiple nerves, or more effects are nausea and paralytic ileus. Dislodge
comfortably by continuous and/or extrapleural ment can be prevented by subcutaneous tunnel
infusion (Majid, 1 992). Respiration is not ling (Burstal et ai., 1 998).
------ 257
CHAPTER 10 PHYSIOTHERAPY FOR PEOPLE UNDERGOING SURGERY
Intrathecal
The subarachnoid space can be directly targeted,
producing profound analgesia without motor,
sensory or sympathetic block. Complications
include 'spinal headache' in nearly half the
patients (Nilsson, 1997) due to leak of cere t=.�ooo::::='" Demand
valve
brospinal fluid (CSF) through a punctured dura Exhalation
and loss of the intracranial CSF 'cushion'. If this valve
occurs during mobilization, the patient should
be returned to bed to lie still.
Oral
Drugs can be administered orally several days
after surgery if acute pain has subsided. Effects
are variable.
Transdermal
For a local painful procedure, EMLA (eutetic
mixture of local anaesthetics) skin patches create
superficial anaesthesia when applied to the skin
an hour beforehand. No child should be
submitted to venipuncture, lumbar puncture or
indeed, any injection without prior application Figure 10.5 Entonox cylinder for rapid pain relief.
of their 'magic cream'. Needle-phobic adults also
benefit (Biro, 1 997).
a 50% mlX of nitrous oxide and oxygen
Transmucosal (Entonox or laughing gas), delivered from a
Mucous membranes impose less of a barrier than cylinder by face mask and demand valve (Figure
skin, as cocaine abusers have discovered. Drugs 1 0.5), or an IPPB machine or ventilator.
such as buprenorphine administered sublingually Entonox is not metabolized, but eliminated
are speedily absorbed. unchanged by the lungs so that side effects such
as light-headedness, drowsiness or nausea are
Other routes minimal (Sacchetti, 1 994). Entonox is also
If the paravertebral, intrapleural, extrapleural or suitable for children able to understand its use
extradural routes are used, pneumothorax is a (Lawler, 1 995).
risk. Patients need to hold the mask firmly over
their face and inhale with sufficient force to
Cryoanalgesia activate the demand valve. It is usually effective
Pain after thoracotomy or rib fracture can be in 2-3 minutes but occasionally up to 10
eliminated by cryoanalgesia, an open procedure minutes is needed. The gas must be self-adminis
that freezes the intercostal nerves, creating total tered so that drowsiness would cause the mask
pain relief until they regenerate over a period of to drop away and prevent overdosing. Patients
weeks or months. Its use is limited because 20% must be under observation until fully alert.
of patients develop neuralgias (Kavanagh, 1 994). If used continuously for over 32 hours, bone
marrow changes occur (Oh 1997, p. 683), but
Entonox this is not a problem with intermittent use.
Short-lived analgesia can be achieved by inhaling Entonox is not utilised for the many minor but
258
POSTOPERATIVE PHYSIOTHERAPY
distressing hospital procedures for which it is soon as possible after surgery. Alternatively,
ideal. Local protocols govern its use in individual acupuncture points can be stimulated. If sterile
workplaces. electrodes are used, two long electrodes are
Precautions are: applied in theatre alongside the wound under
the dressing, with controls set at a level deter
• Sealed pockets of air (e.g. urgical emphy
mined before surgery.
sema, bullae, pneumothorax, bowel obstruc
Re-adjustment is necessary as the patient
tion, ear surgery, tracheal tube cuffs or
adapts to the sensation or becomes more awake.
balloon-tipped catheters) because nitrous
Patients can use the pulsed or boost mode to
oxide is 32 times more soluble than air and
reduce accommodation or when moving or
diffuses into air-filled spaces. The X-ray of a
coughing. They can adjust their own controls,
patient with fractured ribs should be exam
decide how many days to use it, and whether to
ined for a pneumothorax.
continue at night. Liaison with nursing staff and
• The first 16 weeks of pregnancy.
daily skin washes are needed.
• Acute head injury because of increased cere
TENS near the chest is contraindicated for
bral blood flow.
people using a synchronous pacemaker, and
• Severe heart failure because of a risk of
TENS near the head is inadvisable for people
pulmonary oedema (Hahn, 1997).
with epilepsy (Scherder, 1 999). The electrodes
Entonox is unsuited to patients who need must be placed away from ECG electrodes to
more than 50% oxygen. Conversely, hypercap minimize interference (Sliwa and Marinko,
nic COPD patients dependent on a hypoxic 1 996). Stimulation should not be applied over a
drive to breathe require a lower proportion of pregnant uterus or damaged skin.
oxygen and may not be suitable because less Phantom limb pain has shown a response to
than 40% nitrous oxide does not provide TENS applied to sites on the remaining limb
analgesia (Tobias, 1 994). Cylinders must be corresponding to painful sites on the amputated
stored on their side when not in use, as nitrous limb as identified by the patient (Kawamura,
oxide liquefies and falls to the bottom. 1 999).
Transcutaneous electrical nerve stimulation Other techniques
(TENS) Acupressure may reduce postoperative pain
Analgesics are normally adequate, but there are (Felhendler, 1996) and hypnosis can be useful
occasions when TENS is useful. It is time if analgesics are inadequate (Ohrbach et al.,
consuming for the physiotherapist, but does not 1998).
depress the respiratory system, is non-invasive,
non-toxic and produces mobile and happy
POSTOPERATIVE PHYSIOTHERAPY
patients. TENS can decrease narcotic require
ments, reduce pulmonary complications and Is physiotherapy necessary for postoperative
improve mobility (Wang et al., 1997). Agreeable patients? Research has shown positive outcomes
side effects include reduction in nausea and (Chumillas et al., 1 998; Hall et al. , 1996; Ntou
paralytic ileus (Akyiiz, 1 993). The following are menopoulos and Greenwood, 1996; Warren,
practical points additional to conventional 1 980). But individual techniques need scrutiny
TENS. to identify which are appropriate for which
Skin sensation is checked because it is ineffec patient.
tive to stimulate anaesthetic areas, and stimula Postoperative physiotherapy is based on tech
tion of areas of hyperaesthesia worsens pain. niques to increase lung volume and clear secre
Two or four electrodes are applied, half-way tions (Chapters 6 and 8). Modifications specific
along the incision or close to each corner, as to surgery are discussed here.
--
-- 259
Mobility Positioning
Bed mobility and independence following If pain, surgical procedure or instability delay
abdominal surgery are encouraged with a rope mobilization, emphasis should be on accurate
attached to the end of the bed by which patients and comfortable positioning, alternating from
can pull themselves up (Figure 1 0.6). As soon as side to side and if possible sitting out of bed.
possible they are encouraged to sit with their Positioning can re-expand atelectatic lung
legs dangling over the edge of the bed. Post (Westbrook and Sykes, 1 992), but regular
operative mobilization out of bed helps increase position change is needed to prevent atelectasis
lung volume, improve VA/Q matching and reappearing in dependent zones. If lying well
mobilize secretions (Cockram et aI. , 1 999). If forward on the side (p. 150) pulls on the wound,
surgically and medically acceptable, this should the position may need to be modified. Clinical
be on the first postoperative day. Intravenous assessment and the X-ray (Figure 10.7) will
equipment that is plugged into the mains can assist in decisions about positioning.
usually be temporarily unplugged for ambulation
but the standby battery must be functioning. For Breathing exercises
patients with a urinary catheter, leg bags are Breathing exercises are not usually necessary
more dignified than loose catheter bags. Posture even after major surgery (Stiller et aI. , 1994)
correction is incorporated as soon as discomfort but, if mobilization is delayed, positioning
has eased. For safety aspects, see page 148. limited, or respiratory complications develop,
Figure 10.6 Rope to assist independent bed mobility.
260 ------
POSTOPERATNE PHYSIOTHERAPY
Figure 10.7 Opacity in right lower zone suggests consolidation. Upward shift of right hemidiaphragm suggests some lower
lobe collapse. Thin angled line on the right suggests segmental collapse rather than displaced horizontal fissure because it does
not attach to the hilum. Opacity in left lower zone is probably breast shadow but auscultation is required to rule out
consolidation . Positioning should be in altemate side-lying, with extra time in left-side-Iying to encourage expansion of collapsed
lung tissue.
deep breathing is required. After oesophagect accessible secretions, and coughing is necessary,
omy, or upper abdominal surgery in high risk patients may prefer to remain in side-lying, but
patients, regular prophylactic deep breathing is if they are willing, sitting over the edge of the
advisable. bed is mechanically efficient and allows
Deep breathing is done in a position that maximum support (Figure 1 0.8). Pressing on the
achieves a balance between comfort and optimal incision with a pillow is less effective than
ventilation, usually well-forward-side-Iying. For sensitive and accurately timed manual support
patients who cannot achieve this, upright sitting but, when patients are alone, they may find a
is the next option. pillow, towel or cough belt (see Figure 1 0. 15)
Accumulated secretions are usually cleared helpful. If patients are too weak, fatigued or
postoperatively as mucociliary transport drowsy to co-operate, mechanical aids may be
recovers. Superficial secretions in the throat can indicated.
be dispersed by throat-clearing. Stronger expira
tory manoeuvres are used if necessary, but Prevention of deep vein thrombosis
expiration beyond FRC causes airway closure,
Half the deaths from pulmonary embolism could
which is not easily reversible in patients who are
be avoided by prophylactic guidelines for DVT
weak and in pain (Craig, 1 9 8 1 ) . Unnecessary
prevention (Forbes, 1 994). Some examples are:
forced expiration, coughing, percussion and
vibrations cause pain and splinting, and may • intermittent or sequential pneumatic leg
simply create the lesion that they are supposed compression devices during and after
to cure. surgery, so long as there is no arterial disease
If there is subjective or objective evidence of (Oakley et at., 1 998)
------ 261
and carers to smooth out the omnipresent tour

niquet-like wrinkles that reduce blood flow and
are counterproductive (Sigel, 1 973) .
But whither leg exercises? The theory that
postoperative leg exercises have any place in
prevention has been relegated to the realms of
fantasy, unless someone can be found to set up
camp beside patients and prod them into near
continuous ankle exercises both during and
after surgery. The fact that sluggish circulation
is a predisposing factor for DVT does not mean
that ankle exercises after the operation will
have an effect. There is also no evidence that
getting a patient out of bed several times a day
prevents DVT, especially as the thrombus
usually forms during surgery and the risk
continues for 6-8 weeks after discharge when
most patients have been fully mobile for some
time (Forbes, 1 994). It is also remotely possible
that exercising the ankles could trigger an
asymptomatic DVT to form a pulmonary
embolus, as has been reported following appli
cation of a sequential compression devise
(Siddiqui, 2000).
Figure 10.8 Manual support for postoperative coughing
Two decades-old studies have been unsuccess
after laparotomy. Gentle firm pressure is directed at holding ful in proving the benefits of ankle exercises for
the wound edges together. After thoracotomy, the DVT prevention:
physiotherapist can sit beside the patient on the opposite
side to the wound so that s/he can support the wound • Flanc ( 1969) found that a combination of
while giving counterpressure to the patient's body. elastic stockings, elevation of the foot of the
bed and six-times-daily physiotherapy-super
vised leg exercises reduced the incidence of
• leg elevation before, during and after postoperative DVT in elderly people,
surgery, to avoid calf compression (Ashby, without indicating which component was
1 995) effective
• avoidance of leg-crossing • Scurr (198 1 ) found that DVT formation
• for high risk patients, drugs such as dextran during surgery was reduced by a mechanical
or heparin device that continually moved the ankle
• graduated thromboembolism (TED) stock during the operation.
ings to facilitate deep venous blood flow.
Exercises are, however, necessary after ortho
TED stockings must apply graduated paedic surgery or if bed rest is prolonged, in
compression that is greater in the lower calf and order to prevent joint stiffness and ·muscle
diminishes up the leg, and must be individually weakness. If DVT has been confirmed, leg
fitted, otherwise they are of no value (Moser, exercises and mobilization are contraindicated
1 990). Excessive pressure may reduce deep until several days after anticoagulation therapy
venous flow (Lawrence and Kakker, 1 980). The (usually heparin) has been established, or after
physiotherapist's main task is to advise patient discussion with medical staff.
262 ------
ABDOMINAL SURGERY
amenable to the laparoscope, but procedures

Discharge such as laparoscopic cholecystectomy take
Advice on self-management after discharge is longer than laparotomy and entail tilting the
often the main intervention. This is to encourage head down and pumping CO2 into the perito
progressive activity suited to the individual's neum. This impairs diaphragmatic function
lifestyle, along with regular rest. For patients (Lindgren, 1 997) and can refer pain to the right
who have been doing breathing exercises, a shoulder. However, compared to laparotomy,
reminder to stop them prevents conscientious laparoscopy causes less pain, lung dysfunction
patients continuing them indefinitely. In the light and mood depression and allows patients to be
of evidence that early discharge can lead to more discharged and return to work sooner (Freeman
complications and re-admission rates (Moore, and Armstrong, 1994).
1 994), physiotherapists need to ensure that their Full-incision surgery of the upper abdomen is
vOICes are heard when discharge decisions are more problematic than either chest or lower
taken. abdomen. It is associated with more pulmonary
complications than chest surgery (Luce et aI.,
1 993, p. 300), and is followed by a 20-40%
ABDOMINAL SURGERY incidence of chest complications compared to 2-
5% with lower abdominal surgery (Celli, 1 993).
The effect of an upper abdominal incision
Patients having lower abdominal surgery, e.g. via
seems to strike at the root of normal
the transverse incision in Figure 1 0.9, do not
respiration.
require formal physiotherapy (Giroux et aI.,
Bevan, 1964
1 987) unless they fall into a high-risk category,
Abdominal surgery impinges less on respira but it is advisable to check pain control and
tion now that most abdominal organs are mobility.
Limited thoracotomy
Sternotomy ----+-
----I-- Thoracolaparotomy
Cholecystectomy
Paramedian ----t-----;
Appendicectomy ----+_\.
Midline
Hernia repair
Transverse
Figure 10.9 Conventional surgical incisions.
263
CHAPTER 10 PHYSIOTHERAPY FOR PEOPLE UNDERGOING SURGERY
Bowel resection leads to significant loss of - postoperative nausea and precanous

exercise tolerance. Up to 40% maximal appetite
workload is lost, which directly relates to loss of - unfamiliar food.
employment (Brevinge, 1 995), thus reinforcing
Poor nutrition reduces mobility, predisposes
the need for rehabilitation.
to infection, depression, muscle weakness,
An abdominal aortic aneurysm (AAA) means
pressure sores and prolonged hospital stay, and
that the vessel has bulged to twice its normal
delays wound healing (Edington et al. , 1997). It
size (Sternbergh, 1998). Severe abdominal pain
may or may not be coincidental that while most
and backache suggests a contained rupture,
of the 1980s Maze hunger strikers died after 60
which leads to complete rupture after 2-3
days, the one who had sustained a prior fracture
hours. Mortality from surgical repair is 5%
died at 45 days (Leary et al. , 2000)
before the vessel leaks and 50% afterwards
To facilitate rehabilitation, the following are
(Bell, 1 996). A long midline or flank incision
suggested:
leads to prolonged paralytic ileus, large fluid
- routine nutritional assessment for every
shifts and significant pain (Cerveira et aI. ,
patient facing major surgery and a course of
1 999). There is a risk of cardiovascular instabil
ity, and patients are not usually mobilized for at preoperative feeding for the 27% of general
surgery patients who are malnourished on
least 2 days.
admission (Edington et al. , 1 997)
Patients who have had an aortofemoral graft
avoidance of preoperative fasting in excess of
should avoid hip flexion on the affected side for
3 days. They may mobilize before they are 6 hours (Thomas, 1987)
early postoperative nutntIOn to reduce
allowed to sit.
complications, length of hospital stay and
Complications of abdominal surgery, m
mortality (Baublys et aI. , 1 997), including
addition to those previously described, are the
enteral feeding in the recovery room for
following:
patients at risk, using small bowel access if
there is paralytic ileus (Babineau, 1 994).
• Paralytic ileus: Loss of gut actIVIty silences
bowel sounds and is normal for the first day Routes of enteral feeding are the following:
or two. It becomes problematic if prolonged, - nasogastric : used to prevent vomiting and
and causes distension if swallowed air is held gastric distension, but hinders coughing,
up in the atonic colon, exacerbating disables the oesophagogastric sphincter and
diaphragm dysfunction and requiring a naso increases risk of aspiration (Smithard, 1995)
gastric tube and nil-by-mouth order. - gastrostomy: delivers food directly to the
• Pain: Analgesia tends to be taken less stomach via a catheter through the
seriously than after sternotomy, even though abdominal wall, known as a PEG
pain after laparotomy is often worse because (percutaneous endoscopic gastrostomy tube)
most activity requires some abdominal - jejunostomy: also placed percutaneously,
muscle contraction. avoids problems of acidic stomach secretions.
• Malnourishment: Abdominal surgery IS
usually associated with poor nutrition due
LUNG SURGERY
to:
- malabsorption associated with pre-
existing gut pathology Incisions
- preoperative fasting 'The pain was everywhere. I couldn't get
- the catabolic effects of surgery across what I felt. I wanted to move myself
- intestinal handling which affects the but they were insistent on moving me. I lost
delicate mucosal lining (Anup, 1 999) the ability to control the situation. I felt
264
LUNG SURGERY
very alone. The whole thing was one of the with emphysema, it can be removed by thoraco
most personal experiences of my life. It took scopic laser bullectomy. This shows an average
a long time to be able to talk about it. ' 290/0 improvement in exercise capacity and
Katie, a nursing sister, following her thoracotomy sometimes discontinued need for oxygen therapy
A standard posterolateral thoracotomy involves (Hazelrigg et al. , 1 996).
Small peripheral lesions can be removed by
an incision below the scapula, the division of
lung biopsy or wedge resection (Giacomo, 1 999).
latissimus dorsi and spreading or resection of the
A lung segment is occasionally removed by
ribs. This leads to restricted shoulder and chest
segmentectomy.
wall movement and, if analgesia is not adequate,
A patient with a preoperative FEV 1 of more
'one of the most intense postoperative pain
than 2 L is considered to have adequate post
experiences known' (Kavanagh, 1 994). Pain is
operative pulmonary reserve to undergo
best controlled by regional anaesthesia rather
lobectomy. This is usually to remove a cancerous
than intravenous opioids (Brodner, 1 997).
lobe and may be curative if mediastinal lymph
Muscle-sparing thoracotomy is less disabling
nodes are not involved. The vacated space is
(Landreneau et al. , 1 996). Thoracoscopy can be
accommodated by expansion of the rest of the
used for pulmonary, pleural, cardiac and oeso
lung and occasionally shift of the hemidiaph
phageal surgery (Figure 1 0 . 1 0).
ragm and mediastinum (Klein, 1 999). With thor
acoscopy and meticulous attention to patient
Procedures education, pain control and mobilization, one
If a large bulla is restricting function in a patient day admissions are possible (Tovar et ai. , 1 99 8 ) .
A sleeve resection is removal of the T-junction
of a bronchus with its lobe. This causes twice as
much atelectasis as a lobectomy, plus oedema
around the anastomosis and ciliary impairment
from nerve damage (Massard and Wihlm, 1 998).
Modified postural drainage may be needed.
Positive pressure techniques such as manual
hyperinflation may damage the anastomosis or
cause a pneumothorax in the immediate post
operative period.
A complete lung is removed by pneumonect
omy. The lung space is filled with air, blood and
fibrin (Figure 1 0. 1 1 ) , the quantity of which is
regulated by one of the following:
• a chest drain, which is kept clamped except
when drainage is required
• a temporary small thoracic catheter
• needle aspiration (Deslauriers, 1 999).
A chest drain allows recognition of haemor
rhage and, if the suture breaks down, prevents a
Figure 1 0. 1 0 Patient in position for minimal-access lung tension pneumothorax, but it increases the risk
surgery. The shoulder joint ligaments are vulnerable to
overstretch. (Redrawn from Benetti, F. et 01. ( 1 996) Video
of empyema and bronchopleural fistula. These
assisted minimally invasive coronary operations without drains must never be attached to suction, nor
cardiopulmonary bypass. Journal of Thoracic and clamped or unclamped by anyone other than the
Cardiovascular Surgery, 1 1 2, 1 478- 1 484, with permission.) surgeon. Excess drainage of the vacated space
------ 265
CHAPTER 1 0 PHYSIOTHERAl'Y FOR PEOPLE UNDERGOING SURGERY
Figure 10.12 Image of a chest some months after left

pneumonectomy, showing the vacated space now filled and
Figure 10.11 X-ray one day after right opaque Also visible are the deviated trachea, healed rib and
pneumonectomy, showing a horizontal fluid line separating stitches. The remaining lung shows the cystic appearance of
the exudate from the air-filled space , which shows no lung bronchiectasis.
markings. The trachea is shifted towards the vacated space.
Speckled appearance in the soft tissue outside the rib cage
on the right is surgical emphysema. mobility, and improved oxygenation, spirometry
and quality of life (O'Brian et at. , 1 999). It is
unknown how much benefit is due to surgery
pulls the remaining lung into the space, and too and how much to pre-and postoperative rehabili
little drainage leads to the bronchial stump tation. Lung volume reduction is performed in
becoming soggy (Valji, 1 9 9 8 ) . patients with incapacitating dyspnoea who are
A few days after chest drain removal, the unsuitable for transplantation, or as a bridging
pneumonectomy space has filled with inflamma procedure while awaiting a donor. The main
tory exudate. Once the level is above the stump complication is prolonged air leak. The
and all is well, the patient goes home. The air is operation can be combined with tumour
absorbed in 4-6 weeks (Klein, 1 999) and, in the resection when indicated (DeRose et at. , 1 998).
ensuing months, the space shrinks by upward Lung volume reduction involves sternotomy or
shift of the hemidiaphragm, lateral shift of the thoracoscopy, and is best done bilaterally
mediastinum and crowding of the ribs (Figure (Kotloff, 1 99 8 ) .
1 0. 1 2) . Mortality after pneumonectomy IS on Thoracoplasty used to be performed to resect
average 6.9%, compared to 2.9% after ribs, collapse the chest wall and obliterate TB
lobectomy (Bisson et at. , 1 99 8 ) . infected lung. It may make a comeback if drug
Lung volume reduction is palliative resection resistant strains overwhelm the pharmacological
of useless lung in patients whose emphysema is industry.
characterized by regions of destruction and large
bullae that take up space and compress relatively Complications
normal underlying tissue. The diaphragm returns As well as the complications described
to a functional dome shape, which results in previously, the following are specific to lung
decreased work of breathing, greater energy and surgery.
266 ------
LUNG SURGERY
Diaphragm dysfunction occurs if the phrenic need chest drainage, sealing via bronchoscopy
nerve is injured. Extended resection of hilar or (Varoli, 1 998), surgery to resuture the bronchial
mediastinal tumours may sacrifice the phrenic stump or, as a last resort, long-term open
nerve unavoidably, leacling to hemidiaphragm drainage. Positive pressure physiotherapy techni
paralysis. During pneumonectomy, some ques are inadvisable. Patients requiring mechani
surgeons deliberately cut the phrenic nerve to cal ventilation might benefit from a high
diminish the residual space. frequency system (Campbell et al. , 2000).
Following lobectomy, contusion in adjacent Average functional effects include the
lung may cause VA/Q mismatch and hypoxaemia. following:
Following pneumonectomy, hypoxaemia often
• Lobectomy leads to 1 0% reduced spirometry
occurs on exercise.
values but negligible loss of exercise capa
Escape of air into the pleura is to be expected
city.
after lobectomy. This air leak manifests as
• Pneumonectomy leads to 33% reduced
bubbling in the underwater seal drainage bottle.
spirometry, 20% loss of exercise capacity
The chest drain is not removed until bubbling
and some dyspnoea on exercise (Bolliger,
stops.
1 998).
Escape of air into subcutaneous tissue may
occur, causing surgical emphysema. This is rarely Long-term pain occurs in 5 0% of patients but
of more than cosmetic significance, but patients can be reduced by aggressive pain control imme
need reassurance that it is temporary. If secre diately after surgery (Katz et aI. , 1 996).
tions are a problem, ACB/AD (p. 1 9 8 ) is prefer
able to coughing. If a swollen face has forced the Physiotherapy
eyes shut, relatives can be shown how to massage Following uncomplicated thoracoscopic surgery,
the eyelids to allow temporary vision. patients can sit out 4-6 hours postoperatively
Damage to the recurrent laryngeal nerve, espe (Nicholson, 1 993) but chest assessment must
cially following left pneumonectomy or upper continue.
lobectomy, may affect speech and cough (Carew Following thoracotomy, many patients
et al. , 1 999). require respiratory care. Shoulder and postural
Problems associated with malignancy (the exercises begin once pain allows. This maintains
usual reason for lung resection) include malnu range of movement and is sometimes seen to
trition and COPD (Wong and Shier, 1 997). improve Sa02. Some patients suffer pain from
Bronchopleural fistula is a breach between thoracic joints stretched during surgery, which
lung and pleura, due to breakdown of the may be eased by mobilizations of the joints at
bronchial stump. This has the same effect as a the spine. Progressive exercise should proceed
pneumothorax. It is a dreaded event, usually apace, and some weeks after discharge, patients
associated with infection, and with mortality of benefit from outpatient rehabilitation.
over 3 0% (Varoli, 1998). It is most likely if Points to note in relation to pneumonectomy
mechanical ventilation is required, and is are the following:
suspected if there is a spiking temperature, X-ray
evidence of a decreasing fluid level post-pneumo • If sputum clearance is necessary, ACB/AD is
nectomy, or expectoration of bloody-brown preferred to coughing, in order to protect
secretions, especially when lying down with the the stump.
fistula upwards (p. 152). Empyema usually • Following a normal pneumonectomy,
follows (Deschamps et al., 1 999). Spread of patients should not lie on the non-operated
infected material is minimized by the patient side, to prevent fluid spilling onto the stump,
slttmg up or lying on the thoracotomy side. and some surgeons demand that this be life
Small fistulae close naturally but large defects long.
------ 267
• Patients should not lie on either side after

CHEST DRAINS
radical pneumonectomy, which entails
entering the pericardium, in case of cardiac Simple wound drains are adequate to remove
herniation. blood from the affected site after most forms of
• There should be no head-down tip and, for surgery, but if the operation has interfered with
some patients, no lying flat. pleural pressures, underwater-seal drains are
• Suction, if necessary, should be shallow. usually required. The airtight system becomes an
• Normally the remaining lung is able to extension of the patient's pleura and allows air
accommodate the entire resting pulmonary and blood to escape from the pleural space while
blood flow but, during rehabilitation, preventing their re-entry. It restores normal
pulmonary hypertension may occur on exer negative pleural pressure and allows the lung to
cIse. re-expand. Chest drains are also used after heart
surgery, although some cardiac surgeons find
that simple wound drains are sufficient.
An alternative to the underwater seal system
PLEURAL SURGERY
is the flutter valve (Waller, 1 999) which allows
The commonest indication for pleural surgery is release of air on expiration but collapses shut by
recurrent, bilateral or persistent pneumothorax. negative pressure on inspiration. They are cheap,
Other indications are problematic pleural safe, effective unless suction is required, and
effusions or bronchopleural fistulas. Pleural allow earlier mobility (Graham et al. , 1 992).
surgery leaves a long-term mild restrictive
defect. Procedure
A pleurodesis introduces irritant chemicals, All tissues down to the pleura are infiltrated with
tetracycline, fibrin glue or laser pulses into the local anaesthetic and, after this has taken effect,
pleura via thoracoscopy, setting up a sterile the drains are inserted above the rib where there
inflammation, fibrosis and adherence of the two are fewest vessels and nerves. Following heart
layers of the pleura. If sterile talcum powder is surgery, one drain is usually placed inside the
the irritant chemical, it should be confined to pericardium to prevent cardiac tamponade, and
elderly people because it is carcinogenic and one outside the pericardium to drain blood from
systemic distribution may occur over time the mediastinum. After lung, pleural or oesopha
(Werebe, 1 999). Procedures relying on an geal surgery, two drains are placed in the pleura,
inflammatory response should not be followed traditionally one in the apex to remove air and
by anti-inflammatory analgesia. Kindly surgeons the other in the base to remove blood, but both
instil local anaesthetic into the pleura before air and blood will find the drain, especially when
closure. suction is applied. Pleural drains may also be
A pleurectomy strips off the parietal pleura so required if the pleura has been cut after heart,
that a raw surface is left at the chest wall, to kidney or upper abdominal surgery. Following
which the visceral pleura adheres. This may pneumonectomy, a single drain may be left in
require a thoracotomy but is less painful than the vacated space. For a pneumothorax, a single
the acute pleurisy set up by a pleurodesis. chest drain in the pleura restores negative
Chronic empyema may be managed by debri pressure and allows reinflation of the lung.
dement via thoracoscopy, but if infection is not
contained, decortication may be required, which Mechanism
involves peeling off the thickened fibrosed One bottle may be adequate for minimal
visceral pleura. The parietal pleura is spared drainage, or more commonly, two or three
unless long-standing empyema and deformity chambers are used (Figure 10. 13). The under
mean that it will impair lung expansion. water seal, comprising the distal end of a tube
268
CHEST DRAINS
into the chest is trivial and reversible. Clamping

is best avoided except in an emergency or when
lifting the bottle above the patient when fluid
could be siphoned into the chest. The drains
should be clamped close to their exit from the
chest.
The principles of safe handling of chest drains
are the following:
• Before treatment, the location of the clamps
should be checked so that they can be found
in case of need.
• Junctions in the tubing should not be taped,
Drainage Underwater Collection
bottle seal bottle otherwise a disconnection might be missed.
• If the bottle needs to be lifted above the level
Figure 10.13 Classic 3-bottle drainage system.
of the patient's chest when the patient turns,
the tubing should be clamped. Clamping
submerged in 2 cm of sterile water, acts as a one must be avoided if there is an air leak.
way valve. Fluid drains by gravity, and air is • Drainage is assisted by deep breathing,
expelled through the water into the atmosphere. coughing or mobility, but care should be
Fluid cannot return so long as the system is taken to avoid disconnection.
below the level of the patient's chest. Air cannot • When handling patients, the tubing should
return because the water acts as a seal while be held in alignment with the patient's chest
offering minimal resistance to drainage. The to minimize discomfort.
length of tube below the water in the underwater • The bottles and tubing should be kept
seal bottle determines the pressure required to exposed throughout, to avoid accidental
expel the unwanted contents from the chest, so knocking or kinking.
is kept short without breaking the underwater • The system should be observed before and
seal. after treatment to check for any change in
Drainage depends on gravity or suction. Free drainage, air leak or swing in the water level.
drainage occurs when the exit tube is open to Extra drainage is expected after treatment,
the atmosphere. This allows the water level in but excessive loss suggests haemorrhage and
the underwater seal tube of a pleural drain to should be reported.
swing, reflecting the change in pleural pressure An air leak is present if au 1S bubbling
with breathing. If the negative pressure of the through the water, this air having passed
patient's breathing is inadequate to reinflate the through the visceral pleura from the lung at each
lung, e.g. with excess fluid drainage or air leak, breath. The hole should seal in time but positive
suction is applied at pressures of 1 0-20 cmH20. pressure techniques would hinder this process
Management and are to be avoided unless essential. If there is
any change in air leak after treatment, this
Patients with a chest drain need advice on should be reported. Clamping is dangerous with
act1v1ty, posture correction and shoulder an air leak and might precipitate a tension pneu
mobility. Some need respiratory care. mothorax. If there is no pressure swing, this
Chest drain clamping was rife in the past on means that:
the assumption that dire consequences would
follow disconnection. In practice, disconnection • the tube is kinked or blocked (sudden)
of the drain with entry of a small volume of air • the lung has successfully re-expanded,
------ 269
thereby occluding the pleural end of the tube to the heart as the source of life (Maguire,
(gradual) 1 998). However, 97-98% of them will survive
• the system contains a collection bottle, coronary artery bypass graft (CABG) and find
which obliterates the swing relief from angina and improved quality of life
• the system is on suction, which overrides the (Sj6land et aI. , 1 996). CABG is the commonest
swmg. heart operation, consuming more health-care
resources than any other single treatment and
The procedure of 'milking' chest drains to
using the most ICU beds (Feneck, 1 996).
dislodge clots and maintain patency can cause
pulmonary trauma. Gentle squeezing is preferred Incision and procedures
(Kam et aI. , 1 993).
Conventional open-heart surgery by median ster
Chest drains are removed by nursing staff
notomy (Figure 1 0 . 1 0) involves dividing the
after the lung has fully expanded and drainage is
aponeurosis of pectoralis major, cutting through
complete. The distress of the procedure has been
and retracting the sternum, then instigating
described by nearly half the patients in one
cardiopulmonary bypass to allow surgery on a
survey as the worst memory of their hospital
quiescent heart in a bloodless field. Cardiopul
stay (Carson, 1 994). This can be avoided by
monary bypass, or extracorporeal circulation,
topical anaesthetic cream applied to the site
involves the heart being stopped, the aorta cross
three hours before removal (Valenzuela and
clamped to clear the coronary arteries of blood,
Rosen, 1 999), or Entonox. The patient is asked
then the circulating blood being removed from
to take and hold a deep breath during removal
the right atrium, filtered and oxygenated outside
to prevent air being drawn into the chest.
the body, and pumped back into the ascending
aorta. Neither heart nor lungs are functioning
Problems during this period and the lungs are partially or
If any junction in the system becomes discon totally collapsed. Some surgeons fill the pericar
nected, the ends must be cleaned and recon dial sac with chilled saline to reduce tissue
nected, the patient asked to cough a few times to oxygen demand, protect the brain and other
force out any air that has been sucked into the vital organs and reduce the flow required for
chest, and the incident reported. bypass. This is no longer considered essential but
If the tubing becomes disconnected from the moderate cooling to 3 0° may provide a safety
patient, the following steps should be taken: margin.
Less invasive procedures use a 'beating heart'
1. Ask the patient to exhale and, at the same
technique that avoids cardiopulmonary bypass
time, press gauze, sheet or a hand against the
and cross-clamping (Oz et aI. , 1 997).
wound at end-exhalation, speed taking
Patients are mechanically ventilated until
precedence over sterility.
rewarmed and haemodynamically stable, then
2. Ask the patient to breathe normally.
extubated and transferred to a cardiothoracic
3. Summon assistance but stay with the patient
ward.
and maintain pressure on the wound.
For CABG, the saphenous veIns and/or
4. Observe breathing rate and chest symmetry.
internal mammary artery (IMA) are used to
5. If the patient is distressed, give reassurance
replace diseased coronary arteries (Figure
and oxygen.
1 0. 14). Patency rates for IMA grafts are 2.0 years
compared to an average 8 years for saphenous
vein grafts (Scarlett, 1 99 8 ) . However, the lMA is
HEART SURGERY
harvested from the chest wall, punctures the
For many patients, heart surgery carries a parti pleura, causes greater shoulder and chest wall
cular fear because of the significance attributed pain (EI-Ansary et at., 2000) and greater impair-
270 ------
HEART SURGERY
Regeneration occurs over a number of

months. Severe damage may lead to
diaphragmatic paralysis, sometimes bilateral
and occasionally persistent (Katz et al. ,
Vein grafts 1998).
• Haemorrhage is particularly dangerous if
blood is trapped in the pericardium, causing
Right Marginal branch tamponade (p. 3 84).
coronary
artery • Pulmonary oedema or pleural effusion may
\"" ,----1-Ar'f-- Left anterior
descending artery be caused by aggressive fluid replacement or
the effect of cardiopulmonary bypass in
releasing vasoactive substances and altering
capillary permeability (Wehberg et al. ,
Figure 10.14 Grafts to the heart, including internal 1 996). Pleural effusion is usually left-sided
mammary artery. (From Adam, S. K. and Osborne, S.
( 1 997) Critical Care Nursing, Oxford Medical, Oxford)
and not significant.
• Disorientation is due to impaired cerebral
perfusion during bypass, the alien environ
ment in which the patient wakes up, hypoxia
ment of lung function than the saphenous veins and sleep deprivation. It IS especially
(Rolla, 1 994). common in elderly people.
Angioplasty is invasive but non-surgical revas • Retraction of the sternum and ribs may
cularization. A balloon-tipped catheter is passed cause diaphragm impairment (Dickey, 1 9 89),
through the femoral artery and threaded up into musculoskeletal pain (Stiller et al. , 1 9 9 7) , or
the blocked coronary artery, where the balloon first rib fracture (Wiener, 1 992).
is intermittently inflated to clear the lumen. • Hypotension may impair perfusion to vital
After several hours of lying flat to prevent organs, as indicated by acute renal failure.
bleeding, and then a period of observation, Neurological defects range from a 25-30%
patients are discharged with minimal activity incidence of cognitive defect at 1 year to a
restrictions. Re-stenosis is commoner with angio 2-3% incidence of stroke (Taylor, 1 99 8 ) .
plasty than CABG, but complications are fewer. Impaired gut perfusion is reported to occur
in 600/0 of patients and is a better predictor
Complications specific to heart surgery of complications than BP (Welsby and
• Postoperative cardiovascular instability, Mythen, 1 997). Cardiac output is supported
although minimized by control of pain, as necessary with inotropic drugs or mechan
fluids and oxygenation (Sonksen, 1 998), may ical devices (Chapter 1 2).
restrict turning or other forms of • Cardiopulmonary bypass contributes to
physiotherapy. neurological defects, and exposure of blood
• Lower lobe atelectasis, mainly on the left, to any surface other than vascular endothe
occurs in 30-88% of patients (Jindani, lium may upset the clotting cascade or
1 993), due to either compression of the left generate a systemic inflammatory response
lower lobe, or trauma or cold injury to the (Dodson et al. , 1 997).
phrenic nerve. This is so common as to be • Pain increases cardiac workload by sympa
hardly considered a complication unless it thetic drive, and can lead to respiratory
progresses, and indeed many patients leave failure by breathing inhibition (Nelson et al. ,
hospital with radiological changes not yet 1 99 8 ) .
resolved. • Sternal dehiscense may occur 2-3 weeks
• Some phrenic nerve damage is common. postoperatively. It is usually associated with
271
infection and is suspected if the X-ray shows Bed exercises provide the opportunity to
broken sutures or a gradually widening check for neurological damage. For those
lucent line at the sternotomy site. confined to bed because of complications, they
• In the ensuing years, atherosclerosis may are necessary for joint range and muscle
progress in the grafted vessels and re-opera strength. Shoulder elevation should be limited to
tion may be necessary, which carries a higher 90° for 24 hours, especially after IMA grafting,
mortality than the first operation. and should be performed bilaterally to avoid a
shearing stress on the sternum.
Physiotherapy Within the limits of fatigue, patients without
After CABG, blood pressure should be observed complications should aim at gentle walking one
before, during and after treatment because or two days after surgery, stair-climbing on the
hypertension increases cardiac work and can fourth postoperative day and gradual increases
cause bleeding. Diastolic pressure is more signifi thereafter. Mobilization without supplementary
cant than systolic pressure because coronary oxygen begins when the patient's Sa02 is >
artery perfusion is highest during diastole. The 92% while breathing oxygen at less than 6 L/min
operation notes may indicate the limits within at rest.
which BP should be maintained. Contraindications to mobilization are:
For a stable patient on IPPV, manual hyperin
• i or 1 BP
flation is acceptable in the immediate postopera
• complete heart block reliant on external
tive period (Patman et ai. , 1 9 9 8 ) so long as it is
cardiac pacing
indicated.
• atrial fibrillation with compromise of cardio-
If hypoxaemia persists after extubation, CPAP
vascular stability
can be helpful if comfortable, and may prevent
• sinus tachycardia above 1 20 bpm
the need for re-intubation (Romand and Donald,
• heart failure requiring inotropic drugs
1 995). Until the patient can mobilize, regular
• IV vasodilator drugs
positioning on alternate sides reduces postopera
• Swan-Ganz catheter
tive complications (Tidwell, 1 990), so long as
• new myocardial infarct or symptomatic
this can be achieved with comfort and safety.
angma
Right-side-Iying may be associated with better
• neurological event.
gas exchange than left-side-Iying (Banasik and
Emerson, 1 996). Some surgeons request that the Contraindications to stair-climbing are the
patient not be turned immediately after IMA above plus heart rate at rest over 1 00 bpm or
graft. HR prior to stair-climbing over 1 1 0 bpm
A proportion of patients will appear euphoric (Cockram et aI., 1 999). After less invasive
on the first day, possibly reflecting delight at cardiac procedures, patients can often sit out 4
their survival, but then sink into depression for hours after surgery and walk later the same day.
some days afterwards. When identified, these If the sternum is heard or felt to click on
patients should be encouraged to take things movement, a cough belt (Figure 1 0 . 1 5 ) or towel
gently on the first day to avoid debilitating mood is needed to stabilize the chest wall. One handle
swings which interfere with rehabilitation. The of the cough belt is passed through the other and
relationship between pain and anxiety IS pulled on coughing. Other patients may have
strongest on day 2 (Nelson et aI. , 1 998). continuing chest wall pain and benefit from joint
If breathing exercises or incentive spirometry mobilizations (Dickey, 1 989).
are necessary for respiratory complications, Patients are usually ready for discharge within
manual support of the wound on inspiration a week. It is useful to check the breathing
may improve comfort and allow greater pattern and posture to make sure that there are
excursIOn. no lingering signs of tension that could become a
2 72
TRANSPLANTATION
sometimes causes profound change in a patient's

attitude to life. Postoperative feelings of resur
rection are not unusual and the patient's mood
may swing between depression and euphoria
(Ellis, 1 995). For those who survive the waiting
list, operation and complications, each day is
precious and life is usually sweet.
The indication for transplantation is end-stage
organ disease. Patients must be well enough to
cope with the operation and aftermath.
Examples are:
• cardiomyopathy for heart transplant
• cystic fibrosis (CF) for double lung or heart
lung transplant
• non-infective lung disorders such as
Figure 10.15 The 'Cough 10k'. pulmonary fibrosis and emphysema for single
lung transplant (which makes efficient use of
the donor pool).
habit. Patients need to understand the distinction
The operations are no longer technically
between incisional pain and anginal pain, receive
awesome, and now that immunosuppressive
advice on rest/exercise balance, and be given
therapy is better able to prevent organ rejection,
written information, an example of which is
the main limiting factor is lack of donor organs.
provided in Box 1 0 . 1 for patients after a full
Lobar transplants are easing this problem in
incision operation. They require a comprehen
relation to lungs, and xenotransplantation from
sive exercise programme such as that described
other species is currently being examined by
by Ungeman-deMent et al. (1 98 6), and/or assess
ethicists.
ment at an outpatient physiotherapy clinic to
Recipients are matched with donors for factors
check for musculoskeletal problems (EI-Ansary
such as blood type and organ size. Strict criteria
et al., 2000) and/or cardiac rehabilitation.
are applied to donor and recipient (Maurer et aI. ,
CABG is effective in reducing angina but
1 99 8 ) . Recipients must be free of HIV infection ,
functional impairment often continues after
recent malignancy, tobacco and other addictions
surgery (Allen, 1 990), especially without rehabi
be optimally nourished and on minimal steroids:
litation, and atherosclerosis continues. Patient
Delays to heart transplant can sometimes be
and family are well advised to cultivate a
bridged by a left ventricular assist device (Koul et
lifestyle that retards the disease process in the
aI. , 1 9 9 8 ) . One-year survival is 85 -90% for
grafted vessels.
heart, 75 -850/0 for heart-lung and 60-90% for
lung transplantation (Oh, 1 9 9 7, p. 8 1 8 ).
TRANSPLANTATION
Procedures
'Each new day is welcomed with open arms
Cardiopulmonary bypass is used for heart and
come sun, rain or snow. Gone are the
occasionally double-lung transplant. For single
excuses for putting off activities until the
lung transplant, a thoracotomy incision and
weather is better or the time more
bronchial anastomosis are used. For bilateral
opportune. '
lung transplants, a massive trans-sternal bilateral
Marsh (transplant patient), 1986
thoracotomy (clamshell incision) allows sequen
Receiving a transplanted heart, lung or both tial single-lung procedures, creating two separate
273
Box 10.1 Home advice following heart surgery, to be modified for individual needs
1. On returning home, take regular walks around the house, progressing to 1 0-minute walks
outside within a week. In the second week, do light housework. Progress to 30 minutes exercise
daily, possibly split into two walks a day. Increase the intensity gradually so that you aim to
produce a rise in pulse rate to over 1 00 per minute (unless you are on beta-blockers). Find some
enjoyable exercise that you can maintain indefinitely, e.g. a daily 2-mile brisk walk. For the first 2
months, delay exercise for 1 hour after meals or 30 minutes after bathing.
2. For the next 6 weeks, allow yourself an hour a day to lie down for a nap.
3 . Women are advised to wear a bra as soon as comfortable in order to reduce strain on the
wound.
4. Swimming, fishing and cycling can be taken up after 6-8 weeks. Golf and tennis can be enjoyed
so long as unilateral arm movements are not forced. Competitive sports such as squash or team
games are not recommended for at least 3 months, and then only with the doctor's advice.
5. Sexual activity can be started after about 2 weeks or when you can manage everyday activities
such as climbing stairs. It is advisable to remain in the dependent position in the early stages to
avoid strain on the incision. Your partner may be more anxious than you about resuming sex, and
may need reassurance. Some drugs such as beta-blockers can affect sexual performance.
6. Avoid driving for at least 6 weeks, or 1 week following angioplasty. Do not drive if it brings on
angina. In the UK it is not necessary to notify the DVLA, but advise your insurance company.
7. Sedentary work can be resumed after 4 weeks.
8. Do not lift, push or pull anything heavy, especially with breath-holding, for 6 weeks. This
includes mowing, digging and vacuum-cleaning.
9. Expect a degree of breathlessness, tiredness, poor concentration, memory loss and aches and
pains across the shoulders and chest. These are normal and should improve over 6 weeks. Take
painkillers for as long as you need them. Breathlessness that hinders speaking should be reported
to the doctor. Some arm movements cause a clicking feeling in the breast bone. If this continues
after 3 months, let the doctor know. Depression or anxiety may come and go for several weeks.
1 0. It is safe to fly after 1 0 days, and airports will supply a wheelchair if necessary. However you
are unlikely to get the best out of a holiday for at least 6 weeks.
1 1 . The wires in your breast bone will not rust or set off security alarms.
12. Make a list of questions to ask the doctor at your follow-up appointment.
13. No smoking.
14. Keep happy!
bronchial anastomoses and preserving the and lungs en bloc and retains the collateral circu
coronary-to-bronchial circulation. A sternotomy lation. HLT may incorporate a domino
is used for other procedures. procedure in which the recipient's healthy heart
A heart-lung transplant (HLT) provides heart is used as a donor for a second recipient.
274
TRANSPLANTATION
Pulmonary oedema can be caused by loss of

Complications lymphatic drainage or the ischaernic insult of
All transplants are complicated by the side effects surgery followed by reactive reperfusion. 'Reper
of life-long drugs to inhibit organ rejection, fusion pulmonary oedema' peaks 8 - 1 2 hours
including increased risk of malignancy. Cyclos postoperatively, causing hypoxia and reduced
porin causes immunosuppression by inhibiting lung compliance. Treatment with fluid restric
lymphocytes and can cause renal damage. The tion and diuretics may thicken secretions, dry
side effects of steroids include opportunist the mouth and inhibit expectoration.
infection and altered body image due to extra Hypercapnia may develop in people with
body hair or cushinoid appearance. preoperative CO2 retention because the new
normal oxygenation suppresses their hypoxic
Heart transplant respiratory drive. This normalizes within a week.
Acute heart rejection is suspected if there are Acute or chronic lung rejection can occur
temperature or ECG changes, and confirmed by from a few days to several years postoperatively.
biopsy. Chronic heart rejection accelerates ather FVC and FEV 1 should rise to a plateau some
osclerosis of the transplanted arteries and is months after surgery and then remain stable, but
identified by annual angiography. The only a subsequent reduction of 1 0 - 1 5 0/0 is a warning
treatment for chronic rejection is re-transplanta of possible rejection. Suspicions are confirmed if
tion. there is fever, breathlessness, hypoxaemia and
Lung transplant
fine crackles on auscultation. X-ray signs are
Transplanting the lung has proved difficult similar for both rejection and opportunistic
because it is the only organ in contact with the infection, and gentle bronchoscopy is needed to
atmosphere and has evolved a strong protective distinguish the two. Patients are given a diary in
immunity to anything foreign. Many complica which to record spirometry readings, tempera
tions may emerge, as described below. ture, weight and medication. Treatment of
rejection is by increased steroids. Confirmation
Infection is the main cause of death in the of rejection indicates that physiotherapy should
early stages. Contributing factors are immuno be modified as follows:
suppression, lymphatic interruption and hilar
• suction must be minimal because it may
stripping during surgery. Denervation of the
damage the anastomosis and exacerbate
lung impairs mucociliary transport and the
oedema from surgery and erythema from
patient's awareness of the presence of secretions,
rejection
an awareness that people with CF have
• exercise training is temporarily ceased or
developed to a fine art. Patients are reminded to
modified.
expect some secretions in the immediate post
operative period because it takes a few days for Obliterative bronchiolitis is a devastating
the debris to clear. Secretions also continue to be complication following repeated episodes of
produced from the native airway of CF patients rejection. It occurs in 1 0-50% of recipients at
above the anastomosis. A further hindrance to around 6- 1 8 months after surgery and has a
secretion clearance in the short term is post mortality of 3 0-50% (Nathan, 1 995). It creates
operative oedema around the anastomosis. a combined obstructive and restrictive defect,
Denervation IS often permanent but the the small airways becoming obstructed by
bronchial arteries and lymphatic system are inflammation and then obliterated by granula
thought to regenerate in some weeks (Oh, 1 997, tion tissue, which then fibroses. It may be
p. 8 1 6). An advantage of denervation is that complicated by extending into alveoli and devel
reduced neural drive may contribute to oping into pneumonia (see 'BOOP' in the
decreased breathlessness (Brath et al., 1 997). Glossary). Monitoring bronchodilator response
275
in the small airways may identify the process so following precautions:

that augmented immunosuppression can be
started (Rajagopalan et aI. , 1 996). PEP or CPAP • Transplanted hearts can show a trammg
give symptomatic relief. Re-transplantation may effect but are denervated so that the trans
be required but carries a high mortality. mission of angina is impaired, the pulse is
Stenosis may occur at the anastomosis site. not a reliable monitoring tool and there is a
Treatment is by balloon dilation or insertion of a delayed heart rate response to exercise,
silastic stent, but the condition is usually asso requiring ample warm-up and cool-down
ciated with obliterative bronchiolitis. periods. After 6-12 months of exercise,
responses may become near-normal,
although the intensity and duration of exer
Physiotherapy cise is limited.
Preoperative physiotherapy takes place when the • Steroids may cause osteoporosis, myopathy
patient attends the surgeon's assessment clinic, or delayed healing.
because there is little time once a donor has been
found. An exercise programme should be Attention is focused on the recIpIent, and the
adhered to for those who are not deteriorating donor and donor's relatives are vulnerable at this
rapidly. Noninvasive ventilation may be required time. Respiratory physiotherapy may be
while awaiting a donor organ. requested to maintain oxygenation to the organ
Postoperative respiratory care is similar to to be transplanted. A brain-dead donor must be
other forms of chest surgery, with extra cared for as any moribund patient and not
attention to prevention of infection, plus other talked over. Conversation with relatives must
considerations described below. avoid terminology such as 'harvesting' the
Following lung transplant or HLT, endobron organs, or comments on the importance of main
chial suction if needed should be undertaken taining vital signs.
without the catheter reaching the anastomosis,
which in ventilated patients is just below the end
of the endotracheal tube. Continuous humidifi REpAIR OF COARCTATION OF THE AORTA
cation and sometimes modified postural drainage
may be needed because of impaired mucociliary Stricture of the aorta raises BP due to impaired
clearance. Long-term chest clearance is not renal perfusion. Patients may be symptomless,
needed, and some innervation may occur over the condition often being picked up on routine
time. Manual hyperinflation and IPPB should be X-ray, but surgery is advisable before hyperten
used with caution because of the risk of pneu sion wreaks damage in later life. Repair is by
mothorax or bronchial dehiscence. resection of the narrowed segment and anasto
Many patients are debilitated and need mosis or insertion of a graft.
extensive rehabilitation. In the early stages, the The following precautions are needed post
following is a guide to a progressive exercise operatively to avoid a sudden rise in BP that
regime: might strain the anastomosis:
• day 1 -2: sitting out in a chair • The head-down tip should be avoided. Some
• day 2: upper limb exercises, static pedals surgeons prefer the patient not to lie flat.
• day 2-3 : walk round room • Mobilization should be slow and fatigue
• day 4: walk outside room avoided. Extra care is needed when patients
• day 5 : exercise bike, gym, stairs. are beginning to feel well enough to exert
themselves.
After discharge, patients pursue an exercise • Vigorous exercise should be discouraged for
programme at home or in the gym, with the several months.
276
HEAD AND NECK SURGERY
OESOPHAGECTOMY • leakage or dehiscence at the anastomosis

• empyema (Figure 1 0. 1 6) or abscess (Klein,
Oesophageal cancer leaves only 1 0-20% of
1 999)
patients alive 1 year from diagnosis and 5-10%
• pleural effusion
alive after 5 years (Mills and Sullivan, 2000). It
• weakness after protracted preoperative
is usually diagnosed too late for successful
malnourishment.
resection, but surgery can relieve the distressing
symptom of dysphagia and sometimes effect a Postoperative precautions are:
cure. Oesophagectomy is a harrowing operation,
• avoid the head-down tilt in case reflux of
with access by thoracolaparotomy, thoracotomy
gastric contents damages the anastomosis
and laparotomy/laparoscopy, or thoracotomy
(some surgeons prefer patients to maintain
with neck incision, depending on the location of
head elevation)
the tumour. ·
• avoid neck movements that might stretch the
Complications are reduced with early extuba
anastomosis
tion, adequate pain control and meticulous preo
• with a high resection, avoid naso- or
perative preparation (Caldwell, 1 993), but the
oropharyngeal suction because the catheter
following may occur:
might accidentally enter the oesophagus.
• significant atelectasis as the stomach is pulled
Sputum retention is common and a request
up into the chest to be anastomosed to the
for early minitracheostomy is advisable in
oesophageal stump
selected patients. Discharge advice is detailed by
Savage ( 1 992).
BREAST SURGERY
Complications of mastectomy include lymphoe

dema, joint stiffness, muscle weakness and
shoulder pain, especially after axillary node
dissection (Kelley and Jull, 1998). Patients
require advice on upper limb movement and
posture correction, but should not elevate the
shoulder joint beyond 90° until the drains have
been removed. An example of an exercise sheet
is given in Box 1 0.2. After lumpectomy, patients
may have no significant complications but will
need a reminder on arm movement.
Swallowing dysfunction and aspiration are

common complications of head and neck
surgery. Head and neck cancers are among the
most emotionally traumatic because of disfigure
ment, loss of natural speech, impaired taste,
Figure 10.16 X-ray showing an empyema in the left
upper zone that developed in a 1 7-year-old youth after
mucus discharge, complications of radiotherapy,
oesophagectomy. In the left chest can be seen the cut rib of limited ability to express feelings, and difficulties
the thoracotomy and the colon transplant that replaced the with swallowing, breathing and nose-blowing
oesophagus, partially filled with fluid. (Monga et al. , 1 997). Frustration, social with-
277
CHAPTER 1 0 PHYSIOTHERAPY FOR PEOPLE UNDERGOI G SURGERY
Box 1 0.2 Examples of exercises after breast surgery, to be tailored to the individual
For the first day or two after the operation you may have one or two drains to allow fluid to
escape into a sealed bottle or bag.
Days 1-3 :
Shrug shoulders up and down.
Roll shoulders back and down.
Walk round the ward taking your drains with you, allowing your arm to swing gently as you walk.
Avoid standing with shoulders hunched.
Use both hands as normal.
Days 2-3 onwards:
Do the following exercises, trying to go a little further each time and ensuring a gentle stretch but
no pain.
• Clasp hands together, lift hands up, first with elbows bent, then gradually straighten elbows as it
gets easier.
• Clasp hands behind neck and move your elbows apart.
• Clasp hands behind back with elbows bent, lift them up towards bra strap level.
• Clasp hands behind back with elbows straight, stretch arms backwards.
Continue these exercises three times each, twice a day, for about 3 weeks or until you have full
movement. If movement is not regained in 6 weeks, ask your doctor to refer you to a physiothera
pist.
drawal, depression and problems with close rela trachea, through which a tube can be inserted.
tionships are common, and 50% of patients may
develop psychiatric morbidity (McQuellon and Tracheotomy: incision into the trachea through
Hurt, 1 997). the skin to create a tracheostomy.
A tracheostomy is formed for the following
Laryngeal cancer reasons:
Cancer of the larynx is highly curable in its early
stages, and laryngectomy has been practised for • temporarily during some operations to
1 00 years. However, there has been little
protect the airway from aspiration and swel
improvement in cure rate (Levine, 1 997), and ling
the main aim is early diagnosis, or preferably • permanently after laryngectomy
prevention. Smoking is the main risk factor • to provide airway access for some patients
(Koufman and Burke, 1 997). Partial or total on ventilators
laryngectomy is required if radiation treatment • after facial trauma.
fails. Partial or radical neck dissection is The physiological effects are reduction in dead
performed for malignant invasion of other space, reduction in the work of breathing
tissues. A more extensive commando procedure (WOB) compared to nose breathing but
resects part of the mandible, tongue, neck struc increased WOB compared to mouth breathing
tures or floor of the mouth. (Prichard, 1 994).
Percutaneous tracheotomy is a dilational
Tracheostomy technique that causes less trauma and scarrIng
Tracheostomy : artificial openmg into the than a full surgical tracheotomy. It can be
278
(a) (b)
Figure 10.17 (a) Tracheostomy tube in situ. (b) Tracheostomy and laryngectomy.
performed under local anaesthesia and is often inner cannula (Burns et al., 1 998) whose
used for mechanically ventilated patients. function is to prevent trauma from repeated tube
Figure 10. 1 7a shows the location of a changes and as a safety factor in case of
tracheostomy with its tube, and Figure 1 0 . 1 7b blockage. It is left in situ for suction, but may
shows a permanent stoma following laryngect need to be removed and cleaned beforehand, as
omy. follows:
For the first few days after surgery, there is an • Support the neck plate with one gloved
inflated cuff that encircles the tube within the hand.
trachea to limit aspiration (Figure 10.1 8a). For • Unscrew, unlock or unclip the inner tube
non-laryngectomy patients, the cuff is deflated as with the other gloved hand, then remove
soon as there is a cough reflex and when swal outwards and downwards.
lowing is adequate. If the tube is to be removed, • Clean with a brush and sterile water, dry
it will be plugged, with the cuff deflated so that inside and out with gauze.
the patient can breathe, for lengthening periods • Put it back in, screw, lock or clip into place.
until the plug can be left in situ for 24 hours
without distress. Longer than 24 hours creates The tapes are best secured with Velcro and
its own distress because WOB is greater with a should be loose enough to fit one finger between
plugged tracheostomy tube than breathing the tape and neck.
through the natural airway. For laryngectomy Variations are the following:
patients, the cuffed tube is removed after about • A silver tube (Figure 1 0. 1 8c) is uncuffed and
48 hours when haemorrhage is no longer a risk, helps maintain the stoma.

and replaced with an uncuffed tube (Figure • For people without a laryngectomy but
10.1 8b). requiring a long-term tracheostomy, speech
Uncuffed tubes are used for patients requiring is possible with a fenestrated tube (Figure
permanent tracheostomies. They incorporate an 1 0 . 1 8d). This has inner and outer cannulae
--
-- 2 79
(c)
\It-H---l--- fenestration
Figure , O. , 8 (a) Cuffed tracheostomy tube. cuff

(b) Uncuffed tracheostomy tube. (c) Negus silver tube.
(d) Fenestrated tube and inner tube.
with matching windows (fenestrations) on are not to be used with mechanical ventila
their posterior curves. With the cuff deflated tion.
and stoma occluded by a plug or gloved • A speaking valve such as the Passy-Muir
finger on expiration, the patient can speak allows speech, in patients who have not had
by breathing out through the windows, a laryngectomy, without occluding the stoma
around the tube and up through the larynx. with a finger. The valve opens on inspiration
An unfenestrated inner cannula is used for and closes on expiration to force air through
suction, eating and drinking, but a new the vocal cords (Manzano, 1 993), and can
model is available that can be left in place be free-standing or in-line with a ventilator
for suction because it has many tiny circuit. Improved sense of smell and appetite
windows (Mallingcrodt, Appendix C). The are added advantages.
patient must sit upright when eating and for
20 minutes afterwards. Fenestrated tubes Practical points when using a speaking valve are:
280
• Before connecting the valve, suction the movement of the tube in the immediate post
airway, then let the cuff down slowly, with operative period, uncontrolled coughing or
another suction catheter prepared in case of over-loose tracheal ties.
need. • Aspiration, even though aspiration itself is
• Remove the valve for sleep to avoid sometimes the indication for tracheostomy.
impaired Sa02 due to extra dead space, and This has been found in 5 0% of medically
take precautions against falling asleep with stable patients admitted to a chronic ventila
the valve in situ tion unit, most of whom had no symptoms
• For ventilated patients, PEEP can sometimes (Elpern et a/. , 1 994). The cuff needs to be
be reduced. deflated during eating to facilitate swal
• Increase tolerance gradually to allow accom lowing, but patients with neurological disor
modation to the dead space. ders should be assessed by a speech-language
therapist before cuff deflation.
Complications of tracheostomy • Dysphagia, nausea and vomiting if pressure
is exerted on the posterior wall of the
'We can never make the sounds of crying, trachea and oesophagus by the wrong size or
shouting or laughter. ' shape of tube.
Ulbricht, 1986
• Infection, partly because the oropharynx is
teeming with bacteria and partly because
Unavoidable complications of a tracheostomy poor suction technique is widespread.
tube are the following: Prolonged hospitalization or poor nutrition
encourage infection.
• impaired cough, because there is no closed • Weight loss due to dysphagia and reduced
glottis behind which air can build up appetite. Food is less appetizing because of
• impaired swallow because of reduced muscle impaired taste and smell, which are never
co-ordination, upset pressure gradients and fully restored.
anchoring of the larynx, especially with an • Fistula formation, which is suspected if
inflated cuff suctioned secretions contain food and drink.
• damage to the trachea, increased by the pull • Erosion of the trachea due to excess move
of ventilator tubing or mishandling ment of the tracheostomy tube, and late
• loss of the modest natural PEEP normally onset stricture due to granulation tissue as
maintained by the larynx (p. 357). eroded areas heal.
Complications that may occur are the following: • Stenosis, which may take months or years to
develop. Signs are cough, retained secretions
• Obstruction due to a blood clot, or if poorly and increasing dyspnoea. Laser treatment, or
managed, due to thick secretions. resection and anastomosis, may be required.
• Haemorrhage. This may be obvious, or indi
cated by pulsation of the tracheostomy tube Management
synchronously with the pulse. If suspected, It takes about a week after tracheostomy for
the airway should be suctioned and cuff fascia and muscle to fuse and form a tract,
inflated. This will temporarily limit aspira during which time tracheal dilators are on hand
tion of blood into the lungs, until medical in case the tube becomes dislodged. Two spare
attention arrives. The head-down position tracheostomy tubes must be available, one a size
also inhibits aspiration. smaller in case a change is needed urgently. At
• Surgical emphysema (Douglas and Flabouris, the bedside there is also an obturator, a solid
1 999). insert that, when inside the tracheostomy tube,
• Displacement, especially if there is excessive assists its insertion and which is removed imme-
281
diately afterwards so that the patient can exposed cosmetic changes. Self-esteem often
breathe. Tracheostomy tubes should normally improves when patients are encouraged in activ
only be changed by a specifically trained nurse, ities ranging from cleaning their own inner tube
physiotherapist or doctor. to helping other patients. With a long-term
The greatest fear of tracheostomy patients tracheostomy, patient or carer will need to be
during their early postoperative days is the taught to do their own suction (although many
inability to summon help, and a bell must always patients can huff out their secretions) and deal
be within reach. For patients unable to call for with a blocked tube (see next page).
help immediately, a bell is not sufficient and Patients require postural correction and
they should be in sight of the nurses' station, not advice such as avoiding traction on the brachial
in a side room. plexus and supporting the neck plate when
Continuous hot water humidification is coughing or sneezing. An exercise regime begins
needed for the first 48 hours. If the tracheost with gentle range of movement exercises on
omy is permanent, the airway acclimatizes to day 1 . Respiratory care is provided as required,
its new exposure to the environment. Patients and an incentive spirometer, attached with a
will then need to maintain adequate fluid connector, has been shown to improve lung
intake, and are supplied with sterile saline and function (Tan, 1 995). Major head and neck
a syringe to moisten the airway if necessary. surgery should be followed by a comprehensive
An 'artificial nose' can be used as a heat exercise programme such as that described by
moisture exchanger (p. 1 90), or a bib over the Herring et al. ( 1 9 8 7).
stoma can filter out large particles. Humidifica The speech-language therapist assists with
tion is restarted if infection occurs, and people swallowing and, after laryngectomy, voice
with chronic lung disease may need intermit restoration by methods such as the following.
tent humidification. Gloves should be worn for
all contact with the tracheostomy area. • An electrolarynx held at the neck produces a
Liberal mouthwashes are required after head tone that is shaped into mechanical-sounding
and neck surgery, even for patients with excess speech as the user mouths the words.
salivation. Suction of the mouth requires low • Oesophageal speech involves compressing air
pressures and avoidance of areas of anastomosis. into the oesophagus and releasing it, causing
If the sternomastoid muscle has been excised, a vibration. The technique is difficult to
the patient's head will need support posto learn but creates a more normal sound than
peratively when s/he is moving around the the electrolarynx.
bed. If the spinal accessory nerve has been • A tracheo-oesophageal puncture can be
transected, there might be shoulder pain and created and a valve inserted through which
limited abduction. Connecting tubes must be patients can be trained to generate oesopha
supported during movement so that they do geal speech.
not drag on the wound. Staff need to allow Isolated laryngeal transplants have been
time for lip-reading and deciphering written performed and provide hope for the future.
requests. Patients need questions that require Decannulation of the tracheostomy tube is
only a yes or no answer. They do not need a described on page 359. Discharge advice for
raised voice. patients with an ongoing tracheostomy includes:
For disfiguring surgery, a mirror should be
given to patients only if someone is available to • sterile suction
be with them for their first view. Visitors need • protecting the stoma from water
preparation before their first visit. Women may • keeping the home dust-free
have more difficulty adapting to their new self • avoiding people with chest infections
image because of a low-pitched voice and more • winter flu vaccination
282
CASf STUDY
• instructions for carers on mouth-to-stoma Charts: intermittent intramuscular analgeSia,

resuscitation pyrexia, Sa02 94%.
• replacement or removal of a blocked tube in Patient slumped in bed, on 40% dry oxygen.
an emergency Rapid shallow breathing pattern.
• a contact number in case of problems Auscultation: 1 BS LLL, coarse crackles.
• for those with facial disfigurement, informa- PA and lateral films show two fluid-filled cavities in
tion on support groups (Appendix C). left upper zone (Figures I 0. 1 9a and b) Scan at
tracheal level identifies largest cavity (Figure
Respiratory arrest with a tracheostomy I 0. 1 9c). Radiology report states that cavities may
If a tracheostomied patient suffers respiratory be abscesses, empyema or bronchopleural
arrest due to obstruction, the following steps fistula.
should be taken:
1 . Press the crash button or ask a colleague to Questions
call the crash team. I . Analysis?
2. Suction the airway. 2. Patient's problems?
3. If there is an inner cannula, remove it. If this 3 . Precaution?
was obstructed, removal may be sufficient. 4. Goals?
Otherwise, continue as below. 5. Plan?
4. Move the patient's head in case this relieves BS = breath sounds; LLL = left lower lobe; PA =
the obstruction. postero-anterior.

S. Remove the tracheostomy tube as follows:
• Deflate cuff
• Cut securing tape
• Slide out tube, using tracheal dilators to

Id£ig.,��i'<·'iiiIiIi) ·A
maintain the patency of stoma
6. Continue ventilation via tracheal dilators, I . Analysis
either encouraging the patient to breathe Inadequate analgesia contributing to shallow
spontaneously or blowing down the stoma. breathing and probable LLL atelectasis.
LLL atelectasis suggested by 1 BS in L lower zone
Experienced physiotherapists can insert a new
and raised hemidiaphragm on left (too large a
tracheostomy tube, or a nasopharyngeal tube can
shift to be attributable to loss of the upper lobe).
be used if necessary.
2. Problems
Pain.
Poor sleep.
1 lung volume LLL, contributing to poor gas
Identify the problems of this 74-year-old man on exchange.
his first day after left upper lobectomy for small cell Retention of infected bronchial secretions,
carcinoma. contributing to poor gas exchange.
Subjective 3. Precaution
Pain on coughing. Avoid right-side-Iying to prevent infected fluid
Bringing up thick green phlegm. spreading from abscess or bronchopleural fistula.
Unable to sleep.
4. Goals
Objective I ncrease lung volume and clear secretions.
Notes: Pseudomonas chest infection. Rehabilitate.
283
(c)
,
Figure , 0. ' 9 M r LS.
• Check that flow of oxygen meets patient's

5. Plan subjective requirements.
• Liaise with team to clarify location of infected • Humidify oxygen.
fluid. • Controlled mobilization.
• Obtain adequate analgesia. • Sitting in chair or upright in bed: deep
• Identify cause of poor sleep, then remedy if able. breathing with end-inspiratory hold, then
284
RECOMMENDED READING
incentive spirometry, then identify which is Basse, L. (2000) A clinical pathway to accelerate
most effective. recovery after colonic resection. Ann.Surg, 232,
• Sitting in chair or upright in bed: ACB/AD. 5 1-57.
• If secretions do not clear, choose another Bartsch, M . H., (2000) Exercise capacity and extent
of resection as predictors of surgical risk in lung
method that is simpler and less tiring, e.g. gentle
cancer. Eur. Resp.j., 1 5 , 828-832.
vibrations or flutter.
Burke D . T. (2000) Prevention of deep venous
• If secretions still do not clear, request
thrombosis: overview of available therapy options
minitracheostomy. for rehabilitation patients. Am.j.Phys.Med.Rehab.,
• Ask patient, with reminders from nurses or 79 (supp! .), S3-S8.
patient's visitors if possible, to practise either Chua,K. S . G., Reddy, S . K. and Lee, M. C. ( 1 999)
deep breathing or incentive spirometry, then Pain and loss of function in head and neck cancer
ACB/AD if able, preferably for a few minutes survivors. J.Pain Symptom Man., 1 8 , 1 93-202.
every waking hour. Cockram, J., Jenkins, S . K., and Clugston, R. ( 1 999)
• Visit patient little and often: remind him about Cardiovascular and respiratory responses to early
exercises, check position/comfort/humidification, ambulation and stair climbing following coronary

artery surgery. Physiother.Theory Pract., 1 5 , 3- 1 5 .
treat as required.
Eliachar, 1. (2000) Unaided speech i n long-term tube
• Upper limb exercises and posture correction.
free tracheostomy. Laryngoscope, 1 1 0, 749-760.
• Progress.
Good, M. and Stanton, M. ( 1 999) Relief of
ACB/AD: active cycle of breathing and/or autogenic postoperative pain with jaw relaxation, music and
drainage their combination. Pain, 8 1 , 1 63-1 72.

Harden, B. ( 1 997) Lung volume reduction surgery for
emphysema. Physiotherapy, 8 3 , 1 3 6- 1 4 0
Hogue, S. L . , Reese, P. P . a n d Colopy, M . (2000)
Assessing a tool to measure patient functional
Can you criticize the following title before ability after outpatient surgery. Anesth.Analg., 9 1 ,
reading the rest of the article? 'Are incentive 9 7- 1 06.

Huerta-Torres, V. ( 1 998) Preparing patients for early
spirometry, intermittent positive pressure
discharge after CABG. Am.j.Nurs., 9 8 , 5, 49-5 1 .
breathing and deep breathing exercises effective
Hyde, J . (2000) Reducing morbidity from chest
in the prevention of postoperative pulmonary drains. Br.Med.j, 3 1 4, 9 1 4.
complications?' (phys. Ther. ( 1 994), 74 , 3-1 6) Moores, L. K. (2000) Smoking and postoperative
pulmonary complications. Clin. Chest Med., 2 1 ,
1 3 9 - 1 46 .
RESPONSE TO LITERATURE APPRAISAL Orringer, M. K. ( 1 999) The effects o f tracheostomy
tube placement on communication and
1. The single word 'and' indicates that several swallowing. Respir. Care, 44, 845-853
modalities are being tested. This does not Pandit, S . K., Loberg, K. W. and Pandit, U. A. (2000)
help us to identify which. Toast and tea before elective surgery?
2. IS, IPPB and deep breathing are indicated for Anesth.Analg., 90, 1 348-1 3 5 1 .
different levels of patient ability and Rosenberg, A. D . (2000) Reducing post-traumatic
cooperation, and are not interchangeable in morbidity with pain management.
this way. Curr. Op.Anaesthesiol., 1 3 , 1 8 1- 1 84 .
Schwaiblmair, M. ( 1 999) Cardiopulmonary exercise
testing before and after lung and heart-lung
RECOMMENDED READING
transplantation. Chest, 1 5 9 , 1 277- 1 2 8 3 .
American Society of Anesthesiologists (2000) Practice Siafakas, N. M., Mitrouska, 1 . and Bouros, D . ( 1 999)
advisory for the prevention of peri operative Surgery and the respiratory muscles. Thorax, 54,
peripheral neuropathies. Anesthesiology, 92, 1 1 68- 458-465
82. Stevensen, C. J. ( 1 9 94) The psychophysiological
285
CHAPTER 10 PHYSIOTHERAPY FOR PEOPLE UNDFRGOING SURGERY
effects of aromatherapy massage following cardiac Weissman, C. (2000) Pulmonary function after
surgery. Complem.Ther.Med., 2,27-35. cardiac and thoracic surgery. Curr.Op.Anaesthes.,
Street, D. (2000) A practical guide to giving entonox. 13,47-51
Nurs.Times, 96,34,47-48. Wong, D. H. (1997) Chronic obstructive pulmonary
Thompson, M.N. and Bell, P.R.F. (2000) Arterial disease and postoperative pulmonary
aneurysms. Br.Med.J, 320,1193-1196. complications. Curr.Opin.Anaesth., 10,254-258
Warner, D.O. (2000) Preventing postoperative Young, P. J. and Matta, B. F. (2000) Anaesthesia for
pulmonary complications. Anesthesiology, 92, organ donation in the brainstem dead - why
1467-1472. bother? Anaesthesia, 55, 105-106.
286
11 PHYSIOTHERAPY FOR SPECIFIC GROUPS OF PEOPLE
SUMMARY
Overview of cardiac rehabilitation People who are dying

Hyperventilation syndrome • Reactions of patients
• Introduction • Reactions of relatives
• Causes· • Reactions of staff
• Effects • Communicating with dying people
• Assessment • Management of symptoms

• Education • On dying well
• Breathing re-education Case study
• Progression and home management Literature appraisal
• Outcomes Recommended reading
Elderly people
• ! hospital re-admission rates by 38% (Huang

OVERVIEW OF CARDIAC REHABILITATION
et ai., 1990).
Coronary heart disease is the commonest cause • ! risk of sudden death with vigorous exercise
of death in the UK (DoH, 1993). Hospitalization 50-fold (Bartsch, 1999).
continues to shorten and rehabilitation is taking The exercise component does not affect the
on a higher profile. It would be ideal for rehabi atherosclerotic process but can enlarge coronary
litation to be initiated before heart surgery, but arteries to provide protection by increased flow
it usually starts after the operation or after a (Morris, 1991). Benefits have also been shown if
myocardial infarction (MI), and increasingly for patients are very elderly (Hellman, 1994), have
people with chronic heart failure. congestive cardiac failure (Cahalin, 1996) or
Once arrhythmias, acute heart failure and intermittent claudication, for which it can be an
ischaemia have been stabilized after surgery, reha alternative to surgery (Hunt et ai., 1999).
bilitation begins with a balance of rest and gentle Education, exercise and relaxation are similar
progressive exercise from sitting out, to walking, to pulmonary rehabilitation (Chapter 9), with
to stair-climbing. After discharge, a convalescent the differences outlined below.
programme of steady but not progressive exercise
is maintained. An outpatient rehabilitation Education
programme involving physical reconditioning Education is a central component of the
begins 3-6 weeks after surgery or angioplasty and programme because, firstly, distress hampers the
4-8 weeks after MI. The following benefits of recovery process (Melamed, 1999) and,
cardiac rehabilitation have been demonstrated: secondly, morbidity and mortality caused by
• i work capacity angina are not necessarily proportional to the
• i myocardial perfusion number of vessels involved (King and Nixon,
• ! angina 1988), indicating the importance of factors
• ! fatigue, depression and anxiety outside the coronary system. Post-MI anxiety is
• ! in mortality by 20% (Finlayson, 1997) likely to be related to fear of a repeat heart
287
CHAPTER 11 PHYSIOTHERAPY FOR SPECIFIC GROUPS OF PEOPLE
attack, which is associated with ischaemia and • acute disorder such as pulmonary embolism,
arrhythmias (Moser and Dracup, 1996). Depres pericarditis or systemic illness Oones and
sion occurs in an average 20% of patients after West, 1995).
MI, usually after discharge from hospital, and
this itself increases the risk of cardiovascular Unsupervised exerC1se training 1S contraindi
mortaliry (Seiner, 1999). cated if there is:
Education should include information on • exercise-induced hypotension
medication, especially as beta-blockers are asso • exertional angina uncontrolled by drugs
ciated with depression, and 30% of patients • complex arrhythmias
taking amiodarone experience neurological • inability to self-monitor (Brannon et at.,
problems that may appear as symptoms of 1998, p. 5).
depression (Seiner, 1999). Information on lifting
techniques are included for those who have had Participants should bring their anti-angina
a sternotomy. Hyperventilation is common after medication with them. They must not exercise
a cardiac event, and once identified is usually after a large meal or in extremes of heat or cold.
manageable by education (p. 299) before the Systolic BP should not rise more than 20 mmHg
new breathing pattern becomes established and or fall more than 10-20 mmHg during exercise
the full hyperventilation syndrome develops. (Brannon et at., 1998, p. 4), and dynamic
Fatigue is also common and needs to be exercise is preferred to isometric exercise (Figure
explained as a normal response. 11.1).
Patients on anticoagulation drugs after valve
Safety
surgery should avoid high-impact activiry or
The role of the cardiologist is to screen patients, contact sports in case of bruising or bleeding,
arrange an exercise ECG (stress test) to detect and those on diuretics should avoid prolonged
ischaemic changes on graded exercise, and assist exercise in the heat in case of reduced potassium
with risk assessment, summarized as follows: and fluid volume (Cahalin, 1996). For post-ster
• low risk: uncomplicated recovery from a notomy patients, exercise should not place a
small MI, no angina shearing stress on the sternum because union
• medium risk: previous MI or angina, satis takes 8-12 weeks.
factory recovery from recent MI, no medica
tion for heart failure
Exercise training
• high risk: recent large MI, angina on moderate The physiotherapist learns to identify the charac
exercise, medication for heart failure (these teristics of each patient's angina and the feel of
patients do their exercises in sitting). their individual pulse. Exercise prescription is
based on exercising to a percentage of rate of
If a stress test is not available, heart rate (HR)
perceived exertion (RPE), maximum HR (MHR)
should be maintained at 10 beats below angina
or modifications of MHR Oohnson and Prins,
threshold level and exercise should be symptom
1991). For MHR, 75% maximum is usually the
free (Hertanu and Moldover, 1996).
aim, although improvements have been shown at
Exercise training is contraindicated if there is:
intensities as low as 40% maximum (Lavie et ai.,
• unstable angina 1992). Excessive HR is inadvisable because a
• uncompensated or symptomatic heart failure brief diastole prevents blood nourishing cardiac
• resting hypertension over 200/100 muscle. Beta-blocker or calcium channel blocker
• orthostatic BP drop of more than 20 mmHg drugs dampen the heart's response to exercise.
with symptoms Borg's RPE scale (Box 11.1) correlates with
• aortic stenosis, third-degree heart block or HR, oxygen uptake, ventilation and blood
uncontrolled arrhythmias lactate.
288
OVERVIEW OF CARDIAC REHABILITATION
Systolic Systolic
t t Mean
�
::J Diastolic
(/)
-----==== Mean
(/)
OJ
0..
�
"0
o
o
CD Diastolic
Workload ---+- Workload ---+-

(a) (b)
Figure 11.1 Comparison of (a) dynamic and (b) isometric exercise, showing a lesser increase in BP during dynamic work
compared to isometric work. (Modified from Laslett, L. et 01. (1987) Exercise training in coronary artery disease. Cardiology
Clinics, S, 211-225, with permission.)
Most patients exercise to levels 11-13 but exercise trammg, or if risk assessment is not
aerobic fitness can be improved at levels 10-11, available, improvement in quality of life is
corresponding to 55-60% MHR or brisk possible with gentle exercise for which risks do
walking, an intensity to which patients are likely not need to be comprehensively assessed
to adhere (Paley, 1997). Perceived exertion is (Worcester et ai., 1993).
explained to patients as the total inner feeling of If HR is used for monitoring, participants
exertion, not leg ache, breathlessness or other take their pulse before, immediately after and 5
perception. People with a predominantly type A minutes after exercise, noting the time it takes to
personality (Ferguson, 1992) may underestimate return to normal. A more comprehensive
their RPE. method is shown in Box 11.2. Exercise sessions
If patients do not enjoy the intensity of last about 30 minutes, preferably three times a
week. When maintaining the programme at
home, three 10-minute bursts of exercise are as
Box 11.1 Borg's RPE scale (Borg, I 982)
effective and may be preferable for some
patients (DeBusk, 1990). Less intensive exercise
6
should be continued between sessions.
7 very very light
Anaerobic exercise can strain the left
8
ventricle. Patients should not exercise through
9 very light
angina or excessive breathlessness. If a partici
10
pant gets angina during exercise, they should
11 fairly light
stop exercising and take their medication. If
12
symptoms are unrelieved after 15 minutes of
13 somewhat hard
repeated medication, the doctor should be
14
called. Meanwhile, the patient can be asked if
15 hard
they forgot to take their regular tablets.
16
A check ECG should be requested if the pulse
17 very hard
behaves abnormally, if exercise tolerance declines
18
over two or three sessions or if patients feel that
19 very very hard
their heart is not 'right'. Patients often detect that
20
something is amiss before it becomes obvious, and
289
CHAPTER 1 1 PHYSIOTHERAPY FOR SPECIFIC GROUPS OF PEOPLE
Box 11.2 Example of documentation for circuit exercises. A new record sheet is used each week
INFORMATION SHEET
• Start with the same station each week throughout the programme
• Exercise for one minute at each station, followed by 30 seconds rest period, during which proceed
with your group to the next station
• Record your RPE after every station and HR after every second station
Level A: weeks 1 -2
Level B: weeks 3-5
Level C: weeks 6-8
Station Exercise Level
Shuttle walks A: I 0-14 lengths

B: 20-25 lengths
C: 28--32 lengths
2 Arm raises A: out to side x 50

B: out to side x 70
C: plus I kg x 70
3 Sit-to-stand A: 25-50
B: 35-40
C: 45-50
4 Step ups A: 32-36

B: 45-50
C: 5 2-56
5 Floor mats A: 20 bridges, hold for 5

B: 40 sit ups, hand on thigh
C: 40 sit ups plus twist
6 Marching A: knee high 1 00 paces

B: arm swing 200 paces
C: elbow to knee 1 20 paces
7 Punching A: 1 25 punches forward

B: 150 punches overhead
Push ups C: 70 on parallel bars
8 Calf exercise A: up/down on toes x 70

B: up/down multigym x 70
C: step marching 60 paces
9 Trampet A: march I 20 paces

B: slow jog 240 paces
C: fast jog 300 paces
10 Cycle A: gently, minimum resistance

B: moderately, some resistance
C: brisk with moderate resistance
Continued overleaf
290
OVERVIEW OF CARDIAC RFHABILITATION
Box 11.2 continued
RECORD SHEET
MAXIMUM HEART RATE: TRAINING HEART RATE:
(220 -AGE) (220 - AGE) X 0.75
WEEK 1 WEEK 2 WEEK 3 WEEK 4
DATE HR at rest DATE HR at rest DATE HR at rest DATE HR at rest
START STATION HA APE HA APE HA APE HA APE

(circle)
1 1 1 1
2 2 2 2
3 3 3 3
4 4 4 4
5 5 5 5
6 6 6 6
7 7 7 7
8 8 8 8
9 9 9 9
10 10 10 10
reports of 'impending doom' need to be taken trallllllg alone, relaxation and exercise trallllllg
seriously. Referral for drug review is required if have shown a greater reduction in re-admission
angina occurs, side effects increase or if exercise rates, mortality, recurrent infarctions and need
tolerance is reduced by pulmonary oedema. for surgery (van Dixhoorn et al., 1987). Stress
If patients say they do not feel well or feel management should be included because patients
unusually tired, they should be advised to sit have a tendency to tolerate stress without being
down. They can have a drink if they feel thirsty. If aware of it. Angina provoked by stress is thought
patients develop dizziness or palpitations, change to last longer than exertional angina (Brannon et
colour or develop an irregular pulse that takes aI., 1998, p. 95).
more than 1 minute to recover, they should lie
down. Observation of their breathing should be HYPERVENTILATION SYNDROME
maintained. When one participant feels unwell
Hyperventilation can fairly claim to have
and is being attended to, the rest of the class
replaced syphilis as the great mimic.
should be kept occupied to reduce their anxiety.
Lum, 198 1
Details of exercise specific to cardiac patients
can be modified from page 232 or found in Broad Introduction
(1991) or Brannon et al. (1998). Improvement Breathing in excess of metabolic requirements
normally levels off in about three months, after has been used for centuries by religious sects in
which a maintenance programme is followed. order to achieve trance-like states of conscious
ness. These states incorporate some of the
Relaxation symptoms of acute hyperventilation but without
Relaxation is an essential component of the the fear associated with the disorder of hyper
programme. When compared to exercIse ventilation syndrome (HVS).
291
We are all familiar with the light-headedness If HVS is not identified, patients trek fruit
associated with acute hyperventilation at times lessly from clinic to clinic, accruing ever-fatter
of excitement or stress, an adaptive response case files, being labelled as depressive or neurotic
preparing for fight or flight. Hyperventilation or hysterical, and submitting to invasive investi
syndrome, however, is a chronic condition asso gations and sometimes years of debilitating
ciated with habitual overbreathing and somatic medication. Without treatment, the condition
or psychological symptoms (Malmberg et aI., persists or worsens in 750/0 of people. Some 40%
2000). HVS has no known organic basis, but it of children with HVS have symptoms into
depletes the body's stress-coping mechanisms adulthood (Timmons and Ley, 1994, p. 113),
and produces an array of alarming symptoms, which is unsurprising as 8 6% of children appear
usually intermittently. to go undiagnosed and are often dismissed as
HVS is a diagnosis begging for recognition, having growing pains Goorabchi, 1997). But
perhaps because it occupies the boundary HVS is eminently treatable, with symptoms
between body and mind. Most sufferers have being abolished in 75% of patients (Timmons
their diagnosis unrecognized, sometimes and Ley, 1994, p. 113). Relaxation and
descending into chronic invalidism, but it is a breathing re-training are found to be significantly
surprisingly common condition that occurs to more effective than psychological methods or
some degree in 6-11% of the population and drugs (Kraft, 1984).
contributes to nearly 40% of symptoms in
general practice (Duncan, 1987). It appears Causes
more commonly in women (often in early
The thread of the breath is woven
adulthood) than in men (often in middle age).
throughout the tapestry of a person's entire
Attempts to understand the condition have led
life experience.
to successive definitions such as irritable heart,
Harris, 1996
autonomic imbalance, cardiovascular neurosis,
effort syndrome, neurocirculatory asthenia, Physiologically, HVS is simply an abnormality of
soldiers' heart, designer jeans syndrome and, as a respiratory control, but the original factor that
last resort, 'factor X syndrome'. It was first identi sets off the pattern is often difficult to identify.
fied during the American Civil War, and again Body memory is thought to be held particularly
exacerbated during the 20th-century world wars, in the breathing pattern (Harris, 1996), and
when many thousands of young soldiers were patients may have experienced a bereavement or
invalided out with so-called heart disease. It was other loss. Contributing factors are chronic pain,
still not fully recognised during the Falkland and withdrawal from drugs such as opiates
Gulf wars, although the symptoms overlap with (Brashear, 1983), liver cirrhosis because of intra
those of Gulf War syndrome. cellular acidosis (Karetzky, 1967) and hypermo-
The lucky few who are correctly diagnosed bility syndrome because of mobile
form the tip of an iceberg of disability. Wide thoracovertebral Jomts (Innocenti, 1998).
spread failure to identify the syndrome is Although there is usually a combination of
because: factors, there may be one single cause (Brashear,
1983), e.g. viral illness.
• there is cursory coverage in medical texts Breathing occupies a central role in translating
• physiological adaptation has taken place so psychological changes into somatic changes
that few patients are conspicuously breath (Gilbert, 1999). A vicious cycle develops in
less which hyperventilation, symptoms and anxiety
• symptoms are non-specific and widely vari reinforce each other (Figure 11.2), with sympa
able thetic dominance further driving ventilation.
• there is no unequivocal diagnostic test. Symptoms are brought on by a trigger such as
292
HYPERVENTl.lATION SYNDROME
Origin
•
Trigger
•
� Hyperventilation �
\
:� :
Anxiety �
Catecholamines
IJ
I&� CO'
Figure " .2 Vicious cycle into which people with hyperventilation become trapped.
anxiety or prolonged conversation. Once the school sports, with the common conse
cycle is established, cause and effect are inter quence of fainting in assembly or possibly
changeable. The question that continues to tease 'mass psychogenic illness' Gones et at.,
researchers is whether hyperventilation or 2000)
anxiety come first, but in practice they both • conditions such as hypertension, chronic
augment each other. Either way, the syndrome is fatigue syndrome, 'fibromyalgia', sleep disor
associated with: ders, Raynaud's disease, migraine, panic
attacks and agoraphobia.
• food intolerance, premenstruation (Widmer
et aI., 1997) because progesterone is a Panic disorder is characterized by unpredictable
respiratory stimulant, drugs (e.g. caffeine, and overwhelming feelings of fear accompanied
nicotine, aspirin), menopausal hot flushes, by symptoms of sympathetic nervous system
spastic colon (Gilbert, 1999), prolonged arousal such as sweating, palpitations, tremor
mechanical ventilation and angina-like chest pain (Mansour, 1998).
• emotional factors such as fear, suppressed Agoraphobia has been found in 60% of
anger, depression, laughter, orgasm people with HVS, and HVS has been found in
• occupations such as singing, which encou 60% of people with agoraphobia (Garssen,
rage deep inhalation, call centre work, which 1983). Other phobias can be related to HVS and
entails prolonged telephone speaking, and may be its presenting complaint.
musicians (Widmer et aI., 1997) Although hyperventilation is a recognized
• restrictive clothes, hence tightly corseted stress response, it is not known why some
Victorian women taking the vapours after people respond to stress with chronic hyperven
collapsing on sofas, and a century later the tilation while others develop, say, backache or a
alternative name 'designer jeans syndrome' skin disorder. It may be related to past events
• conditions that cause overbreathing and may around fear and breathing, such as a hypoxaemic
predispose to HVS by reprogramming the birth, a ducking in the school swimming pool, a
respiratory centres, e.g. heart failure, pain, forcefully applied anaesthetic mask in childhood
interstitial lung disease, long-term low grade or a history of abuse in which crying out is
fever or asthma physically prevented. Personality plays a part
• in children, family discord or anxieties, e.g. because people who respond to stress in this way
------ 293
CHAPTER 1 1 PHYSIOTHERAPY FOR SPECIFIC GROUPS m PEOPLE
(Alkaline)
tend to suppress their emotions and are often 7.5
conscientious, perfectionist and enthusiastic. It is
these qualities, along with the high motivation
pH 7.3
that accompanies their relief at finding construc
tive help, which makes people with HVS a
7.1
delight to treat.
(Acidic)
L-________________________
(a)
Effects
6.0
These patients sit at the crossroads of
cardiology and neuropsychiatry.
5.3 - - - - - - - - -- - - - - - - - - -
Mansour, 1998
Overbreathing and/or unstable breathing washes

out the body's CO2 stores of about 120 L
(Gardner, 1996), causing low and/or fluctuating 4.0..1.------
PaC02 levels and raising the pH of cerebrospinal (b)
fluid and blood. This reduces plasma calcium
and potassium, excites neuromuscular junctions
and causes the sensory aberrations characteristic . --. .
. ...
of HVS. Autonomic instability of blood vessels i, ,.- . ."
. , .
, " .. .
(Figure 11.3) and nerves causes symptoms in ••• * .... *

I
almost any system of the body, sometimes one

sided (Gardner, 1996).
Cerebral vasoconstriction causes dizziness, Arterial diameter (e)
faintness, blackouts, headaches, visual distur
bance and sometimes a dissociated state of Figure 11.3 Hyperventilation causing (a) respiratory
unreality that feels like a floating sensation or a alkalosis, (b) hypocapnia and (c) vasoconstriction. (From
barrier against the real world as if s/he is an Gilbert, V. E. (1989) Detection of pneumonia by
auscultation of the lungs in the lateral decubitus positions.
outsider looking in (Lazarus, 1969). Children are
American Review of Respiratory Disease, 140, 1012-1016)
often misdiagnosed with epilepsy (Enzer et ai.,
1967).
Coronary vasoconstriction, compounded by
decreased oxygen yield to the tissues due to left
shift of the oxygen dissociation curve, may cause Left shift of the dissociation curve, caused by
angina (Magarian, 1982) or atypical chest pain. respiratory alkalosis, depresses phosphate levels
Up to 900/0 of non-cardiac chest pain is thought and leads to disturbed glucose metabolism,
to be associated with HVS (DeGuire et al., fatigue, disorientation, paraesthesia and muscle
1992) but misdiagnosis with heart disease is cramps (Widmer et ai., 1997). The kidneys try
frequent, especially as patients may have tachy to offset the alkalosis by excreting bicarbonate.
cardia, arrhythmias and adrenaline-induced ECG An increased drive to breathe re-sets the respira
changes. A flattened T-wave and depressed ST tory centres in order to maintain normal pH,
segment is typical, but compared to heart obliging the patient to continue low-grade
pathology, these tend to disappear with exercise hyperventilation despite a persistently low
(Missri and Alexander, 1978). As well as its PaC02·
independent existence, HVS is thought to be Misdiagnosis of asthma is common because
both a risk factor and a complication of the disorders commonly overlap (Morice, 1998).
ischaemic heart disease (Weiner, 1991). They augment each other's symptoms and hypo-
294
HYPERVENTILATION SYNDROME
capma can cause bronchoconstriction (van Table 11.1 A selection of the clinical features associated
Doorn, 1982). Demeter (1986) identified asthma with hyperventilation syndrome
in 80% of patients seen for HVS. Patients System Manifestation
diagnosed with asthma may bring on their HVS
symptoms every morning when they test to see if Neurological Tingling and numbness (especially
extremities mouth)
they need their inhaler by taking a 'nice deep
Faintness
breath'. Weakness
The breathlessness of HVS is distinctive. It is Blurred vision. migraine
Poor memory and concentration
disproportionate, fluctuating, poorly correlated
Tremor, tetany
with exercise, greater with inspiration than Emotional Panic attacks
expiration and exacerbated by crowds, conversa Phobias (especially claustrophobia,
agoraphobia)
tion or social situations. It usually improves with
Anxiety
rest but occasionally worsens at night, Suppression of emotion
mimicking asthma and the orthopnoea of heart Depression
Mood swings
disease (Magarian, 1992). The breathlessness of
Depersonalization
HVS is sometimes described as air hunger, Gastrointestinal Oesophageal refiux
heaviness on the chest or smothering. Negative Difficulty swallowing
Nausea
trials of nitroglycerine or bronchodilators help
Indigestion
to eliminate a diagnosis of heart disease or Wind
asthma, and a normal peak flow reading when Irritable bowel
Musculoskeletal Myalgia
breathless can be reassuring.
Stiffness, cramps
Activity may relieve symptoms, but sometimes Tetany in severe cases
loss of fine tuning means that breathing may not General Air hunger
Insomnia
adjust to activity, and occasionally symptoms
Hypoglycaemia
worsen on exercise. Even though fatigue is a Blurred body image
common symptom, some patients choose to Exercise intolerance
work out in a gym because it provides the

opportunity to take deep breaths. Occupations
that heighten arousal without an accompanying
increase in activity, e.g. driving or watching TV,
can worsen symptoms. problem is taken seriously. They need space,
Other signs and symptoms are shown in Table time, privacy and an attentive ear.
11.1. The case notes are checked for disorders that
cause breathlessness. Low haemoglobin should
be identified because breathing retraining can
Assessment exacerbate symptoms of anaemia. If patients are
People with HVS may or may not arrive for on beta-blockers, these can either exacerbate
physiotherapy having been screened to exclude HVS by causing bronchospasm, or ameliorate
organic disease. They may have received a autonomic symptoms and help break the vicious
selection of diagnoses from peripheral neuropa cycle of sympathetic stimulation and hyperventi
thy or neurosis to myocardial infarction or lation. If patients are being weaned off sedatives,
multiple sclerosis. Some have been dismissed as relaxation will be difficult unless treatment
malingerers or told that it is all in their mind. coincides with the peak effect of the drug. With
Others have been told that it is 'only hyperventi drawal from medication can itself trigger anxiety
lation', somehow disqualifying further considera and panic attacks. �ragonists given for asthma
tion. The first priority therefore is to ensure that can provoke palpitations and agitation (Criner
patients feel welcome and know that their and Isaac, 1995).
295
Subjective because it relieves tension and reduces their need

'Feelings of flying apart, absolute terror, to talk during treatment, which upsets the
falling down through the world, spinning breathing pattern.
through the universe. . . .
'
Patient quoted by Bradley, 1994 Observation

It is normal to sigh when sad, breath-hold when
Feelings vary from anxiety to fear of impending frightened, say 'phew' when relieved and breathe
madness. Fear of dying is common (Timmons fast when stressed, but people who chronically
and Ley, 1994, p. 142), as is fear of flying, being hyperventilate often have a habitually labile
trapped in a lift or feeling unable to escape from breathing pattern, with disturbance continuing
a crowded supermarket. Patients may complain after the stress is withdrawn. Minute ventilation
of an inability to take a satisfying breath, or may is more likely to be observed by tidal volume in
in fact be unaware of any breathing abnormality. men and RR in women. The rhythm shows a
If symptoms have worsened while they are on a variety of patterns:
waiting list, this may be because a common
response to a diagnosis of a breathing disorder is • shallow, fast and apical
to practise deep breathing exercises. • sighing and yawning
It is useful to identify factors that precede • irregular
symptoms and the patient's interpretation of • prolonged inspiration and curtailed expIra
them. Patients are often puzzled as to why tion
symptoms affecting so many parts of the body • excessive thoracic movement, sometimes
can be caused by a breathing disorder, and may with abdominal paradox
not report 'irrelevant' symptoms. Specific • 'cogwheel' breathing, as if the patient dare
questions about symptoms that are likely to not let the air out
correspond to their experience help elicit these, • breath-holding.
and also facilitate acceptance of the diagnosis. Despite the variety of possible breathing
Questions on lifestyle may reveal a hyperac patterns, changes may be subtle and not evident.
tive trait and a pattern of rushing to meet Breathlessness and hyperventilation are not
deadlines. Some 63% of patients show a necessarily synonymous. The breathing required
tendency to perform tasks quickly, immediately, to maintain hypocapnia is less than that required
impatiently, often several simultaneously and to induce it, and resting CO2 levels may be
with a tendency to think ahead, whereas only halved with only a 10% increase in minute venti
20% of normal subjects show these characteris lation (Gardner, 1996).
tics (van Dixhoorn, 1986). Other commonly Other signs are a stiff posture and gait, lack of
encountered factors are: coordination between talking and breathing,
• general hyperresponsiveness (Garssen, rapid speech as if the patient is trying to cram
1980), as shown in breathing, emotions, and several sentences into one, excessive hand
sometimes allergy to food or medication movements or other indication of tension, and
• light-headedness, sometimes leading to strategies to sneak in more air such as a dry
'postural sway', which is similar to feelings cough, throat clearing or chest heaving before
produced by standing on foam (Sakellari, speaking. Belching may be caused by air swal
1997) lowing, cold hands by vasoconstriction, and
• exercise deconditioning due to avoidance of moistening of the lips by a dry mouth. If chest
activities that cause dyspnoea, as occurs with wall tenderness is present, palpation can reassure
people who have asthma (Trooster, 1997). patients that it is not heart pain. Patients are
further reassured if thoracic mobilizations
Patients should say all they want at this stage ameliorate this tenderness.
296
Questionnaires not just the dizziness that is a normal response

Suspicions of HVS are raised when any person to acute hyperventilation. The test may
demonstrates an unusual mix of clinical features reassure patients of the validity of their
that include some of those described. The symptoms and show them that they have some
diagnosis can be confirmed by a score above 23 control, but it is neither sensitive nor specific
out of 64 on the Nijmegen questionnaire (Figure (Malmberg et al., 2000). Vasospasm can be
11.4). This has been validated by Vansteenkiste hazardous, and cerebral vascular disease,
et al. (1991) and shows a positive and negative epilepsy and sickle cell disease are
predictive power of 94% and 92% respectively contraindications (Brashear, 1983).
(van Dixhoorn, 1986). Further relevant informa 3. A low PaC02 is not in itself diagnostic
tion and outcome data can be gleaned by a ques because the syndrome is intermittent, but if
tionnaire such as that in Figure 11.5. patients have a series of blood gas results, a
value below 4.3 kPa (32 cmH20) raises
Tests suspicions of HVS. A more specific test is
Objective tests can be distressing and are limited capnography to measure expired CO2 at the
in accuracy because of the absence of normal mouth, this 'end-tidal CO2' being 4-6% in
precipitating factors. The following are available normal subjects. The mouthpiece alone can
but none have been validated. upset the CO2 level (Han et al., 1997), but if
the resting level is low or erratic, HVS is
1. Breath-holding time of less than 30 seconds implicated (Timmons and Ley, 1994, p. 109).
is suggestive of HVS. Capnography is not distressing and can be
2. A provocation test entails rapid breathing for 1 used to provide feedback for patients and
minute, which, in patients with a chronically outcome measures for physiotherapists
low PaC02, may bring on familiar symptoms, (Figure 11.6).
Never 0 Rarely 1 Sometimes 2 Often 3 Very often 4
Chest pain
Tension
Blurred vision
Dizzy spells
Confusion
Faster or deeper breathing
Shortness of breath
Tight feelings in chest
Bloated feelings in stomach
Tingling fingers
Unable to breathe deeply
Stiff fingers or arms
Tight feelings around mouth
Palpitations
Anxiety
Figure 11.4 Nijmegen questionnaire. Patients mark with a tick how often they suffer from the symptoms listed.
------ 297
CHAPTER 11 PHYSIOTHERAPY FOR SPECIFIC GROUPS OF PEorLF
Name............... .
First session date last session date

Subjective
Headache
Chest pain
Abdominal pain
Muscle pain
Other pains
Stiffness
Weakness
Faintness
Fatigue
Dry mouth
Depression
Anxiety
Panic attacks
Sleep
Fitness level
Digestion
Swallowing
Concentration
Feelings of unreality
Objective
Hand movements
Eye contact
Posture/gait
Cough
Throat clearing
Chest heaving
Speech rate/rhythm
Chest mobility
Nose/mouth breathing
Respiratory rate
Breathing pattern
Figure 11.5 Supplementary questionnaire.
298
HYPERVENTILATION SYNDRO�IE
Pre-therapy
Education
3.8% 3.5% _.:...
1 m::.:in.:. -'--- �.2% 3.8%
r-
_
....:;
If a waiting list precludes prompt treatment,
education can begin in advance. Sending an advice
sheet (Box 11. 4) or information about a patient
friendly book such as that by Bradley (1994) will
do much of the physiotherapist's work, and
Base-line HV Recovery sending a questionnaire to be filled out (Figure
11.4) saves time and brings some relief to the
Post-therapy patient if they identify familiar symptoms.
At the first appointment, expectations are
checked and goals agreed e.g. in the short term
to cope with panic attacks and in the long term
to integrate a normal breathing pattern into
everyday life, as identified by elimination of
Base-line HV Recovery symptoms. The mechanism of HVS can be
explained using the vicious cycle (Figure 11.2),
Figure'1.6 End-tidal CO2 trace (%) before and after
physiotherapy. (From Rowbottom, I. and Lothian and this explanation can reduce anxiety and
Respiratory Function Service, City Hospital, Edinburgh). HV improve symptoms. The explanation includes
= voluntary hyperventilation. reassurance that HVS does not cause harm, nor
does it indicate any physical damage. It is a
normal response to stress or other trigger, not a
Box' ,.4 (from Veronica Bastow, Physiotherapy Dept, Kings Lynn Hospital)
What is hyperventilation syndrome?

'Hyperventilation' means overbreathing, which may be taking too many breaths or breathing too
deeply. 'Syndrome' means a collection of symptoms.
Our breathing normally happens without us having to think about it. The number of breaths
and size of breath is controlled by our 'breathing regulator' system. This system causes us to take a
breath of air into our lungs so that oxygen can move into our bloodstream and be used by the
different parts of our body. As the oxygen is used up, we produce carbon dioxide which is our
'exhaust gas'. This moves back to the lungs in the bloodstream, and as we breathe out, some of
this carbon dioxide is breathed out into the air. However, we need to keep some carbon dioxide
- it plays an important role in our blood.
If we breath faster or more deeply than our body needs, we may breathe out too much carbon
dioxide. This can give us some funny feelings varying from quite mild symptoms in some people to
quite severe symptoms in others.
All of us at some time in our life will probably overbreathe and have some of the symptoms
caused by this - this is nothing to worry about. However, a few people will go on to have Hyper
ventilation Syndrome, where the symptoms happen more often and help is needed to stop them.
How do I know if I have Hyperventilation Syndrome?
It is sometimes spotted by your doctor, although some people feel so unwell during an attack that
they go to the casualty department.
299
Box 11.4 continued
What are the symptoms likely to be?
The symptoms are quite variable and may include tingling fingers, tingling around the mouth,
dizziness, fainting, chest pain, tiredness, disturbed vision, a sensation of not being able to get a
deep enough breath, sighing and yawning. No two people will feel the same - the symptoms may
be quite different.
What causes it to start?
Quite often there has been an event which has caused the first episode of overbreathing. This may
be an emotional happening such as death of a loved one or family breakdown, or it may be a
physical cause such as intense pain or an asthma attack. Sometimes it is not possible to identify the
first event.
What tests might be done?
Sometimes a blood test is done, but normally the history and symptoms alone identify the
problem. The doctor or physiotherapist will probably listen to your chest and may ask you to blow
into a peak flow meter to check how well your lungs work.
What treatment can be given?
A physiotherapist will work with you to help you to be more aware of your breathing and to teach
you to breathe in a more normal way. You will probably be given breathing control exercises to
practice at home.
Will I get completely better?
Most people do get better. However there is always a chance that you may have another attack if
something triggers it. However, hopefully you will have learned how to cope and will be able to
control it with the breathing exercises.
How long will I need to have physiotherapy?
This will be different for each patient. If may take many weeks for some to learn the breathing
techniques and for their body to adjust to the higher (more normal) level of carbon dioxide. Your
physiotherapist will want to be sure that you are much better and have learned how to cope if a
relapse should occur.
psychiatric illness. When patients understand break out of the vicious cycle and gam
that their symptoms stem from chemical changes control over breathing.
in the blood, they can feel exonerated from the • Commitment is required in the early stages
stigma of not having had their complaints when learning to control breathing, and in
validated by a diagnosis. The following advice the later stages when incorporating practice
may be found helpful: into everyday life.
• It is useful, and for some people essential, to
• Physiotherapy will not eliminate the cause integrate a small but fundamental shift in
nor remove precipitating factors, but a colla attitude and lifestyle that allows time for
borative approach helps to identify triggers, relaxation and reflection.
300 ------
• A nice deep breath does not help relaxation.

• Re-Iearning the new lower level of breathing 40
involves experiencing the discomfort of air
hunger, but after practice the respiratory
centres will become re-tuned to registering a
more normal breathing pattern.
To anticipate the feelings experienced with 30

breathing re-education, 'bad breathlessness' can
be explained as the distressing and uncontrolled
symptom that is familiar to patients, and 'good
breathlessness' as the feeling of air hunger that
they initiate and control as part of their
breathing re-education. Although 'good', it is
not comfortable, and patients appreciate
acknowledgement of this.
Patients are advised that symptoms are occa
sionally worse in the first week of treatment.
This is thought to be due to a paradoxical but
10
transient increase in minute volume. The respira
.---.Run1
tory centres may interpret breathing re
____ Run 2
education as a form of suffocation and find
subconscious ways of increasing ventilation
temporarily. For people with long-standing
HVS, symptoms sometimes worsen during the o IL � I ----�I ----�I ----�I----�I
I ----�
R1 R2 15 30 45 60 75
first session when they attempt to reduce the
Watts
minute volume, possibly as the body's reaction
to an apparently threatening intervention.
Figure 11.7 Ventilatory response to graded exercise in a
Education enables patients to step out of their patient before (higher lines) and after (lower lines) education
vicious cycle and begin to take control of their on the process of HV5. Two measurements were made
breathing. Figure 11.7 shows the ventilatory 30 min apart on each occasion. The stippled area represents
response to graded exercise before and after the range of response seen in normal subjects. (From
Howell, J. B. L. (1997) The hyperventilation syndrome
gaining insight into the nature of the condition.
under threat. Thorax, S2(suppl. 3), 530-534)
Breathing re-education
According to psychoanalyst Wilhelm Reich,
changing a person's breathing pattern is tanta Awareness of breathing
mount to emotional surgery. The safe environ Patients can learn the feel of their breathing,
ment of a physiotherapy department is unlikely to using some (but not all!) of the following:
excavate the depth of emotion that is expected
from the analyst's couch, but feelings may surface • Rest one hand on the upper chest and one
and if this brings tears, a proffered box of tissues on the abdomen to distinguish upper chest
lets patients know that this is acceptable. A quiet and abdominal breathing.
room is required, with an open window or fan. • Experiment with slight alterations in depth
The patient settles comfortably into half-lying, and rate of breathing, to distinguish the two
with a pillow under their knees. concepts.
301
• Try alternate nose and mouth breathing to A habit of nose breathing can be established
feel the difference. during this session, by explanation and role
• Feel the passage of the breath as it passes modelling. To settle the breathing pattern, the
through the nose, down the windpipe and physiotherapist encourages regular and gentle
into the lungs, then visualize the air gently speed, depth and synchrony, using a rhythmic
returning along the same route. voice. Abdominal breathing (p. 154) is useful,
• Feel cool air on the in-breath and warm air taking care to maintain small gentle breaths.
on the out-breath. Abdominal breathing may be facilitated with the
• Feel the size of the breath, feel its shape. elbows above waist level, or hands behind the
• Try a pause between the out-breath and the head or back, and/or by lying prone, while main
in-breath. tammg relaxation. Occasionally abdominal
• What is the rest of your body doing? breathing is easier after reducing the minute
volume.
Relaxation
Breathing cannot be re-educated in a stressed Reducing the breathing
person, and most patients need a session of A combination of education, relaxation and
relaxation (p. 170). Some people find that the abdominal breathing has shown improvement in
thought of being 'obliged' to relax causes 94% of patients (Pinney et aI., 1987). But
tension itself and prefer to do relaxation after patients with established HVS may require
the breathing session. further intervention to reduce minute volume.
Tense people often find relaxation an alien Patients can be asked simply to 'breathe less',
concept, and it may be easier after a brief neck very gently to avoid tension and exacerbation of
massage, during which it is helpful for patients abnormal breathing patterns. Some patients need
to focus on the experience and not feel that they the explanation that this means reducing the rate
have to talk or 'do' anything. Even the old or depth of breathing, or both, but thinking too
fashioned infrared lamp can be helpful prior to hard about an automatic process may be coun
relaxation, usually to the back with the patient terproductive. So long as the patient understands
prone. Lying prone may facilitate relaxation, that the aim is to achieve the slight discomfort
possibly because this is a less vulnerable of 'air hunger', s/he can often achieve this inde
position. A highly developed sense of success pendently without too much control by the
and failure is often prevalent with HVS, and the physiotherapist.
relaxation session is an opportunity to reinforce 'Low and slow' is the key. Some patients need
that there is no 'right' or 'wrong' way. only a pause at end-exhalation, so long as this
Focusing on the breath itself helps relaxation, does not go further than air hunger and cause
especially if patients are encouraged to very tension. If patients tense up, they should focus
gently 'breathe in the good air' and 'breathe out on returning to smooth, gentle, rhythmic
the tension', as if freeing the breath. A relaxed breathing.
state can be maintained by bringing the patient's To help patients maintain their rhythm, It IS
awareness to areas of tension throughout best not to ask for verbal feedback during the
treatment, including the Jaw and throat. practice, although they can nod or shake in
Physiotherapists should ensure that they them answer to quiet questions. Observations of the
selves are relaxed. breathing pattern will indicate tension, suggest
ing that they have gone too far and need a
Settling the breathing
reminder not to allow more air hunger than is
Man should no more breathe through his 'slightly uncomfortable'. They are advised to
mouth than take food through his nose. then gently get their breath back.
Clifton-Smith, 1999, p. 30 The physiotherapist watches closely and may
302 ------
need to give selective advice on rate or depth. sometimes with a preliminary breath-hold as
Manoeuvres to slip in a covert deep breath compensation (but not if this causes tension).
include a subtle change in breathing pattern, The concept of control is important for people
body movement, shift in position, or preceding who hyperventilate because they have felt out of
speech with a sharp intake of breath. The control of their most fundamental physiological
physiotherapist and patient can compete as to function. Advice can be given at intervals if
who notices these first! However, much of the necessary:
time is spent in silence as the patient focuses on
their breath and achieving air hunger. • Keep it smooth/shallow/slow.
In the first session, when patients feel air • Swallow if you need to suppress a deep
hunger, they are congratulated and advised to breath.
start getting their breath back by allowing them • Keep the rhythm going, you don't need to
selves slightly deeper and/or slightly faster hold your breath.
breathing, without gasping. When they are able • Maintain relaxation, avoid trying too hard.
to tolerate the air hunger, they are asked if they • Don't fight your breath, befriend it.
can experience it for a few moments so that • Be assured that you are in control and can
their respiratory centres can begin receiving stop at any time.
normal messages. The patient gradually learns
the right balance for themselves of 'slight
Variations
discomfort but no tension'. It is similar to the
'slight breathlessness' taught to respiratory A process as individual as breathing needs a
patients when desensitizing to breathlessness. flexible approach. Suggested variations are the
The periods of air hunger can be gradually following.
extended.
If this is too nebulous for the patient, more • Physiotherapists can use themselves or a
structured support can be given by pacing the mirror to demonstrate the patient's
patient's breathing to the physiotherapist's voice. breathing pattern and different options.
The patient is asked to breathe in time with the • Patients can slow down by 'breathing in' to
physiotherapist's words, the rate of which is areas of muscle tension, then 'breathing out'
slightly slower than the patient's rate. Counting the tension, or they can visualize inhalation
or pacing may be used e.g.: as if going up a hill and exhalation as if
coming down the other side.
• 'In-and-out, in-and-out. . . . ' • The simple yoga technique described on
• 'In-and-out-two-three, in-and-out-two page 172 suits the most hardened worka
three. . . . ' holic because it is so brief.
• 'In-and-relax-out, in-and-relax-out. . . . '
• Some patients slow down if the physiothera
• 'In-and-let-it-out, in-and-let-it-out . . . .' pist moves physically away and asks them to
Words and timing should be flexible to suit 'breathe from where l am'.
the patient, but words need to be repeated rhyth • Humming may slow the breath.
mically. Some patients find that this pacing • Putting the tip of the tongue between the lips
brings a sense of security in the early stages, the encourages nose breathing.
words acting as a 'breathing pacemaker'. • Neurophysiological facilitation (p. 154) may
Progression is aimed at independent control have beneficial results.
without the physiotherapist's voice.
If patients feel an irresistible need for air, they By the nature of the syndrome, it is essential
can take a conscious and controlled deeper that patients are not hurried, and an undisturbed
breath, then get back gently into rhythm, hour should be set aside for the first session.
303
going without a snack for more than 3 hours,

Progression and home management and avoiding carbohydrate binges, which may
As control is established, the process of modified lead to reactive hypoglycaemia. This should be
relaxation, rhythmic breathing and breathing re emphasized for patients who are too busy to eat
education is repeated in sitting, standing, during the day and eat heavily at night, which
walking and activities that might cause breath can produce night-time or early-morning
holding such as bending, stair-climbing or symptoms. Meals should be slow and enjoyable,
eating. Particular attention is required for jobs with patients avoiding excessive coffee, cola or
that involve speech such as teaching or using the chocolate. If patients must smoke, deep inhala
phone. If prolonged talking brings on symptoms, tions are to be avoided.
slowing down speech can be practised by reading To assist sleep, some patients find it helpful to
aloud, starting with poetry in order to use the follow the yoga practice of spending the first 5-
natural pauses, then reading stories to children. 10 minutes lying on the left side, to warm the
Tips for maintaining control during speech are: body, then turning to the right side to assist
relaxation (Clifton-Smith, 1999, p. 30).
• check shoulder relaxation and breathing
Panic attacks occur in 50% of people with
pattern
HVS (Cowley, 1987). Once started, they may be
• take small breaths and inhale through the
as impossible to stop as a firework, but they
nose between sentences instead of gulping
become less prevalent once patients begin to
through the mouth
gain control. Coping strategies include identify
• add mental commas (Bradley, 1994).
ing trigger factors, talking through the process,
Pacing functional activities is often beneficial, relaxing the shoulders, swallowing, behavioural
although difficult for people who are hyperac techniques such as rehearsals or distraction,
tive. Conditioning is improved by exercise that acupressure to LuI two thumb-widths lateral to
is steady, rhythmic and enjoyable, with the the nipple line in the second intercostal space
patient discouraged from indulging in either (Ellis, 1994, p. 49) and techniques to manage
anticipatory hyperventilation or obsessive overa breathlessness (p. 173) or coughing fits (p. 204).
chieving. If out in crowds, window shopping can be used
Posture and breathing may be affected by while focusing on coping strategies. An internal
tense abdominal muscles, which may compress dialogue can be initiated at the onset of panic,
the abdomen on inspiration, especially in people e.g.: 'these symptoms are frightening but this has
who need to appear in public or are obese. A happened before and I know it's simply over
balance can be negotiated between allowing breathing and I'm not going mad or dying'.
outward abdominal movement while feeling Breathing gently into cupped hands held over
comfortable with their appearance. Tight clothes the nose and mouth helps to retain CO2.
and belts should be avoided. Much encouragement is needed to help
In the early stages, some people with severe patients integrate their new breathing pattern
HVS find that wearing a large-volume oxygen and attitude into the distractions of everyday
mask (minus oxygen) at home helps to retain life. If progress is slow, attention can be given to
PaC02 at night or during ADL, so long as they identifying individual fears and precipitating
do not become emotionally dependent on it. factors. Reassessment of the abnormally high
Paper bags, or plastic bags with the corners cut demands to which patients often subject them
out, can be used as a 'bandaid' for acute selves may be fruitful.
episodes. A handout helps to correlate this mass of
Patients are advised to maintain a steady information, especially as poor concentration is
blood sugar by having breakfast (including a common symptom. Audio tapes of advice and
protein which is slow to metabolize), avoiding relaxation can be helpful, sometimes including
304
the physiotherapy session. If counting is used, such as Christmas or a wedding, but they will
this can be taped at fast, medium and slow recognize it and should be able to control it. A
speeds. If commercial relaxation tapes are used, hint of symptoms can become a useful
patients are reminded to ignore any instructions barometer.
to breathe deeply. If patients ask for advice on complementary
It is worth motivating patients to work hard therapies, many techniques such as reflexology
during the first crucial week. Some are able to and aromatherapy are helpful for relaxation, as
set aside 20 minutes a day for relaxation. Others are meditative practices that exclude deep
find individual ways of relaxing such as a breathing techniques. Some osteopaths and
rocking chair, personal stereo or fishing. An Alexander teachers specialize in HVS.
extended hot bath is not advised because Hypnotherapy is unwise for people who suffer
excessive heat stimulates the respiratory centres. episodes of depersonalization.
Practice in breathing re-education should take If patients do not improve after several
place little and often, after brief relaxation and sessions, and it becomes apparent that they are
with the patient's mobile phone switched off. not practising at home, or if they exhibit a 'yes,
This could be around three times a day for 15 but . . .' tendency, it is possible that they sublim
minutes, or mini-sessions of 3 minutes every 1-2 inally 'need' their hyperventilation to block out
hours. Times can be flexible to suit the indivi memories, in the same way that some patients
dual. Spot checks throughout the day can be with chronic pain express their emotional
assisted by memory aids and use of opportunities distress on a physical level (Bruera, 1997). This
such as red traffic lights, coffee breaks, queues is not a conscious process and makes the
and 'grey bar time' while the computer is proces disorder no more tolerable, but if it is the case,
sing. Computers can have beeps programmed in physiotherapy is unhelpful and may just 'feed'
at set intervals to act as reminders. Gradually the the somatization.
practice sessions become less defined as the
correct minute volume becomes automatic. Outcomes
Patients who tend to become preoccupied The simplest outcome is reduced RR, almmg at
with a daily programme should not be burdened 12 breaths per minute, which Sakakibara (1996)
with excessive homework. After the first hard has reported as alleviating panic attacks. Subjec
working week of raising awareness and develop tive report of reduced symptoms is relevant to
ing new habits, it is best to use education as the the patient. Outcomes can include the breathing
basis for individuals to make their own pattern, breath-holding time, a Nijmegen ques
decisions, with advice as required. Flexibility is tionnaire or capnography. The following
particularly necessary for mothers, who find a outcomes have been documented:
tight routine impossible.
• doubling of breath-holding times (Maskell et
Physiotherapy is needed weekly until self
ai., 1999)
management is stabilized, usually after a few
• improvements in capnogrophy, anxiety,
sessions, then sometimes monthly for adjustment
depression and other symptoms after 3-14
and encouragement, followed by advice that
weeks of treatment (Tweeddale et ai., 1994)
patients can ask for a review session if required.
• reduction in Nijmegen scores and Hospital
Once learned and reinforced, the new breathing
Anxiety and Depression Scale in all patients
pattern can be maintained automatically because
audited after 2 treatment sessions and a
there has been no physical damage, as there is
phone call (Williams, 2000).
in emphysema. Self-awareness and stress
management however must last a lifetime. Discharge letters to both GP and consultant
Patients are advised that hyperventilation may help raise awareness of the syndrome and effec
never return, or it may return at stressful times tiveness of treatment.
305
CHAPTI'R 1 1 PHYSIOTHERAPY FOR SPECIFIC GROUP, OF PEOPLE
To be wholly alive is to breathe freely, asserting themselves. This underlines the

move freely and to feel fully. importance of consulting patients
Lowen, 1991 throughout. Millard (1983) asks 'When
autonomy is removed, is death the only
personal choice?' Depression should always
ELDERLY PEOPLE
be considered if health staff comment that
Work is now urgently needed to rehabilitate 'she's forgetful, she's a wanderer, she's
rehabilitation for elderly people. beginning to dement'.
Young, 1998 3. Postural hypotension is a drop in systolic BP
of 20 mmHg or more on standing, and is
Age is becoming less acceptable as an explana
present in a third of people over age 65. It is
tion for ill-health. The majority of respiratory
related to vascular insufficiency, dehydration
patients are elderly, and they need to start reha
or the side effects of certain drugs including
bilitation as soon as they are admitted to
tricyclic antidepressants, and it causes 5% of
hospital. This helps to reduce the dependency,
falls (Lubel, 1989).
anxiety and depersonalization to which they are
4. Impaired absorption, distribution, metabo
susceptible in this environment. Rehabilitation
lism and elimination of drugs is common,
for elderly people is cost-effective (young,
and side effects are often missed. Some 600/0
1998). It can reduce death rates by 35%, re
of serious adverse drug reactions in elderly
admissions by 12% (Kings Fund, 1998) and
people have been blamed on diuretics, which
maintain independence. Without rehabilitation,
are often given for oedema even though
one study found that as many as 75% of inde
oedema in the elderly is usually caused by
pendent elderly people were no longer indepen
immobility (Valacio and Lie, 1994).
dent on discharge from an acute hospital
5. Regulation of body temperature may be
(Hamilton and Lyon, 1995).
unstable, causing impaired response to a
Physiological changes associated with ageing
cold environment or inability to develop a
are discussed on page 18. Some distinctions
pyrexia in response to pneumonia (Irwin et
between clinical changes due to ageing and
ai., 1998).
those due to avoidable factors are discussed
6. Silent aspiration of stomach contents may
below.
occur, especially at night.
1. Confusion can be caused by hypoxaemia, 7. Aches and pains are pathological and not to
dehydration, infection, pain, over be accepted as part of ageing.
medication (especially sedatives), disturbed 8. Some reduction in exercise tolerance is
sleep, depressive illness, lack of hearing aid expected, as demonstrated by a linear
or glasses, or disorientation resulting from reduction in V02 max with age (Paterson,
admission to hospital. Several of these 1992), but poor mobility is more likely to be
factors contribute to postoperative due to treatable conditions such as anaemia,
confusion (Moller, 1998). Confusion should painful feet, fear of exercise or lack of
not be accepted without investigation unless vitamin D which is common in
dementia has been diagnosed by a specialist. institutionalized elderly people (Bischoff et
2. Depression is an independent risk factor for ai., 1999). People in their ninth decade have
mortality in institutionalized older people shown increased exercise tolerance with a
(Schulz, 2000). It is a common outcome of low-frequency training programme
the helplessness associated with (Hamdorf, 1999). Box 11.5 is an example of
hospitalization or the move to an institution, a mobility progress sheet kept at the bedside
and often goes unrecognized, especially in and used by all members of the team.
people who have got out of the habit of 9. An assumption that incontinence IS
306
Box 11.5 Progress chart, Dates are added to the left column, Mobility aids are added as relevant. + 2 = with two
assistants, + I = with one assistant.
Mobility
none +2 +1 independent
Baseline
at Die
Ex.tolerance (yds)
Baseline
at Die
Stairs (no.)
Baseline
at Die
ADL
toilet:
wash:
dress:
other:
307
inevitable may lead to mopping-up taking 1994), because for older generations this
precedence over preventive action such as tends to be seen as a sign of disrespect rather
maintenance of mobility, ensuring access to than a sign of friendliness.
the bathroom and emptying the bladder • Encourage patients to wear normal clothing
before peak flow readings. when possible.
10. Constipation may be due to an inefficient • Ensure patients are kept fully informed
thirst mechanism (Hyde, 1999), medication, throughout.
change of diet, dementia, immobility, lack of • Encourage patients to bring to hospital their
privacy or feeling hurried when on the budgerigars Gones, 2000) and as much
commode. As well as addressing the cause, clutter of personal possessions as allowable.
exerCIse and abdominal massage show • Avoid physical restraints.
positive outcomes (Resende and O'Neill,
1992), and massage has the added benefit of Physical restraints slow rehabilitation,
restoring the benefits of touch, which are decrease mental functioning, cause fear and
sometimes lost to elderly people (Fraser and discomfort and can increase rather than decrease
Kerr, 1993). the risk of injury (Schieb et al., 1996).
11. Breathlessness is considered common Untreated pain can reduce mobility, disrupt
(Boezen, 1998) which may be why sleep and lead to malnutrition, social isolation
respiratory disease is often overlooked and depression. Some of these effects may result
(Patterson et al., 1999), and reversible in yet more prescription of drugs (Closs, 1996).
components may not be treated even if a A variety of pain scales have been developed for
diagnosis is made (Sherman et al., 1992). assessing pain in the elderly (Morrison et al.,
Self-imposed ageism prevents some patients 1998 ; Herr, 1998).
reporting symptoms (Luce, 1996). Other problems which can hinder rehabilita
12. Misery is not an inevitable accompaniment tion are malnutrition, to which elderly patients
to old age. are particularly susceptible (Tierney, 1995), and
memory loss. Rastall et al. (1999) advise writing
Unsteady gait can be affected by changes in down physiotherapy advice and exercise
any of the three main afferents of the posture programmes. Exercise programmes not only
and balance control mechanism: vision, vestibu improve ADL but have been shown to reduce
lar input and proprioception. Other possible daytime agitation and night-time restlessness in
causes of falls are: nursing home residents (Alessi, 1999).
Autonomy is central to rehabilitation. It has
• poor eyesight
been found that the less residents of institutions
• poor balance
have control of their lives, the more they lose
• poor footwear
control over the use of their faculties (Bach and
• weakness
Haas, 1996, p. 448). Autonomy can be facili
• lack of confidence
tated by respecting patients' senior status,
• postural hypotension
experience and wishes regarding management.
• medication
This means, for example, allowing them to
• transient ischaemic attacks
return to bed when they request, rather than
• breathlessness
enforcing unhappy hours slumped in hospital
• pam.
chairs. Discomfort reduces the depth of
Practical ways to help maintain orientation in breathing, and the zeal with which patients are
elderly people are the following: hauled out of bed for lengthy periods has led to
'chairsores' becoming more prevalent than
• Avoid using first names uninvited (Gordon, bedsores in some hospitals (Mulley, 1993).
308
ELDERLY PEOPLE
Box 11.6 Daily exercise programme for MrIMs . . . . . . .
TO BE DONE ONCE/TWICE A DAY
Sitting up in bed or sitting in your chair:
(1) Circle your shoulders: shrug both shoulders up slowly, then pull them forwards, then down,
then backwards, then relax.
(2) While breathing in, lift both arms up forwards until over your head. while breathing out,
bring them down sideways slowly.
TO BE DONE . . . . . . . TIMES A DAY
(3)
IF IN YOUR CHAIR:
Tighten your thigh muscle and straighten your knee slowly. Hold for a count of 3, then let it
down slowly. Repeat with other leg.
Repeat . . . . . . times
IF IN BED:
Pull your toes up, push your knee into the mattress, lift up your straight leg slowly. Hold for a
count of 3, then let it down slowly. Repeat with other leg.
Standing
(1) Stand up, take a relaxed breath, sit down.
(2) Walk to . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,
Rest and get your breath back.
Walk back to your chair.
Respiratory health is best maintained by a it is boiled fish. . . .

personally tailored programme of little-and it is doctors who n o longer stop by your
often mobility, and return to a home environ bed. . . .
ment as soon as possible. it is terror every minute of conscious night
Box 11.6 is an example of an exercise sheet and day to a background of pop music. '
that can be customized to each patient and Wilkes, 1 9 8 3 .
brightened up with pictures from PhysioTools.
Physiotherapists are suited to working with
people who are dying because of their skill
PEOPLE WHO ARE DYING
with physical contact, which can communicate
CIt begins with an easy voice saying, what words cannot, and their experience with
Just a routine examination; disabled people, who often have similar needs
as October sunlight to people who are dying (Purtilo, 1976). An
pierces the heavy velvet curtains. area as subjective as death requires more of us
Later it is the friends who write but do not as humans than as 'experts', and working with
visit. . . . dying people can be enriching and painful.
------ 309
End-stage disease is not a time to withdraw they expect to get better. Denial is a defence
physiotherapy, because there is much that can mechanism to be respected because it is a natural
be done to ease the passage towards a good response and a necessary cushion. When and if
death. patients are ready to confront the truth, they
Palliative care is the aim for patients with may sink into a dark place that can paradoxically
advanced, progressive and ultimately fatal be a creative process by which they begin to take
disease, e.g. metastatic malignancy, some neuro responsibility for the way they respond to
logical conditions and end-stage AIDS or respira change. Only then can they accept their loss and
tory failure. allow fear to dissolve.
These reactions are not stages that occur with
Reactions of patients defined boundaries but they weave in and out of
a patient's awareness, so that a moment of anger
'Now and then the whole thing becomes
may open into acceptance, followed by the mind
unreal. Out of the middle of the nighfs
curling back into the darkness of fear. Time is
darkness, or bringing me to a sudden,
needed, and patients with cancer or emphysema
chilling halt during the day, the thought
have time, which, with support, can be used
comes: this can't be happening to me. Me
wisely.
with only a few months to live? Nonsense.
And I stare up at the darkness, or out at the
sunlit street, and try to encompass it, to feel Reactions of relatives
it. But it stays unreal.' 'When someone you love dies, you pay for
Bell, 196 1 the sin of outliving them with a thousand
piercing regrets. '
When told that they are dying, most people feel
Simone de Beauvoir, 1966
overwhelmed and experience a variety of
reactions. Fear is usually predominant at first, Support for relatives assists the patient.
although not primarily fear of death itself Families and friends can feel a kaleidoscope of
(Murray-Parkes, 1998). There is fear of the emotions such as remorse, relief, impotence at
dying process, fear of isolation, fear of being a being unable to help, and similar reactions to
burden, fear of symptoms and disintegration, those of the patient. Bereavement can be eased
fear of the unknown, and reflected fear in the before death by involving relatives in decisions
eyes of those around them and the questions about levels of support for patients who are
that are not asked. unable to make their own decisions (Billings,
For a person dying from a smoking-related 2000). Risk factors for the more difficult
disorder, guilt is an extra burden. Anger is emotions include:
another ever-ready emotion that may arise from
feelings of helplessness, or act as a defence • prior ambiguous or dependent relationship
against the experience of grief. Grief is a normal with the dying person
response but if suppressed can develop into • in Western societies, advanced age
depression, which amplifies pain, distresses • minority groups unable to follow their own
relatives and erodes the patient's ability to do customs
the emotional work of separating and saying • those who have learning difficulties or are
goodbye (Block, 2000). Patients should be confused (Sheldon, 1998).
allowed to express sorrow, anger, guilt, unusual
humour or any other feeling, for which they A demented person who loses a partner may
should not have to apologize. repeatedly forget, and can feel shock and grief
Many patients deny reality in order to avoid each time they are told. They need much
the pain of grief or fear, acting and talking as if support through their bereavement, including
3 10
involvement in rituals such as the funeral and

visiting the grave. Communicating with dying people
Relatives need the opportunity to share the 'His yellow eyes watched us being taught at
truth with the person who is dying. Patient and the bedside of each patient and when we
spouse are often given contradictory information came to his bed we all walked directly past
(Thomsen, 1993) which leaves them out of step him to the patient on his other side. Not a
with each other. Both might try to 'protect' the word was said. Not a greeting. Not even a
other, sometimes with the collusion of health nod. . . . Dismay turned to guilt with the
staff. Ju'st when they need each other the most, thought that I, too, had no idea how to
they are separated by a conspiracy of silence. approach or comfort a dying patient.'
Talking is helpful (Timmons and Ley, 1994, Carmichael, 198 1
p. 246) as i� assistance in providing comforts for
the dying person. Children also benefit from It is not easy to find the right words to say to
open communication and need the opportunity people who are facing death. The key is to
to be close to their dying relative. They know listen. Patients find relief if they feel that it is
their own limitations and may simply want to acceptable to talk, and the astute listener can
pop in and out of the sick room. Children often pick up indirect questions. Patients may drop
fantasize that they are to blame for the death of hints that they would like to talk by ploys such
a parent or sibling, or they may feel they must as mentioning other people who have died,
not distress their parent and so avoid talking joking about their future or asking how long
about it. Telephone contact with bereaved before they get better. We can indicate a willing
relatives after the death has been found helpful ness to listen by asking if we can sit on the bed,
(Stone et al. , 1999). maintaining eye contact and asking non-threa
tening questions such as 'How do you feel in
Reactions of staff yourself?' While patients are talking, they can be
encouraged by prompts such as 'Go on' or
'The Sister was very cross with me and told
simply 'Mm? '.
me to pull myself together because the
During and after talking, patients need time
Consultant was coming. '
to process their thoughts, and silence can be
Blanckenhagen (cancer patient), 1986
used constructively. It is not helpful to rationa
Once a patient's condition is known to preclude lize patients out of their feelings, tell them what
recovery, this can be interpreted as a failure by to do, or say that we know how they feel (we do
health staff. Reactions may include avoidance, not). It is however helpful to provide informa
heroic measures to prolong life, unsuitable tion that reduces anxiety, and discussion itself
bonhomie, the use of drugs to suppress patients' helps to divest death of its power. Uncertainty is
expression of emotion, inaccurate optimism one of the hardest things to bear (Bortoluzzi,
(Billings, 2000) or inappropriate reassurance. 1994), and patients who are left in ignorance
Reassurance has been criticized as 'social feel a loss of control that shackles their coping
bromide' aimed at making staff feel better rather strategies.
than the patient (Fareed, 1996). We might also find it useful to ponder our
Health staff working with people at the end own reactions: 'Am I feeling uncomfortable? Am
of life need support themselves. They need I helping or hindering her flow of thought? Am I
access to their own feelings because expression responding to his needs or mine? Am I frigh
of feelings by staff, when appropriate, has been tened of death myself?'
found to be therapeutic for patients, who find Honesty is essential for this form of commu
professional detachment unhelpful and even nication. The majority of patients want to be
offensive (Fallowfield, 1993). told their diagnosis and feel they should have a
311
say in who else is told (Buckman, 1 996). Infor minor achievement. And it is always worth
mation increases the ability to cope (Falk, casting a backward glance when leaving the
1 9 9 7) . Fear of the unknown is a heavier bedside, because it is sometimes necessary to
burden than the truth. Those who do not want return and pick up the pieces.
to hear have their safety strategy of denial. It is
thought that most patients realize eventually 'Bearing the agony of knowing one has a
that they are dying (Barbato, 1 998) and then life-threatening condition is not as
may be alone to face the truth from which they problematic as not being given adequate
were being sheltered. information. '
When patients ask questions about their Dewar, 1995
prognosis, however indirect, it is unethical to
avoid giving information, and keeps patients in a Management of symptoms
subordinate position. Lying to patients may stem As soon as it is known that patients are in need
from a false assumption that distress equals of care rather than cure, the emphasis is on
harm, or uncertainty about who should take the allowing them to choose both the method and
initiative. In theory physiotherapists have as timing of their treatment. Palliative care does
much right and responsibility to inform patients not preclude rehabilitation, including setting
as other health staff (Sim, 1 98 6), and UK guide goals and maximizing independence.
lines give physiotherapists discretion (Barnitt,
1 994). In practice, it is often another member of Breathlessness
the team who communicates difficult informa Breathlessness is the most common severe
tion; while the physiotherapist's role is to ensure symptom in the last days of life (Molen, 1 995)
that patients' questions are answered, and that and is present in up to 90% of people with a
issues of power about who 'owns' the truth do variety of advanced cancers (Dudgeon and
not hinder this. These problems are not new; in Lertzman, 1 998). Patients are less likely to have
1 672 a French physician considered the idea of developed coping strategies than with slowly
telling the truth to patients, but concluded that progressive COPD. The pharmacological and
it would not catch on (Buckman, 1 996). physical management of breathlessness is
Honesty should be tempered by sensitivity, discussed in Chapters 5 and 7 but further
with an emphasis on what medical science has to measures can be taken for people who are
offer, and a check that patients do not associate dying.
emotive words like 'cancer' with misconceptions Dyspnoea may be caused by a tumour, lung
about an inevitable and distressing death. fibrosis following radiotherapy, cachexia, or a
To reveal the diagnosis to the family without coexisting condition. Treatable causes of breath
the patient's knowledge creates tension and lessness should be identified, e.g. pleural
mistrust, and is unethical. Family requests, e.g. effusion, ascites, anxiety, obstruction or
to suction a patient, should be respected and compression of the lung, or anaemia. Steroids
discussed, but should not take precedence over may relieve breathlessness associated with
the rights of the patient (Snider, 1 995). diffuse malignant lung involvement. The normal
Reaction to bad news is varied and sometimes constraints on using these drugs are unnecessary
irrational, including regression to child-like at the end of life. The cannabinoids are licensed
behaviour, relief, despair at the loss of fulfil in the UK for treating nausea, vomiting and lack
ment, or projection of hostility. Patients may of appetite (Sharpe, 2000). Patients being
choose to face in a different direction from that managed at home often feel relieved if they can
which we intend, but defence mechanisms are self-administer, for example, nebulized
rarely maladaptive. Patients should be left with morphine or lignocaine for breathlessness. The
some realistic hope, even if directed towards a reassuring presence of a nebulizer may reduce
312
PEOPLF W H O ARF DYINC,
respiratory panic, but nebulized drugs vary in cramps, but almost all experience thirst (Blower,
effectiveness and require collaboration with the 1 997), and in the late stages when patients can
local nebulizer service. Carers can use mechani no longer communicate, they may suffer dehy
cal or fine manual vibrations over the chest to dration-related delirium (Bruera, 1 99 8 ) . The
provide some relief. Patients vary in their best option is often physical assistance to drink,
response to oxygen. It is usually of no value and according to the patient's response, using a
simply sets up a barrier between patient and spoon or feeding cup, with if necessary advice to
family (Burford and Barton, 1 998), but it is the patient about when to swallow. This often
worth a trial in those with hypoxaemia (Bruera requires the time and patience of a relative.
et at., 1993), so long as a dry mouth is avoided. If oral fluids cannot be tolerated because of,
for example, nausea, dysphagia or bowel
Cough obstruction, subcutaneous fluids are often accep
Cough occurs in 3 0% of people with cancer and table to patients and manageable at home. Occa
80% of people with lung cancer (Twycross and sional patients prefer rectal hydration (Bruera,
Lack, 1 9 84). If pulmonary oedema, infection or 1 9 9 8 ) . Dehydration symptoms of a dry mouth
bronchospasm contribute, they can be dealt with can be relieved by the measures on p. 202, and a
pharmacologically. Smoking cessation will ease coated tongue with unsweetened pineapple
the cough but this takes 2-4 weeks. Nebulized chunks (Reynard, 1 997).
lignocaine is useful for a terminal cough caused
by pooling of saliva, but may increase the risk of Pain
aspiration and sometimes causes bronchospasm
Omitting to attempt to provide cancer pain
(Ahmedzai and Davis, 1 997). Excessive secre
relief amounts to a type of bodily harm.
tions can be controlled by inhaled indomethacin
Zenz, 1 997
(Homma et ai., 1 999). Physical management
depends on whether the cough is productive Some 8 00/0 of cancer patients experience pain
(Chapter 8). (Bruera, 1 997) and over 90% of it can be
controlled (Paice, 1 9 9 8 ) . If pain is allowed to fill
Nicotine withdrawal the patient's field of consciousness, it can lead to
Once smokers are unable to take oral fluids, they distress, withdrawal, indifference to personal
are also unable to smoke and may become appearance and degeneration of personality.
agitated. Nicotine patches can be applied by Drug management for palliation of pain in
carers and can relieve patients' distress acute hospitals is often characterized by under
(Gallagher, 1 998). estimation of symptoms and overestimation of
side effects. Prescribers can be reassured that
Difficulty swallowing physical dependence on opioids is rare in
Hyoscine is useful to dry the saliva of people terminal care, and not an issue unless medica
who cannot swallow, delivered by patch, subcu tion is withheld. 'Opiophobic' prescribers need
taneous injection or nebulization (Criner, 2000). to understand that dose requirements vary
A speech-language therapist provides support. 1 000-fold, and that there is no upper limit
(Hanks, 1 996). Constipation must be prevented,
Dehydration but other side effects are usually transient. Since
the Dr Shipman case in Britain, patients may
When it comes to dying, arms are for
need reassurance that diamorphine is not a
hugging not for intravenous infusions.
polite way to kill patients.
PottS, 1 994
Other pain-relieving strategies are TENS for
Some patients may escape symptoms associated localized pain, pain meditations (Levine, 1 9 8 8),
with dehydration such as headache, nausea and massage (Wilkinson, 1 996) and any of the
31 3
patient's own strategies such as ointments and unsafe because of the risk of fracture. Suction is
hot water bottles. Pellino ( 1 998) found that not indicated.
feeling in control of pain played a larger role in
adjustment than belief that cancer could be On dying well
cured. All I want to know is that there will be
someone there to hold my hand when I need
Discomfort it. I am afraid. Death may be routine to
Regular turning and posItIoning to suit each you, but it is new to me. . . . I've never died
individual eases the discomfort of immobility. before.
Some patients like to be propped up with their Gallagher and Trenchar, 1 9 8 6
head well supported, while others like to be

This message from a dying student nurse advises
curled up on their side with generous quantities
her colleagues how they can best help her
of pillows. Skin needs care.
towards a good death. When patients are free
If movement eases the discomfort of immobi
from fears, they can live their remaining life to
lity, simple brief exercises may tempt patients
the full. Conscious dying is possible when a
who feel that activity is unnecessary. Osteoporo
pain-free state without undue sedation has been
sis is common and exacerbated by radiation,
achieved, so that patients are not trapped
chemotherapy, poor nutrition and immobility. In
between perpetual pain and perpetual somno
advanced malignancy, there is a risk of bony
lence. Death can be a positive achievement when
deposits and the clinician should be alert to any
patients are not consumed by anxiety about
new palO.
symptoms, and have stopped fighting for life.
Through the many little deaths of dying, they
Depression
have plumbed the depths of their being, but fear
Depression is underrecognized but can usually
has dissolved, there is peace without defeatism
be identified by the simple question 'Are you
and they are free to look for some meaning in
depressed ?' (Billings, 2000). Whether manage
the experience.
ment is by talking, medication or a combination
Working with dying people is demanding and
should be decided by the patient. The majority
requires us to be emotionally healthy. It means
of patients who express a wish to hasten their
sharing anguish, absorbing misdirected anger
death are depressed, often due to feelings of
and providing comfort and dignity for people
helplessness and being a burden on their family
who are totally dependent. It is about emotional
rather than symptoms such as pain (Billings,
involvement, wherein lies its challenge and
2000) . This may be manageable by maximizing
reward.
independence, providing emotional support and/
or use of rapid-onset psychostimulants.
Death rattle
People who are too weak to expectorate may
collect excessive secretions in their throat. The
resulting 'death rattle' is distressing for visitors
and neighbouring patients. The noise may ease
with repositioning. Secretion formation can be
prevented by a hyoscine patch or syringe pump
at the first indication of moist breath sounds
(Ahmedzai, 1 9 8 8 ) . Low doses of a tricyclic anti
depressant help to dry up mouth and throat
secretions. Chest percussion is not indicated and
314
Sighs before speaking.

Nijmegen score 28.
Identify the problems of this 70-year-old woman
with a 48-year history of fatigue and non-specific Questions
symptoms. I . Analysis? .
2. Patient's problems?
Background 3. Goals?
RMH 4. Plan?
I nvestigated for multiple sclerosis: NAD. RMH = relevant medical history; NAD = nothing
Some depressive symptoms, labelled as 'abnormal abnormal discovered.
ill ness'.
Barium swallow NAD, awaiting endoscopy.
M igraine with certain foods.
Many other i nvestigations but NAD. I;!*1g.]�k1''••1Iiii)-q
SH
Lives with husband, does not use stairs.
Spends most of the time sitting down. I . Analysis
HPC Subjective and objective signs of hyperventilation
Since age 22: overwhelming chronic fatigue. syndrome. Patient using excess energy to
4-5 years: dysphagia. maintain breathing pattern and avoid fal l i ng.
2 weeks: i SOB.
2. Problems
Subjective Fatigue.
Fatigue since started work, only ever able to work Anxiety.
part-ti me, worse with stress, everything is a Poor sleep.
great effort, feels like battery going down.
Tend to drop things. 3. Goals
Difficulty in shops, go dizzy, need someone with Shop without anxiety.
me in case I fall , use a stick to keep me steady Visit friends.
and to keep people at a d istance.
Worse since read ing book on relaxation and trying 4. Plan
deep breathing exercises. • Control breathing.
Always been anxious, e.g. taking the iron with me • Pacing and energy conservation.
in the car when I go out to ensure I 've not left it • Stairs.
on. • i exercise tolerance.
Difficulty sleeping.
Aches and pains since teenager, medication
unhelpful.
It's like I can feel all my muscles.
Reflexology has helped.
Fed up with hospitals.
'4·}ifa;!i;I'.1*1Iiii) )1 -
Objective Sequence of progress

Nervous posture including excess hand I . No change in symptoms, but 'husband says less
movements. huffing and puffing'.
Breathing pattern normal in sitting, tense and rapid 2. No change i n symptoms, but ' I 'm a little more in
in lying. control of my breath ing'.
315
3. Able to control n ightly chest pain with shallow for breathlessness in lung cancer. Pal/iat. Med. , 1 0,
breathi ng. 299-305.
4. Improved symptoms. Felhendler, D . and Lisander, B. ( 1 999) Effects of non

invasive stimulation of acupoints on the
5. Improved function including stairs.
cardiovascular system. Compo Ther. Med. , 7, 23 1-
6. Visiting friends and d istant family.
234.
Fraser, S. 1. (2000) Death - whose decision? J. Med.
Discharge summary
Ethics, 26, 1 2 1 -125.
Some fatigue stil l present but not preventing Gilbert, C. ( 1 999) Hyperventilation and the body.
activities. Accident Emerg. Nurs., 7, 1 3 0- 1 40.
Nijmegen score 1 2. Gilbert, C. ( 1 999) Yoga and breathing. J. Bodywork
Christmas card 9 months later indicated that Mov. Ther., 3, 44-54.
im provement was maintai ned. Han, J. N. ( 1 996) Influence of breathing therapy on
complaints, anxiety and breathing pattern in
patients with HVS and anxiety disorders. J.
Psychosom. Res., 4 1 , 48 1 -493.
Hayes, R. ( 1 995) Pain assessment in the elderly. r. J.
Nurs., 4, 1 1 99-1 204.
Could the following slgns and symptoms Molloy, D. W., Guyatt, G. and Russo, R. (2000)
Systematic implementation of an advance directive
indicate anything else ?
program in nursing homes. J. A. M. A., 2 83 ( 1 1 ) ,
Signs and symptoms which indicate a need 1437- 1 444.
for suctioning include: patient restlessness Nolan, M. and Nolan, J . ( 1 999) Cardiac rehabilitation
or anxiety, diaphoresis, increased BP and following myocardial infarction. Br. j. Ther.
HR. Rehab., 60, 1 42- 1 4 8 .

Paley, C. A . ( 1 997) A way forward for determining
Accident Emerg. Nurs. ( 1 997) 5, 92-98
optimal aerobic exercise intensity ? Physiotherapy,
Diaphoresis = sweating. 8 3 , 620-624.
Pounsford, J. c. ( 1 997) Nebulisers for the elderly.
Thorax, 52(suppl. 2), S53-55.
RESPONSE TO LITERATURE APPRAISAL Roberts, D. K., Thorne, S. E . and Pearson, C. ( 1 993)
The experience of dyspnea in late-stage cancer.
There are many possible causes of restlessness, Cancer Nurs., 1 6, 3 1 0-320.
anxiety, sweating and increased vital signs. If not Rowbottom, I. ( 1 992) The physiotherapy management
identified and remedied, these could be of chronic hyperventilation. ACPRC journal, 2 1 ,
increased by suctioning. 9-12.
Tierney, A. J. ( 1 996) Undernutrition and elderly
hospital patients. J. Adv. Nurs., 23, 228-236.
Watson, R. ( 1 993) Thirst and dehydration in elderly
RECOMMENDED READING
people. Elderly Care, 5 (4), 4 1 -44.
Billings, J. A. (2000) Palliative care. Br. Med. J. , 3 2 1 , Wolf, S. I. ( 1 996) Reducing frailty and falls in older
5 55-55 8 . persons: an investigation of Tai Chi. r Am.
Collins, F. (2000) Selecting the most appropriate Geriatr. Soc., 44, 48 9-497.
armchair for patients. j. Wound Care., 9 (2), 73- Zimmermann, P. G. ( 1 9 9 8 ) Effective communication
76. with patients with dementia. J. Emerg. Nurs., 24,
Corner, J. ( 1 996) Non-pharmacological intervention 4 1 2-4 1 5 .
31 6 ------
12 INTENSIVE CARE, MONITORING AND SUPPORT
SUMMARY
Introduction • Cardiac output

The environment • Electrocardiography (ECG)
• Effects on the patient Support
• Effects on relatives • Fluids
• Effects on staff • Nutrition
• Patients' rights • Medication
• Teamwork • Plasmapheresis
• Infection control • Pacemaker
Monitoring • Advanced cardiac support
• Ventilator interactions • Advanced pulmonary support
• Gas exchange • Advanced cardiopulmonary support
• Tidal volume Mini case study
• Fluid status Literature appraisal
• Haemodynamic monitoring Recommended reading
• Tissue oxygenation
INTRODUCTION A high dependency unit (HDU) is for patients

who require support for a single organ system or
Patients are admitted to an intensive care unit
who need closer monitoring than provided on a
(ICU) for intensive therapy, intensive monitoring
general ward (DoH, 1996).
or intensive support. They are not necessarily
critically ill, but are at risk of failure of one or
more major organs. Their needs range from THE ENVIRONMENT
observation of vital signs after major surgery to
When the link to life seems tenuous the
total support of physiological systems.
immediate world is clung to desperately . .
. .
Admission usually depends on expectation of

I had a passionate need to make that corner
recovery.
of the world a home. '
The importance of rehabilitation in the ICU is
Moore, 1991, p. 12
emphasized by evidence of the after-effects.
Follow-up clinics have revealed: Effects on the patient
• impaired mobility, continuing pain, 15% It is ironic that seriously ill people find them
incidence of posttraumatic stress disorder selves in an environment that exacerbates stress.
(Waldmann and Gaine, 1996) This saps energy and is a major contributor to
• compression neuropathies Gones and Grif slowing a patient's recovery (Swann, 1989). The
fiths, 1998) physiological damage inflicted by stress is
• prolonged weakness, fear of falls, panic described on page 25. It is not an optional extra
attacks (Griffiths and Jones, 1999) to give attention to this aspect of patient
• significant anxiety and depression a year management, but an integral part of physiother
after discharge (Shelly, 1998). apy.
317
CHAPTER 12 INTENSTVE CARE, MONITORING AND SUPPORT
The severity of the stress response varies with amplified threefold in the absence of
the patient's ability to control the situation. windows (Criner and Isaac, 1995).
Sensory and sleep deprivation, psychotropic 5. Sensory overload (Figure 12.1): Patients find
drugs, immobility, isolation, reduced communi themselves lost in a sea of electronic
cation and re-regulation of the biological clock wizardry, bombarded by unfamiliar beeping,
have been classified as psychological torture by overhead lights, telephones, confining
Amnesty International (Dyer, 1995). These equipment, painful procedures (sometimes
conditions are found in the ICU, albeit without without warning), tubes in various orifices
intent. Examples are described below. and incomprehensible conversation over their
heads. Most ICU conversations are between
1. Communication problems: Inability to staff rather than with the patient (Wood,
communicate has been found the most 1993). Noise is consistently above
stressful experience in the ICU (Pennock, internationally recommended levels, leading
1994; Villaire, 1995). to physiological damage (Kam, 1994)
2. Sleep fragmentation: Lack of sleep leads to including hearing loss (Halpern, 1999). A
death faster than lack of food (Wood, 1993). combination of sensory deprivation and
A full 90-minute cycle is needed to achieve overload can cause disorientation, often after
the restorative benefits of sleep, yet this is the first two or three lucid days. A third of
rare in the ICU (Wood, 1993). The more ill postoperative patients develop delirium
the patient, the more sleep they need and the (Smith et al., 1997), which more than
less they are likely to get it. Lack of sleep doubles the risk of death (Nuttal, 1998).
increases morbidity, mortality, confusion 6. Sensory monotony and loss of time sense:
(Pilbeam, 1992, p. 260) and reduces Patients struggle to keep track of time
respiratory drive (Shneerson, 1996b). through a tranquillized haze, which is
Confused patients are more likely to self worsened when there is no day-night
extubate (Nuttal, 1998) and are unable to co sequence in lighting or routine. This
operate with physiotherapy. Sleep disruption compounds disorientation, or, for more alert
is caused by noise, interruptions, anxiety, patients, causes boredom. Boredom is usually
pain, reversal of the day-night cycle, a negative experience, but occasionally the
difficulty in finding a comfortable position or empty time gives patients an opportunity for
fear of falling asleep and not waking again. reflection, especially if they have been close
3. Fear: Patients face previously unmet fears for to death. Some may emerge with a sharpened
which they have not developed coping perception of what is important in their life.
strategies. Fear is compounded by 7. Discomfort: Patients experience immobility,
helplessness. Patients try to assess their gagging on the endotracheal tube, dribbling,
progress by watching staff and family sweating, a dry mouth, distended abdomen,
reactions and comparing themselves to others unscratchable itches and lack of synchrony
on the unit. Agitation can lead to myocardial with the ventilator. Discomfort is increased
arrhythmias, ischaemia and sometimes with paralysis or other form of restraint.
infarction (Nuttal, 1998). Physical restraints have been found to
4. Sensory deprivation: Social isolation, loss of increase rather than decrease the risk of self
comforting touch, immobilization, certain extubation (Taggert, 1994).
drugs, a limited visual field and removal of 8. Helplessness, dependency and depression: The
hearing aid or glasses lead to a form of less patients are able to do for themselves,
emotional solitary confinement that can leave the more frustrated they feel. This may
patients felling intense loneliness despite become internalized as depression, especially
constant attention. These stress factors are as they are inhibited in expressing feelings
3 18
Figure 12.1 Sensory overload. (From Lindenmuth, J. E., Breu, C. S. and Malooley, J. A. (1990) Sensory overload. Am. j.
Nurs., 80, 14S6)
when dependent on the goodwill of those should be asked before visitors are ushered
who care for them. One patient commented in willy-nilly.
that 'it is the helplessness of illness that is
He may cry out for rest, peace, dignity, but
humiliating' (Moore, 1991, p. 12).
he will get infusions, transfusions, a heart
Depression is particularly apparent in the
machine . . . he will get a dozen people
recovery period and can hinder
around the clock, all busily preoccupied
rehabilitation.
with his heart rate, pulse, secretions or
9. Loss of privacy, dignity and identity: It is
excretions, but not with him as a human
easy for us to forget how people feel when
being.
they lose their autonomy, clothes, teeth,
Kubler-Ross, 1973
personal space and surname. Patients who
are elderly or from a different culture are
particularly vulnerable to this form of Effects on relatives
depersonalization. Sometimes patients want Relatives can do much to ease a patient's stress,
privacy from their own relatives, and they so long as they in turn are given support. They
3 19
CHAPTER 12 INTENSIVE CARE, MONITORING AND SUPPORT
may feel bewildered, daunted by the environ • multidisciplinary training to increase confi
ment and reluctant to voice their concerns. dence
Enforced passivity leads to frustration. Visitors • staff support, e.g. feedback, sharing of ideas,
need: debriefing after traumatic incidents and
recognition that doubts are acceptable.
• information about the patient's condition,
equipment and the reason for physiotherapy
Patients' rights
• the opportunity to say what they are
thinking or feeling Legal rights
• reassurance that touch and conversation The following are currently valid in the UK and
from them are welcomed by most patients are taken from Dimond (1999) and esp (1995).
• visible evidence that staff care about the A competent person over age 16 is entitled to
patient refuse treatment even if the treatment is life
• encouragement to become involved In saving and if the reasons for withholding
patient care, e.g. hairbrushing, mouth care, consent are irrational, unknown or non-existent.
foot massage, physical comforts and certain It is illegal to force physiotherapy on patients
passive movements. who resist or who are unable to resist but have
made their wishes clear by words or gesture, or
The benefits of relatives' involvement is
have made their wishes clear prior to becoming
demonstrated by the trend towards allowing
incompetent. Patients may withdraw consent
them to witness resuscitation attempts, with
during treatment. They do not need to have
appropriate support. As the veil of mystery and
suffered harm from physiotherapy in order to
heroism is lifted by TV medical dramas, and as it
sue and recover damages. If patients do not
becomes less acceptable to sequester families in
know that they have these rights, they should be
waiting rooms during resuscitation, benefits are
informed. In the face of refusal, physiotherapists
apparent in terms of grieving and an awareness
should seek to persuade a change of mind, but
that everything possible had been done (van der
must not use duress or deceit. Giving inadequate
Woning, 1997).
information can lead to litigation (Bury and
Mead, 1998, p. 32). The following allow
Effects on staff treatment without consent:
Emotional responses can become dulled by the • common law power to act out of necessity
frequency with which they are elicited. People • statutory authorization, e.g. Mental Health
working in an leu need defences against the Act 1983
suffering around them, but these are not incom • patient incompetence.
patible with sensitive patient care.
If we become stressed, we are not only less A patient is considered incompetent to give or
able to identify with the experience of the withhold consent if s/he is incapable of one of
patient, but are more likely to make mistakes. the following:
Reactions to working in the leu include over • comprehending and retaining treatment
detachment, anxiety due to the responsibility, information
frustration at communication difficulties or • believing such information
inability to relieve suffering, and inappropriate • weighing such information and arriving at a
joking with other staff which can be misunder choice.
stood by patients or relatives. Strategies to
reduce staff stress include: Panic, indecisiveness, irrationality and mental
illness in themselves do not amount to incompe
• involvement of all staff in decision-making tence. However, if mental illness renders the
320 ------
THE ENVIRONMENT
patient incapable of understanding or retammg tion directs that 'do not resuscitate' (DNR)
information so that s/he is unable to make a orders be made in consultation with the patient
decision and assess risks, this constitutes incapa unless this is impossible. This should be done in
city to consent. good time because:
Refusal of treatment and subsequent action
• 85% of patients prefer to be offered the
must be documented, and difficult decisions
choice (Heffner, 1996)
discussed with the team. Relatives cannot give
• the wishes of 40% of patients differ from
valid consent for adult patients even if patients
those of spouse and physician (Bach and
are unconscious, but their opinion should be
Haas, 1996, p. 184)
considered.
• by the time a DNR order is made, only
about 20% of patients are capable of being
Moral rights involved in the decision (Ryan, 1998)
Patients have the right to know the truth, to • most patients do not consider advance
partICipate in decision-making, to refuse to be consultation to be insensitive (Kerridge et
used for teaching, and to be given full care even ai., 1998).
when their choice differs from ours. Their rights
should not be violated if they are young or have DNR criteria are based on medical judgement
learning difficulties. In North America the right that there is a high probability of death or severe
to the truth is enshrined in law. brain damage, plus if possible the patient's
judgement on quality of life. Only in exceptional
circumstances can the consultant make DNR
End-of-life decisions
decisions based on quality of life without
Ethics is the exercise of moral reasoning in
discussing this with the patient (Blackie et at. ,
circumstances where strong feeling is not
1999), which is often impossible in the ICU.
always the surest guide to action nor
Patients may or may not want their families
procedural powers the surest way to justice.
involved in the decision. DNR decisions are
Dunsran, quored by Branrhwaire, 1996
reviewed at intervals and documented in the
Making a choice between undesirable alterna medical and nursing notes. DNR status does not
tives is the task facing those who make end-of preclude physiotherapy, or m some cases,
life decisions. Unfortunately few patients at surgery (Clemency, 1997).
present get the opportunity to discuss this in A decision to withdraw mechanical ventilation
advance of a situation when treatment may be is followed by 'terminal weaning', which is
extending death rather than prolonging life weaning in the knowledge that it will be
(Hofman et at. , 1997). When this has not been followed by death. This should be accompanied
discussed early enough, discontinuation of by titrated narcotics and non-invasive monitor
treatment is considered by the relevant team ing. Extubation should be avoided if this could
members, with the consultant taking the final cause respiratory distress (Krishna, 1999).
decision. The views of the family are considered,
but if they are burdened with taking the final Teamwork
decision, it can leave lasting guilt (Phelan, 1995). Interpersonal factors are the main causes of
Advance directives, or living wills, allow indi stress in high-dependency areas (Biley, 1989),
viduals, when competent, to express a wish to be and poor communication is the chief cause of
spared life-sustaining treatment in case of errors (Gosbee, 1998). Teamwork is enhanced
intractable or terminal illness. These are not by mutual respect and assertiveness, mutual
legally binding in many countries, and are often teaching and learning, shared coffee breaks, flex
not available, retrieved or honoured during ibility and above all good communication.
acute hospital care. The British Medical Associa- Problems may arise over boundaries and
321
autonomy. If physiotherapists would like to ask • removal of watches and avoidance of long
for review of a medical therapy that is not their sleeves (Singer and Webb, 1997, p. 78)
direct responsibility, they can raise the subject • fastidious attention to sterile suction tech
diplomatically by asking for advice about it, or nique, including resting the disconnected
by making the link between medical manage catheter-mount on the glove paper to avoid
ment and rehabilitation. If physiotherapy is touching the sheets
medically prescribed, physiotherapists can thank • care of tracheostomies as the surgical
the doctor for his/her advice and clarify that the wounds that they are
patient will be assessed and treated as appropri • minimizing the time that patients spend
ate. Results are likely to be positive when supine, which increases the risk of aspiration
communicating in a way that makes it easy for of gastric contents (Torres, 1992)
others to agree. • avoidance of frequent changes of ventilator
Communication between physiotherapists and tubing (Fink et al., 1998), tracheal tubes
nurses is facilitated by the physiotherapist (Feldman et al. , 1999) or pulmonary artery
offering to help change sheets when it fits in catheters (Saint and Matthay, 1998).
with turning the patient during treatment, and
The methicillin-resistant staphylococcus
the nurse incorporating regimes such as hourly
aureus (MRSA) bacterium is often found on the
incentive spirometry into the nursing plan.
skin of the general population, but MRSA and
Turning for physiotherapy should be co
other antibiotic-resistant bugs create havoc in
ordinated with turning for pressure area care.
hospitals, where they are easily spread by staff
hands to compromised hosts.
Infection control
Hospitals are curious places and ICUs even MONITORING
curiouser. lmmunocompromised patients are
'Frankly it feels quite awful to be connected
crowded together and bombarded with ICU
to machines through every available orifice,
hardened bacteria which flourish in the invasive
plus several new medically made ones, in
machinery. Widespread broad-spectrum antibio
spite of feeling thankful for all the life
tics are then added, which encourages superin
sustaining help and healing ministrations. '
fection by resistant organisms. Loss of upper
Brooks, 1990
airway defences in mechanically ventilated
patients leaves them vulnerable to colonization. From the patient's point of view, monitors bring
Cross-infection by the hands of staff contributes both anxiety and reassurance. From the staff
to 30% of pathogens (Weinstein, 1991). ICU point of view, they are useful to record sudden
patients are 5 to 10 times more likely than other or subtle changes in a patient's status. They are
patients to acquire nosocomial infection (Weber complementary to clinical observation and not a
et aI., 1999), and overall hospital-acquired infec substitute. Monitoring differs from measuring: it
tions cost the NHS £1 billion a year (Rennie, implies regular observation and a systematic
·
2000). Measures to prevent infection include: response if there is deviation from a specified
range.
• most importantly, handwashing or glove
changing between patients (Rossoff, 1995) Ventilator interactions
• avoidance of hot-air hand-dryers which leave Ventilator graphics demonstrate flows, pressures
hands still moist (Gould, 1994) and volumes that represent the patient's
• plastic aprons, colour-coded to ensure they response to the ventilator. Details are given in
are changed between patients (Gill and Pilbeam (1998, p. 42) or the manufacturer's
Slater, 1991) handbook. Below is an outline.
322
THE ENVIRONMENT
Peak airway pressure
/ Plateau pressure
/
0 / Q)
CJ) Time
:::l
Ventilator Insp. &. Exp. Mean airway pressure
trigger (area under curve)
Figure '2.2 Pressure-time curve representing controlled mandatory ventilation.
Pressure-time curve
Airway pressures throughout the respiratory
cycle are shown in Figure 12.2. Peak airway
pressure is equivalent to peak inspiratory
pressure. Mean airway pressure is associated (a)
positively with oxygenation and negatively with
60
the haemodynamjc side effects of intermittent
positive pressure ventilation (JPPV). End-inspira
tory plateau pressure reflects peak alveolar Flow
1 0
Time
j
pressure, and is kept below 30-40 cmHzO if
possible to reduce the risk of lung injury
60
(MacIntyre, 1996).
Flow-time curve
(b)
The flow-time curve is useful to verify the
�fV-
presence of intrinsic PEEP, as shown by inade
quate expiratory time, and the effect of broncho
dilators in a patient with reversible airways
obstruction (Figure 12.3). 60
Pressure-volume loop
Lung compliance is represented by the pressure (c)
volume loop (Figure 12.4), which is related to
the pressure-volume curve (p. 6). Spontaneous Before After
60
inspiration is shown by negative pressure to the
left, the area of which represents the patient's
work of breathing. The work done by the venti o+-��----�- -�--4-�r----
lator is shown by positive pressure plotted to the
right, the area becoming larger when the ventila
60
tor has to work harder. Work of breathing
(WOB) can be calculated from this loop (Banner
Figure '2.3 Flow-time curve. (a) Normal: inspiratory
et al., 1996).
flow above the x axis and expiratory flow below.
(b) Intrinsic PEEP: expiratory flow unable to return to zero
Flow-volume loop before the next inspiration begins. (c) Before and after
Figure 12.5 shows a flow-volume loop, which is bronchodilator: prolonged and normal expiratory flow.
323
CHAPTER 12 INTE SIVE CARE, MONITORING AND SUPPORT
(a) VT litres (b) VT litres

1.2 1.2
-60 -40 -20 0 20 40 60 -60 -40 -20 0 20 40 60

Paw emH20 Paw emH20
Slope
(c) VT litres
1.2
(d) VT litres
1.2 � t
)
-60 -40 -20 o 20 40 60 -60 -40 -20 o 20 40 60
Figure 12.4 Pressure-volume loop. PAW airway pressure: Vr

= =
(e) VT litres tidal volume. (a) A spontaneous breath in a clockwise loop, with
1.2 inspiration to the left and expiration to the right. (b) A pressure
triggered pressure-supported breath. The small clockwise loop to the
left represents the patient's negative pressure to trigger the breath.
The large anticlockwise loop to the right represents the ventilator
taking over with positive pressure support. (c) A flow-triggered
pressure-supported breath. The patient's work of breathing is
negligible. (d) How the shape of the loop is maintained while the
steepness of the slope varies with lung compliance, moving upwards
with increased compliance and downwards with reduced compliance.
-60 -40 -20 0 20 40 60
(e) A mandatory breath overdistending the lung. The pressure
Paw emH20
continues to rise with no corresponding increase in volume
(Mallinckrodt).
similar to that for spontaneously breathing bility, and patients should be undisturbed for 20
patients (p. 60) except that peak expiratory flow minutes before each measurement and stay in
is not forced. Peak inspiratory pressure is the the same position. These conditions are not
maximum value on the x axis. Tidal volume is always achieved in the hurly-burly of the ICU.
the maximum value on the y axis.
Gas exchange Arterial oxygen saturation

Oximetry is the physiotherapist's friend. It gives
Arterial oxygen gases instant feedback on arterial oxygen saturation.
Arterial blood samples from an indwelling The different absorption of light by saturated and
arterial catheter are subject to spontaneous varia- unsaturated haemoglobin is detected by the
324
MONITORING
3 Expiration
Ul
�
OJ
� 0
3:
0
u::
2
Inspiration
4
PIF
5
Volume (L)
Figure 12.5 Flow-volume loop. The scooped-out dashed line of the expiratory curve indicates obstructed airways. PEF =
peak expiratory �ow (peak �ow); FEFsO% =forced mid-expiratory �ow, FVC =forced vital capacity; PIF peak inspiratory �ow.
=
oximeter, which continuously displays the percen hypothermia, peripheral vascular disease and
tage of haemoglobin that is saturated with anaemia. In low perfusion states, a finger probe
oxygen. A sensor is attached close to a pulsating is advised (Goodfellow, 1997), preferably one of
arteriolar bed such as the ear, finger or toe, with the middle two fingers. The sensors are affected
its position changed regularly to protect the skin. by movement, nicotine stains, bruising, clubbing,
A level of 92% indicates adequate arterial jaundice, nail polish or, for an ear probe,
oxygenation (Komara and Stoller, 1995). Sa02 pierced ears. Carbon monoxide poisoning falsely
below 90% corresponds to a Pa02 of less than elevates Sa02 (Hampson, 1998).
8 kPa (60 mmHg) under normal conditions, and Physiotherapy can upset gas exchange, and if
obliges patients to increase their cardiac output desaturation occurs, treatment should normally
to maintain oxygen delivery (Ahrens, 1999b). stop and the '100% oxygen' knob on the ventila
During severe or rapid desaturation, the oxygen tor activated if appropriate. If Sa02 does not
dissociation curve is shifted to the right and a return to its baseline value within minutes,
below-normal S302 is recorded. S.02 is always remedial action should be taken such as reposi
interpreted in relation to the F102• tioning the patient, increasing FI02 in consulta
Oximetry is less accurate than arterial blood tion with the nurse or manual hyperventilation
gas analysis, but is acceptable at values above (p. 373).
75%. Sa02 is dependent on perfusion, and
accuracy is compromised by cold peripheries, Capnography
vasopressor drugs, hypotension, hypovolaemia, A capnograph displays expired CO2 concentra-
325
CHAPTER 12 INTENSIVE CARE, MONITORI G AND SUPPORT
tion as a waveform called a capnogram, which between peripheral and central temperature and,
provides continuous non-invasive assessment of representing the kidney'S sensitivity to perfusion,
the adequacy of ventilation. A sensor between urine output. Fluids in the interstitial and intra
the tracheal tube and ventilator tubing detects cellular spaces are more difficult to assess, but
the amount of infrared radiation absorbed by dehydration is suggested by thirst and dry mucus
expired CO2, Values at end-exhalation indicate membranes, and overhydration may increase
'end-tidal CO2', which approximates alveolar weight or oedema, either peripheral or
PC02 unless there is VAlQ mismatch. Many ICU pulmonary (Twigley and Hillman, 1985) .
patients have VA/Q mismatch, and CO2 produc
tion also varies with nutrition and WOB (Napo Haemodynamic monitoring
litano, 1999) , but the trend is still helpful. Preload is the volume of blood returning to the
Normal value is 1 mmHg below P aC02, with an ventricle, i.e. its filling pressure at end-diastole. It
acceptable range up to 5 mmHg difference. assists contraction by stretching the myocardium
and is determined by venous return and blood
Transcutaneous monitoring (Ftc02 and PtcC02) volume. It is increased in heart failure or fluid
Oxygen and CO2 diffuse across the skin and can overload, and decreased in hypovolaemic shock
be measured by a sensor on the skin, which is or dehydration. Left preload is monitored by
heated to increase gas permeability across the PAWP (p. 329) and right by CVP (p. 327) .
skin barrier. In haemodynamically stable Afterload relates to the amount of pressure
patients, values relate to respiratory status, but against which the ventricle must work during
measurements vary with cardiac output, skin systole, as if opening a door against a wind. It is
metabolism or capillary blood flow, and values increased with systemic/pulmonary hypertension,
are thought to reflect tissue gas tension rather peripheral vasoconstriction or aortic/pulmonary
than arterial gas tension, Skin burns are avoided valve disease, and decreased with vasodilation,
by rotating sites every 4 hours and incorporating e.g. in septic or neurogenic shock. Left ventricu
a temperature alarm. lar afterload is reflected by systolic BP and
Neonates show a correlation between Ptc02 systemic vascular resistance. Right ventricular
and arterial oxygenation, and accuracy is greater afterload is reflected by pulmonary artery
than with end-tidal CO2 (Tobias, 1997) . Adults pressure and pulmonary vascular resistance.
have varying skin thicknesses and results are less
reliable. Ptc02 is at least 10% below Pa02, and The heart and vascular systems act as a
PtcC02 is similarly higher than PaC02, but math continuous loop in which constantly shifting
ematical correction can neutralize the error pressure gradients keep the blood moving. In
(Rosner et aI. , 1999) . many patients, cardiovascular function can be
gauged from clinical signs such as BP, HR, urine
Tidal volume output and mental status. However these may be
unreliable in critical illness and invasive haemo
If tidal volume is not continuously monitored
dynamic monitoring is then required. _
and displayed, it can be measured by attaching a

Wright spirometer to the tracheal tube and
Blood pressure
taking the average of 5 breaths.
BP can be measured by an automated cuff that
intermittently compresses the limb and senses
Fluid status arterial pulsations. Continuous monitoring of BP
The fluid balance chart gives an overview of by an indwelling catheter gives a beat-to-beat
fluid status. Fluids in the intravascular space waveform display and provides more accurate
affect pulse, BP, cardiac output, left and right and instant feedback than cuff pressure. The
atrial pressures (p. 327, 9) , the difference most relevant reading is mean arterial pressure,
326
MONITORING
representing the perfusion pressure over the are required for patients who need nutrition
cardiac cycle. without too much fluid volume, which cannot be
given through peripheral veins. However, one
Right atrial pressure study found that central venous lines create a
The central venous pressure is monitored by 64-fold higher risk of catheter-related sepsis
creating an extension of the patient's vascular than peripheral lines (Collignon, 1994). Implica
system via a central line and measuring the tions for physiotherapy are the following:
pressure within it by a transducer, a device that
converts pressures to electrical signals, or a • Cannulation of a large vein near the pleura
water manometer (Figure 12.6). A radio-opaque may cause a pneumothorax, haemothorax or
catheter is passed through a large central neck surgical emphysema. After placement of a
or arm vein until it is just outside the right central line, the X-ray should be examined
atrium, through which all venous blood passes. before any positive pressure treatment such
The central venous pressure (CVP) within this as manual hyperinflation.
system is equivalent to the right atrial pressure • The supine position is often used for
(RAP), which reflects the preload of the right measurement because the transducer must be
ventricle. level with a zero reference point. If the
The CVP (i.e. RAP) indicates circulating patient is not repositioned afterwards,
blood volume and the ability of the heart to prophylactic chest care is compromised.
handle that volume. It is affected by the interac Despite the tradition of supine measurement,
tion between blood volume, right heart function, Wilson (1996) shows that readings are accu
peripheral venous tone and posture. CVP is rate when sitting up, and claims that supine
equivalent to JVP (p. 34). is illogical because in this position intrathor
Normal values are 3-12 cm H20 (measured acic pressure is sensitive to pressure from
by manometer) or 0-8 mm Hg (by transducer). abdominal contents.
Single values are less relevant than the trend, but • A high CVP may indicate pulmonary
a high value might indicate heart failure, oedema, which impairs gas exchange. A low
pulmonary embolus, COPD, pneumothorax or CVP may indicate hypovolaemia, which can
over-transfusion of fluid. The CVP provides lead to adverse haemodynamic response to
early warning of cardiac tamponade (p. 384), manual hyperinflation.
which causes a sudden rise in CVP, or haemor
rhage, which causes a sudden drop. CVP is more The CVP directly measures right atrial
sensitive to haemorrhage than BP, because BP is pressure but usually reflects filling pressures for
maintained for longer by vasoconstriction. both sides of the heart. However, left atrial
Dynamic CVP measurements are used to pressure may need to be measured separately for
assess fluid status if the cardiac status is stable. A two reasons:
fluid challenge of 50-200 mL colloid is infused
over 10 minutes, and a rise in CVP of 3 mmHg • it may take 24-48 hours for the CVP to rise
indicates an adequate circulating volume (Singer in response to left ventricular failure because
and Webb, 1997, p. 262). It it does not rise the pressure has to back up through the
significantly, the patient is relatively hypovolae pulmonary circulation and the right ventricle
mle. may initially compensate
Multiple functions are serviced by multilumen • CVP does not reflect left atrial pressure if
catheters. Central venous catheterization is now the compliance of either ventricle is affected
a routine procedure used not just for CVP by septic shock, ischaemia, vasopressors or
measurements but also for infusing fluids, drugs, vasodilators
blood and hyperosmolar feeds. These thick feeds • CVP does not reflect left atrial pressure if
327
35
30
Water manometer
25
measured in centimetres
20
(a)
(i) (ii) (iii)

(b)
Figure 12.6 (a) Haemodynamic monitoring using a manometer. A multilumen catheter monitors CVP from the right
atrium, PAP from the pulmonary artery, and PAWP from the pulmonary vasculature. Zero point on the manometer is at the
level of the right atrium. The CVP reading is 5 cmH20. RA = right atrium; RV
= right ventricle; PA
= pulmonary artery; LA
=
left atrium; LV= left ventricle. (b) Passage of catheter as it measures (i) CVP, (ii) PAP, (iii) PAWP.
328
MONrrORING
pulmonary hypertension pushes up the CVP Values are also affected by valve stenoses, floppy
even when the patient is systemically hypo ventricles following serial myocardial infarcts or
volaemic. sepsis, or stiff ventricles following sympathetic
stimulation caused by hypovolaemic shock. The
Left atrial pressure more ill the patient, the less accurate are single
If left atrial pressure measurement is required, a measurements, but the trend is helpful.
pulmonary artery catheter incorporating three to PAWP shows left ventricular changes more
five lumens is used. Sometimes called a Swan promptly than CVP and gives a more accurate
Ganz catheter, it is passed along the CVP indication of fluid status because it is affected by
catheter route, then floated through the right fewer variables. This allows fine tuning when
ventricle into the pulmonary artery, drawn by an establishing optimum PEEP (p. 353), helps to
inflated balloon at its tip (Figure 12.6). The rationalize fluid and drug therapy and distin
pulmonary artery catheter monitors cardiac guishes between hypovolaemia U PAWP) and
output (p. 330) and the two following vascular left ventricular failure (j PAWP). Normal values
pressures. are 5-15 mmHg. Implications for physiotherapy
Mean pulmonary artery pressure (PAP) reflects are similar to those for CVP readings.
the pressure that needs to be generated by the PAWP is also known as pulmonary artery
right ventricle to pump blood through the occlusion pressure, pulmonary capillary wedge
pulmonary vasculature. Normal values are 10- pressure or, on ward rounds, simply wedge
20 mmHg. A raised PAP indicates pulmonary pressure. The glamour of this expensive technol
hypertension, pulmonary embolism or fluid ogy has led at times to misuse of a system that
overload. People with advanced COPD show a demonstrates a 24% complication rate (Cooper,
PAP of up to 40 mmHg, rising further during 1996), including thrombosis, sepsis, arrhythmias,
sleep and exercise. trauma to the delicate pulmonary vessels
The catheter can then be carried further by (resulting in bloodstained secretions) and
the flow of blood until it wedges in a branch of pulmonary ischaemia or infarction. Its use is best
the pulmonary vasculature and occludes it. The reserved for haemodynamically unstable patients
catheter tip is isolated from pressure fluctuations who are refractory to medical treatment after
in the right side of the heart and is in direct scrupulous assessment.
communication with the left atrium via the
pulmonary capillary bed, so long as there is a Tissue oxygenation
continuous column of blood between the two. The efficiency of a bus journey is best measured
The pressure monitored at this point is the when it arrives at its destination rather than
pulmonary artery wedge pressure (PAWP) or left when it leaves the garage. Similarly, oxygen
atrial pressure. It reflects pressure in the left delivery to the tissues is more relevant than
ventricle via the left atrium and lung vasculature. oxygen in arterial blood.
The balloon acts as a form of pulmonary
embolus so is deflated between measurements to Mixed venous oxygenation
prevent ischaemia. Oxygen levels in the pulmonary artery indicate
The continuous column of blood in the the extent to which oxygen supply (cardiac
pulmonary vascular bed is tenuous if the catheter output, haemoglobin, Sa02) has met demand
is in the upper zone (Zone 1, p. 10) of the lungs (oxygen extraction at tissue level). Both haemo
where there is no perfusion under the positive dynamic and gas exchange components of the
pressure of IPPV. Measurements are compro oxygen cascade can be monitored in the
mised if the patient is severely hypovolaemic, pulmonary artery.
changes position, or is subject to high lung Mixed venous blood in the pulmonary artery
inflation pressures (Brandstetter et al. , 1998). comprises individual streams from a multitude of
------ 329
CHAPTER 12 INTENSIVE CARE, MONITORINC, AND SUPPORT
capillary beds which have been mixed in the supplied. Its susceptibility to hypoperfusion IS
right ventricle before returning to the lungs. The because of:

oxygen in this pooled blood is what is left after
• the mucosa's high metabolic demand
its journey, and reflects events anywhere from
• its tendency to vasoconstrict because of a
alveoli to mitochondria. It is especially useful in
rich innervation by sympathetic nerves
identifying problems at tissue perfusion and
• the intense ischaemia to which the narrow
extraction level, beyond the reach of arterial
villus tips are prone.
blood gas measurements.
The mixed venous oxygen saturation of Gastric tonometry entails passing a saline
haemoglobin in pulmonary artery blood (S� O2) filled balloon into the stomach and measuring
is on average 65-75%, and should be more than the PC02 that passes across the membrane.
10% below Sa02' A low S� O2 reflects: Gastric mucosal pH can also be measured
directly, or a fibreoptic sensor can be used
• 1 oxygen delivery, e.g. suction, anaemia, low
(Knichwitz et al., 1998). Acidosis indicates hypo
cardiac output, hypoxaemia, haemorrhage
perfusion, which if not corrected may contribute
• i oxygen demand, e.g. suction, exercise,
to multisystem failure (Ruffolo, 1998).
pain, fever, anxiety, agitation, laboured
The splanchnic circulation is the largest
breathing or hypermetabolic states.
regional circulation, containing 25-40% of
S� O2 does not pinpoint which of the variables systemic blood volume (Ruffolo, 1998;
is responsible for any change, and acts more as Grounds, 1997). Its vulnerability is demon
an early warning system to advise on further strated by the following:
investigation. Cardiac output is simultaneously
• A 20% reduction in systemic blood flow
monitored so that it can be distinguished from
reduces gut blood flow by an average 55%.
other variables.
• 20% hypovolaemia causes a 60% reduction
Values below 50% are normally associated
in gastric blood flow (Ricour, 1989).
with anaerobic metabolism, and values below
40% are incompatible with life following
myocardial infarction (Edwards, 1997). People Cardiac output (CO)
with chronic heart failure are more tolerant of Invasive measurement of CO is by thermodilu
low levels. S� O2 can be improved by increasing tion. A known quantity of a cold sterile solution
FI02 or cardiac output, reducing stress or is rapidly injected into a channel of the
addressing other relevant factors. Excessively pulmonary artery catheter, which exits into a
high values above 85% indicate 'luxury central vein near the right atrium. The tempera
perfusion', in which oxygen cannot be extracted ture of blood when it reaches the pulmonary
by tissues that have been damaged by global artery indicates the speed with which the
ischaemia caused by, for example, hypothermia solution has been warmed, providing a measure
or severe sepsIs. ment of cardiac output (Figure 12.7). CO can
During physiotherapy, if S� O2 varies by more also be assessed non-invasively by transoesopha
than 10% from the baseline for more than 3 geal Doppler ultrasound to measure aortic blood
minutes, treatment should be stopped (Hayden, flow (Baillard et aI., 1999). S� O2 can be a
1993). If it has not recovered 3 minutes after surrogate for CO if oxygen consumption is
suctioning, extra FI02 is required. stable. Reduced urine output is the simplest
indicator of reduced CO.
Gastric tonometry Cardiac output usually reflects BP but they do
The gut is the crystal ball of tissue hypoxia. It not always change in harmony. If the myocar
provides advance warning because it can be dium is poorly contractile, peripheral vasocon
starved of oxygen when other tissues are well striction may maintain BP in the face of falling
330
MONITORINC,
Thermodilution Distal . -;--. - �--- .. --

connector lumen
(PA) - --t- • -. ... ----. __ .....
. .. . __ ._--
- _. - •
-
- - --- --...t.t--�� - - -----.
Proximal
lumen
- · -- rI ---- =1 I
(RA) I
Balloon lumen
stopcock ----t S
i
Figure 12.8 Normal ECG trace of one heart beat. P

wave atrial depolarization; PR interval
= atrioventricular
=
conduction time; Q ventricular depolarization; R

= first =
positive denection during ventricular depolarization, S first =
negative denection during ventricular depolarization, QRS

complex total ventricular depolarization, T
= ventricular =
repolarization (recovery period) in preparation for next cycle.
Figure 12.7 Four-lumen pulmonary artery catheter. CVP respectively. Sinus tachycardia or supraventricu
= central venous pressure; PA
= pulmonary artery; RA
= lar tachycardia is HR over 100 bpm, recognized
right atrium. by rapid rate, regular rhythm and normal QRS
complex. Causes include sympathetic activity,
electrolyte imbalance or excess �2-agonist medi
CO. A septic patient in a hyperdynamic state cation. Cardiac output is rarely compromised.
may have a high CO, but vasodilation will drop Sinus bradycardia is HR under 60 bpm with
the BP. Accurate measurements require the normal rhythm.
patient to be in a steady state. Ventricular tachycardia is distinguished from
supraventricular tachycardia by a lost P wave
Electrocardiography (EeG) and broad and bizarre QRS complex. It usually
Disturbances such as hypoxia, physiotherapy, impairs cardiac output, BP and tissue perfusion,
electrolyte imbalance, myocardial ischaemia or and can lead to pulmonary oedema or ventricu
anxiety can cause disorders of heart rate (HR) or lar fibrillation.
rhythm. The effects are significant if they affect Nodal rhythm occurs when the AV node takes
cardiac output. They are picked up on the ECG, over from a non-functioning or slow SA node.
which is a recording of electrical activity in the This causes lost P waves and a variable or absent
heart compnsmg waves, complexes and PR interval. Cardiac output may fall because
intervals. atrial contraction is out of synchrony with the
Sinus rhythm is normal rhythm ongmating ventricle, which loses its 'atrial kick'.
from the sinoatrial (SA) node (Figure 12.8) . The SA node is the natural pacemaker, but if
Supraventricular arrhythmias ongmate from it does not initiate an impulse at correct
above or in the atrioventricular (AV) node and intervals, an ectopic (abnormal) focus outside
are known as atrial and nodal arrhythmias the SA node may take the initiative. These
331
CHAPTER 12 INTENSIVE CARE. MONITORING AND �UPPORT
(a)
Pwaves
(b)
(c)
(d)
Figure 12.9 ECG traces indicating (a) myocardial infarction, (b) atrial fibrillation, (c) ventricular fibrillation, (d) complete
(third-degree) heart block.
ectopic beats are seen as premature beats inverted T wave. They occur following heart
followed by a compensatory pause, sometimes surgery or myocardial infarction (Figure 12.9a),
felt as missed heart beats by the patient. They in smokers or in those suffering from hypoxia or
are common and do not contraindicate low potassium levels. Bigeminy means that every
physiotherapy unless they increase in number or other heart beat is ectopic and trigeminy means
cause haemodynamic disturbance. However, that every third beat is ectopic.
they may signal the onset of a more senous ST segment elevation suggests pericarditis,
arrhythmia. coronary artery spasm or acute myocardial
Atrial ectopics manifest as occasional infarction (MI) which will respond to thrombo
abnormal P waves or an early normal beat, and lytic drugs. ST segment depression (Figure
are of little significance unless frequent. Nodal 12.9a) indicates myocardial ischaemia or infarc
ectopics are the main cause of nodal rhythms. tion that does not respond to thrombolytic
Ventricular ectopics are caused by an irritable therapy.
focus in the ventricle, producing an absent P Atrial fibrillation (AF) occurs when ectopic
wave, wide and wayward QRS complex and foci throughout the atria discharge too fast for
332
MONITORING
the atrial muscle to respond other than by disor indicated. In third-degree HB, atrial and ventri
ganized twitching out of sequence with ventricu cular rhythms are independent of one another
lar activity. It appears as a rapid rate, irregular (Figure 12.9d). This requires a pacemaker to
rhythm and the replacing of P waves with a avoid a form of syncope called a Stokes Adams
chaotic baseline (Figure 12.9b). It can be attack. Bundle branch block disturbs intraventri
worsened by sympathetic stimulation, hypoxia, cular conduction and widens the QRS complex.
hypokalaemia, over- or underhydration,
pulmonary embolism, myocardial ischaemia or
SUPPORT
heart surgery. The ventricles lose their support
from the atria and may be unable to sustain
normal cardiac output. Patients may have no Fluids
symptoms . or suffer palpitations, dyspnoea, Dehydration: intracellular and interstitial water
fatigue or stroke. Treatment is by anti-arrhyth deficit stemming from hypertonicity and
mic drugs or cardioversion by DC shock. Slow disturbed water metabolism
AF does not necessarily contraindicate Hypovolaemia or volume depletion: extracel
physiotherapy. AF is a common arrhythmia in lular fluid depletion which affects vascular circu
the general population, affecting 4% of people lating volume and haemodynamic status.
over 70 years (Kamalvand and Sulke, 1999) due
to heart failure or advanced age. An adequate circulating volume is the primary
Atrial flutter is less common than AF and consideration before drugs or other forms of
short-lived. It causes regular sawtooth undula support are given. Blood volume determines
tions on the ECG and either deteriorates to AF preload and is the single largest contributor to
or spontaneously recovers. cardiac function (Wilkins et ai. , 1995, p. 322). A
Ventricular fibrillation (VF) is the commonest well-filled patient is less likely to suffer haemo
cause of cardiac arrest. Breakdown of ordered dynamic compromise with manual hyperinflation
electrical activity causes an ineffectual quivering and suction (Schwartz, 1987). Fluid homeostasis
of the ventricles, appearing as a chaotic line and normally operates to preserve tissue perfusion
providing no cardiac output (Figure 12.9c). first and tonicity second (Mange et al. , 1997)
Asystole is ventricular standstill that also leads to but unstable patients may have difficulty
cardiac arrest. It is caused by VF that has 'burnt achieving this balance.
itself out' or a bradyarrhythmia that has become The fate of administered fluids depends on
so slow that asystole occurs. It shows as a which type of fluid is chosen. Colloids are thick
straight line with occasional minor fluctuations. fluids such as plasma, blood and dextran that
VF and asystole can be misinterpreted when contain large molecules and are retained in the
similar traces are produced by manual techniques circulation. Colloids are normally unable to
to the chest or disconnected electrodes respec escape through the capillary endothelium and
tively. therefore help keep water in the vascular compart
Heart block (HB) is an anatomic or functional ment by exerting oncotic (colloid) pressure from
interruption in the conduction of an impulse, within. Transfused colloid therefore stays in the
shown as a disrupted relationship between P intravascular compartment and influences cir
wave and QRS complex. Causes are hypoxia, MI, culatory function (Golster, 1995). Colloids that
digoxin therapy, heart disease or complications have an oncotic pressure greater than plasma are
after heart surgery. First-degree HB shows a called plasma expanders. Blood is sometimes
prolonged PR interval, but there are no classified separately because it has oxygen
symptoms or need for treatment. Second-degree carrying capacity. Albumin is a colloid that has
HB shows dropped beats, and if it causes recently been condemned until further research
dizziness, fainting or reduced CO, a pacemaker is measures its safety (Roberts 1998a).
333
CHAPTER 1 2 INTENSIVE CARE, MONITORING AND SUPPORT
Crystalloids are thin fluids with small ance or impaired perfusion to the liver and
molecules such as dextrose and saline. They kidney. Further obstacles common in the ICU
have less effect on intravascular volume because are:
over 70% is lost from the plasma into the inter
• inadequate feeding in an attempt to limit
stitial space (Helmqvist, 2000). Excess crystal
weight gain following fluid overload during
loid transfusion, when escaping from the
surgery (Lowell, 1990)
circulation, may cause interstitial oedema which
• lack of recognition of a process as undra
impairs oxygen transport from blood to tissue
matic as malnourishment
cells, or pulmonary oedema which impairs gas
• limited understanding of the importance of
exchange in the lungs (Choi et ai. , 1999). Crys
nutrition in the healing process
talloid is used to provide the daily requirements
• the patient's lack of hunger, ability to
of water and electrolytes. Too much crystalloid
express hunger or capacity to eat normally.
is risky in patients with ARDS because of leaky
capillaries and impaired compensating mechan On top of this is hypermetabolism. Sykes and
Isms. Young ( 1999, p. 230) calculate that a postopera
There is some controversy over which to tive patient might require 10% extra calories,
choose for fluid resuscitation in hypovolaemic someone with peritonitis 250/0 extra calories,
patients. Colloid is usually recommended but it and a person with severe burns 60% extra.
is more expensive and has more side effects. In Increased WOB may demand another 20% extra
general, hypovolaemia is often treated rapidly calories overall. Rennie ( 1998) considers that
with normal saline, and dehydration slowly with neglect of nutritional support could be construed
5% dextrose (Mange et ai. , 1997). as malpractice.
Some degree of malnutrition is unavoidable in
Nutrition septic patients if the inflammatory response
causes protein breakdown and obligatory
Recovery is often dependent upon ability to
nitrogen loss.
complete the healing process prior to the
exhaustion of fuel.
Effects of malnutrition
Shikora, 1996
Malnutrition leads to muscle wasting, delayed
The mythical comparison between the nutri weaning, impaired healing, atelectasis due to
tional status of prisoners of war and ICU depleted surfactant, pulmonary oedema due to
patients comes perilously close to the truth at low albumin, increased risk of oxygen toxicity
times. Patients who require the most nutrition (Durbin, 1993), prolonged effect of paralysing
are those least likely to be adequately fed drugs (Sinha, 1998) and the effects described on
(Shikora, 1996). Physiotherapists may watch page 131.
their patients waste away on the empty calories
of a dextrose infusion while they are struggling Management
uphill to maintain the condition of lungs and If patients are able, they should sit out and eat at
limbs. Rehabilitation is directly affected: one normal times. If the gut is functioning, it should
study showed how extra postoperative nutrition be used. If patients cannot swallow, PEG feeding
in orthopaedic patients enabled them to be inde (p. 264) is suitable for prolonged enteral
pendently mobile 5 days earlier than controls nutrition. Patients on continuous morphine have
(Bastow et ai. , 1983). reduced upper gut motility and may be better
fed via the duodenum or jejunum than via the
Causes of malnutrition stomach (Bosscha et ai. , 1998). Enteral feeding
Patients may be disadvantaged by a pre-existing may be easier in right-side-lying because of the
nutritional deficit, gut problems, glucose intoler- shape of the stomach.
334
SUPPORT
Intravenous (IV) feeding is used only if Cardiovascular drugs

necessary. It is deficient in certain essential The relationship between heart function,
nutrients, trebles the incidence of pneumonia vascular tone and fluid volume can be manipu
compared to enteral feeding and causes atrophy lated to augment cardiac output, reduce myocar
of the gut lining (Reiland, 2000). The gut must dial oxygen demand or redistribute blood flow
keep moving to prevent stasis, bacterial over to vital organs.
growth, permeability and invasion of intestinal
flora into the systemic circulation, whence to Diuretics
wreak havoc in the rest of the body and risk Reduction in blood volume and preload are the
multisystem failure (p. 409). aims of diuretics (p. 138). They are used as the
Problems can also arise from rapid feeding, first-line drug for hypertension, heart failure and
overfeeding or inappropriate feeding. Starvation pulmonary oedema. When mobilizing a patient
for over 48 hours can lead to 'refeeding who is taking diuretics, a wary eye should be
syndrome' if subsequent feeding is too quick, kept for signs of postural hypotension.
with possible cardiopulmonary and neurological
complications (Marik 1996b). Rapid administra Systemic vasodilators
tion of high carbohydrate feeds causes hypergly Hypertension, heart failure and angina are
caemia, which favours bacterial growth, may treated by venodilators such as the nitrates,
increase mortality (Elia, 1995) and increases which predominantly reduce preload, and
CO2 production. IV feeds with glucose arterial dilators such as hydralazine, which
providing more than 50% of the non-protein reduces afterload. Side effects include postural
calories can increase CO2 production two- to hypotension, especially in the early stages, and
eightfold (Tobin, 1991, p. 4). Extra WOB is headache. Calcium channel blockers such as
needed to increase minute ventilation and blow verapamil, and ACE inhibitors such as captopril,
off the COl. and for patients with marginal decrease vascular resistance and can lower BP.
respiratory reserve, this can precipitate respira ACE inhibitors can cause a dry cough and, with
tory failure (Liposky, 1994). Slow administration the first dose, a drop in BP. If the cough is a
of high-fat low-glucose feeds may assist patients problem, angiotensin II antagonists may be
with hypercapnic COPD, especially during substituted.
weaning. Immune-enhancing formulas show
benefit for patients at risk (Singer and Little, Inotropes
1999). A failing heart can be assisted by inotropes,
which augment the force of cardiac contraction.
Medication Before giving inotropes, fluid status should be
sufficient to ensure that the drug will not be
Infusion pumps are required to titrate drug
stimulating an empty heart.
dosage to the individual patient because:
Adrenaline is an inotrope that stimulates the
• response varies due to complex interactions sympathetic system and increases the speed and
of multiple drugs force of cardiac contraction. At low doses it
• ICU drugs are potent and some have a raises systolic pressure and at high doses it raises
narrow window between effective and toxic both systolic and diastolic pressures. It increases
doses HR, cardiac output and myocardial oxygen
• physiological processing may be affected by demand. It dilates coronary and skeletal muscle
the stress response or impaired circulatory, vessels, constricts peripheral vessels and at high
renal or liver function. (Drugs should prefer dose constricts renal blood vessels. Noradrena
ably not rely on a failed organ for excre line causes generalized vasoconstriction and
tion). increases systemic vascular resistance.
335
Dopamine is used in low doses because side Pulmonary vasodilators

effects include tachycardia, arrhythmias and Patients with acute pulmonary hypertension may
increased pulmonary shunt. A small 'renal dose' benefit from pulmonary vasodilators such as
may increase urine volume but benefit to the prostacyclin, nitric oxide or a combination (Hill
kidney is doubtful (Nolan, 1996) . At high doses, and Pearl, 1999). Prostacyclin is administered
dopamine causes vasoconstriction. Dobutamine intravenously or by nebulizer, has a half-life of 5
gives a greater boost to oxygen delivery, has less minutes and is less toxic than nitric oxide
adverse effects on shunt and does not cause (Scheeren, 1997) but can affect the systemic
vasoconstnctI on. Dopexamine is a weak vasculature and cause hypotension.
inotrope, an arterial vasodilator and specifically Nitric oxide has an unpromising background
increases renal and splanchnic blood flows. It is as a corrosive gas that is found in bus exhausts,
sometimes used perioperatively in high-risk cigarette smoke, smog and welding fumes. But it
patients as prophylaxis against renal failure. plays a role in controlling blood vessel wall tone,
Inotropic agents are used for circulatory and its Janus-faced nature allows it to be
failure and to offset the depressant effects of exploited to dilate vessels adjacent to ventilated
PEEP on cardiac and renal function. They do so alveoli, decreasing shunt, reducing VA/Q
at the expense of increasing myocardial oxygen mismatch and benefiting 50% of patients in
demand. In patients with tachycardia, inotropes severe respiratory failure (Singer and Webb,
may cause myocardial ischaemia and actually 1997, p. 180) . When inhaled, its effects are
decrease oxygen delivery. They are therefore limited to the pulmonary vasculature because it
only used after regulation of fluid and vasodila has a 1500 greater affinity than carbon
tor therapy. Side effects mimic the effects of monoxide for haemoglobin (Greenough, 1995)
over-stimulating the sympathetic nervous and is inactivated by the time it reaches the
system. systemic circulation. Side effects include loss of
Digoxin is a cardiac glycoside with mild surfactant and platelet function, toxicity with
inotropic effects that has been in and out of high FI02 levels and rebound pulmonary hyper
fashion for two centuries. It helps control atrial tension if the dose is reduced too quickly. Heat
fibrillation by strengthening and slowing HR, moisture exchangers are safer than hot-water
but may cause other arrhythmias in the presence baths because excessive humidification can
of hypoxia. combine with nitric oxide to form nitric acid
(Singer and Webb, 1997, p. 180).
Beta-blockers Patients should not be removed from their
Beta-blockers such as propranolol and atenolol nitric oxide during physiotherapy. If manual
are 'negative inotropes' which inhibit sympa hyperinflation is necessary, the gas can be
thetic action, block the action of adrenaline, filtered into a rebreathing bag. However, many
slow the HR, reduce cardiac work and relieve of these patients are critically ill and dependent
hypertension, angina and arrhythmias. They are on PEEP to maintain gas exchange, in which
also used for anxiety, migraine and glaucoma. case manual hyperinflation is relatively contrain
Beta-blockers may induce bronchospasm and dicated.
tingling and numbness of the extremities, and
are contraindicated in asthma. Other side effects Sedatives
are fatigue, hypotension, breathlessness and the Sedation is required for most patients on IPPV,
blunting of cardiac exercise responses. but should not be used as first line management
of anxiety or asynchrony with the ventilator.
Anti-arrhythmic drugs Drugs that cloud consciousness cause delusions
These include amiodarone, which can cause if anxiety stems from patients' realistic percep
pulmonary fibrosis (Goldschlager et al., 2000). tion of their situation. Sedatives are no substitute
336
SUPPORT
for the primary task of explanations, relief of patients. They may be used as a last resort if
discomfort and accurate ventilator management. patients are resisting ventilation and deep
Commonly prescribed anxiolytics are: sedation is inadequate. Neuromuscular blockade
should not be used to keep a patient quiet. They
• diazepam or midazolam , which have a long act as a form of chemical restraint, and for
half-life patients this can feel frightening, especially if
• chlormethiazole, which can increase bron they are not told that they are being given a drug
chial secretions that will make them feel weak. Patients feel,
• iso{lurane, which if prolonged can cause liver hear and think normally, and need regular expla
failure nation and orientation.
• propofol, which stabilizes HR and BP. The induction of weakness, rather than
All sedatives reduce oxygen consumption but paralysis, is normally sufficient (Marino, 1995 ) .
can cause respiratory depression, loss of time Patients should be sedated t o the point o f unrou
sense and misinterpretation of voices and noises sability beforehand (Oh, 1997, p. 6 75 ) and
which can paradoxically increase anxiety. appropriate analgesia administered because
Midazolam can cause dizziness and hiccups. paralysing drugs obliterate the only means by
Propofol carries a high lipid load, which can which patients can indicate discomfort. Accurate
increase CO2 production (Sykes and Young, monitoring can be provided by a peripheral
1999, p. 229), but its quick onset makes it useful nerve stimulator (Rowlee, 1999) , but the drug
as a bolus 2 minutes before physiotherapy. It should be withdrawn every 48 hours to assess
attenuates metabolic as well as haemodynamic the need for continued paralysis (Marcy, 1994).
disturbance, stabilizing excess oxygen consump Disadvantages are risk of pneumonia (Cook,
tion and CO2 production (Cohen et al. , 1996) . 1998) and persistent myopathy in patients who
Both midazolam and propofol can reduce BP. are taking steroids (Behbehani, 1999) especially
if those in renal failure are taking pancuronium,
which is excreted by the kidney.
Analgesia
Treatment for pain, anxiety and ventilator
Prior to physiotherapy, a bolus of intravenous
asynchrony is interwoven, but medication for
analgesia is often indicated, using a short-acting
each should be distinguished. Harvey ( 1996 ) has
drug such as fentanyl or alfentanil. If this is not
shown that up to 25 0/0 of ICU staff believe paral
adequate, Entonox may be used before and
ysing drugs reduce anxiety, and up to 80%
during treatment. This can be administered
believe that diazepam has analgesic properties
through some ventilators either by the intensivist
despite evidence that sedatives can increase
or, after training, by a respiratory technician or
sensitivity to pain. Withdrawal syndromes can
physiotherapist.
develop when analgesics, sedatives or muscle
relaxants are stopped after prolonged use
Muscle relaxants (Cammarano et al. , 1998).
cyou can't scratch your arm if it itches. You
Drugs for airflow obstruction
can't do nothing. Except lay there in one
Airflow obstruction increases airway pressure
position. That's very, very uncomfortable.'
and heightens the risk of barotrauma and
Patient quoted by Jablonski, 1 994
haemodynamic disturbance. Bronchodilators or
Neuromuscular blocking agents such as atracur steroids can be delivered to ventilated patients
ium or pancuronium are paralysing agents. They by metered dose inhaler (MDI) or small-volume
are used if it is detrimental to allow patients to nebulizer. The effect of aerosolized drugs is
move after acute head injury, or as a means to variable and should be monitored, e.g. by
reduce oxygen consumption in severely hypoxic decreased wheeze on auscultation, a drop in
337
peak airway pressure, a normalized flow curve

(Figure 12.3a) or reduced intrinsic PEEP Advanced cardiac support
(Wollam, 1994). For patients in profound heart failure,
Nebulizers should be removed and cleaned temporary assistance by an intra-aortic balloon
after each use. Craven et al. (1984) found that pump can increase survival in high-risk patients
bacterial aerosol was produced by 71 % of in-line (Arafa et al. , 1998). The pump, housed in a
medication nebulizers. The hot-water humidifier console, is connected to a catheter with a
or HME should be removed during administra deflated balloon at its tip. This is threaded
tion. through the patient's femoral artery and into the
Nebulizers are more commonly used than aorta (Figure 12.10). Here it is triggered into
MDIs, but can increase the effort to trigger a action by the patient's ECG. Diastole causes
breath. An MDI with spacer delivers more drug balloon inflation, which assists aortic valve
than a nebulizer for the same dose (Marik et al. , closure and augments perfusion of myocardium,
1999). The MDI is placed at the Y-connector brain and kidneys. In systole, the balloon
and fired just after the beginning of inspiration, deflates, decreasing afterload and assisting the
using double the dose compared to sponta ventricle to empty.
neously breathing patients (Hess, 1994). Dry The effect is similar to combined inotropic
powder inhalers cannot be used in ventilator and vasodilator therapy, increasing myocardial
circuits. perfusion and reducing workload. Complications
include vascular damage, embolism and lower
Plasmapheresis limb ischaemia; peripheral perfusion should be
Plasma exchange is used to remove circulating checked hourly (Bentall, 1998). Heparinization
toxins or replace missing plasma factors in lessens the risk of thrombosis but increases the
people with immune-mediated diseases such as risk of bleeding.
Guillain-Barre syndrome or myasthenia gravis Indications for the baloon pump are critically
(Appleyard and Sherry, 1998). Blood is impaired cardiac output, e.g. cardiogenic shock
separated into its components in a centrifuge, or inability to wean from cardiopulmonary
plasma is discarded and a plasma replacement bypass. As patients recover, assistance is reduced
fluid is infused in equal volume. gradually from every beat (1: 1) to every 4th beat
(1:4). Implications for physiotherapy are the
following:
Pacemaker
When the heart's conducting pathways are • The augmented BP, visible on the console,
damaged, an artificial pacemaker can deliver an should be monitored throughout.
electrical stimulus to the myocardium. For • Hip flexion should be avoided on the cannu
temporary use, pacing wires connect the lated side.
patient's myocardium to an external pacing box. • Patients are often too unstable to turn, but if
For permanent support, the energy source is turning is indicated, care is required to avoid
implanted under the skin. disconnection of the catheter.
Indications are third-degree heart block, • If manual hyperinflation is necessary, cardiac
arrhythmias refractory to medication, and output should be monitored throughout.
prophylactic support in the first days after heart • Manual percussion or vibrations are unwise
surgery. Insertion of a permanent pacemaker because of interference with the ECG, and
requires the patient to rest afterwards, but they mechanical percussors and vibrators are
can mobilize fully in 24 hours. A cardioverter contraindicated. If vibrations are needed,
defibrillator may be implanted into patients at one supporting hand underneath the patient
risk of VF (Collins, 1994). minimizes movement.
338
SUPPORT
pump implanted in the abdomen. Developed as a

Diastole bridge to heart transplantation, mortality can be
reduced by 55% for patients awaiting a donor
(Tector, 1998) . It has also been developed for
permanent circulatory support Qarvik et at. ,
1998) .
Advanced pulmonary support

IPPV rests the respiratory muscles but does not
rest lung tissue itself. If potentially damaging
! volumes and pressures are being delivered by the

ventilator, they can be reduced by augmenting
gas exchange with intravascular oxygenation
(IVOX). Gas exchange occurs via a mop-like, 2-
foot-long bundle of hollow fibres lying free in
the vena cava. These are permeable to gases but
not fluids and are flushed continuously with
oxygen, while CO2 is discharged through a
double-lumen catheter. The device can provide
10- 25% of the patient's oxygen requirements
but obstruction to venous return may offset the
Systole benefits and it is little used at present.
Liquid ventilation eliminates the gas-liquid
interface in the lungs by filling them with an
Figure 12. 10 I ntra-aortic balloon pump, An external

balloon indicates the inflation or deflation of the intra-aortic
balloon, (From Collier, p, S, and Dohoo, p, J, ( 1 980) The
intra-aortic balloon pump, Physiotherapy, 66, 1 56- 1 57, with
permission,)
• To reduce the risk of bleeding, coughing

should be avoided for some hours after
removal of the balloon.
A ventricular assist device is a supplementary Figure 12. 1 1 Radiograph of liquid ventilation,
339
CHAPTER 1 2 INTENSIVE CARE, MONITORING AN D SUPPORT
inert colourless liquid called perfluorocarbon. carotid artery in infants, but it is well established
This is twice as heavy as water, highly soluble to in specialist neonatal units. Logistic difficulties
respiratory gases and opaque to X-rays (Figure for adults are more daunting, but both adults
12.11) . Partial liquid ventilation fills the lungs to and children can have protracted runs of up to a
FRC so that conventional IPPV can continue. month (Fiddler and Williams, 2000).
This support system eliminates surface tension, If patients are stable enough for physiother
allows ventilation at lower pressures, and helps apy, the ECMO cannulae require careful
alveolar recruitment in dependent areas by a handling and a technician should stand by in
'liquid PEEP' effect. Disadvantages are that case the machinery needs attention. Reliance
spontaneous breathing is hard work, and radio cannot be placed on auscultation because of the
opacity makes densities such as consolidation reduced ventilation. Bleeding during suction is
impossible to detect on X-ray, although pneu only a minor risk if there is tight heparin control
mothoraces are crystal-clear. Mucus cannot mix and percutaneous cannulation (Peek, 1997) but
with perfluorocarbon and tends to float on top, clotting status should be checked. Physiotherapy
from where it can be debrided by saline lavage is less likely to cause hypoxaemia than with
(Fuhrman et al. , 1998). Suction is forbidden. conventional IPPV because oxygenation is main
Liquid ventilation has so far shown benefits III tained outside the lungs.
paediatrics only. Support systems such as haemodialysis and
surfactant replacement are discussed with the
Advanced cardiopulmonary support relevant pathologies.
As a last resort for people with severe but poten
tially reversible cardiopulmonary failure, extra
I;ii�ilUi'i,i)·tI;i;'t4
corporeal gas exchange is a modified form of
cardiopulmonary bypass and buys time for an
injured lung to recover. Typical criteria include
Pa021FI02 ratio of less than 11. 2 and shunt of Identify the problems of this man, who collapsed in
more than 30% on 100% oxygen. A&E, then was intubated and ventilated in the
Extracorporeal membrane oxygenation ICU.
(ECMO) supports cardiorespiratory function via RM H : alcoholism, epi lepsy.
a veno-arterial (VA) circuit, or respiratory On S I MV and pressure support with 5 cmH20
function via a veno-venous (VV) circuit. The VA PEEP.
system requires 800/0 of the cardiac output to be Heavily sedated.
drained from the right atrium via a large vein, CVS stable.
pumped and oxygenated outside the body,
rewarmed and returned to the internal carotid Questions
artery, with CO2 transferring back as a I . Auscultation and percussion note (Figure
secondary effect. The VV system is less 1 2. 1 2a)?
damaging, requiring 20% of the circulating 2. Analysis?
volume to be outside the body at one time, at a 3. Problems?
lower flow and with less heparinization. It relies 4. Goals?
on some heart function. The lungs are held open 5. Plan?
with high PEEP levels, and oxygen is insufflated 6. Passive movements?
through an intratracheal cannula, then trans 7. Outcome (Figure 1 2. 1 2b)?
ferred to the blood by apnoeic diffusion.
Both systems reduce the need for IPPV and CVS = cardiovascular system, SIM V = synchronized
facilitate lung healing. There is concern about intermittent mandatory ventilation, RMH = relevant
neurological damage from cannulation of the medical history.
340 ------
SUPPORT
Figure 12. 12 X-ray of Mr FA before and after physiotherapy,
Idf14·]�k1', ,;ii�i'$1IiIi).ij
• Optimize analgesia
.
• Position in left-side-Iying
• Manual hyperinflation
• Percussion and vibrations
I . Auscultation and percussion note
• Suction.
Reduced breath sounds on right. percussion note
dull on the right. 6. Passive movements
Unsafe until patient is able to report pain and
2. Analysis
orthopaedic team has assessed fractured left
Collapse probably due to a seizure.
humerus. head of right humerus and right clavicle.
Figure 1 2. 1 2a suggests aspi ration to right lung.
Possible alcohol intake increases risk of aspiration. Outcome
Figure 1 2. 1 2b : short-term goal achieved.
3. Problems
Loss of lung volume on right.
Poor gas exchange.
• Possible pain. LITERATURE APPRAISAL
Comment on the choice of interventions for

4. Goals
lesser and greater degrees of atelectasis.
Short term: restore functioning lung vol ume.
Medium term: restore patient mobility. Those with a lesser degree of atelectasis
Long-term: team management of follow-up support were randomized to receive either early
and rehabilitation, mobilization or sustained maximal
inflations (SMI) . Those with a greater
5. Plan degree of atelectasis were separately
Review radiologist report in case of hidden rib randomized to receive either SMI or single
fractures. If all clear: handed percussions.
---- 34 1
C HAPTER 12 INTENSIVE CARE, MONITORING AND SUPPORT
. . . adding single-handed percussions to Duarte, A. G. (2000) Bronchodilator therapy with

patients with marked atelectasis does not metered-dose inhaler and spacer versus nebulizer
improve outcomes over those obtained with in mechanically ventilated patients. Respir. Care,
4 5 , 8 1 7-823.
SMI and early ambulation.
Fulbrook, P. ( 1 999) on the receiving end: experience
Postoperative physical therapy after coronary artery of being a relative in critical care. Nurs. Crit. Care,
bypass surgery. Am. J. Respir. Crit. Care Med. 4, 222-230.
1995; 1 5 2 : 953-958 Gelling, L. ( 1999) Causes of ICU psychosis. Nurs.
Crit. Care, 4, 22-26.
Girou, E. (2000) Infection control in the ICU. Int.
Care Med. , 26, 13 1-132.
RESPONSE TO LITERATURE APPRAISAL Grant, I. S. and Nimmo, G. R. ( 1 995) Oxygen
transport. Care Crit. Ill. , 1 1 (2), 67-69.
This appears to be based on the assumption that
Griffiths, R. D . ( 1 997) Feeding the critically ill.
mobilization is indicated for less severe atelecta
Intens. Care Med. , 23, 246-247.
sis and percussion is indicated for more severe
Hess, D. (2000) Detection and monitoring of
atelectasis. hypoxemia and oxygen therapy. Respir. Care, 45,
Mobilization IS indicated for atelectasis. 65-80.
Percussion is indicated for sputum retention. Kahn, D . M., Cook, T. E. and Carlisle, C. C. ( 1 998)
A glance at the physiology might have saved Identification and modification of environmental
the authors a bit of time. noise in an ICU setting. Chest, 1 1 4, 5 3 5-540.
Kavanagh, R. J. ( 1995) Crystalloids and colloids in
the critically ill patient. Care Crit. Ill, 1 1 , 1 1 4-
1 1 9.
RECOMMENDED READING Lawrence, M. ( 1 995) The unconscious experience.
Ahrens, T. ( 1 999) Continuous mixed venous Am. J. Crit. Care, 4, 227-232.
monitoring. Crit. Care Nurs. Clin. North Am., 1 1 , Quirk, J. (2000) Malnutrition in critical ill patients in
33-48. ICUs. Br. J. Nurs., 9, 5 3 7-5 4 1 .

Ahrens, T. ( 1 999) Capnography. Crit. Care Nurs. Schallom, L . and Ahrens, T . ( 1 999) Using oxygenation
Clin. North Am., 1 1, 49-62. profiles to manage patients. Crit. Care Clin. N.
Ahrens, T. ( 1 999) Pulse oximetry. Crit. Care Nurs. Am., 1 1 , 437--446.
Clin. North Am., 1 1, 8 7- 9 8 . Shelly, M. P. ( 1 99 8 ) Sedation in the ITU. Care Crit.

Barnitt, R. and Partridge, C. ( 1 997) Ethical reasoning Ill., 14, 85-8 8 .
in physical therapy and occupational therapy. Theaker, c . , Mannan, M . , Ives, N. and Soni, N.
Physiother. Res. Int. , 2, 1 78-192 . (2000) Risk factors for pressure sores in the
Cowie, M. R . ( 1 994) Understanding critically ill. Anaesthesia, 5 5 , 221-224.
electrocardiograms. Student Br. Med. ]., ii, 229- Webb, J. M. (2000) Delirium in the ICU. Crit. Care
232. Nurse, 22, 47-60.
342
13 MECHANICAL VENTILATION
SUMMARY
Introduction Modes
Indications Positive end-expiratory pressure
Airway High-frequency ventilation
Principles Weaning and extubation
Benefits Mini case study
Complications Literature appraisal
Settings Recommended reading
INTRODUCTION INDICATIONS
Patients often had difficulty understanding Patients may not have primary respiratory
where the machinery ended and their bodies disease but are in impending or established
began [others] resented health respiratory failure. Indications are the following:
professionals touching their ventilators ...
[others] perceived the surrounding • Patients who are unable to ventilate
machinery as reassuring. Patients reported adequately, oxygenate adequately or both.
a need for repeated explanations. Examples are respiratory depression due to
Jablonski, 1994
post-anaesthesia or drug overdose, inspira
tory muscle fatigue due to exacerbation of
Intermittent positive pressure ventilation (IPPV) COPD, inspiratory muscle weakness due to
augments or replaces the function of the inspira neurological impairment, or severe hypox
tory muscles by delivering gas under positive aemia due to lung parenchymal disease.
pressure to the lungs. This substitutes for the • Patients who are able to breathe adequately
respiratory pump but is not necessarily beneficial but for whom this is deemed inadvisable,
for lung tissue, which is vulnerable to the shear e.g. those with acute head injury.
forces of repetitive opening of alveoli. There is a • Patients who require intubation for airway
narrow range of pressures and volumes within protection or to overcome upper airway
which the lungs are safe from either overdisten obstruction. They require some ventilatory
sion or atelectasis. support to compensate for the work of
The traditional philosophy of ventilator breathing (WOB) through the tubing.
management was the aggressive pursuit of text
book blood gas values, with secondary concern
AIRWAY
for complications. Now the primary aim is to
minimize complications even if this leads to a 'like a toilet paper roll ... a hard rubber
degree of respiratory acidosis. IPPV is less about tube ... a soggy cigar ... like you were
the application of a machine to a passive patient, gagging on something.'
and more about the complex interaction between Patient describing his endotracheal tube Oablonski,
patient and machine. 1994)
343
CHAPTFR 13 MECHANICAL VENTILATION
Patient and ventilator are connected through a

sealed tracheal tube (endotracheal or tracheost
omy tube Figure 13.1), which reaches sufficiently
beyond the vocal cords to safely allow some
head movement.
An endotracheal tube (ETT) through the
mouth or nose can be used for up to 2 weeks,
but causes discomfort, distress and sometimes
panic (Stauffer, 1999). A nasal tube is marginally
better tolerated than an oral tube and causes less
movement-related injury to the larynx, but
creates more airflow resistance and increases the
risk of sinusitis Guniper, 1999b). Average
internal diameter sizes are 8 mm for oral and
7 mm for nasal tubes.
A percutaneous tracheostomy tube is more
comfortable than an Err, causes less resistance,
is easier for suctioning, may allow the patient to
eat and is used when longer-term ventilation is
anticipated. A newly created tracheostomy
signifies the need for extra care during patient
handling, especially suctioning.
A cuff (p. 279) prevents escape of ventilating
gas past the tracheal tube and inhibits large
volume aspiration. It is not watertight and does (e)
not compensate for the small-volume aspiration
caused by inability of the vocal cords to close.
All patients on IPPV therefore have some gastro
oesophageal reflux (Carter and Hornick, 1999).
The optimum cuff pressure to maintain mucosal
perfusion but minimize risk of aspiration is
25 mmHg, checked by nursing staff regularly
with a manometer.
The problems of tracheal tubes are:
• disrupted communication Figure 13.1 Tracheal tubes. (a) Oral endotracheal tube.
• swallowing dysfunction in up to 50% of (b) Nasal endotracheal tube. (c) Tracheostomy tube.
patients (Tolep, 1996)
• risk of chest infection because of the damage
described above, loss of defence mechanisms over-salivation, airflow resistance and
and an invitation for bacteria to breed in the damage to the trachea and larynx.
pool of secretions that collects above the cuff
and then trickles down past the cuff into the Airway damage is exacerbated by mishandling,
lungs traction from the weight of the ventilator circuit
• with a tracheostomy, the complications and excessive neck movement which can cause
described on page 281 2 cm excursions of the cuffed tube on either
• with an ETT: discomfort, gagging, retching, flexion or extension (Weiner et aI., 1991).
344 ------
BENEFITS
Humidification is provided by a hot-water Volume control (or volume-limited ventila

humidifier, which is the most effective device tion) delivers a specific minute volume at a
and only needs to be changed between patients constant flowrate, using preset variables such as
(Dreyfuss, 1995). Temperature alarms are set at respiratory rate (RR), tidal volume (VT) and
maximum 37°C and minimum 30°C. An alterna inspiratory:expiratory (I:E) ratio. Airway
tive is a heat-moisture exchanger (HME), which pressure rises slowly during inspiration to a peak
is adequate for short-term use in well-hydrated value that varies with airway resistance and lung
patients who do not have excessive or thick compliance. A pressure limit is set for safety.
secretions. HMEs pose a lesser infection risk, Pressure control (or pressure-limited ventilation)
and incorporate antibacterial properties. delivers a preset pressure during inspiration,
However, their use should be limited to between resulting in a variable VT that depends on the
24 hours (Marcy, 1994) and 5 days (Branson et preset pressure, airway resistance, lung compli
aI., 1993) because they have not been shown to ance, patient effort and inspiratory time.
reduce the incidence of pneumonia (Dreyfuss, Volume control is commonly used for adults
1995) and can cause obstruction with thick for three reasons:
secretions (Marcy, 1994).
• It can be relied on to deliver a consistent
minute volume regardless of airway resis
PRINCIPLES tance and lung compliance.
A bewildering array of all-singing all-dancing • It maintains steady PaC02 levels when this is
ventilators are flooding the market, leading to a imperative, e.g. III acute head-injured
terminology jungle which becomes more patients.
complex as their versatility increases. A ventila • Inspiratory pressure increases gradually and
tor breath can, however, be classified according may cause lesser shear forces on the alveoli.
to how it is triggered into inspiration, controlled Pressure control is usually considered to be
(generated) during the inspiratory phase, and safer for patients with stiff lungs (indicated by
cycled into expiration. peak airway pressure above 35 cmH2 0 on
volume control), especially for those with ARDS,
Trigger
for whom it reduces the work of breathing
Either the patient or ventilator can trigger (Kallet, 2000). For babies, it limits alveolar
inspiration. For patient-triggered breaths, older pressures and may reduce the risk of barotrauma.
machines require patients to trigger their breaths
by a preset pressure of typically between -1 and Cycle
-2 cmH20. This entails activation of a demand Inspiration cycles into expiration when a preset
valve and a degree of effort, because an inbuilt time has elapsed (time-cycled) or a preset
insensitivity is necessary to prevent artefacts pressure has been reached (pressure-cycled) or
setting off inspiration. New machines use a more when a preset volume has been delivered
comfortable flow trigger, which senses a drop in (volume-cycled). Time cycling is the commonest
the patient's flow at a sensitivity of, say, 3 L/min. and is adjusted via flow and/or I:E ratio.
For ventilator-triggered breaths, the inspiratory Pressure control is different from pressure
trigger is set according to time so that inspiration cycling, a pressure-controlled breath being
occurs automatically at a set rate. usually cycled into expiration after a preset time.
Control
BENEFITS
The method of control is the driving mechanism
that delivers the inspiratory breath. It remains • IPPV acts as an accessory muscle to supple
constant despite changes in ventilatory load. ment patient effort. This is hindered if there
345
CHAPTER 13 MECHANICAL VENTILATION
is a narrow Err, obstructed airways, stiff Haemodynamic compromise is most likely if

lungs, poor trigger sensitivity or inap mean airway pressure is high, inspiratory time
propriate settings so that patient and prolonged or mean expiratory pressure raised as
machine are not synchronous. with PEEP. These effects can be modified by
• IPPV allows control of gas exchange and fluids, inotropic drugs (p. 335) or reduced I:E
acid-base homeostasis by manipulating ratios so that the heart has time to fill during the
inspired oxygen, minute volume, aIrway longer expiratory phase. Patients with poor lung
pressure, I:E ratio and PEEP. compliance suffer less haemodynamic compro
mise because the alveolar pressure is transmitted
less easily through the stiff lung.
COMPLICATIONS
The negative effects of IPPV are of particular Barotrauma

interest to the physiotherapist because some Barotrauma is extra-alveolar aIr, e.g. pneu
complications are worsened by the extra positive mothorax. The name arose from assumptions
pressure of manual hyperinflation. that the cause was excess pressure, because
affected patients tend to have high peak
Impaired cardiac output pressures. It is now understood that excess
Positive pressure in the chest impedes venous volume is the cause, because sustained alveolar
return (preload) to the heart, which tends to distension can rupture the delicate alveolar
decrease cardiac output, which in turn reduces capillary membrane (Heulitt, 1995). This
renal, hepatic and splanchnic blood flow. explains why coughing, when pressure increases
Compensatory peripheral vasoconstnctlOn massively but volume is stable, rarely causes
normally maintains blood pressure, but this barotrauma. The term 'volutrauma' rather than
mechanism may not be viable in patients who are 'barotrauma' is sometimes used to describe
elderly, who suffer autonomic neuropathy such as extra-alveolar air in this context.
Guillain-Barre syndrome, or are hypovolaemic, Air first extrudes from distended alveoli,
either absolutely, or functionally due to vasodila then tracks centrally along bronchovascular
tion e. g. in septic shock. These patients may drop sheaths (Figure 1 3.2), causing pulmonary inter
their BP, especially when first ventilated. stitial emphysema, i.e. air in interstitial lung
�====t;;>""1 Arteriole
Figure 13.2 Developm ent of barotrauma. Second picture shows overdistended alveoli l eadi ng to rupture of delicate
alveolar-capillary m em branes. (From Maunder, R. T. , Pierson, D. J and Hudson, L. D. ( 1 984) Subcutaneous and mediastinal
emphysema: pathophysiology, diagnosis and management. Arch. Int. Med., 144, 1 447- 1 453)
346
COMPLICATIONS
spaces. This can lead to pneumomediastinum,

sometimes detectable on X-ray and usually Displaced ventilation
evident on CT scan (Wiener et al., 1 991). A Spontaneous breathing draws ventilation down to
pneumomediastinum tends to vent into subcu dependent lung regions, causing a downwards
taneous tissue and cause surgical emphysema ventilation gradient (p. 9). If the patient is
(Figure 1 3.3), which may herald a pneu receiving full ventilator-triggered IPPV in the
mothorax Gantz and Pierson, 1994). Pneumo form of controlled mechanical ventilation, this
pericardium is not easily distinguishable from gradient is reversed (Figure 1 3.1 4) and ventilation
pneumomediastinum but is rare and usually is abolished in dependent lung regions (Heden
occurs only after heart surgery or in neonates stierna, 1 997). Reasons are the following:
with stiff lungs.
• Positive pressure gas takes the path of least
Barotrauma is a significant risk in lungs that
resistance which is to the more open upper
are stiff, hyperinflated or unevenly damaged. X
regIOns.
ray identification is discussed on page 49.
• The diaphragm is inactive and it is irrelevant
that its dependent fibres are more stretched
Displaced perfusion by abdominal viscera.
The positive pressure of controlled mandatory • The lower region is compressed by the
ventilation (p. 350) displaces blood from the increased perfusion gradient and IS less
thorax and accentuates the perfusion gradient compliant.
from upper to lower regions, leaving non
Dependent areas therefore receive the least
dependent lung regions virtually without blood
ventilation and are vulnerable to progressive
flow (Figure 1 3.4). The degree to which
atelectasis. The ventilation gradient is less
perfusion is affected depends on the proportion
disturbed when a mode is used in which sponta
of positive pressure created by the mode of
neous breathing is encouraged.
ventilation.
Increased dead space
Dead space increases because of reduced overall
perfusion, and to a lesser extent because of
distension of ventilator tubing.
VAIQ mismatch
Disturbed ventilation and perfusion gradients,
and increased dead space, result in VA/Q
mismatch, which would lead to hypoxaemia if
not offset by ventilator strategies such as PEEP,
inspiratory pause and supplemental oxygen.
Fluid imbalance
Fluid retention can be caused by decreased renal
perfusion, redistribution of blood flow within
the kidneys, and stress- mediated ADH secretion
(Pilbeam, 1998, p. 1 48). Fluid maldistribution
Figure '3.3 Soft tissue shadowing outside the rib cage in
can occur with large lung volume changes,
the subcutaneous tissues of the upper trunk, indicating
surgical emphysema. The patient is intubated, has a chest causing overdistension of alveoli, depletion of
drain su ggesting a recent pn eumothorax, and a calci fied surfactant, microvascular damage, leakage of
aorta suggesting advanced age. fluid and pulmonary oedema (Heulitt, 1 995).
347
Perfusion
gradient
_=-::.. Alveoli
Ventilation o
gradient o
o
o
Perfusion o 0
gradient o o
o
o
Pressure
from
I abdominal
Ventilation
contents
gradient
..
..
Figure 13.4 Effect of controlled mandatory ventilation on ventilation and perfusion gradients. In contrast to spontaneous
respiration, the perfusion gradient increases downwards and the ventilation gradient is reversed . Compare with Figure 1 . 6.
tion capabilities and is dependent on arterial

Discomfort blood pressure. It is therefore vulnerable to
IPPV can be uncomfortable if full explanations haemodynamic changes and abdominal disten
are not given and if ventilation is not matched sion. Reduced perfusion can increase the perme
synchronously to the patient. ability of the gut mucosal barrier and increase
the incidence of paralytic ileus, bleeding, ulcera
Breathlessness tion (Pilbeam, 1 998, p. 1 49) and systems failure
Even when minute volume is adequate, patients (p. 409). Positive pressure also delays gastric
can feel breathless because of asynchronous emptying, which increases the risk of aspiration
ventilation, loss of control of their breathing, (Rennie, 1 997).
increased airflow resistance in the tracheal tube
and abnormal stimulation of lung stretch Complications of high oxygen levels
receptors. Oxygen toxicity (p. 1 20) can occur with
prolonged high Fj02 levels. Absorption atelecta
Gut dysfunction sis (p. 1 20) can occur when a high FI02 is used
Splanchnic blood flow does not have autoregula- with low tidal volumes.
348
SETTINGS
respectively. A healthy spontaneously breathing

Excess secretions adult maintains adequate ventilation with a VT
Bronchial secretions are increased, partly by irri of 450-600 mL and RR of 1 0-1 5/min to give
tation from the tracheal tube and partly because an approximate minute volume of 5-9 L.
secretion clearance is impaired. Secretion Minute volume is adjusted according to PaC02,
volume increases with length of intubation VT being adjusted for a small change in PaC02,
(Palmer and Smaldone, 1 998). and RR adjusted for a larger change. Normal
range for minute volume on IPPV varies
widely; a COPD patient with chronic hypercap
Gas trapping
nia requires a great deal less than a hypermeta
Intrinsic PEEP (p. 68) occurs unintentionally bolic septic patient.
when exhalation has not finished before the next Inspired oxygen concentration (FI02) is
breath starts. It is more likely with volume adjusted according to Pa02, although the rela
control ventilation and commonest with hyperin tionship between FI02 and Pa02 is less direct
flation conditions such as emphysema or acute than that between minute volume and PaC02
asthma, when air is trapped in the lungs by (Chatburn, 1 991 ) because Pa02 is subject to
obstructed airways and a narrow tracheal tube. more variables.
The result is overdistended alveoli and risk of Inspiratory flow rate is related to the I:E
barotrauma. ratio. I:E ratio is normally 1 :2 to allow
Signs of hyperinflation such as reduced breath adequate expiratory time for CO2 clearance and
sounds and hyperresonant percussion note venous return. It can be set as low as 1 :4 to
suggest that intrinsic PEEP is present. Confirma prevent intrinsic PEEP or as high as 4:1
tion is by a flow-time curve showing persistent (inverse-ratio ventilation) in severely hypoxae
flow at end-expiration (see Figure 1 2.3b). The mic patients in order to recruit alveoli. For a
effects of this unwanted PEEP can be mitigated patient with emphysema and prolonged expira
by ventilator manipulations and airway tion who normally has a spontaneous I:E ratio
clearance to reduce airways resistance. Extrinsic of 1 :5 or 1 :6, inspiratory flow is increased for
PEEP (p. 353) can be deliberately imposed to rapid inspiration and long exhalation. For a
counterbalance intrinsic PEEP, provided it is patient with fibrotic lungs who works hard to
below the intrinsic PEEP level (Patel and Yang, inhale and whose high recoil pressure speeds
1 995). exhalation, the flow rate is slowed for
prolonged inspiratory time and short expiratory
Weak inspiratory muscles time.
Resting the respiratory muscles causes atrophy, Inspiratory pause (plateau) provides an end
the degree of which depends on the relative inspiratory-hold, which enhances gas distribu
contribution of ventilator and patient. tion by allowing time for recruitment of
poorly ventilated alveoli. Trigger sensitivity
dictates the patient's negative pressure that is
SETTINGS required to initiate the breath if pressure-trig
'Sometimes it's going too fast for you, so gering is used. A sigh mechanism is available
instead of the machine synchronizing with with some ventilators but little used; in most
you, you have to synchronize with the patients the risk of atelectasis is better reduced
machine. ' by PEEP (Chatburn, 1 991 ), but patients with
Patient quoted by Jablonski, 1994
acute respiratory distress syndrome (ARDS)
have shown improved gas exchange with this
Ventilation and oxygenation are matched to 'automatic sigh' facility (Pelosi et al., 1 999).
the patient according to PaC02 and Pa02
349
MODES Synchronized intermittent mandatory

IPPV can take over the WOB by controlled ventilation (SIMV)
mandatory ventilation, or the work can be If patients do not breathe after a preset time
shared between ventilator and patient using a interval, the SIMV mode delivers a mandatory
variety of ventilatory modes. These create the breath. Breaths are mandatory or spontaneous
pressure, flow and volume patterns that allow according to the stage of the SIMV cycle
ventilatory support to be adjusted to the indivi (Figure 13.5a). SIMV has superseded IMV
dual so that less sedation is required and less because synchrony with inspiratory effort is
complications ensue. Modes have to be matched more comfortable, thus avoiding breath
skilfully to the patient because all are less stacking and excess WOB. Preset variables
efficient than spontaneous breathing (Shelledy, include RR, VT, inspiratory time and pause
1 995). Too much support leads to muscle time. Cycling is by pressure or time, whichever
atrophy, and too little overworks the patient. comes first.
Terminology varies according to country and
manufacturer but the following are common Pressure support
parlance. Pressure support (PS) is a patient-triggered flow
cycled mode which provides a preset pressure
Controlled mandatory ventilation (CMV) boost to each inspiratory effort. This pressure
Fully controlled mandatory ventilation is a continues on a plateau until inspiratory flow is
ventilator-triggered mode that is only needed less than 25% peak, when cycling into expiration
for patients who are unable to breathe at all or occurs. Patients can determine their own RR, VT
for whom complete control is necessary (see and I:E ratio (Figure 13.5b). The preset variables
Figure 1 2. 2). CMV is an unforgiving mode that are trigger sensitivity and pressure support level.
dictates the depth and frequency of each breath PS reduces WOB in proportion to the pressure
and time-cycles into exhalation. Patients do not delivered. A pressure of 5-8 cmH20 overcomes
like to be controlled and sedation is always the work imposed by the ventilator circuit and
required. Risks of intrinsic PEEP and other ETT, and is therefore equivalent to spontaneous
complications are significant. Minute volume is breathing. A pressure of 25 cmH20 effectively
set high enough to maintain a mild respiratory eliminates the patient's need to do more than
alkalosis so that spontaneous breathing 1S trigger the breath.
inhibited. PS is relatively comfortable and ensures
synchrony because patients have control. It acts
Assist-control like IPPB (p. 1 59) but inspiration is terminated
Assist-control is patient- triggered CMV. Breaths according to flow rather than pressure, thus
are triggered or imposed according to patient discouraging the unhelpful expiratory effort that
effort. In some ventilators the only difference can impair the effectiveness of IPPB. PS is used
from CMV is the trigger sensitivity, while in for patients who can reliably trigger the ventila
others there are more sophisticated differences. tor. A modification of PS is called proportional
Hyperventilation and respiratory alkalosis are assist. This acts as a form of 'power steering' by
risks. responding to the patient in proportion to
inspiratory effort.
Intermittent mandatory ventilation (IMV)
The IMV mode allows patients to breathe spon Assist mode
taneously between a preset number of mechani This is similar to the PS mode, and the term is
cal breaths, without regard for the patient's sometimes used interchangeably, but the
breathing pattern. breathing pattern is fixed by the characteristics
350 ------
MODES
SIMV period Spontaneous period SIMV period Spontaneous period
(a) II
"" Patient
trigger
(b) o
Spontaneous period
CJ
., 0
"
1 CPAP level
(d)
.......
!
High pressure
Low pressure
(e)
Time ai Time at
high pressure low pressure
Figure 13.5 Pressure-time curves. Negative deflections ind icate patient-triggered breaths. The baseline would normally be
raised above zero to indicate PEEP. (a) SIMV. The first cycle shows a mandatory breath synchronized with the patient's
inspiration, then spontaneous breaths. The second cycle shows an apnoeic period, then a mandatory breath triggered by the
ventilator after a preset time interval. (b) Pressure support. Breaths vary according to the patient's breathing pattern. (c) SIMV
with pressure support. Spontaneous breaths are supported by inspiratory pressure. (d) CPAP. All breaths are spontaneous
breaths at an elevated pressure level. (e) Airway pressure release ventilation. All breaths are spontaneous and at an elevated
pressure level, but the pressure is released at timed intervals.
351
of the lung and the machine rather than the

patient (Sykes and Young; 1 999, p. 1 53). Inverse-ratio ventilation
For patients with refractory hypoxaemia and
SIMV with pressure support high peak airway pressures, mean airway
SIMV is often combined with pressure-supported pressure can be raised and peak airway pressure
spontaneous breaths in order to overcome the reduced by prolonging inspiratory time to the
resistance of the tubing or, at higher pressures, to point of reversing the I:E ratio. The inspiratory
provide extra support (Figure 1 3. 5c). flow rate is slowed or the inspiratory pause
increased so that a longer inspiration recruits
Continuous positive airway pressure collapsed alveoli and a shorter expiration
(CPAP) prevents recollapse. Disadvantages are risk of
CPAP (Figure 1 3.5d) is used with spontaneously distended alveoli, intrinsic PEEP, compromised
breathing patients. For intubated patients, it cardiac output and the discomfort of an
follows the same principle as non-invasive CPAP unnatural breathing pattern during which the
by mask. It carries the same disadvantage of patient is often unable to fully exhale. Heavy
increased expiratory WOB, but when delivered sedation is required and no spontaneous
through a ventilator, it is more beneficial than breathing allowed. Inverse-ratio ventilation is
mask CPAP because: usually used with pressure control to reduce the
risk of barotrauma for people with ARDS
• it imposes less inspiratory WOB because the (Ludwigs, 1 998).
trigger is by a demand-flow system
• it carries no mask complications Airway pressure release ventilation
• it substitutes for the bypassed larynx by This modified form of BiPAP allows unrestricted
creating a form of physiological PEEP (p. spontaneous breathing throughout the cycle
357) to prevent alveolar collapse. (Putensen et ai., 1 999), with intermittent 1-2
second releases so that CO2 can be eliminated
CPAP is specifically suited to patients who and fresh gas can fill the alveoli (Figure 1 3.5e).
have poor gas exchange or intrinsic PEEP due to Preset parameters are the high and low
airflow obstruction. When combined with pressures, and the times at each pressure level.
pressure support, it is similar to BiPAP. The pattern of lung volume change is similar to
inverse ratio ventilation and therefore reduces
Bilevel positive airways pressure (BiPAP) peak pressures, but the patient can breathe spon
BiPAP through the ventilator is equivalent to the taneously.
support provided by non-invasive ventilation for
the spontaneously breathing patient (p. 1 79). Permissive hypercapnia
Beware the terminology 'BIPAP' with a capital I, This is not a mode as such, but an outcome of
which is a different and obscure mode (Silver, the current approach towards limiting the
1 998) similar to airway pressure release ventila pressure and volume risks of ventila�ion. Delib
tion (see below). erately underventilating the patient causes CO2
retention but helps mitigate some of the compli
Mandatory minute ventilation (MMV) cations of IPPV. Blood gas targets are modified
MMV is a little-used mode in which the ventila and a low minute volume allows PaC02' to rise
tor provides a guaranteed preset minute volume up to 8 kPa (60 cmH20), with pH and oxygena
if the patient's spontaneous breathing drops tion closely monitored. Compensation restores
below a preset level. Pressure support is pH in the brain and myocardium towards
sometimes added to ensure an adequate VT for normal over several hours (Allan, 1 998). If there
patients with rapid shallow breathing. is no cerebral or cardiac injury, hypercapnia is
352
POSITIVF END-EXPIRATORY PRFSSURF
normally well tolerated and pH might be In healthy adults, 5 cmH20 of PEEP raises
allowed to drop to 7.2, at which level compen FRC by 400-500 mL (Wilkins et aI., 1 995, p.
sating mechanisms are usually adequate if the 251 ). At optimum pressures, PA-a02 is reduced
kidneys are functioning normally (Freichels, and oxygen saturation improved. The risk of
1 998). Permissive hypercapnia is used for people atelectasis is decreased at pressures above
with damaged lungs such as ARDS, or those 1 0 cmH20, as shown by reduction in radiologi
sustaining high airway pressures e.g. acute cal lung densities, but these reappear within a
asthma. minute of removing the PEEP (Brooks-Brunn,
1 995).
POSITIVE END-EXPIRATORY PRESSURE (PEEP)

Complications
There are several ways to boost Sa02: Excess PEEP can cause hyperinflation, which is
• i F102 risky and does not increase recruitment for gas
• prolong the plateau exchange (Peruzzi, 1 996). High levels of PEEP
• i I:E ratio are associated with complications that are exag
• apply PEEP. gerations of the complications of mechanical
ventilation, especially the following:
To all intents and purposes, PEEP is CPAP,
but the term is used for ventilated patients only. • The continuous positive pressure impairs
PEEP maintains constant positive pressure in the venous return and cardiac output. This can
lungs throughout exhalation so that airway offset the beneficial effects of PEEP by
pressure does TJot fall to atmospheric pressure at causing a net decrease in oxygen delivery to
end-exhalation. Like CPAP, it prevents alveoli the tissues. Haemodynamic compromise
from collapsing and aims to improve oxygena usually occurs at over 1 5 cmH20 PEEP in
tion. Unlike CPAP, it does not require the normovolaemic patients, at lower pressures
patient to breathe. in hypovolaemic patients and at higher pres
PEEP can be used with any mode of ventila sures in patients with stiff lungs. Fluid
tion. Pressures vary from 3 cmH20 to over administration may compensate by boosting
20 cmH20 and are shown when the manometer intravascular volume and stabilizing cardiac
of the ventilator returns to this value instead of output, but this may incur pulmonary
zero at end-exhalation. For pressure-triggered oedema when PEEP is discontinued. Haemo
breaths, the machine is set to cycle into inspira dynamic monitoring is required, especially if
tion a few cmH20 below the PEEP level so that perfusion to the gut and kidney is at risk
the patient does not have to make an inspiratory (Azar, 1 996). PEEP should be applied in
effort all the way down to zero. This applied small increments and titrated against oxygen
PEEP is termed 'extrinsic PEEP' when it needs delivery.
to be distinguished from intrinsic PEEP. • PEEP increases the risk of barotrauma in
patients who have lung disease, especially in
Benefits hyperinflation conditions, unless carefully
controlled extrinsic PEEP is being used
Positive effects of PEEP include:
specifically to reduce intrinsic PEEP
• stability of alveoli and conservation of • Raised pressure within the thoracic cage
surfactant (Verbrugge, 1 998) increases CVP and PAWP readings (p. 327
• resting lung volume raised out of the range and 329) at the same time as the ventricular
of airway closure filling pressure that they represent is
• increased alveolar availability for gas declining because of impaired venous return.
exchange. • High-level PEEP may disrupt the alveolar-
353
capillary barrier and redistribute alveolar

fluid, leading to pulmonary oedema.
• When disconnecting the ventilator circuit for
Q)
suction, pressure from PEEP increases blow E
::J
back, with risks to staff and other patients of (5
>
cross-contamination. This risk is eliminated
with an in-line suction catheter.
Precautions
Pressure
High-level PEEP should be avoided with an
undrained pneumothorax and used with caution
in patients who have surgical emphysema, bulla Figure 13.6 Effect of PEEP on regional pressure and
or bronchopleural fistula. Hypovolaemia is a volume relationships, showing how it improves ventilation in
relative contraindication, but if PEEP is dependent lung. Compliance is greater (the curve s teeper)
in the upper part of the lung without PEEP, and in the base
necessary, measures can be taken to support
of the lung with PEEP. (From Lumb, A. B. (2000) Nunn's
cardiac output with fluids and inotropes. At Applied Respiratory Physiology, 5th edn. Butterworth
levels above 1 0 cmH20, manual hyperinflation Heineman, London)
requires certain precautions (p. 375).
Best PEEP
While effective PEEP increases lung compliance
RR up to 600/min, its VT is less than its dead
and boosts Sa02, excessive PEEP decreases
space but it still manages to achieve gas
compliance by over-distending alveoli (see Figure
exchange by a mechanism similar to the intri
1 .3), and reduces cardiac output. Best PEEP
guing phenomenon of high frequency ventilation
means optimum oxygen delivery. If tissue oxyge
(HFV).
nation monitoring is not available, PEEP is
There are three basic methods of this form of
titrated against the optimum balance of Sa02 and
mechanical ventilation:
cardiac output. The effect on oxygen delivery is
measurable within 1 5 minutes of initiating PEEP • High frequency positive pressure ventilation
(Patel, 1 993). Figure 13.6 shows how best PEEP uses time-cycled conventional ventilation at
improves ventilation to the lung bases. a RR of 50-1 00/min.
• High frequency jet ventilation, the most
Indications widely available method, directs short rapid
'Physiological' PEEP at 3-5 cmH20 is routinely jets of gas through a nozzle into the airways
applied in order to maintain alveolar stability, and entrains air by the Venturi principle.
and is especially useful in low lung volume states Expiration is by passive recoil and a RR of
to prevent progressive parenchymal mJury. 1 00-600/min is achieved.
Higher levels of PEEP promote gas exchange • High frequency oscillation (HFO) forces
and reduce the necessity for toxic levels of mini-bursts of gas in and out of the airway.
inspired oxygen. Occasionally, differential venti Both inspiration and expiration are active,
lation with selective PEEP is used for targeting which avoids the gas trapping that often
specific atelectatic areas (Klingstedt et aI., 1 991 ). occurs with passive exhalation (Hardinge,
1 995). This can be superimposed on sponta
neous breathing to reduce WOB or mobilize
HIGH FREQUENCY VENTILATION
secretions (pp. 1 81 , 202) or it can be the
How does the Himalayan mountain shrew sole method of ventilation. Rates up to
maintain oxygenation during copulation? With a 4000/min are possible.
354
WEANlNG AND EXTUBATION
• Except with HFO, secretion clearance may

Mechanism be adversely affected (McEvoy et al., 1982).
With such a meagre VT, gas exchange is complex • HFV is noisy.
and cannot rely on bulk flow of gas. The classic
concept of 'dead' space is no longer applicable, Indications
and this space is in fact thought to play an active HFV tends to be used as a rescue mode when
part in gas exchange by the following mechan other techniques have failed. Enthusiasts
isms (Bower, 1995): consider the following to be indications:
• vulnerable lungs such as occur with ARDS
• High velocity flow creates turbulent mixing
• bronchopleural fistula, large air leak, flail
in the central airways, which is propagated
chest, acute head injury or unstable cardio
peripherally by convective inspiratory flow.
vascular status, so long as low airway pres
• Gas mixing may occur by asynchronous
sure is assured
filling and emptying of alveoli independent
• patients with an inordinate respiratory drive,
of each other, an effect known merrily as
or a need for minimum sedation
'disco lung'.
• patients with unilateral lung stiffness, usmg
• Molecular diffusion, the primary mechanism
differential ventilation to each lung
of normal gas exchange in terminal lung
• neonates, especially HFO.
units, is augmented, especially by the
vibrating gas of HFO.
Physiotherapy
Advantages Jet ventilation through a minitracheostomy
• Lung tissue is protected because alveoli are allows patients to take deep breaths and cough.
subject to minimal volume and pressure Suction can be performed without interruption
changes (Durbin, 1993). of ventilation. Suction has less adverse effects on
• Spontaneous respiration is inhibited and oxygenation or heart rhythm than IPPV. Manual
little sedation is needed. Most patients find hyperinflation is not possible and Fr02 must be
the sensation comfortable, as if being increased by about 20% for 3 minutes before
massaged from the inside. and after suction.
• HFV provides an even distribution of venti
lation because diffusion is independent of WEANING AND EXTUBATION
regional compliance and gas flow does not
take the path of least resistance. <1 was sure 1 would not be able to breathe
• Jet ventilation via minitracheostomy allows on my own. The machine was put to a
spontaneous respiration through the normal setting which gave me a couple of breaths
aIrway. and the rest was up to me. 1 hated that, 1
never knew when to take my breaths.'
Ludwig, 1984
Disadvantages
• Shallow breaths hinder lung recruitment for Weaning should be a seamless process through
oxygenation (Herridge and Slutsky, 1996). out the period of mechanical ventilation. The
• With jet ventilation, humidification is diffi physiotherapist starts on the process straight
cult, although possible with a hot-plate away. After a preliminary rest, an exercise
vaponzer. programme is initiated as the patient is able: on
• Except with HFO, high inspiratory flows the bed, m slttmg, standing or walking
and limited exhalation time create the risk of connected to a rebreathing bag. Systemic
intrinsic PEEP (Herridge and Slutsky, 1996). exercise has shown the following benefits:
355
CHAPTER 13 MECHANlCAL VENTlLATION
• shorter ventilatory time • previous night' s uninterrupted sleep

• improved weaning success • haemodynamic stability
• better ADL status on discharge (Koll et at., • no abdominal distension
1999). • reversal of sedation
• minimal pain
The physiotherapist's contribution to the • absence of abdominal paradox and rapid
team management of weaning is to advise on the shallow breathing (Howie, 1999).
balance of rest and exercise, contribute to
weaning decisions by assessing the breathing The trend is away from set values and
pattern, and occasionally to extubate the patient. towards indices based on the breathing pattern.
Weaning may be protracted for patients with Patients who fail to wean tend to have a
chronic lung disease, neuropathies or for anyone breathing pattern similar to that of acute respira
after prolonged ventilatory support. Difficulties tory failure (Rosario et at., 1997). If a disturbed
in weaning may be managed by transitory nonin breathing pattern is ignored, exhaustion sets in
vasive ventilation or multidisciplinary rehabilita (Figure 13.7). Pilbeam (1998, p. 327) has
tion (Merveille et al., 1999). Liberation from the suggested the following test to identify if
ventilator requires:
• progressive reduction In support until the

patient is able to sustain spontaneous
breathing Onset of (pH 7.22)
0)70 paradoxial
• a trial of spontaneous breathing through the I respiration
tracheal tube E 60
-S
• extubation. 0''' 50 (pH 7.42)
() (pH 7.47)
��40+-�--'-�--'--'-�r-�--r-�
Criteria for weaning
Patients need the neuromuscular ability to
breathe and adequate ability to oxygenate
arterial blood (Bruton et at., 1999). This can be
identified by various criteria:
• correction of the underlying reason for IPPV

• maximum ventilatory reserve and optimum c
0 10
gas exchange, i.e. pH and PaC02 related to �
the individual's premorbid state, plus vital �E 8
OlE
capacity > 10 mL/kg, maximum inspiratory >:::J 6
2�
pressure > 20 cmH20, shunt < 15%, dead :::J
C
space < 60% of tidal volume, Pa02 � 4
> 11 kPa on FI02 of 0.4 (Pa02iFI02 ratio>

27.5).
Figure 13.7 Seque nce of changes as the diaphragm tires
• optimum nutrition, fluid, metabolic and during a failed 20-mi nute attempt at weani ng. Fatigue is
cardiovascular status, including adequate represented at first by a ! PaC02 and alkalosis, caused by 1
haemoglobin levels, and no fever respiratory rate and minute ventilation. As breaths become
shallower, PaC02 progressively rises and acidosis develops.
• maximum, endurance, mobility and ability
As e xhaustion sets in, respiratory rate d rops rapidly. (From
to cough
Cohen, C, Zagel baum, G. , Gross, D. et 01. ( 1 9 8 2) Cli nical
• optimum bronchodilation and clear airways manifestations of inspiratory muscle fatigue. Am. J. Med., 73,
• restoration of normal diurnal rhythm 308-3 1 6)
356
WEANING AND EXTUBATION
patients are ready to breathe on their own: atrophy and/or perpetual muscle fatigue. Patients
undergoing protracted weaning are best given
• The patient is disconnected from the venti
adequate ventilatory support at night and short
lator.
periods of significant work during the day
• Spontaneous breathing is maintained on the
(Macintyre, 1995). The principles of balanced
same FI02, with CPAP equivalent to the
rest and exercise are illustrated by the following
previous PEEP, for 5 minutes.
studies:
• RR and VT are measured, and a RR: VT ratio
of less than 100 suggests that weaning will • Schonhofer et al. ( 1996) found that individu
be successful. ally adjusted CMV, interrupted by sponta
neous breathing, was superior to IMV or PS
Weaning. weanmg.
• Esteban ( 1995) found that intermittent spon
Reduction in ventilatory support takes the form
taneous breathing led to extubation three
of periods of decreased number of breaths in
times as quickly as gradually decreasing IMV
SIMV mode or decreased pressure in PS mode.
and twice as quickly as gradual PS weaning.
The following steps are then taken:
Other factors to consider are:
1. Explanations are given, with assurance that it
is only a trial. • Spending over 30 minutes on a T-piece alone
2. The patient takes up his or her preferred can lead to atelectasis (Singer and Webb,
posture, usually sitting upright. 1997, p. 14) because of high WOB and loss
3. Humidified oxygen is connected to the of 'physiological PEEP' provided by the
tracheal tube by a T-piece, which allows high larynx, whose resistance prevents exhaled air
flows of oxygen without entrainment of rushing out too quickly.
room air. For breathless people, 30 cm of • The inspiratory resistance caused by an
extension tubing attached to the exhalation HME may be significant, and weak patients
side is required to prevent entry of room air. may be more weanable with a hot-water
Oxygen flow should be high enough, and humidifier (Bourdelles et aI., 1996).
extension tubing long enough, to prevent
Inadequate nutrition is a common cause of
interruption of the stream of mist that exits,
weaning failure. Basili ( 198 1) showed how 93%
even during inspiration.
of adequately nourished people could be weaned
4. The airway is suctioned if necessary.
compared to only 55% of inadequately
5. The patient is disconnected from the
nourished people. Some patients require a
ventilator, given oxygen, encouraged to
period of 'nutritional restitution' in which
breathe, and monitored for signs of laboured
weaning is postponed while they are fed up to
breathing, anxiety, desaturation, rIsmg
11/2 times their normal requirements (DeMeo,
PaC02, fatigue or drowsiness. A
1992), so long as overloading with carbohy
breathlessness visual analogue scale allows
drates is avoided (p. 335).
the patient to contribute to weaning decisions
Other difficulties may be due to undetected
(Bouley, 1992). If the diaphragm tires, it may
diaphragmatic paralysis, obstructive sleep
need 24 hours to recover, and it is better to
apnoea (Noureddine, 1996), claustrophobia or
return the patient to respiratory support than
fear of suffocation. Fears are managed by
to await respiratory distress (Sykes and
providing information and truthful reassurance
Young, 1999, p. 238).
that the patient can return to the ventilator by
Continuing problems may be due to weaning request at any time.
strategies that provide neither sufficient muscle Weaning success can be improved with
work nor sufficient rest. This leads to muscle biofeedback using oximetry (Holliday, 1999),
357
tidal volume monitoring Oacavone, 1 998) or The ability to sustain a head lift has been
relaxation (Acosta, 1 988). Another form of suggested as indicating sufficient strength to
biofeedback is to connect the patient briefly to a protect the airway (Tobin and Yang, 1 990). The
rebreathing bag with an open valve, which cough response can be assessed by asking the
patients watch to reassure them that they can patient to cough or by gently stimulating the
breathe and are in control. A bedside fan may upper airway with a catheter. Patients at risk
decrease breathlessness. need testing to ensure they have a peak cough
Extended use of a CPAP mode is only helpful flow above 3 Li s (Bach and Haas, 1 996, p. 423)
if there are narrow airways or poor gas and a speech-language assessment. If there is no
exchange, but is not indicated routinely (Bailey, leak when the cuff is d eflated, post-extubation
1 995) because it tends to impose an additional stridor is a danger (Marik 1 996a). Algorithms
workload (Patel et al. , 1 999). and details of criteria can assist extubation
There is some evidence that strategies to d ecisions (Maxam-Moore, 1 996; Campbell
enhance respiratory muscle endurance may facili 1 999b).
tate weaning (Rosario et al. , 1997), and inspira A sustainable 30-60 minutes of spontaneous
tory muscle training can be used to provide brief ventilation suggests that the patient is ready for
periods of exertion alternating with rest (Figure extubation (Laghi, 1995), unless IPPV has been
1 3.8). prolonged.
Criteria for extubation Extubation

The ETT should be removed as soon as possible, If sputum retention is anticipated, it may be
so long as the following criteria are met: better to request a mini tracheostomy as prophy
laxis rather than await respiratory distress. The
• The patient can maintain a patent airway.
steps for extubation are the following:
• The patient can protect the airway from
aspiration. 1 . Give physiotherapy if indicated, or simply
• The patient can maintain a clear chest. suction the airway. Check for a cough reflex.
• The reason for intubation has been alle 2. Ensure that reintubation equipment and
viated. personnel are available.
30 Patients 3 dropped out after
_______ ______
< 1 0 sessions
•
T
27 ed
1 2 weaned to
'POO""' b",ath 'o,
5 weaned to
"""'"' """'OO !
1 0 not weaned
T
1 died in hospital
T
1 died in hospital 8 died in hospital
5 transferred to chronic 2 transferred to chronic 1 transferred to chronic
care facility care facility care facility
5 home 2 home 1 in hospital
1 i n hospital
Figure 13.8 The effect of inspiratory muscle training in 30 ventilator-dependent patients. (From Aldrich, T. K. ( 1 989)
Weaning from mechanical ventilation. Crit. Care Med., 17, 1 43- 1 47 , with permission.)
358
CASE STUDY
3. Sit the patient upright.

4. Explain how the tube will be removed and Background
that some hoarseness IS commonplace RM H : Several admissions for I P PV.
afterwards.
5. Suck out the mouth and throat to clear Nurse report
secretions that have pooled above the inflated Patient needs regular reminders to breathe.
cuff.
6. Cut the tape holding the tube in place, insert Subjective
a fresh catheter to reach just distal to the tip
I hate this tube in my throat.
of the tube, d eflate the cuff, slide the tube
out in a gentle downward curve, at peak Objective
inspiration when the vocal cords are dilated,
suctioning d uring withdrawal. Intubated, on CPAP.
7. Encourage the patient to cough out Patient alert, in Side-lying.
secretions that have accumulated around the Vital signs, auscultation and X-ray normal.
end of the tube. If this is impossible, bag

squeeze while deflating the cuff, which forces
Day 2
secretions into the mouth from above the Diagnosed with Ondine's curse.
cuff.
8. Give oxygen, non-invasive ventilation Questions
(Girault, 1 999) or other support, observe I . Does the patient have a problem with im paired
monitors and breathing pattern, listen for oxygenation?
stridor. 2. Does the patient have a problem with im paired
9. Enjoy patient's delight at their renewed ventilation?
VOlCe. 3. Does the patient have a problem with her
inspiratory muscles?
Decannulation of tracheostomy
4. Does the patient have a problem with her
Weaning for tracheostomied patients can incor respi ratory pump?
porate an intermediate step of replacing the 5 . Is the mode of ventilation suitable?
cuffed tube with an uncuffed or fenestrated tube, 6. Goals?
which can be plugged for increasingly longer 7. Plan?
periods to test for adequate breathing and
coughing. Ondine 's curse apnoea caused by loss of automatic
=
When the tube has been removed, the patient control of respiration, usually due to defective
is taught to hold a sterile dressing over the chemoreceptor responsiveness secondary to
stoma when coughing. Delayed decannulation neurological or other disorder.
increases the risk of exacerbation in COPD
patients (Clini et aI., 1 999). For those leaving
the lCU with a tracheostomy, a removable inner I;jf14-]��1'i-,;ii�i1$$1Iiii)Ilj
tube is essential in case of blockage.
I . No, the lungs are clear, observations and X-ray
normal and there is no predisposing history such
I;ii�i1!J1Iiii) 1M;�J3;I as surgery or respi ratory d isease.

2. Yes, spontaneous breathing is inadequate.
Identify the problems of this 58-year-old woman 3. No, she is not complaining of fatigue or breath
who has been admitted for mechanical lessness and she is able to breathe when
ventilation because of apnoea of un known cause. prompted.
359
4. Yes, the d iagnosis implicates a component of her

respi ratory pump.
5 . No, CPAP supports oxygenation, not ventilation. 1 . Comparing percussion to coughing is not
Ms CM needs a mode that provides mandatory relevant and does not itself justify chest
breaths if she does not breathe, e.g. S I MV. perCUSSiOn.
6 . Goals: maintain function while short- and long- 2. Oh well, that's OK then.
term management is organized, rehabilitate. 3. Lung abscess and lung contusion are
7. Plan: different. The first may be an indication for
• Liaise with team re mode of ventilation. physiotherapy and the second may be a
• Check patient's understanding of diagnosis. contraindication.
• Mobil ize patient fully, including outside if 4. The fact that a condition has a high mortality
possible, with nurse and equipment. does not itself justify physiotherapy, unless
• N egotiate with patient and nurse a daily exercise there is evidence that physiotherapy could
programme of getting d ressed, sitting out and reduce this mortality.
walking. 5. Well, well.
• Liaise with physiotherapist in referral centre to
which patient will be sent for long-term home
ventilatory planning. RECOMMENDED READING
AARC Clinical Practice Guidelines ( 1 999) Removal of
the endotracheal tube. Respir. Care, 44, 85-90.
Alvisi, R. and Volta, C. A. (2000) Predictors of
weaning outcome in COPD patients. Eur. Resp. ]. ,
LITERATURE APPRAISAL 1 5 , 656-662.
The following statements were made to justify Bruton, A., Conway, J. and Holgate, S. T. ( 1 999)
Weaning adults from mechanical ventilation.
therapeutic percussion over rib fractures,
Physiotherapy, 85, 652-6 6 l .
thoracic abrasions and lung contusion. Comment
Hawker, F. F. ( 1 996) PEEP and CPAP. Curro Anaesth.
on the logic (1-4 ) and the conclusion (5).
Crit. Care, 7, 236-242.
1. . . . coughing causes more pain and Jantz, M. A. and Pierson, D. J. ( 1 9 94) Pneumothorax
and barotrauma. Clin. Chest Med. , 1 5 ( 1), 75-92.
greater alterations in intrathoracic pressure
Juniper, M. ( 1 999) Ventilator associated pneumonia.
than properly performed percussion . . . .
Care Crit. Ill, 1 5 , 1 9 8-20 l .
2. . . . more than 406 patients have received
Tonelli, M . R . ( 1 9 9 9) Withdrawing mechanical
chest wall percussion . . . . ventilation: conflicts and consensus. Respir. Care,
3 . . . . lung abscess and lung contusion are 44, 1383-13 87.
indications for chest physical therapy.
4. A 42% mortality is reported following
lung contusion with a flail chest.
5. . . . there was no statistically significant
difference between the patients who did and
did not receive manual percussion . . . .
Phys. Ther. Pract. 1 994; 3 : 92-108
360
14 PHYSIOTHERAPY FOR PATIENTS IN
INTENSIVE CARE
SUMMARY
• Assessment • Exercises
• Charts • Mobilization
• Patient • Transfer from I CU
• Monitors Recognition and management of emergencies

• Ventilator • Cardiac arrest
• Imaging • Respiratory arrest

Handling patients who are critically ill • Seizure
• Minimizing oxygen consumption • Haemorrhage
• Turning • Massive haemoptysis
• Handling unconscious or paralysed people • Cardiac tamponade
• Pressure area care • Tension pneumothorax
Techniques to increase lung volume • Traumatic pneumothorax
• Positioning • Pulmonary embolism
• Deep breathing on the ventilator • Air embolism
• Manual hyperinflation • Equipment malfunction or disconnection

Techniques to clear secretions • Patient distress on IPPV
• Postural drainage On calls

• Manual techniques Mini case study
• Suction Literature appraisal
Exercise and rehabilitation Recommended reading
ASS ESSM ENT indicates pyrexia, the patient is consuming extra

oxygen, but moderately pyrexial patients should
'No-one explained . . . all they said was not not be actively cooled unless they have acute
to worry about it. ' head injury or significant hypoxaeroia (Gozzoli,
Thomson, 1973
Assessment is required before, during and after Box 14.1 Addenbrooke's Sedation Score (Shelly, 1998)
treatment, especially if patients are unable to
complain of new symptoms. The sequence of o Agitated
assessment described in Chapter 2 is used, with 1 Awake
additions described below. 2 Roused by voice
3 Roused by suction
Charts
4 Unrousable
Sedation may be charted (Box 14.1) but there is 5 Paralysed
no reliable means of assessing awareness 6 Asleep
(Coursin and Coursin, 1998). If the chart
361
CHAPTfR 14 PIIYSIOTHERAPY FOR PATIENTS IN INTENSIVE CARl:
of hypovolaemia are:
• i HR
• i RR
• 1 vascular pressures (CVP, PAWP)
• 1 systolic BP
• pallor
• 1 urine output
• 1 pulse pressure.
Hypovolaemia reduces pulse pressure because

I
,
compensation by reactive vasoconstriction assists
venous return and helps maintain diastolic
pressure, so that in the early stages systolic
pressure drops faster than diastolic pressure.
Extended clotting time is apparent for
patients on anticoagulants or with DIC (p. 408)
and increases the risk of bleeding during suction.
Conversely, hypercoagulable states increase the
'The physiotherapist will come and do exercises on his risk of deep vein thrombosis (DVT) in a group
chest'. From ACPRC Newsletter, II, 1987, with permission.
of patients already at high risk (Saint and
Matthay, 1998). Hypercoagulation is increased
with malignancy, dehydration and pain (Shapiro
et ai. , 1995). Details of clotting parameters are
2001). Pulmonary artery blood temperature is in the Glossary.
the gold standard for measurement of core body Low serum albumin is common in ICU
temperature. Peripheral temperature is measured patients because of fluid and permeability
by a probe on the toe, and if it is more than 5° problems. This is associated with reduced surfac
lower than the core temperature, poor circula tant, poor wound healing and a drop in osmotic
tion is implicated. Survival is unlikely if periph pressure, leading sometimes to peripheral and
eral temperature is less than 27°C Goly and pulmonary oedema. Potassium levels below
Weil, 1969). 4 mmol/L predispose patients to arrhythmias,
Blood pressure should be checked for any contraindicating most forms of physiotherapy.
response to previous sessions of manual hyperin Neutropenia can be caused by poor nutrition,
flation (MH). If BP is low, unstable or sags on immune disorders or anticancer drugs, and is
inspiration, or if mean arterial pressure is less associated with vulnerability to infection and
than 60 mmHg, the patient may be unable to sepsIs.
maintain cardiac output during MH.
Fluid status may be measured by daily weight, Patient
a change of more than 250 glday suggesting fluid '1 couLd think and 1 couLd hear, b�t 1 couLd
gain or loss (Parker and Middleton, 1993). The not move and 1 couLd not taLk or open my
fluid balance chart is affected by a multitude of eyes.'
factors but is still a useful guide. Electrolyte and Lawrence, 1995b
haematocrit values are decreased with fluid
excess and increased with fluid loss. Fluids and Is the patient conscious, confused, agitated,
electrolytes are disturbed by diuretics, diabetes, sedated, paralysed? Paralysis, whether pathologi
vomiting, diarrhoea, heart or kidney failure, cal or pharmacological, indicates the importance
burns, ascites or large open wounds. The signs of clarity in communication because patients
362
AsSESS�IENT
may be trying to make sense of sounds and • In side-lying, the dependent compressed lung
sensations but cannot give feedback. Uncon generates more dullness to percussion than
scious patients hear and understand more than the upper lung (Gilbert, 1989).
we expect (Lawrence 1995b; Sisson, 1990). • Apical breath sounds should be scrutinized
What channels of communication are available? to pick up problems such as a pneu
Is perception or interpretation of information mothorax, haemothorax or intubated right
altered by drugs or cerebral damage ? main bronchus (Figure 14.1).
Agitation may be due to the endotracheal • The stethoscope may pick up the wheeze-like
tube, fear, lack of information, incorrect ventila sound of air leaking around the cuff of the
tor settings, restraints, awkward positioning, tracheal tube, or the bubbling of condensed
pain or gut distension. For ventilator-related humidifier water in the tubing.
distress, see page 386. Other points to note • If manual ventilation is undertaken, breath
before treatment are: sounds can be heard more clearly, and some
times crackles can be elicited with a sharp
• Accessory muscle activity suggests excess
release on expiration.
work of breathing (WOB), and laboured
breathing may indicate an obstructed airway. Clinical signs of decreasing cardiac output are
• Lines and tubes, including femoral lines, the following:
haemofiltration lines, pacing wires and lines
• pale or dusky colour
in the feet, should be kept In view
• cold extremities
throughout treatment.
• sweating
• Hydration is difficult to assess clinically
• dizziness with position change
because oedema or overhydration can
• confusion or altered consciousness
coexist with intravascular depletion in criti
• i HR
cally ill people (Dobb and Coombs, 1987).
• i RR
• Vasoconstriction or low cardiac output is
• 1 PaC02
indicated clinically by cold hands.
• 1 urine output.
Monitors
Hypoxaemia can precipitate arrhythmias. If Sa02
falls, treatment should be halted until it stabi
lizes, and/or FI02 should be increased. S�02 can
be used to monitor the effect of procedures such
as suction, which reduces oxygen supply.
Changes in BP and HR reflect factors as
diverse as septicaemia, pain, drugs or fluid status.
Monitors should be observed during treatment in
order to identify responses relating to physiother
apy. Systolic pressures as low as 80 mmHg may
be adequate so long as this is normal for the
patient and the patient is warm and passing suffi
cient urine, but caution must be exercised if MH
Figure 14.1 This endotracheal tube has passed into the IS necessary.
right main bronchus and beyond the right upper lobe
Spontaneous arrhythmias occur in 78 % of
bronchus. The right upper lobe is not being ventilated and is
collapsing as its air is absorbed. Breath sounds would be patients (Artucio and Pereira, 1990), but those
reduced and the percussion note dull. Physiotherapy is caused by physiotherapy can be identified by
contraindicated until the tube has been repositioned. ECG changes during treatment.
363
CHAPTER 14 PH)� IOTHERAP) FOR PATIENTS I:--J 1i'.'TENSIVI CARE
Positive pressure ___•

from ventilator
r
i airways resistance
e.g. bronchospasm .J. lung compliance
e.g. ARDS
Figure 14.2 Causes of increased peak airway pressure for patients on volume-control ventilation. ARDS = acute respiratory
distress syndrome.
mia if they are disconnected from the ventilator.

Ventilator A saw-tooth pattern on the flow-volume curve
Charts indicate ventilator settings and trends in may indicate excess secretions (Figure 14.3).
the patient's response, while the machine
indicates what is occurring from moment to Imaging
moment. In volume control, airway pressure Portable X-rays are taken with the patient supine
provides the following information: or sitting up as able. A supine or slumped
position causes a pleural effusion to lose its clear
• Peak pressure is normally 20 cmH20.
boundary (Figure 14.4). Pleural effusions are
• Values above 30 cmH20 may be due to
common and not well tolerated in the ICU,
airflow obstruction, stiff lungs, pulmonary
contributing to hypoxaemia and sometimes
oedema, pneumothorax or obstruction by
cardiovascular instability (Mattison et aI. , 1997).
upper airway secretions, a kinked tube or
A third of pneumothoraces are not clearly seen
clenched teeth (Figure 14.2).
in a supine film because the boundary between
• Peak pressure below normal is due to a leak
air and lung may be lost, and the classic apicolat
in the circuit.
eral location is less common Guniper and
• Oscillation in airway pressure signifies spon
Garrard, 1997).
taneous breaths between ventilator breaths.
The tracheal (endotracheal or tracheostomy)
• Erratic readings indicate a patient fighting
tube is identifed by its radio-opaque line
the ventilator or coughing, which can be
reaching to just above the carina. If it is too long
confirmed by observation.
the right main bronchus may be intubated,
• Readings that dip substantially below the
leaving the left lung, and sometimes the right
end-expiratory baseline suggest excess WOB.
upper lobe, unventilated. If it is too short, there
• The complete cycle is raised in proportion to
is a risk of it becoming dislodged, and the
the level of PEEP.
patient's head should be moved as little as
Alveolar pressure is not equal to airway possible.
pressure readings, unless there is zero flow, The nasogastric tube should be in the stomach
because resistance to gas flow in the airways and not the lung. A central venous line is usually
creates a pressure gradient. Alveolar pressure is traceable to the vena cava. A pulmonary artery
more negative than airway pressure during catheter passes through the heart in a loop, with
patient triggering and more positive during a its tip in a branch of the pulmonary artery.
positive-pressure breath. A high level of PEEP Films before and after initiation of high levels
means that patients are at risk of severe hypoxae- of PEEP may show an apparent clearing of infil-
364
AsSESSMENT
(a)
u u
Q) Q)
(/)
::::J �
o
� �
o
o
u::: u:::
_1L------" _1L-------�
+0.5 o +0.5 o
Volume, L Volume, L
u u
Q) Q)
(/)
::::J �
- 0 0
� �
0
0
u::: u:::
-1 -1
+0.5 0 +0.6 0
Volume, L Volume, L
(b) 1-
u u
Q)
0
Q)
(/)
::::J
�
0 0
� �
0
0
u::: u:::
-1 -1
+0.5 0 +0.5 0
Volume, L Volume, L
CJ
u
CJ
u
Q) Q)
�- �
0 0
� �
0
0
u::: u:::
-1 -1
+0.5 0 +0.5 0
Volume, L Volume, L
Figure 14.3 Flow-volume loops. (a) Jagged curves indicate the presence of secretions. (b) Smooth curves indicate clear
airways. (From Jubran, A. (1994) Use of flow-volume curves in detecting secretions in ventilator dependent patients. American
Joumal of Respiratory and Critical Care Medicine, ISO, 766-769)
365
CHAPTER 14 PHYSIOTHERAPY FOR PATIENTS IN INTENSIVF CARE
Figure 14.5 Evidence of barotrauma in a ventilated

patient. Air is evident in the mediastinum and pericardium,
and the chest drain on the patient's left indicates that there
has been a pneumothorax. The opacity on the patient's right
is a loculated pleural effusion.
Figure 14.4 Representation of a pleural effusion on x
ray. Top picture of a supine patient would show a diffuse
ipacit y. Bottom picture of an upright patient would show a
clear fluid line and decision making for the ICU patient. This
can be computerized for adaptation to individual
patients.
trates through redistribution of pulmonary
oedema and recruitment of lung units (Ely et
HANDLING PATIENTS WHO AR E CRITICALLY ILL
al., 1996).
Early signs of barotrauma are difficult to Who am I?
detect radiologically. Pulmonary interstitial Where am I?
emphysema can usually be identified only in Why do I hurt so much?
neonates (small cystic lucencies, perivascular cuff Nursing Times, 1 981
of air around vessels and linear streaking
towards the hilum), or in adults if there is Minimizing oxygen consumption
contrast provided by a background of general Oxygen consumption is increased' by stress.
ized opacification such as acute respiratory Motivation is reduced by stress. Treatment is
distress syndrome (ARDS), or by CT scan. Pneu most effective in a motivated patient. Stress is
momediastinum may show as air outlining the better prevented than treated.
mediastinum or a 'continuous diaphragm'
extending from one hemidiaphragm to the other Preliminaries
below the heart. Pneumopericardium presents as 'Someone would come near me and would
a lucency or halo around the heart (Figure 14.5). just be working and not saying anything to
Box 14.2 provides guidance on assessment me. That would be frightening because I
366
AsSESSMENT
Box ' 4.2 leu clinical reasoning model 0/. Bastow, S. Randall and A. Ludlow, Queen Elizabeth Hospital, Kings Lynn, with
modifications)
Precautions
MRSA status: +ve/-ve/unknown in sputum YIN
Clotting status
Other
Assessment
Nurse comments
Subjective assessment
Charts
• Pain score Sedation score GCS
• Temp BP HR RR Sa02
• CVS stable YIN
• ABGs on FI02 pH BE
Acidosis/alkalosis/
Respiratory/metabolic
Acute/compensated
• Fluid balance
• Relevant medication
• Other
Ventilation
• FI02
• Self-ventilating Y/N Breathing pattern

• NIV YIN Mode
• IPPV Y/N VC/PC Peak pressure if on VC
• Tidal volume
• Mode SIMV PS SIMV+PS Other

• PEEP
• Patient triggering YIN

• Humidifier/HME
CXR date Radiology report/own interpretation
Clinical assessment
Appearance
Auscultation breath sounds added sounds
Abdominal distension Y/N
Percussion note
Other
Continued overleaf
367
CHAPTER 14 PHYSIOTHERAPY FOR PATIENTS IN INTENSIVF CARE
Additional respiratory information
Additional non-respiratory information
Indication(s) to treat Precautions/reasons not to treat
Treatment
Positioning
Breathing techniques: DB IS ACB/AD Cough Other
MH
Vibs/shaking/percussion
Saline instillation YIN mL
Suction
Ex: PMs Act/assisted Active SOOB Mob
Other
Outcomes (document changes only)

Auscultation: Breath sounds Added sounds
Sa02
Secretions
Peak pressure (VC)
CVS stability
ROM
Mob
CXR
Other
Plan (including instructions for patient/family/staff)
ABGs = arterial blood gases; ACB = active cycle of breathing; AD = autogenic drainage; CVS = cardiovascular
system; DB = deep breathing; Fr02 = fraction of inspired oxygen; GCS = Glasgow Coma Scale; HC03- =
bicarbonate; HME = heat-moisture exchanger; IS = incentive spirometry; MH = manual hyperinflation; NN

= non-invasive ventilation; PC = pressure control; PMs = passive movements; ROM = range of movement;
SOOB = sit out of bed; VC = volume control.
didn't know what they were going to do intervention that is unnecessary. All patients
next. need explanations, and some need sedation
Parker et ai., 1984 (Horiuchi, 1995), increased PI02 before
treatment, or extra pressure support (Kemper,
The traditional protocol of turning, percussion, 1993). All patients, including those who are
vibration and suction can release stress unconscious or paralysed, need warning before
hormones, destabilize cardiac output, increase all procedures and any physical contact. Without
oxygen consumption by over 50%, raise BP and this, fear can further increases oxygen consump
HR, increase PA-a02 and reduce Pa02 tion (Turnock, 1997). Fluids and medication
(Weissman, 1993). This varies with how patients may be required to ensure adequate cardiac
are handled, but it is a reminder to avoid any output and minimum pain.
368
HANDLING I'ATIFt-.'TS WHO ARt (RITICAU.Y ILL
Orientation • the patient's understanding of why they

Patients need a visible clock, calendar, family cannot speak and how long this is expected
photographs, personal belongings in an area that to last, as they have often forgotten or may
they can control, information on progress, inter not have been told
pretation of noises and voices, attendance to • clear and explicit explanations, repeated as
alarms promptly, explanations of neighbours' necessary, including why physiotherapy is
alarms, a personal telephone if they are able to necessary, what it will feel like, how long it
talk, trips outside the unit when possible, and will last and instructions on how to ask for it
treatment with the same physiotherapist before, to stop
during and after admission to the ICU when • hearing aid or glasses if used
feasible. We should enter the patient's space • if lip-reading proves inadequate, communica
gently, introduce ourselves and explain our tion aids such as word or picture charts,
purpose. pencil and paper, or for greater privacy a
magic slate
Sleep and rest • when appropriate, a speaking tracheostomy
Sleep . . . tube for adults (p. 280) or children (Tucker,
Balm of hurt minds, great Nature's second 1991)
course, • referral to a speech-language therapist when
Chief nourisher in life's feast. appropriate
William Shakespeare, Macbeth • if unable to write or use charts, yes-or-no
questions asked one at a time, e.g.: 'Are you
Patients should not, if possible, be woken when hot? cold? itchy? worried? tired? sleepy?
asleep, especially if flickering eyelids indicate nauseous? in pain? Is your mouth dry? the
that they are in the REM phase of the sleep tube bothering you? Do you want to turn?
cycle when tissue regeneration is at its maximum raise or lower your head? Do you need more
(Shelly, 1992). air? less light? less noise ? more information?
bottle or bedpan?'
Family
If visitors are present, they can either be invited Communication should be aimed at patients
to stay or asked to leave during treatment, rather than over them. Chatting over patients
depending on the patient's wish. The presence of can increase stress more than suction (Lynch,
relatives means that they can become involved in 1978). One patient said 'It didn't matter what
patient care and are reassured that physiotherapy they talked about, so long as they talked to me'
is not distressing. (Villaire, 1995). Other patients found that their
attempts at communication were met by being
Communication told to relax or being given a sedative (Jablonski,
1994). If a patient wishes not to communicate,
'So many believe that because you are
this should also be respected.
unable to talk, you either can't or don't
want to listen. '
'The most important thing for me was the
Holden, 1 980
human contact, the communication. '
The priority III stress reduction is to establish Villaire, 1 995
communication. Understanding and memory

may be affected by anxiety or drugs, but patients
Helplessness
who are unable to speak are neither deaf nor
mentally impaired. Aids to communication 'What do you do when you can't bear it?
include: There is only one thing to do: bear it . . .
369
CHAPTER 14 PHY�IOTHFRAPY fOR PATIEI'.T� II'. INTEN'>IVI CARlo
what else are you going to do? What are the

alternatives?'
Rollin, 1976
Helplessness can lead to depression Gones and

O'Donnell, 1994). The more helpless the
patient, the more important is autonomy.
Patients can choose whether they would like
treatment now or later (if possible), whether the
bedhead is the right height. They can have
charge of the TV remote and radio channel, if
required, and decide whether they would like to
regain their day/night rhythm by being woken in
the day or having a sleeping pill at night.
Autonomy is particularly important in this
situation of unequal power. Depression is eased
by allowing expression of emotion and encoura
ging independence and decision-making. Anxiety
is reduced by combining factual information
with advice that enables patients to be proactive being 'popular' at a time when they least need
Gones and O'Donnell, 1994). Benefits have been such a burden. Praise is a potent motivator and
found with imaginative interventions such as a enhances self-esteem.
pet visitation scheme (Giuliano et ai. , 2000).
'Hearing remained acute and was the
primary means of receiving information
Touch
from the environment. "I heard a lot more
'It surprised me how much I valued human
than I think they think I heard".'
touch.'
Jablonski, 1994
Redfern, 1985
ICU patients are extra-sensitive to human Turning

physical contact as a contrast to the cold clinical 'To be talked frankly through a complete
procedures to which they are frequently procedure, particularly its estimated length,
subjected. Therapeutic touch assists relaxation would help curb the deadly effects of
and sleep (Cox and Hayes, 1999) and foot uninformed anticipation.'
massage is accessible for the ICU patient and can Brooks, 1990
reduce tension and lower RR (Stevensen, 1994).
During turning, transient changes in vital
The benefits of even brief massage can be
signs are acceptable, but if Sa02 drops and does
confirmed by watching the monitors. As always,
not return to its usual value within 5 minutes,
it should be remembered that individuals vary
HR increases or decreases by onr 10 bpm and
and some dislike touch.
does not settle, or S� O2 varies as described on
page 330, the patient should be returned gently
Comfort
to the previous position.
Measures to alleviate physical discomfort include
A suggested sequence for turning' is the
regular position change, before the allotted time
following.
if the patient requests.
l. Inform patient
Self-esteem 2. Turn off continuous tube feedings.
Patients should not be expected or coerced into 3. Ensure sufficient slack in lines and tubes.
370
HANDLINe. PATIENTS WHO ARF CRITICAllY ILL
4. Clear ventilator tubing of any accumulated • clearing objects or creases from under the
water that could spill into the patient's patient.
alrway.
5. Ensure that glide sheets are in place, the Pressure area care
team is following the same manual handling Pressure sores are found in a third to a half of
protocol and individuals are responsible for ICU patients (Peerless et al., 1999) and cost the
the airway and vulnerable lines. NHS a billion pounds a year plus litigation
6. Ensl.lre that the team is co-ordinated in care expenses (Allen, 1998). Each grade 4 sore causes
of the skin and joints (e.g. protect heels on average 17 other patients to forgo a bed.
from friction, prevent hip strain by avoiding Pressure sores distress people, kill people and
use of the leg as a passive lever). are avoidable (Kiernan, 1998). Risk factors are
7. Support the tracheal tube. Some trusted malnutrition, obesity, steroids, vasopressor
patients can hold an endotracheal tube drugs, diabetes, advanced age and restricted
briefly with their teeth during the turn. movement due to traction, support systems or
8. Say clearly, so that the team and patient can patient instability.
hear, agreed instructions, e.g. 'Ready, Anything can be put on a pressure sore except
steady, turn'. the patient. Hospitals are full of concoctions for
9. Turn smoothly. treating pressure sores, but better still is preven
10. Check lines, patient comfort and monitors. tion, by means of:
• adequate nutrition (Russell, 2000), especially

Handling unconscious or paralysed people vitamin C and protein (Barratt, 1989)
'You can't do nothing except lay there in one • frequent turning and judicious positioning
position. That's very very uncomfortable.' (Davies, 1994)
Jablonski, 1 994
• pressure-reducing cushions on chairs
(Collins, 1999) and specialized beds (Willis,
We need to act as the consciousness of the 1996)
unconscious. It is easy to depersonalize patients • keeping pressure areas dry
who cannot respond to us, especially if we have • turning without friction
not had the opportunity to get to know them • avoidance of excessive washing or rubbing
when they were alert. When handling paralysed with talc, cream or towels
or unconscious people, attention should be • prevention of hypotension or hypovolaemia.
given to:
Pressure sore risk is reduced by a rotating
• protecting the eyes bed, a low-air-Ioss bed or a thermoreactive
• supporting the head in a neutral position mattress with squidgy foam. Some of these
• reassuring the patient that s/he will not fall mattresses allow the patient to sink into a
off the bed moulded well, which is unhelpful for mobility
• when positioned, aligning the limbs and and respiratory care.
spine in neutral positions, with special care Most effective for skin care is an air-fluidized
of the shoulder joint (which has no stability bed such as the Clinitron, whose silicon beads
without muscle tone) and ulnar nerve float the patient like a semi-submerged iceberg in
(stretched with combined elbow flexion and a current of warm air. This lowers skin contact
forearm pronation) pressure to below capillary occlusion pressure,
• in supine, positioning the upper limbs with controls temperature and absorbs exudate into
palms downwards the beads. Points to note are the following:
• in side-lying, checking that the ear is not
twisted under the head • Good teamwork is needed to ensure regular
371
CHAPTER 14 PHYSIOTHERAPY FOR PATIENTS L'IIl'-IE:-\SIVF CARE
turning for preventive respiratory care, 1992) compared to supine. It also allows easier
because turning is no longer required for movement against gravity for weak patients
pressure area care. (Chung, 1992). The prone position is useful for
• The dry air current may contribute to dehy some severely hypoxaemic patients (p. 415). As
dration. with spontaneously breathing patients, ventilated
• A hoist may be needed for mobilizing the patients with unilateral lung pathology usually
patient out of bed. show optimal gas exchange when lying with the
• The bed should be switched off and affected lung uppermost (Wong, 1999).
unplugged for cardiopulmonary resuscita Factors that modify positioning are head
tion. trauma, abnormal muscle tone, pain, spinal cord
injury, fractures, pressure sores, unstable BP and
A sacral pressure sore that has developed in invasive support systems such as haemofiltration.
supine does not preclude sitting out in a chair, Semi-recumbent positions protect against aspira
so long as a pressure cushion is used and an tion but not gastro-oesophageal reflux (Orozco
upright posltIon is maintained to prevent Levi et aI., 1995). Right-side-Iying is more likely
pressure on the sacrum. to impair cardiac output than left-side-Iying in
unstable patients (Bein et at., 1996).
Kinetic rotating beds turn patients continually
TECHNIQUES TO INCREASE LUNG VOLUME
along the longitudinal axis, and are useful if they
For spontaneously breathing patients, lung can rotate a full 180°. There are inconsistent
volume can be increased by the techniques reports of their benefits to the respiratory
discussed in Chapter 6. For ventilated patients, system. MacIntyre et at. (1999) found that they
the following modifications can be incorporated. had little effect on respiration and increased
patient anxiety, but reduced urine infections.
Positioning Raoof et at. (1999) found them beneficial when
There may be a fine irony in the combined with mechanical percussion.
observation that our advanced knowledge
and technology by themselves cannot save Deep breathing on the ventilator
the patient. Instead, something so simple as
If patients are on a mode of ventilation that
turning the patient from supine to lateral to
incorporates spontaneous breathing, they may be
prone to lateral, at least hourly, may make
able to take deep breaths voluntarily. Deep
the difference between living and dying for
breathing is particularly successful when patients
the intensive care patient.
are motivated by watching the results of their
Bendixen, quoted by Ray, 1 974
endeavours on the tidal volume monitor.
Positioning is the main physiotherapy treatment
for patients in intensive care, and may be the Manual hyperinflation
only intervention for some patients. By prevent
CIt was by far the most frightening thing
ing the abdominal contents encroaching on lung
that happened to me. I'll never forget it. '
volume (p. 149), positioning restores ventilation
Patient quoted by Rowbotham, 1 990
to dependent lung regions more effectively than
PEEP or large tidal volumes (Froese and Bryan, Manual hyperinflation delivers extra volume and
1974). Simply turning from supine to side-lying oxygen to the lungs via a bag such as a rebreathing
can clear atelectasis from dependent regions bag. Compared to positioning, which is accepted
(Brismar, 1985). as preventive care for most ICU patients, manual
Side-lying increases FRC (Ibanez et at. , 1981) hyperinflation is not used routinely because
and enhances gas exchange (Lewandowski, prophylaxis has not been substantiated.
372
HANDLING PATIENTS WHO ARE CRITICALLY ILL
Suction port
Terminology
• Manual ventilation means squeezing gas into
the patient's lungs at tidal volume, e.g. when

changing ventilator tubing.
• Manual hyperventilation delivers rapid Tracheal
tube
breaths, e.g. if the patient is breathless, . - - Adjustable valve
hypoxaernic or hypercapnic.
• Manual hyperinflation provides deep breaths
in o·rder to increase lung volume, e.g. when

treating a person with atelectasis or sputum 2 litre
retention. - - - rebreathing
bag
Physiotherapy is associated with manual
hyperinflation (MH). The words 'bag-squeezing'
or 'bagging' are also used, although it is best to
avoid saying 'bagging' with patients as it can be
misinterpreted (Waldmann and Gaine, 1996).
Figure 14.6 Water's bag system.
Effects
Beneficial effects of MH are:
2. Ensure adequate analgesia and/or sedation.
• reversal of atelectasis (Lumb, 2000, p. 122) 3. Position the patient in well-forward-side
• sustained improvement in lung compliance lying (Figure 14.7). The positive pressure of
and oxygen saturation (Patman et al., 1999) MH hyperinflates the more compliant upper
• improved sputum clearance (Hodgson et al., regions so that in supine the bases are largely
2000) . ignored. For patients who cannot turn, close
Disadvantages are: attention to technique (see 8-9 below) may
deliver some extra volume to the lung bases
• haemodynamic and metabolic upset
in supine. If a different area is to be targeted,
• risk of barotrauma for certain patients
it is placed uppermost.
• discomfort and anxiety if done incorrectly.
4. Check monitors after the turn. MH should
not be started until cardiovascular stability is
Technique
assured in the new position.
A rebreathing bag is a rubber or plastic 2 or 3 L
S. Observe chest expansion.
bag such as a Water's bag (Mapelson's C),
6. Tell the patient that s/he will feel a deep
connected by an adjustable expiratory valve to
breath. They will feel sleepy if Entonox is
an oxygen supply (Figure 14.6). Its compliance
used. They should be free of distractions or
allows the clinician to feel the ease of inflation.
nursing interventions.
Non-rebreathing units such as the Ambu and
7. Connect the bag, with heat-moisture
Laerdal bag consist of semi-rigid material which
exchanger, to the oxygen with a flow rate of
self-inflate from room air with added oxygen.
15 L/min, turn off the low-pressure alarm,
These prevent excessive pressures being reached,
disconnect patient from the ventilator and
but are less responsive to modifications in
connect him/her to the bagging circuit.
technique.
8. Rest tubing on the sheet to avoid tugging on
The following method is recommended:
the tracheal tube, tell the patient when to
1. Ensure the patient's fluid and cardiovascular expect ordinary breaths and when deep
status are optimum to minimize any drop in breaths. Squeeze the bag a couple of times at
cardiac output. tidal volume to acclimatize the patient and to
373
CHAI'TER 14 PHYSIOTHERAPY FOR PATIENTS IN INTENSIVE CARE
Figure 14.7 Manual hyperinflation targeting the left lower lobe, which is being palpated to check for optimum expansion.
(Photograph: Nicholas Taylor.)
assess lung compliance, then give slow the patient, the greater the need to co
smooth deep breaths, adjusting the valve to ordinate the procedure with his/her
increase pressure until expansion is greater breathing. Stop MH if the patient's facial
than on IPPV and the manometer indicates a expression or monitors indicate distress, or if
safe and effective pressure (see below). Slow crackles indicate that secretions have been
inspiratory flows minimize turbulence and mobilized and suction is required. If crackles
the risk of generating intrinsic PEEP (Reick, are heard, give tidal volume breaths until the
1996). patient is suctioned. If MH causes no change,
9. Hold maximum pressure at end-inspiration stop after 6-8 breaths for re-assessment.
for 1-2 seconds to encourage filling of poorly 12. After MH, inform the patient and reconnect
ventilated alveoli, especially if atelectasis is to the ventilator.
the problem. Haemodynamically unstable 13. Check that the alarm is on, observe chest
patients should not receive this end movement and monitors, auscultate the
inspiratory hold, and are best given one deep chest.
breath interspersed with several tidal breaths, 14.To maintain the benefits of MH, the side
or if the patient is able, interspersed with lying position should be continued so long as
spontaneous breaths. it is comfortable for the patient and
10. Release the bag sharply to simulate a huff, convenient for nursing procedures.
especially if secretion retention 1S the
problem. Pressures
11. Watch the chest for expansion, the face for Each bed space should be supplied with its own
distress and the abdomen for signs of manometer to ensure effective and safe pressures
unwanted active expiration. The more alert (Ellis et at. , 1999). The following are guidelines:
374 ------
TECHNIQUES TO INCREASE LUNG VOLUME
• For MH to be effective in normal lungs: a Precautions and modifications

sustained inflation to 40 cmH20 is required
to reverse atelectasis (Novak et ai., 1987; " Pneumothorax with a chest drain.
Rothen, 1993). • Air leak as demonstrated by air bubbling
• For MH to be safe in normal lungs: through a chest drain bottle.

maximum pressures are 60 or 70 cmH20 • BP that is low, high or unstable. If MH is
(Sommers, 1991; Eaton, 1984). essential in a hypotensive patient, the patient

• For MH to be safe in diseased or damaged should be maximally stabilized first and the
lungs: there is no safe limit, so if MH is technique should be brief, with prolonged
necessary, the minimum effective pressure is expiration and no end-inspiratory hold, in
used. order to facilitate venous return.
• Hypovolaemia as demonstrated by low CVP/
PAWP.
Mini literature appraisal • Recent pneumonectomy because of the risk
of bronchopleural fistula. The fifth to the

King and Morrell (1992) are frequently 10th postoperative days are when the
quoted as advising 40 cmH20 for the healing stump is at its most vulnerable
maximum safe MH pressure. The authors (Pierson and Lakshminarayan, 1984).
did not explain that their sources referred to • Acute head injury.
patients with damaged lungs. These findings • Patients at risk of barotrauma, e.g. those
should not be extrapolated to patients with with emphysema, acute asthma, fibrosis,
normal lungs. Pneumocystis pneumonia or ARDS Gantz
and Pierson, 1994).
• Rib fracture because a covert pneumothorax
A useful teaching aid is to set up a test lung
might be present. If MH is essential, the X
with a spare ventilator, set on spontaneous
ray should be scrutinized or a radiologist'S
mode, high flow, and with a pressure-volume
opinion sought.
loop (p. 324) displayed. This will give feedback
• During renal dialysis, which tends to destabi
on the tidal volume and pressure attained with
lize BP.
MH, including maintenance of manual PEEP.
• Arrhythmias or frequent ectopics.
The screen can be frozen to identify details.
• Hyperinflated lungs with intrinsic PEEP. If
essential, a longer expiratory time might be

Complications
required.
The complications of MH are an exaggeration of
• During weaning if patients with hypercapnic
the complications of IPPV, particularly baro
COPD are dependent on their hypoxic drive
trauma and haemodynamic compromise. BP and
to breathe. If MH is essential and the patient
cardiac output may rise (Stone, 1991) or fall
is not severely hypoxaemic, the bag can be
(Singer et at. , 1994). Complications are greatest
connected to air instead of oxygen, the
if MH uses large tidal volumes or is vigorous,
procedure kept brief and the monitors
but if too gentle it may lead to underventilation
watched.
and hypoxaemia.
411 Severe hypoxaemia with PEEP above
10 mmHg, because disconnection of the
Contraindications
patient from the ventilator entails loss of
• Extra-alveolar air, e.g. undrained pneu PEEP. If MH is essential, desaturation can
mothorax, bullae, surgical emphysema. be minimized by:
• Bronchospasm causing peak airway pressure - incorporating a PEEP valve in the
above 40 cmH20. circuit, a method that has no evidence
375
CHAPTER 14 PHYSIOTHERAPY FOR PATIENTS IN INTENSIVE CARE
base (Wainright and Gould, 1996) and 100

can depress BP but which may benefit
individuals
manually preventing the bag fully
deflating at end-expiration � 0
u::
- increasing the flow rate, and bagging
faster to prevent deflation and augment
oxygenation, but briefly, and only if this
100
is safe in relation to the patient's
haemodynamic status
1s
using the 'manual sigh' or inspiratory Time -
pause button, which may encourage

Figure 14.8 Airflow during manual hyperinflation and
some alveolar recruitment. vibrations. (From M aclean, D. , Drummond, G. and
Macpherson, C. (1989) Maximum expiratory airflow during
chest physiotherapy on ventilated patients before and after
TECHNIQUES TO CLEAR SECRETIONS the application of an abdominal binder. tnt. Care Med., IS,
The secretions of patients on IPPV can usually be 396-369)
cleared by humidification, regular posItIon
change, suction as required and MH if necessary.
be helpful, and effectiveness varies with indivi
Jet nebulizers have shown a high instance of
duals. Neurophysiological facilitation or rib
infection risk (p. 142-3) and greater compromise
springing are sometimes beneficial. Monitors
to oxygenation than a hot-water humidifier (Kuo
should be observed closely because some
et at. , 1991), so before 'saline nebs' are consid
patients cannot meet the extra metabolic
ered, it would be wise to ensure that continuous
demand by increasing their cardiac output.
hot-water humidification is optimal.
Suction
Postural drainage
Many dreaded both the suction procedure
The head-down tilt is rarely suitable for patients
and the instillation of normal saline.
on IPPV. Haemodynamics are compromised and
Jablonski, 1 994
abdominal contents weigh heavily on an inactive
diaphragm. Side-to-side positioning, which is Suction is complicated by:
used for maintenance of lung volume, is usually
• ! lung volume by an average 27% (Brochard
adequate as modified postural drainage.
et at., 1991)
Manual techniques • i oxygen demand also by an average 270/0
(White et at., 1990)
Manual techniques are not required routinely
• ! oxygen supply, transient bronchospasm
and have no effect on resolving atelectasis
(Guglielminotti, 1998)
(Denehy, 1999), but excessive or thick secretions
• destabilized haemodynamics and repeated
may be an indication for percussion or vibra
inoculation of the lungs with bacteria from
tions, so long as there is no risk of arrhythmias
the tracheal tube (Sottile, 1986).
(Hammon et at., 1992). There are reports of
atelectasis being caused by vibrations beyond Suctioning secretions rarely reduces respira
FRC (Laws and McIntyre, 1969) but this should tory resistance, indicating that secretions contri
not occur if manual techniques are routinely bute little to airways obstruction, but may clear
followed by strategies to restore FRC, e.g. posi airways sufficiently to reduce intrinsic PEEP
tioning or MH. Vibrations cause less airflow (Guglielminotti, 1998). Occasionally, there is a
than MH (Figure 14.8), but the oscillations may worthwhile reduction in resistance when secre-
376
TrCHN1QUfS TO INCREASl LUNG VOLUME
tions are blocking the upper airways (Chatila et ble with large tubes. Aseptic technique should be
ai., 1995). It is assumed that stasis of secretions pristine. The catheter must not touch the rim of
encourages infection. the tracheal tube on insertion, and sterile gloves
Suction should be carried out when indicated are mandatory. Boxed gloves are not recom
and not routinely Uudson, 1994). Indications, mended because half have been found to be
contraindications and technique for nasopharyn contaminated (Ross off, 1995).
geal suction are described in Chapter 8. Modifi Vibrations are unnecessary during suction
cations for intubated patients are described because, unless the patient is paralysed, enforced
below. coughing overrides outside influences. Occasion
ally apical vibrations can be used to stimulate a
Preliminaries cough. During catheter withdrawal, some
For people with cardiovascular instability, admin patients voluntarily hold their breath longer than
istration of a narcotic analgesic before suction necessary, in which case they can be told, when
can -attenuate haemodynarnic disturbance (Klein the catheter has been withdrawn back to the
et aI. , 1988). Patients are advised that they will tracheal tube, when to breathe again.
feel more in control if they let the catheter pass If more than one suction pass is necessary,
and avoid coughing until it is irresistible. Self Sa02 or S�02 must first return to baseline. The
ventilating patients may find it helpful subjec same catheter should not be used for repeated
tively to hyperventilate beforehand. suction because of the bacteria-laden inner
For access to the left main bronchus, Judson surface of the tracheal tube (Sottile, 1986). The
(1994) recommends turning the head to the left. patient's mouth may need suction afterwards
An angled (coude-tipped) catheter facilitates this with a clean catheter or Yankauer sucker.
when the tip is directed to the left. This is used Patients who are able will prefer to do this them
more by anaesthetists because physiotherapists selves.
usually mobilize secretions sufficiently before Monitors should be observed, and suction
hand. terminated if HR slows by 20 or increases by
40 bpm, if BP drops or arrhythmias develop.
Technique for open suction
Catheter size should be no more than half the Technique for closed-circuit suction
internal diameter of the tracheal tube. A size 12 An in-line catheter (Figure 14.9) avoids discon
catheter is normally used, but size 14 is accepta- nection from the ventilator and can cause less
� Lock-unlock
contrOl valve
�
Suction connection �3 ---7-'/
�
Protective catheter sleeve
�
Black line
Figure 14.9 Components of a closed circuit catheter. The control valve locks the vacuum on or off. The catheter is
protected inside an air-tight sleeve. A T-piece connects the device to the tracheal tube. The irrigation port allows saline
instillation for irrigating the patient's airway or for cleaning the catheter.
377
CHAPTI-R 1 4 PHYSIOTHERAPY FOR PATIENTS I N INTENSIVE CARF
desaturation (Wainright and Gould, 1996). The Returning the patient to the ventilator at
catheter is sealed in a protective sleeve and normal settings between suction passes is not
becomes part of the ventilator circuit via a T adequate to prevent desaturation (Baun, 1984)
piece. Gloves are not necessary and the same and a variety of measures are available to
catheter is used for 24 hours. prevent hypoxaernia:
For people who need high FI02 and PEEP,
• Manual hyperventilation and hyperinflation
there is less physiological disturbance Gohnson,
help to reverse hypoxaemia and atelectasis
1994), and neonates have shown improved Sa02
respectively. This has been shown to prevent
compared to open suction (Castling, 1995). In
desaturation in the majority of patients
line suction should reduce cross-infection but
(Chulay, 1988) and is described as one of
there is no evidence that it influences nosocomial
the most effective techniques (Goodnough,
infection for the patient using it. Disadvantages
1985).
are reduced manual sensitivity, and the obliga
• The ' 1000/0 oxygen' button can be used, or
tion to use intermittent suction to relieve suction
the nurse asked to raise the ventilator FI02
pressure rather than the rocking thumb
2-3 minutes prior to suction then return it
technique. Appendix C lists manufacturers who
to normal 2-3 minutes afterwards, so long as
provide videos on techniques. The following is a
Sa02 has stabilized. A few minutes is
suggested procedure for the Trach-Care system:
normally considered adequate for the extra
1. Ensure black marker is visible except when oxygen to be delivered from the ventilator,
catheter is in use. but washout time varies from several breaths
2. Support T-piece throughout. (Ciesla, 1996) to 15 minutes (Sasse, 1995).
3. Unlock and depress vacuum control valve, This is another reason for physiotherapists
check suction pressure. to become acquainted with their ventilator
4. Release valve to close off suction. handbook.
5. Advance catheter fully, withdraw slightly, " A maximum of 10 seconds should be
depress valve to apply suction, withdraw allowed for each suction. If longer is needed,
catheter slowly until black marker is visible, this can be accommodated by removing the
i.e. catheter is out of the pa!ient's airway. thumb from the catheter port to release the
6. Clean catheter by opening the side port, vacuum, occluding the catheter mount
depressing vacuum control valve, injecting 5- opening (with the catheter still in situ but
10 mL sterile saline into the side port while withdrawn sufficiently to prevent coughing),
continuing suction and keeping the black then giving the patient 100% oxygen by MH
marker in view, releasing valve when or the ventilator. Suction is resumed when
completed, then recapping the port. ready.
7. Lock the vacuum control valve.
Problems
Reduction of hypoxaemia Difficulty passing the catheter may be dtle to
Suction, and the discontinuation of ventilation kinking of the tracheal tube, obstruction by thick
that accompanies it, can cause sustained hypox secretions, herniation of the cuff or the patient
aemia (Schwartz, 1987). Monitoring Sa02 is biting the tube. Biting requires reassurance and
useful but can give a false sense of security sometimes insertion of a bite block or Guedel
because it does not indicate oxygen delivery airway. If secretions are mixed with blood,
(Wainright and Gould, 1996), and suction can liaison with the nurse is required. Possible causes
be accompanied by a significant rise in oxygen are recent tracheostomy change, trauma from a
consumption without a corresponding rise in pulmonary artery catheter, clotting disorder,
cardiac output (Walsh et at., 1989). If available, heparinization or suction that is rough, frequent,
S�02 should be used. too deep or carried out with dry airways.
378
TECHNIQUES TO CLEAR SECRETIONS
Saline instillation quantity of mucus. If too quick, only the saline

Normal saline is sometimes instilled into the will be retrieved. If too slow, the saline will have
lungs with the intention of mobilizing thick been absorbed. Optimal time is usually found to
secretions. Disadvantages are interference with be equivalent to the time it takes to instil the
gas exchange and risk of bronchospasm and saline, turn the patient so that the instilled side
infection. Even with a sterile technique, bacteria is uppermost, then perform a few MH breaths
can be dislodged from a colonized ETT and before suctioning.
seeded . into the lower airway (Hagler and
Traver, 1994). There are also doubts about its Afterwards
efficacy because mucus does not incorporate After suction, patients should not be moved
water easily (Dulfano, 1973). The need for until stable (Riegel, 1 985). After treatment, the
salin� suggests that humidification may be inade following steps should be taken as appropriate:
quate. However, saline may help dislodge
encrusted secretions or encourage coughing • Check alarms.
(Gray et at. , 1990), and limited data suggest that • Ensure that the call bell and other reqUlre
it can be beneficial (Judson, 1 994). If instillation ments are within reach of the patient.
is used, the following points are suggested: • Reassure the patient that s/he is not being
left alone and that their lines are safe so that
• Warm the saline first if there is a risk of they do not feel inhibited from moving.
bronchospasm. • Tell the patient the time.
• Administer it slowly to prevent patients • If a rest is required, liaise with the nurse
feeling as if they are drowning. about dimming the light or using eye shades.
• Do not wet the tracheostomy dressing. • Check any individual concerns, e.g. anxiety
• If the aim is to loosen secretions (rather than about facing a wall.
dislodge debris at the end of the tracheal
tube), the patient can be turned after instilla
tion, so that the instilled side is uppermost EXERCISE AND REHABILITATION
for treatment. '1 gained greater comfort when the positions
• A volume of 5 mL has been advised (Bostick of my legs were varied. . . . Hearing was
and Wendelgass, 1987), but 10 mL or more acute: every sound seemed magnified. '
can be used if it is trickled in slowly and Gandy, 1 968
interspersed with manual ventilation or a
ventilator manual sigh to prevent desatura Exercises
tion.
Activity is required to maintain sensory input,
If this does not clear secretions, saline can be comfort, joint mobility and healing ability (Frank
delivered more distally by injecting it through a et aI. , 1 994), and minimize the weakness caused
suction catheter (p. 443). by loss of up to half the patient's muscle mass
With an in-line catheter, hold the T-piece (Griffiths and Jones, 1999). Patients confined to
upwards so that gravity assists passage of saline, bed need active or passive exercises, with special
unlock the vacuum control valve, advance the attention to the Achilles tendon, hip joint, joints
catheter and inject saline through the side port around the shoulder, two-joint muscles and, for
just before inspiration so it is carried distally long-term patients, the jaw and spine. The longer
with the next breath. a patient is bedridden, the more time is needed
The amount of material recovered has been for exercise, including stretches and mobilizations
described as 41 % following a 20 mL lavage to thoracic joints (Barker, 1998). A stiff chest
(Lam, 1985), but this will depend on timing, wall may respond to manual rotation of the
which is aimed at retrieving the maximum thorax in time with the ventilatory cycle.
379
Precautions include care with passive redistribute skin pressure, change resting muscle
movements for paralysed people whose joints length, assist orientation and load vertebrae to
are unprotected by muscle tone, ensuring that limit calcium loss and promote cartilage
movement is functional and takes account of nutrition. Tipping chairs are useful. A tilt-table
trunk position, and avoiding a long lever. may be helpful so long as there is no postural
Vigorous active exercise should be avoided for hypotension due to loss of the calf pump.
patients who are on inotropic support because Long-term patients may be excited at the
they have limited cardiovascular reserve, or prospect of their much-awaited first expedition
those on CMV because they are unable to out of bed, and some are then disillusioned by
increase their minute volume. the extent of their weakness and fatigue. This is
Patients with fractures, burns or altered when they most need encouragement. A visit
muscle tone need input from specialist collea outside is helpful, 'to maintain my sanity'
gues. Patients with neurological problems, or according to one patient (Clark, 1985). Lack of
damage to peripheries due to impaired outside windows has been shown to double the
perfusion, may need splinting to optimize incidence of delirium (MacKellaig, 1990).
function and circulation. rcus are now considered to be early rehabi
litation units. Assistants can help with exercises
Mobilization and mobilization, under supervision. rcu reha
bilitation has been shown to accelerate
The physician must always consider
recovery (O'Leary and Coakley, 1996), and this
complete bed rest as a highly
should start with the first treatment, even if
unphysiological and definitely hazardous
modestly.
form of therapy, to be ordered only for
specific indications and discontinued as
early as possible. Transfer from the leu
Dock, 1944 When I was moved from intensive care to
the general ward I felt desolate . . . as if my
Bed exercises, even when strenuous, are unable to
life support system had been ripped away. '
prevent deconditioning (Sandler, 1 988). An
Moore, 1 9 9 1 , p. 1 2
attempt should be made to stand and walk all
patients for whom there is no contraindication For patients who have been under constant
such as cardiovascular instability, relevant supervision for some time, transfer to the ward
fracture or paralysis. Attachment to a ventilator can mean anxiety and dread Gones and
does not preclude getting out of bed, but solicitous O'Donnell, 1 994) as well as relief at reaching a
attention to lines and tubes is required. A milestone. One study found that a quarter of
rebreathing bag provides ventilatory support if patients died after leaving the rcu, half of the
the patient walks more than a few steps from the deaths being unexpected (Goldhill and Sumner,
ventilator. Walking should be brief to prevent 1 998). This is more than would be expected
fatigue. from erroneous discharge decisions, and 'reloca
The patient needs to spend time sitting with tion stress' is thought to be the culprit, due to
their legs dangling over the edge of the bed before the change in environment, staff and routine,
standing (Winslow, 1995). Patient and monitors the sudden reduction in technical and human
should be scrutinized when the patient is upright. support Gones and O'Donnell, 1994) and
Pallor, or HR reduction by 5-1 0, indicates that 'inadequate protection against surprise' (Bowes,
the patient should sit down again (Winslow, 1 984).
1995). Suggestions to remedy this include early infor
For patients unable to stand, sitting in a chair mation to the patient, reduction of equipment at
helps prevent hypovolaemia (Wenger, 1 98 2), the bedside, a visit from the patient's named
380 ------
EXERCISE AND REHABILITATION
ward nurse, an exit interview (Sawdon et at. , old-fashioned process of death, but is potentially
1 995) and a booklet for patients and families reversible. It is followed within seconds by loss
Gones and O'Donnell, 1 994}. Follow-up clinics of consciousness and then by loss of respiration.
have been found not only useful for patients,
families and staff, but also cost-effective Anticipation
(Waldmann and Gaine, 1 996). Physiotherapists Before starting work in any new ward or unit,
should involve themselves in these clinics to the first task is to locate the crash trolley. Before
identifY musculoskeletal problems left over from seeing a new patient, the medical history will
extended immobility. provide evidence of risky conditions such as
After discharge from the ICU, patients need ischaemic heart disease, severe respiratory
ongoing rehabilitation to reduce common disease, drug overdose, metabolic disturbance,
problems of imbalance, fear of falling and panic arrhythmias or shock.
attacks (Griffiths and Jones, 1999). All staff are updated regularly on basic life
After discharge from hospital, patients need support, and local training should take prece
continuation of physiotherapy at home when dence over the following guidelines.
necessary because this is often when they realize
how debilitated they are, and few know how and Recognition
when to start exercising and how to pace them Warning signs are change in breathing, colour,
selves (Griffiths and Jones, 1 999) . facial expression or mental function. Hypoventi
lation with altered consciousness is an ominous
'I've tried to help by doing the washing up
combination. Loss of consciousness is the first
but I keep dropping the crockery.
obvious, though non-specific, sign.
When I went home I climbed the stairs on
The patient's colour may be pale, ashen or
my hands and knees and came down on my
blue, depending on the cause. No carotid pulse
bottom.'
can be felt in the groove between the larynx and
Patients quoted by Griffiths and Jones, 1 9 99
sternomastoid muscle.
Respiration may become gasping and then
stops (unless respiratory arrest has been the
RECOGNITION AND MANAGEM ENT OF
primary event).
EM ERGENCIE S
An ECG may show ventricular fibrillation
The key to the successful management of emer (VF), ventricular tachycardia, asystole or electro
gencies is informed anticipation and recognition. mechanical dissociation (EMD).
Physiotherapists are not immersed in life-threa
tening events every day, so it is advisable to Action
review protocols regularly in order to maintain The time between collapse and initiation of
confidence and avoid the indecision that is often resuscitation is critical, and a false alarm is
evident at the scene of an emergency. better than a dead patient. If suspicions are
Some emergencies are covered in the text: raised by a change in consciousness and colour,
feel for the pulse if skilled in this. Call out to the
• tracheostomies, page 2 8 1
patient, and if s/he is unresponsive, follow the
• chest drains, page 270
basic life support stage of cardiopulmonary
• fat embolism, page 407
resuscitation (CPR):
• shock, page 4 1 0.
1 . Summon help by pressing the crash button

Cardiac arrest and by bellowing 'Cardiac arrest! '. If no-one
Cardiac arrest is the sudden cessation of heart is available and a telephone is nearby, call the
function. It is the commonest mechanism of the crash team or ambulance.
381
CHAPTER 14 PHYSIOTHERAPY FOR PATIENTS IN lNTE SIVE CARE
2. Position the patient supine and remove one person is available, the compression-to
pillows. ventilation ratio is 15 :2. For physiotherapists
3. Establish a patent airway. Use one hand to working in the community or out of reach of a
tilt the head back and the other to lift the crash trolley, it is advisable to carry a pocket
chin forward to pull the base of the tongue mask for mouth-to-mask ventilation.
away from the back of the throat. (If neck Do not interrupt CPR to make further checks
injury is suspected, substitute the head tilt by unless there are signs of life. If the patient regurgi
a jaw thrust: with index fingers under the tates, turn the head to the side, suction or wipe out
angles of the jaw, pull jaw forwards without the mouth, and continue CPR. If recovery occurs,
moving the neck, open mouth with the turn the patient into the semi-prone recovery
thumbs). If necessary, suction mouth and position (with the patient's flexed arm supporting
throat with a Yankauer sucker. If an the head to keep the neck in alignment) so that the
obstruction can be seen, extract it if tongue falls safely to the side of the mouth and
accessible, but if there is a risk of pushing it unwanted material can drain out.
further down, use the choking protocol (see Common errors are:
below). Leave well-fitting dentures in place to
• not maintaining a patent airway throughout,
improve the mouth seal.
e.g. inadequate neck extension
4. Keeping the airway open by correct head
• not allowing chest deflation between breaths
posltloning, look, listen and feel for
• not compressing the chest with sufficient
breathing for 1 0 seconds. If breathing is
force
absent or gasping, ventilate with 1 00%
• compressing one side of the sternum rather
oxygen using a face mask, resuscitation bag
than mid-sternum.
and oxygen at 15 L/min. Pull the mask edges
apart before positioning over the face, while When the crash team arrives, they will
maintaining a patent airway. Do not lose the instigate advanced life support, i.e. ECG moni
patient airway position achieved. Bag-mask toring, intubation, medication, defibrillation.
ventilation is easier with two people, but if Staff should stand clear while defibrillation is
only one person is available, it is easier to applied.
resuscitate with a Laerdal face mask or, if When no longer needed, the physiotherapist
necessary, mouth-to-mouth with a pinched can give attention to other patients who may be
nose. The first two breaths should be slow to distressed at witnessing the event. If the patient
minimize risk of aspiration. survives, s/he will need debriefing by an appro
5. Kneel on the bed and apply external chest priate member of staff. If the patient dies, the
compression, using body weight through physiotherapist and those involved will need
straight arms: with the heels of both hands some support.
two fingerbreadths above the xiphoid
process, depress the lower sternum 4-5 cm at
Respiratory arrest
1 00 compressions a minute. Apply pressure
smoothly and evenly to minimize fracture As cardiac arrest leads to respiratory arrest, so
risk. Effectiveness of chest compression is does respiratory arrest, if untreated, lead to
suspected by return of a healthy colour and cardiac arrest.
confirmed by palpation of a spontaneous
pulse when a spare person is available. Anticipation
Predisposing factors include exacerbation of
For two-people CPR, the last two stages are COPD, airway obstruction (e.g. foreign body,
performed concurrently, with chest compres swelling or bleeding from trauma, smoke inhala
sions and ventilation at a ratio of 5 : 1 . If only tion) or aspiration (especially following drug
382 ------
RECOGNITION AND MANAGEMENT OF EMERGENCIES
overdose). Warning signs are inability to speak, ness to major muscle activity, followed by drow
and either violent respiratory efforts, laboured SIness.
breathing or drowsiness.
Action
Recognition 1 . Patients subject to frequent seizures should
Respiratory arrest is indicated by absence of have the bed kept low, side rails up and
movement of the chest, loss of airflow from the padded, and oxygen and suction available.
mouth and nose, and sometimes cyanosis. This 2. If there is advance warning, insert an airway.
progresses to loss of consciousness. Do not attempt this once the seizure is under
way.
Action 3. Protect the patient's head and body from
1. Call for help. Injury. Loosen tight clothing, especially
2. Establish a patent airway as described for around the neck. Do not use restraints or
CPR. If there is no airflow, continue as below. hold the victim down. Keep in side-lying if
3. If a foreign body is the likely culprit, e.g. the possible.
victim is choking, attempt to dislodge it from 4. Afterwards, ensure the patient is in the
the throat by suction or, if it can be seen, by recovery position. Reassure him/her as
hand. If unsuccessful, administer up to five conSClOusness returns. Request medical
piston-like Heimlich manoeuvres: strong assessment.
inward and upward thrusts to the abdomen
applied below the rib cage and above the Haemorrhage
navel, providing the patient is not pregnant
or very fat. This can be done from behind a Anticipation
standing victim or kneeling astride a supine Uncontrolled bleeding can follow surgery,
victim. If the patient is still not breathing, arterial line disconnection or trauma.
continue as below.
4. Ventilate by bag-mask ventilation, Laerdal Recognition
face mask or mouth-to-mouth, as described External bleeding is not easily missed. Internal
above. Inspiration time is 1.5-2 seconds. bleeding is suspected if there are signs of severe
Repeat once every 6 seconds. Continue for 1 hypovolaemia (p. 362). BP and HR are the least
minute, then re-assess. reliable of these signs because BP can be main
tained until 40% of blood volume is lost, and
If cardiac arrest ensues, instigate full CPR. If
HR is responsive to other variables. Bleeding
the patient starts breathing, turn him/her into
into a closed space causes extreme pain.
the recovery position because vomiting is
common as consciousness lightens.
Action
1 . Position the patient supine.
Seizure 2. Apply pressure to the bleeding point if
accessible.
Anticipation 3. Elevate the affected part if possible.
The medical notes indicate whether a patient has 4. Request assistance.
a history of epilepsy. Other causes of fitting are 5. Explain to the patient what is being done.
head injury, alcohol intoxication, or in children,
fever. Some patients sense an aura in advance. Massive haemoptysis
Massive haemoptysis can be defined in relation
Recognition to the volume expectorated or the magnitude of
Seizures vary from transient loss of conscious- the effect, e.g. 1 00-1 000 mL blood over 24
383
CHAPTER 1 4 PHYSIOTHERAPY FOR PATIENTS I N INTENSIVE CARE
hours or sufficient to be life-threatening by virtue • distended neck veins

of blood loss, hypotension, or, most commonly, • pulsus paradoxus (see Glossary)
asphyxiation (Dweik and Stoller, 1999). • narrowed pulse pressure
• enlarged heart on X-ray.
Anticipation
Predisposing factors are lung cancer, bronchiec Action
tasis, abscess or TB. Alert the doctor, who will aspirate fluid direct
from the pericardium.
Action
The patient should be positioned head down, Tension pneumothorax
and if the side of the haemorrhage is known, Gas entering the pleural space on inspiration but
laid on the affected side to prevent aspiration unable to escape on expiration causes tension
into the healthy lung. Cough suppressants and pneumothorax. Cardiac arrest will follow within
sedatives should not be given. Patients with about 20 minutes.
depressed consciousness or risk of asphyxiation
need intubation and suction. Bronchial artery Anticipation
embolization may be required (Mal et ai. , 1999). In ventilated patients, pneumothoraces are likely
to be under tension especially at the following
Cardiac tamponade
times:
Cardiac tamponade is accumulation of gas or
fluid, usually blood, in the pericardium. The • immediately after intubation, if inadvertent
pericardium is not distensible and can only tube placement into the right main bronchus
accommodate 100 mL fluid rapidly without causes hyperinflation of the right lung
affecting cardiac output, after which an addi • in the hours following initiation of mechan
tional 40 mL doubles pericardial pressure, ical ventilation, when air is forced through a
compressing the heart and damming back blood previously unknown leak in the pleura.
in systemic veins (Hyde et ai. , 1996). If increas
mg pressure is not relieved, cardiac arrest is Predisposing factors are emphysema, and
inevitable. surgery or other trauma to the chest. Surgical
emphysema in the neck can be a warning sign.
Antici pation
Tamponade can occur in the first 24 hours after Recognition
heart surgery. Other predisposing factors are Tension pneumothorax is sufficiently rare to be
trauma, dissecting aneurysm, infection or malig sometimes mistaken for bronchospasm. Both of
nancy. these conditions cause respiratory distress,
wheeze, increased airway pressure and laboured
Recognition breathing. The added features of tension pneu
Progressive compression of the heart leads to mothorax are:
precipitate loss of cardiac output and rise m
filling pressures. Hypovolaemia masks some of • ! amplitude in ECG (often the first sign)
these signs, but the following may be evident. • unequal chest movement
• hyperresonant perCUSSlOn note on the
• ! BP, S�02' urine output affected side
• i CVP and JVP • ! breath sounds on the affected side, or both
• i PAWP, HR sides if severe
• CVP and PAWP approximately equal • ! Sa 02
• sudden change in pericardial drain output • cyanosls
384
RECOGNITION AND MANAGEMENT OF EMERGENCIES
• distended neck vems and i CVP (unless and manually ventilate with 1 00% oxygen, using
patient is hypovolaemic) high flow and low pressure. Others should
• displaced apex beat maximize F102 through the ventilator.
• in self-ventilating patients, dyspnoea and
tracheal deviation away from the affected side Pulmonary embolism
• ventilator evidence of high airway pressure, Sudden patient distress and the signs described
and expired minute volume less than preset on page 1 1 3 raise suspicions of pulmonary
minute volume embolism. Disconnection from the ventilator
• 1 BP, i HR, progressing to cardiovascular and manually ventilating the patient do not help.
collapse Monitors will show i HR, i BP i RR, 1 Sa02, i i
• radiograph as in Figure 14. 1 0 (this is an X CVP, 1 cardiac output. See page 1 1 3 for
ray we should never see because there is no management.
time to waste).
Air embolism
Action
Anticipation
Alert the doctor, who will insert a 14G cannula
Air may enter the circulation after cardiac or
into the pleura at the second intercostal space in
neurosurgery, or occasionally from a pneu
the midclavicular line to release the pressure.
mothorax or during insertion or removal of a
While waiting, an experienced physiotherapist
pulmonary artery catheter or vascath.
can disconnect the patient from the ventilator
Recognition
A large air embolus causes respiratory distress,
palpitations, dizziness, weakness and pallor or
cyanosIs.
Action
Summon help. Place the patient head down in
left-side-lying, which diverts air away from the
pulmonary artery and pulmonary circulation.
Give high-percentage oxygen. An embolus larger
than 1 00 mL may cause cardiac arrest, which
requires cardiac compression with heavy and
deep pressure to disperse air bubbles to periph
eral segments of the pulmonary artery.
Equipment malfunction or disconnection

Astute eyes and ears help pick up the slight hiss
of an air leak, identify from an orchestra of
alarms which is the offending malfunction, or
notice the subtle change in a drowsy patient'S
demeanour that signifies that something is
amiss. Prevention includes reading the manufac
turer's handbook in order to understand the
workings of the ventilator, and familiarity with
Figure 14.10 Right tension pneumothorax. as indicated
by a black area devoid of lung markings on the right and the alarms to help distinguish what each
mediastinal shift to the left away from the affected side. signifies.
------ 385
CHAPTER 1 4 PHYSIOTHERAPY FOR PATIENTS I N lNTENSIVE CARE
Alarms • pam
The most relevant alarms for the physiotherapist • fear
are the high-pressure alarm, low-pressure alarm, • pneumothorax, pulmonary oedema, abdom
and alarms for BP, PI02 and humidifier heater. inal distension, bronchospasm or mucus plug
The high-pressure alarm is set at 5-10 cmH20 • biting the tube.
higher than peak airway pressure and it is
activated if there is: Ventilator-related problems include:
• major atelectasis
• kink or leak in the circuit
• sputum retention
• intrinsic PEEP
• condensed water in the tubing
• inappropriate settings for flow rate, tidal
• patient coughing or fighting the ventilator
volume, I:E ratio or trigger sensitivity.
• bronchospasm
• pneumothorax
While awaiting assistance from other
• partial extubation
members of the team, check airway pressure and
• right main bronchus intubation
monitors. Ask the patient if s/he wants more air.
• cuff herniation over the end of the tracheal
If the answer is a nod, or the patient is unable to
tube respond, disconnect the patient from the ventila
• patient biting the endotracheal tube.
tor and connect to the bag with oxygen. Either
If the patient bites the ETT, this requires manually ventilate or allow the patient to self
dissuasion, sedation or change to a nasal tube. For ventilate through the bag with the valve open for
a displaced ETT, the doctor will deflate the cuff, minimal resistance and a high flow rate for
reposition the tube, inflate the cuff, listen for comfort. If distress continues, it is a patient
equal breath sounds and request a check X-ray. based problem, to be sorted with yes/no
The low-pressure alarm indicates that pressure questions. If it resolves, there is some mechanical
has fallen more than 5-10 cmH20 below the mischief.
desired limit and means a leak in the system, Manual ventilation or hyperventilation may
confirmed by reduced expired minute volume settle a patient-based problem. If not, suction
and airway pressure. A disconnected circuit the airway, which indicates if there is a blocked
should be reconnected after a quick alcohol wipe tube or excess secretions. If this is unhelpful, ask
if it has touched anything. The patient's an alert patient yes/no questions, or examine an
condition should be checked, the cause deter unresponsive patient to identify the problem.
mined and appropriate adjustments made or the Unilateral air entry raises suspicions of a malpo
nurse informed. sitioned tracheal tube, pneumothorax or mucus
Alarms are fallible. Patient observation comes plug.
first. Deal with ventilator problems as follows:
• Leaking tracheal tube cuff: inflate cuff with

Arterial line or vascular catheter di sconnection
air from a syringe, just enough to eliminate
Firm pressure to the site is required if an arterial
the leak, inform nurse who will �easure the
line or vascath becomes disconnected from the
cuff pressure
patient. Reassure the patient, who may be frigh
• Tube disconnection: re-connect after
tened at the amount of blood. Observe patient
cleaning the disconnected ends
and monitors for signs of hypovolaemia. Inform
• Inability to locate disconnection or identify
the nurse.
problem: Inform the nurse
• Tracheal tube malfunction, bronchospasm,
Patient distress on IPPV ventilator asynchrony unresolved by talking
Patient-related problems (Figure 14.11) include: to patient: inform the doctor.
386
RECOGNITION AND MANAGEMENT OF EMl:.R('ENClE�
-tt�-+-+---- Sweating and

nasal flaring
Heightened -t---+-\--f-----...j.J.,.
ste rnomastoid
activity
Suprasternal and
---'I<---"Mr-\--I.---- Rapid breathing
supraclavicular
recession
Intercostal recession
-t"'--'t--+-----'.._--'<- Abdominal paradox
Rapid pulse __ -+_+-_-\-_'''''
�I
Figure 14.11 Physical signs of patient distress. (From Tobin, M. J. (1991) What should the clinician do when a patient fights
the ventilator? Resp. Care, 36, 395-406)
alert patient moribund patient Figure 1 4 . 1 2 provides a quick-check guide, after

discussion with other members of the team.
'do you want
rnore air?'
� yes ON CALLS
no
� rnanual ventilation
A well managed on-call system can sustain many
� a sick patient through a difficult night. The key
not OK OK to success is education so that all parties under
identify------
patient's
L
id ify
ventilator
stand the scope and limitations of physiotherapy.
Education should be targeted at relevant staff, as
·follows.
problem problem
Doctors. All levels of medical staff need
(e. g. anxiety, pain advice on the indications for out-of-hours
pneurnothorax, physiotherapy, with particular attention to
haemodynamic upset,
distended abdomen, juniors starting a new rotation. Young doctors in
malpositioned ETT) a new environment can become anxious with an
unfamiliar event and may call out the
Figure 14.12 Flow chart for relieving patient distress physiotherapist unnecessarily or not call when
387
C HAPTER 14 PHYSIOTHERAPY F O R PATIENTS IN INTENSIVE CARE
indicated. Education can be through informal subject of physiotherapy and this is an educa
talks, involvement in doctors' continuing tional opportunity to be grasped gladly.
education programmes and ensuring that the Nurses. Nurses and physiotherapists work
house officers' induction pack contains on-call closely and have an understanding of each
information. Medical training hardly brushes the others' roles. Day-to-day exchange of informa-
Box 14.3 Criteria for on-calls
Indicati ons
Patients who cannot be left until the normal working day for fear of deterioration 10 their
condition, e.g.
• those with atelectasis or sputum retention plus worsening blood gases
• certain patients who may need mechanical ventilation unless treated, such as those with
exacerbation of COPD, acidosis and drowsiness.

Non-indications
Conditions for which physiotherapy is ineffective, e.g.
• pulmonary oedema (see Table 2.5)
• dehydration-related sputum retention (until rehydrated)
• pain-related atelectasis (until pain is controlled).
• pneumonia if consolidation is unresolved (until and if secretions become a problem).
General questions to ask when called

(ask only relevant questions, and diplomatically!)
• doctor's name and contact details
• patient's name, diagnosis and location
• auscultation
• hydration status
• trend in temperature
• trend in blood gases
• X-ray results
• cardiovascular status
• pain, and outcome of analgesia
• patient's problem, e.g. atelectasis, exhaustion, sputum retention
• if productive of sputum, is the patient able to clear it unaided?
• if non-productive of sputum, is there sputum retention, or no sputum?
• availability of X-ray, medical notes and necessary equipment.
If physiotherapy i s not indicated:

• politely explain indications for emergency physiotherapy
• say that if the situation changes, please call again.
If physiotherapy i s indi cated:
• before coming in, ask for analgesics, anti-emetics or humidification if necessary
• ask for patient to be positioned appropriately.
After treatment
Liaise with nursing staff re: ongoing management, e.g. positioning, rest, reminders on incentive
spirometry.
388
O N CALLS
tion lays the foundation for co-operation, and

this can be developed into teaching sessions so
that some nursing staff can perform maintenance Admitted to A&E after inability to sleep due to
chest care and know when to advise doctors that abdominal pain
the physiotherapist be called. SH: unemployed, married, children, 1 5 cigarettes/
Physiotherapists. Junior and non-respiratory day, 80 units alcohol/day.
seniors need confidence in making respiratory
On admission
decisions. Useful time can be spent going
through equipment and practising problem Distended tender abdomen.
solving with case studies. Several steps can be ABGs when self-ventilating on F102 of 0.6: pH
taken to facilitate a sound night's sleep for those 7.26, Pa02 1 2.3 kPa, PaC02 8.4 kPa, BE 1 .5,
on duty: HC03- 23.2.
i WBC.
• time set aside on the preceding afternoon for Medical treatment
the on-call physiotherapist to see any border
Nasogastric tube, analgesia, fluid resuscitation.
line patient with the respiratory physiothera
pist Progress
• a handout such as that set out in Box 14.3 Sa02 deteriorated -+ intubated and ventilated -+
(to include location of equipment), kept by gradual increase in airway pressure.
the on-call physiotherapist's phone
• clarification of departmental policy on who On examination
is authorized to call out the physiotherapist ABGs on inverse ratio ventilation and F102 of 0.85 :
• a respiratory physiotherapist available to pH 7.20, Pa02 7.9 kPa, PaC02 7.5 kPa, BE 1 .0,
inexperienced on-call staff at the end of a HC03- 25.2.
bleep for advice. Breath sounds absent bibasally.
Diagnosis
If called to Accident and Emergency, it is
advisable to check that the patient is not Acute pancreatitis.
immersed in tests and investigations, and to Questions
identify when s/he will be available for
I. What is causing the high airway pressure?
physiotherapy.
2. What is obliterating the breath sounds?
The interests of the patient and good relations
3. Is the acidosis respiratory or metabolic?
with other disciplines can be fostered by the
4. What syndrome may develop?
physiotherapist taking responsibility for pre
5. Problem?
arranging call-outs when appropriate. The
6. Goals?
physiotherapist can also act as advisor and
7. Plan?
consultant over the phone.
Many departments organize evemng
physiotherapy shifts because there is evidence ABGs = arterial blood gases; BE = base excess; WBC
that this can stem deterioration in patients after = white blood cell count.
major surgery (Ntoumenopoulos and
Greenwood, 1 996) or patients with excessive
secretions (Wong, 2000).
l;j£1;.]:�1'<·'RiMIiIi)-q
Guidelines for different on-call problems may I . High airway pressure is caused by pressure
be helpful, e.g. Box 14.4. against diaphragm from distended abdomen.
2. Breath sounds reduced by compression of lungs
from distended abdomen.
389
CHAPTER 14 PHYSIOTHERAPY FOR PATIENTS IN INTEi'-!�IVE CARE
Box 14.4 Management of the acutely breathless patient
Management of objective signs
PaC02
�.--.---- �. -------..
t
Low
�
High and stable,
i.e. base ne value t
Rising
Normal Normal response Can be

response to late stage dangerous if due
to 80B chronic disease to exhaustion
t
Consider NIV (check CXR)
if PaC02 is not available, monitor 8a02 which is less

sensitive to minute volume but will decrease if t MV is severe
� Position �
Optimal I nefficient
t
No action
•
Reposition or simply prop up with
pillows, depending on patient
� Breathing
Fast but stable
� I rregular, tense
or asynchronous
No action
•
Encourage smooth, rhythmic breathing,
or if patient able, abdominal breathing
NB: do not alter RR
• Bronchospasm
Check drug chart and PF chart.
Liaise with team.
• Secretions
Hydration.
Humidification (warm if bronchospasm).
Slow rhythmic percussion.
AD or modified ACB.
Cough suppression until secretions accessible, then cough facilitation.
Continued opposite
390
CASE STUDY
Management of symptoms
• Fatigue
Positioning and some SOB strategies (p. 1 69-175)
• Feeling out of control
Identify patient's coping strategies, suggest any others.
• Lack of sleep
Liaise with team reo environment, check anxiety.
• Anxiety
Identify cause, provide information.
• Pain
Identify cause. If due to coughing, educate on selective cough facilitation and suppression as and
when appropriate. If due to muscle tension, relieve by positioning, relaxation. Suggest or show
massage to relatives.
• Exhaustion
Monitor PaC02 and pH.
Tips for handling the acutely breathless patient

• Avoid noise, bright lights, crowding
• Do not enter patient's personal space until after introductions
• Avoid chatter, be specific, talk gently
• Offer questions with yes/no answers
• Identify patient's view of cause of breathlessness
• Patient or relatives may have information on individual relieving strategies
• Patient may find curtains claustrophobic, may need window open.
ACB = active cycle of breathing; AD = autogenic drainage; CXR = chest X-ray; MY = minute volume; NN =
non-invasive ventilation; PF = peak flow; RR = respiratory rate; SOB = shortness of breath.
3. Respiratory acidosis due to CO2 retention. • Care of musculoskeletal system.

4. Multisystem failure. • Progress.
S . Progression of compression atelectasis, with
deteriorating gas exchange.
6. Reverse and prevent further atelectasis, LITERATURE APPRAISAL
rehabilitate.
7. Plan: (Title: Endotracheal suctioning: ventilator vs
• Avoidance of supine.
manual delivery of hyperoxygenation breaths)
• Initiate kinetic rotation bed.
The researcher delivered a [manual] tidal
• If there is localized atelectasis: try MH in side
volume equal to the patient's ventilator
lying, re-assess for benefits or adverse effects. tidal volume . . . .
• If there are audible secretions: suction.
. . . these findings support the use of the
• Identify if Sa02 responds to above techniques, or
patient's ventilator for hyperoxygenation
whether deteriorating gas exchange is due to during suctioning.
developing ARDS. (NB distended abdomen may Am. ]. Crit. Care 1 99 6 ; 5 : 1 92-1 97
contraindicate prone).
391
Glass, C. A. and Grap, N. ]. ( 1995) Ten tips for safer

suctioning. Am. J. Nurs. , 95(5), 5 1-53.
If the tidal volume delivered by manual ventila Guglielminotti, ]. (2000) Bedside detection o f retained
tion is no more than the ventilator tidal volume, tracheobronchial secretilns in patients receiving
there is nothing to compare. mechanical ventilation. Chest, 1 1 8, 1 095-1099.

Juniper, M. C. and Garrard, C. S. ( 1 997) The chest
X-ray in intensive care. Care Crit. Ill, 13, 1 98-
RECOMMENDED READING 200.
Lapinsky, S.E. ( 1 997) Safety and efficacy of a
AARC Clinical Practice Guidelines ( 1 993) sustained inflation maneuver for alveolar
Endotracheal suctioning of mechanically ventilated recruitment. Chest, 1 12, 1 26S.
adults and children with artificial airways. Respir. McEleney, M. ( 1 998) Endotracheal suction. Prof
Care, 3 8 , 500-504. Nurse, 1 3 , 373-376.
Anzueto, A. ( 1 999) Muscle dysfunction in the ICU. Marcy, T. W. ( 1 994) Respiratory distress in the
Clin. Chest Med., 20, 435-452. ventilated patient. Clin. Chest Med. , 1 5 ( 1), 55-
Bergbom-Engberg, I. ( 1 989) Assessment of patients' 74.
experiences of discomfort during respirator Raymond, S.]. ( 1 995) Normal saline instillation
therapy. Crit. Care Med. , 1 7, 1 068- 1 072. before suctioning. Am.J. Crit. Care, 4, 267-27l.
Cassa, S., Costar, S . and Tracey, C. ( 1 998) Patient Selsby, D. and Jones, ]. G. ( 1 990) Some physiological
handling aids: prescribing guidelines. Br. J. Ther. and clinical aspects of chest physiotherapy. Br. J.
Rehabil. , 5, 7-9. Anaesth. , 64, 62 1-63 l .
Copnell, B. and Fergusson, D. ( 1 995) Endotracheal Voggenreiter, G . ( 1 999) Intermittent prone
suctioning. Am.J. Crit.Care, 4, 1 00-1 05. positioning in the treatment of severe and
Epstein C D , Henning RJ ( 1993) Oxygen transport moderate posttraumatic lung injury.
variables in the identification and treatment of Crit. Care.Med, 27, 23 75-23 82.
tissue hypoxia. Heart Lung, 22, 328-348. Whittaker, ]. and Ball, C. (2000) Discharge from
Gamrin, L. (2000) Protein-sparing effect in skeletal intensive care. int. Crit. Care Nurs., 1 6, 135-143.
muscle of growth hormone treatment in critically
ill patients. Ann. Surg., 231, 577-586.
392
15 DISORDERS IN INTENSIVE CARE PATIENTS
SUMMARY
Lung disease Systems failure

• COPD • Disseminated intravascular coagulation
• Asthma • Acute pancreatitis
Neuromuscular disorders • Collagen vascular disease
• GuillaiIi-Barre syndrome • Kidney failure
• Acute quadriplegia • Liver failure
• Acute head injury Multisystem failure

• Myasthenia gravis Acute respiratory distress syndrome
• Botulism Poisoning and parasuicide
• Tetanus
Smoke inhalation
• Critical illness neuropathy Near-drowning
Chest trauma Case study
• Rib fracture
Literature appraisal
• Lung contusion Quiz
• Fat embolism Recommended reading
LUNG DISEASE within 30 minutes of starting IPPV, close moni

toring is necessary. Manual hyperinflation (MH)
Chronic Obstructive Pulmonary Disease
is inadvisable unless essential because of over
Mechanical ventilation is not indicated for distended alveoli and the uneven distribution of
people with COPD who are suffering an irrever extra positive pressure within the damaged lungs.
sible deterioration in their condition, but it may Weaning can be tiring, protracted and frigh
be needed to buy time during an exacerbation. It tening for patients. Physiotherapy is crucial in
is useful to know in advance whether patients preparing for this in advance. Rest and sleep are
would prefer to be ventilated in the event of required for 48 hours after initiation of IPPV
serious exacerbation. (Corris, 1 990) interspersed with nutritional
Intermittent positive-pressure ventilation support and exercises. Rest is also required
(IPPV) is usually by pressure support, with before the first weaning attempt. Otherwise time
extrinsic (applied) PEEP to counterbalance should be organized around short periods of
intrinsic PEEP (Rossi, 1 994). Patients with exercise alternating with rest. Bed exercises
chronic hypercapnia must have their minute should be demonstrated to the patient, nurse
ventilation titrated to pH rather than PaC02 so and family, written down and left with the
that compensatory renal bicarbonate retention nursing notes. Daily standing and walking are
will be adequate for buffering during weaning. A required unless contraindicated. Early rehabilita
person who has acclimatized to complex acid tion has shown:
base compensations may find that the sudden
change to IPPV has a destabilizing effect, leading • i lung function
to arrhythmias, hypotension and the unmasking • 1 breathlessness
of hypovolaemia. If physiotherapy is needed • i exercise tolerance (Nava, 1 998).
------ 393
CHAPTER 15 DISORDERS IN INTENSIVE CARE PATIENTS
If problems after extubation are encountered, initiation of IPPV because the combination of
non-invasive ventilation has been found to anaesthesia, hypovolaemia and high airway
reduce the need for reintubation by two-thirds pressures may cause profound hypotension. �2-
(Hilbert et al., 1 998). agonists may reduce potassium and further
destabilize the cardiovascular system. Rapid
Asthma infusion of fluids, sometimes with vasopressors,
Mechanical ventilation is a perilous venture for usually restores BP, but physiotherapy is still
people with acute severe asthma, carrying an best limited to stress reduction. If thick mucus
average mortality of 200/0 (McFadden and plugs are present, instillation of warmed sterile
Warren, 1 997). IPPV is indicated if patients saline, e.g. 2 mL every 15 minutes, may be
become exhausted from the effort of maintaining indicated (Branthwaite, 1985). When airway
hyperinflation above TLC in order to keep pressures have settled to normal, other treatment
obstructed airways open, leading to an intracta is given as necessary, but MH is unwise while
bly rising PaC02 with acidosis and impaired the chest is hyperinflated.
conSCIOusness. Any sudden deterioration should raise suspi
Positive pressure volumes above TLC risk cions of tension pneumothorax. The usual signs
intrinsic PEEP, barotrauma, reduced venous (p. 384) can be obliterated in a hyperinflated
return, hypotension, arrhythmias and right heart patient on IPPV.
failure due to compressed pulmonary capillaries.
Dehydrated patients are particularly vulnerable.
High levels of oxygen are required. Permissive
hypercapnia (p. 352) may be used in an attempt Severe respiratory muscle weakness may lead to
to maintain airway pressures below 40 mmHg. hypercapnic ventilatory failure. The physiothera
Hyperinflation and intrinsic PEEP can be pist's role is to maintain chest, muscles, joints
controlled by: and morale, while being alert to inadequate
sedation and analgesia which may occur because
• extrinsic PEEP
of difficulty in assessment and a need for regular
• high inspiratory flow rate (e.g.100 Llmin) to
neurological examination.
prolong expiratory time
• brief disconnection from the ventilator and
allowing the trapped gas to escape through Guillain-Barre syndrome
the airway The physiotherapist was a most welcome
• bilateral expiratory manual compressions of person, as, despite the discomfort endured
the chest during several successive expira to have 'dead' limbs stretched and
tions while disconnected from IPPV, using repositioned, this left me comfortable for
two people in synchrony, or, for one person, several more hours.'
over ribs 8-10 (van der Touw et al., 1998). Clark, 1985
Intractable bronchospasm may require heliox Guillain-Barre syndrome is an autoimmune

(Manthous, 1 997) , inhalation agents (Bellomo, demyelinating peripheral neuropathy' . It causes a
1 994), hypothermia (Browning, 1 992), a contin predominantly motor deficit with some
uous IV bronchodilating anaesthetic such as autonomic and sensory components. The
ketamine (Levy et al., 1 998) or extracorporeal syndrome develops after an infection in .75% of
support. Prolonged paralysis should be avoided patients (Winer, 1 994). Presenting features vary
unless essential because of its association with widely and include backache, paraesthesia and
myopathy when combined with steroids weakness. Weakness progresses for up to a
(Behbehani, 1999). month, and ventilatory failure develops in 20%
Physiotherapy is inadvisable immediately after of patients, sometimes with alarming speed. This
394
can be predicted by difficulties with speech or (Meythaler, 1 997). Self-help groups provide
swallowing, but vital capacity (VC) measure support from the leu stage onwards (Appendix
ments are the most reliable warning sign. Intuba C) .
tion should be considered if ve decreases to
1 8 mLlkg (Meythaler, 1 997). Acute quadriplegia
Medical treatment is mainly supportive, but
'You can't appreciate what it is to be
plasma exchange hastens recovery by removing
paralysed unless you are. The big things
antibodies from the blood (Appleyard and
you get used to easier, like not getting up
Sherry, 1998).
and walking around. The trivial things -
Physiotherapy is mainly prophylactic, espe
like not being able to scratch your nose or
cially to avoid contractures that can develop and
feed yourself - they hurt.'
become major components of disability (Soryal
Patient quoted by Stewart and Rossier, 1978
et ai., 1 992). Muscle pain occurs in up to 72%
of patients (Pentland, 1 994) . This is exacerbated People whose lives have been devastated by
at initiation of movement but eased after a few disease or trauma to the cervical spine are over
moments of mobility exercises. Exercise should whelmed at first and find it difficult to compre
therefore be: hend how savagely their life has been limited.
Physiotherapists who care for people with acute
• regular and frequent
quadriplegia need to allow them to work
• preceded if necessary by anti-inflammatory
through their grief at their own pace, while
drugs or Entonox
endeavouring to prevent the respiratory compli
• gentle at the start
cations that are the leading cause of death.
• precise, to ensure full range without risking
Quadriplegia is paralysis of the limbs and
the damage that can occur with hypotonia
trunk. Tetraplegia is paralysis of the limbs.
and sensory impairment (Soryal et ai., 1 992)
• when active, brief to avoid fatigue.
Pathophysiology and clinical features
Spinal movements should be included, e.g. Spinal damage following trauma is greater if
double knee-and-hip flexion, knee rolling, and there is mishandling at the scene of the accident,
neck movements with due care of the tracheal e.g. helmet removal. Normal neurological
tube. Relatives can assist with some routine function and normal radiology does not exclude
exercises. Extremities may be hypersensitive, and cervical spine injury, and up to 25% of the
a cradle eases the weight of bedclothes. damage is thought to occur after the initial
Autonomic involvement leads to unstable BP trauma due to inadequate protection of the spine
and heart rate (HR), and sustained hypertension (Walker, 1 998).
may alternate with sudden hypotension. The risk Lesions above T6 to Ll paralyse the
of hypotension is reduced by ensuring that abdominal muscles and impair coughing. Higher
turning is gentle, avoiding any intervention if thoracic lesions paralyse the intercostals and
evp is below 5 cmH20, and acclimatization to destabilize the rib cage, causing paradoxical
the upright posture with a tilt table. Risk of inward motion on inspiration. Lesions above e4
bradycardia is reduced by oxygenation before denervate the diaphragm, leaving only the ster
and after suction. nomastoid and trapezius muscles to shift a trace
Progress can be hindered by anaemia or of air into the lungs. Ascending oedema of the
prolonged depression with mental fatigue traumatized spinal cord may further compromise
(Meythaler, 1997). Physiotherapy can incorpo respiratory function shortly after admission.
rate trips outside the leu and, later, hydrother Paralysed abdominal muscles reduce venous
apy. Recovery takes weeks or months. Some return and risk an exaggerated response to hypo
1 0% of patients die and 20% are left disabled volaemia. A complete cervical injury is equiva-
------ 395
lent to a total sympathectomy, reducing tone in should not be attempted if there is a paralytic
blood vessels, denervating the cardiac sympa ileus, which is common for several days after
thetic nerve supply and leaving parasympathetic injury. Quadriplegia at C5 or below allows
tone (mainly the vagus) unopposed. Hypotension patients to learn self-assisted coughing when
and bradycardia can result, especially during able, leaning forward in their chair and using
suction of the mouth or airways, and during any strength in their arms against the abdomen
exertion. A lesion above T6 removes sympathetic (Bach and Haas, 1 996, p. 407) .
control to the splanchnic bed, which is a major Early minitracheostomy is advisable if there is
reservoir for controlling BP. Cardiac monitoring a hint of sputum retention, especially as the neck
is required for the first 2 weeks, and oximetry is cannot be extended for effective nasopharyngeal
advisable to detect nocturnal desaturation. Poor suction. If suction is required, whether for an
circulation creates a high DVT risk (Alderson, intubated or spontaneously breathing patient, it
1999), especially with multiple trauma. Dimin should be accompanied by measures to minimize
ished venous return and interrupted sympathetic hypoxia, monitoring of Sa02 and BP, and avail
outflow blunt the heart's response to exercise, ability of IV atropine or other drug in case of
which can limit exercise capacity (Haas and profound bradycardia.
Axen, 1 9 9 1 , p. 255) . Treatment of the limbs involves close
attention to positioning and range of movement
Physiotherapy (Bromley, 1998). A third to a half of patients
The third to fifth crucial days after injury are develop shoulder pain, which often leads to
when lung complications are commonest. Assess depression (Goldstein, 2000), and hinders wheel
ment must be meticulous because hypoxia or chair rehabilitation (Curtis et al., 1 999). The key
hypotension may cause secondary damage to the is prevention by early and frequent full-range
spinal cord. McMichan et al. ( 1 980) have shown movement, scapular stretches and education to
how preventive measures can reduce the need all team members on the need for care in posi
for IPPV by two-thirds, using regular position tioning, especially if there is cervical traction or
change, hourly incentive spirometry, percussion a rotating bed. In side-lying, direct pressure on
and assisted coughing. the shoulder should be prevented. In supine, the
The head-down position is best avoided, but 'crucifixion' position has been advocated, using
if it is essential for postural drainage, care is padded arm boards on each side, but not to the
needed to ensure that tipping is done slowly extent of discouraging active arm movement
and not fully, that cervical traction is main (Crow et al., 2000). This may be useful for other
tained, that observation is maintained in case of patients with paralysed shoulders, e.g. those with
sudden sputum mobilization, and that arterial Guillain-Barre syndrome.
and venous pressures are monitored because of Patients with complete lesions are mobilized
the loss of compensatory cardiovascular as soon as possible. Those with incomplete
reflexes. lesions are usually maintained on bedrest for
Coughing is assisted by manual pressure using about 6 weeks to ensure optimum perfusion to
a hand on each side of the lower ribs and one the spinal cord. Mobilization takes the form of
forearm exerting strong pressure upwards and elevation gradually with a tilt table, monitoring
inwards against the abdomen, in synchrony with BP with every 1 0° increase in height. Standing is
any expiratory force that the patient can muster. less comfortable than supine because the· floppy
Some patients require two physiotherapists for abdominal muscles allow bulging of the
this. Care should be taken to avoid disturbing abdomen and loss of vital capacity by an average
neck traction, jarring the fracture site, exacerbat 14% (Chen et al., 1 990). The application of an
ing associated injuries, or pushing towards the abdominal binder is helpful for standing or
spine instead of the diaphragm. Cough assistance sitting (Goldman, 1 9 86). Physiotherapy in the
396
acute stage should be little and often to prevent (Morrison, 19 8 8 ) , glossopharyngeal breathing
fatigue, and active exercise may require ventila (p. 180 and Appendix C), short periods on a
tor adjustments to maintain stable blood gases. portable ventilator with a mouthpiece, or
Environmental temperature needs controlling possible use of �rstimulants to improve muscle
because impaired sympathetic outflow hinders strength (Signorile, 1995 ) . Exercise training in
thermoregulation. If a halo vest is used to the form of arm ergometry and incentive spiro
stabilize the fracture, all those involved must metry has shown a 24% increase in FVC (Crane,
know how to open or adjust it in case of cardiac 1994). There is enough evidence on the benefits
arrest. of inspiratory muscle training for it to be
Muscle tone and strength have a complicated attempted with all patients, either with a mouth
relationship in spinal injuries. After the 'spinal trainer or weights on the abdomen (K.H . Lin,
shock' period, which varies from a few days to 1 999), possibly with the addition of expiratory
several weeks, the spinal cord below the lesion muscle training (Ehrlich et al., 1999). Training
begins to transmit reflexes. Lung function may the surviving expiratory muscles may improve
improve as flaccidity changes to spasticity and coughing (Gounden, 1993). Non-invasive venti
stiffening thoracic joints provide some compen lation can provide a fuller and more enjoyable
sation for loss of intercostal muscle function. life than invasive ventilation (Bach and Haas,
People with a lower cervical injury may have a 1996, p. 450).
vital capacity of 1.2 -1.5 L at first, rising to 2 L Phrenic nerve pacing can coax the diaphragm
or more, which allows 8 00/0 of patients with a to life and gain freedom from the ventilator,
lesion at or below C4 to be weaned from IPPV allow near-normal speech, travel, employment
(Sykes and Young, 1999, p. 94). Reflexes can and greater independence (Creasey, 1996). Inter
also be beneficial by reducing muscle wasting costal electrodes can be added (Dunn et al.,
and osteoporosis, but if disabling spasms are 1995) . Magnetic stimulation of expiratory
provoked by minor stimuli, baclofen may be muscles may assist coughing (Lin, 1 998).
required. Osteoporosis is minimized by weight Management of problems such as pain (Bryce,
bearing and the drug pamidronate (Nance et al., 2000), spasticity and sleep apnoea (Burns, 2000)
1999). Bronchodilators may be required for is central to rehabilitation because these can
parasympathetic-induced bronchospasm. High impair lifestyle more than the extent of the
dose steroids administered within 8 hours of injury (Westgren, 1998). The importance of
lllJury may Improve neurological recovery these aspects of quality of life is shown by a
(Bracken et al., 1 997) . study that found marginally disabled patients to
Respiratory rehabilitation is lengthy for have a higher suicide rate than those with func
people with high lesions and may be hindered by tionally complete lesions (Hartkopp et aI.,
a 48% incidence of depression (Krause, 2000). 1 998). The importance of accepting patients'
This is eased by promoting communication, feelings is underscored by Laskiwski (1993) who
sometimes with the help of a speech-language found that expressions of despair were necessary
therapist, and ensuring that patients have as for successful rehabilitation; they represented
much control over their environment and the abandonment of impossible hopes and the
treatment as feasible. Depression increases formulation of realistic goals.
platelet aggregation and DVT risk (Seiner, Exercise training should be initiated early in
1999). Antidepressants that alter serotonergic the rehabilitation process, to minimize the cardi
transmission are not contraindicated but have ovascular deconditioning common in wheel
been known to increase spasticity (Stolp-Smith, chair-users. After the first 2 years, mortality
1 999). parallels that of the general population, and
Ventilator-dependent patients can gain some although some patients develop maladaptive life
degree of independence with biofeedback styles, support and encouragement in the early
------ 397
stages enable most to find the determination to Effect of head injury on the respiratory system
rebuild their lives, including the ability to enjoy (Figure 15.1)
sex and have children (Linsenmeyer, 2000). Chest infection is second only to intracranial
Many patients report that their initial response hypertension as a cause of death following head
was that death was better than living with such a injury (Rudy, 199 1 ) . Reasons for this and other
disability, but one study found 92% glad to be respiratory complications are legion:
alive, and it is a tribute to the human spirit that
• Damage to the respiratory centre may cause
'those who have a WHY to live will put up with
abnormal breathing. Hyperventilation and
almost any HOW' (deLateur, 1 997).
lowered PaC02 cause tissue hypoxia (Figure
15.2). Hypoventilation and raised PaC02
Acute head injury
cause vasodilation and raised intracranial
Nowhere is accurate assessment and finely tuned pressure, usually as a terminal event.
clinical judgement more vital than in the early Cheyne-Stokes or ataxic breathing are signs
stages of acute head trauma. Methods to control of severe damage.
intracranial pressure and prevent lung problems • Loss of protective pharyngeal reflexes in an
may be in conflict, and are often complicated by unconscious patient may cause acute aspira
other trauma. tion.
The effect of most injuries is maximal at • Associated trauma such as facial injury, frac
onset, but head trauma may precipitate a process tured ribs, haemopneumothorax or lung
that sometimes converts a mild injury into a life contusion compromise the airway or impair
threatening condition. Primary damage sustained gas exchange.
at the time of impact is irreversible, but • Immobility, recumbency and depressed
secondary damage, which encompasses every consciousness cause shallow breathing and
mishap that befalls thereafter, can double impaired cough.
mortality by reducing oxygen delivery to the • Over-enthusiastic fluid restriction, in an
brain (Wald, 1993 ) . Secondary damage varies attempt to reduce cerebral oedema, can lead
with the quality of management. to hypotension and reduced oxygen delivery.
Abnormal breathing pattern
Airway obstruction
Chest wall damage
Pulmonary oedema
)
1-- . .. --. --
i work of breathing ____•
i or..1. PaC0
•
2
..1.Pa0
2
.
VA/Q mismatch
Lung contusion
Pneumonia
)
ARDS
Hypermetabolism -------�.� i �02

Hypotension
..1.Hb (if bleeding)

----------- -+
• ..1.002
disrupted .cerebral regulation
Figure 15.1 Effect of acute head injury on gas exchange and oxygen delivery . Some factors overlap. ARDS = acute
respiratory distress syndrome; D02 =oxygen delivery; V02 oxygen consumption.
=
398
___ Hyperventilation
--.
� J,PaC0 2
i Work of breathing
,
�
i Oxygen consumption
Oxygen curve shifted to left
� • � oj,I 0 xygen
' de I'Ivery
HYPoxia
Figure 15.2 Effect of hyperventilation in acute head injury .
• Over-enthusiastic fluid administration, in an oedema, raised ICP, hypoxaemia, anaemia due

attempt to maintain cerebral perfusion, can to bleeding, hypotension, hypertension and
cause pulmonary oedema. In addition, severe infection.
head injury can release catabolic hormones The skull contains 80% brain tissue, 10% CSF
such as noradrenaline at up to seven times and 10% blood volume (Fisher, 1997). Like
the normal level (Bruder, 199 8), creating a other tissue, the brain swells when damaged,
massive sympathetic discharge, vasoconstric reaching a maximum 24-48 hours after injury.
tion and a surge of fluid into the pulmonary Initially, swelling can be accommodated by
circulation to cause neurogenic pulmonary displacement of CSF and venous blood into the
oedema (Kerr, 199 8). spinal subarachnoid space and jugular veins.
• Inflammatory mediators delivered from the When these compensating mechanisms have
injured central nervous system into the reached their limit, a small increase in cerebral
systemic system predispose to multisystem oedema within the rigid container of the skull
failure (Kochanek, 1999). causes a disproportionate upsurge in ICP, as
• Pneumonia is common in the early stages if shown in Figure 15 . 3 . Extreme intracranial
acute aspiration has occurred at the time of hypertension may cause coning, in which the
injury or emergency intubation. It is less brains tern herniates through the foramen
common in later stages because many magnum.
patients are young and few have underlying A decrease in CPP is the principal mechanism
medical illness (Hsieh et ai., 1992).
• Later problems may arise, e.g. DIC (p. 408),
because of fluid imbalance, multisystem
failure or fat embolism.
80
Effect of head injury on the brain
60
CSF: cerebrospinal fluid
fCP: intracranial pressure (normal 0-15 mmHg, ICP
critical > 20 mmHg) (mmHg) 40
CPP: cerebral perfusion pressure (normal
> 70 mmHg, critical < 60 mmHg) 20
MAP: mean arterial pressure (normal 90 mmHg,
critical < 80 mmHg) o �--------------------------__
Intracranial Volume
Primary lllJury is caused by bleeding,
contusion, and shearing forces in which the Figure 15.3 Intracranial pressure-volume curve. ICP is
oscillating brain distracts nerve fibres from their stable at first, but spatial compensation is exhausted at the
bodies. Secondary damage is caused by cerebral inflection point and further swelling causes a steep rise.
399
by which elevated ICP exerts secondary damage cycle that exacerbates the secondary effects of
(Chitnavis, 1 998). CPP is the driving force of head trauma (Figure 15 .4). Lung complications
cerebral circulation and must be kept above can cause hypoxia, to which brain tissue is parti
70 mmHg to perfuse the brain (Punt, 1 9 8 9). cularly sensitive because of its high oxygen
This requires an adequate blood pressure but is requirements and dependence on aerobic glucose
= -
compromised by a high ICP. MAP (which is metabolism. Hypoxia causes cerebral oedema,
related to blood pressure) and ICP are in effect and disturbances in PaC02 add to this woeful
competing for space: picture.
CPP MAP ICP. Cerebral haemodynamics and oxygen metabo
lism are also affected by vascular resistance and
The picture can be further complicated if
oxygen extraction variables (Cruz, 1995). It is
autoregulation is affected. Normally cerebral
no wonder that head injuries have a reputation
blood flow remains constant over a CPP range of
for being treacherous.
5 0-150 mmHg due to compensatory vasodila
The effect on the brain, and the emotional
tion as a response to hypoxia or hypotension. If
effect on the patient, cause 42% of patients to
this mechanism is damaged by brain injury, ICP
show evidence of major depression from the
follows MAP passively rather than remaining
acute stage onwards. This interferes with
independent, and BP must therefore be tightly
recovery (Rosenthal et al., 1 998).
controlled. Medical intervention may be needed
to regulate cerebral vascular resistance (Zhuang
et al., 1 992). Factors that increase ICP
Intracranial dynamics are reflected in a vicious ICP is keenly sensitive to a multitude of factors.
Effect on lungs Effect on brain
Ce"b",' oedema ')

/
Hypoxia tlCP
Cerebral
I
hypoperfusion
)
Capillary
compression
Figure 15.4 Vicious cycle set up by acute head injury.
400
ICP (mm Hg)

� 10 min---l - during surgery, when BP may be delib
70 erately kept low (Pietropauli et aI.,
1 992) .
• Even deeply comatosed patients show a
surprising sensitivity to conversation over
their beds. Discussion about their condition
increases ICP more than general discussion
Positioning for (Mitchell and Mauss, 1 978). However, when
chest X-ray relatives talk to patients, a reduction in ICP
may be seen (Chudley, 1 994) .
Figure 15.5 ICP tracing in a severely head-injured • ICP is increased by pain and discomfort,
patient, showing prolonged elevation after position change. including lllJections, BP measurements
(From Shalit, M. N. and Umansky, F. ( 1977) Effect of
(Ersson et aI., 1 990), noise, restraints, move
routine bedside procedures on ICP. Israel j. Med. Sci. , 13,
88 1 -886, with permission.) ment of the tracheal tube, Yankauer in the
mouth, arousal from sleep or emotional
upset (Mitchell et aI., 1 9 8 1 ) . Head-injured
people show an exaggerated response to the
• Head-down postural drainage lllcreases pain of associated injuries (Mirski, 1 995).
arterial, venous and intracranial pressures Passive movements can transiently increase
because cerebral veins have no valves. It also ICP (Brimioulle et aI. , 1 997).
impairs compensatory venous outflow and is • Transport between hospitals causes an
contraindicated in the acute stage (Lee, adverse event in 40% of patients and
1 989). increased ICP in 5 1 % (Waldmann, 1 998).
• Turning the patient increases ICP (Chudley, Within-hospital transfer is also hazardous.
1 994), much of this being due to head move • Delayed intracranial hypertension may occur
ment obstructing drainage from the brain after removal of monitoring devices and can
(Figure 1 5 .5). be anticipated by a raised WBC count
• Head movement, coughing, suction, manual (Souter et aI., 1 999). Systemic infection may
hyperinflation, vibrations and percussion can exacerbate brain damage (Kochanek, 1 999).
impede compensatory outflow from the
Most of these factors warn physiotherapists to
brain and raise ICP (Paratz, 1 993). Outflow
keep their distance, but the importance of main
is also obstructed by extreme hip flexion
taining gas exchange is a cogent reminder not to
(Mitchell and Mauss, 1 978), a tracheal tube
stray too far.
tied rather than taped, or a poorly applied
cervical collar (Dodd et al., 1 995).
• Hypertension increases ICP, and hypoten General management
sion reduces CPP. Reduction in brain perfu
sion by hypotension is one of the most Monitoring
important predictors of mortality (Lannoo, CPP is monitored non-invasively by trans cranial
1 998). It can double death rates (Pietropauli Doppler (Wong, 1 994) or indirectly by MAP
et al., 1 992), but is not widely appreciated and ICP. The aim is to optimize CPP even at the
and occurs particularly at the following cost of rises in ICP. ICP monitoring (Figure
times: 1 5 .6) is needed for comatosed patients if the
- on admission, when a patient may be Glasgow Coma Scale score falls below 8, or if
quietly bleeding into the abdomen and cerebral oedema is identified on CT scan (White,
losing consciousness because of hypo 1 992). Impending elevations of ICP should be
tension rather than brain injury predicted and managed while still within the
401
CHAPTER 15 DISORDERS IN INTENSIVI- CARE PATIENTS
Box 15. 1 The Glasgow Coma Scale; a score below 8

indicates severe injury and anticipates mortality up to 36%
(Waldmann, 1 998)
o
Best eye-opening response
Spontaneous 4
To voice 3
A To pain 2
None 1
Best verbal response

Oriented 5
B Confused 4
Inappropriate words 3
Incoherent 2
Figure 15.6 ICP monitoring: A = epidura I sensor,
which leaves the dura intact; B = subdural bolt, inserted None 1
into the subdural space; C = subarachnoid bolt, inserted
into the subarachnoid space; D = parenchymal catheter, Best motor response
implanted in brain substance; E = intraventricular catheter, Obeys commands 6
implanted into non-dominant lateral ventricle, can be used
Localizes pain 5
to withdraw CSF for diagnosis or therapy, risks ventricular
displacement. (From Vos, H. R. ( 1 993) Making headway Withdraws from pain 4
with intracranial hypertension. Am . J. Nur., 93, 28-36) Flexes to pain 3
Extends to pain 2
None 1
normal range (Chitnavis, 1998). Clinical mani
festations of neurological dysfunction are not
apparent in a paralysed patient, and for others Head elevation
they simply indicate that secondary damage has It is common practice to elevate the bed-head
already occurred (Harrington, 1993 ) . Reliance 15-3 5 ° in order to reduce ICP and encourage
on clinical evidence of raised ICP can lead to CSF outflow. However, this causes hypotension
blind and inappropriate interventions Ueevarat in hypovolaemic patients (Arbour, 1998) and
nam and Menon, 1996) . Monitoring is assisted may compromise CPP (Feldman, 1992). Head
by the following: position should be established individually rather
• bedside cerebral blood flow measurement than routinely (Ropper et aI., 1982) and not
(Wietasch et aI., 2000) raised above 60° (Durward et al., 1983). The
• end-tidal CO2 (ETC02), which gIves a head should always be kept aligned with the
continuous indication of PaC02 body to allow compensatory outflow.
• jugular venous oximetry, which indicates
cerebral oxygenation (Gopinath et al., 1999) Fluid management
• EEG, which measures spontaneous brain Normovolaemia is the target (Waldmann, 199 8).
activity and is used to detect seizure focus or Excess fluid rushes into injured brain cells and
to localize the source of irritation increases cerebral oedema, and dehydration
• CT scan, which can be transmitted electroni reduces brain perfusion. Small changes in blood
cally from a general ICU to a neurosurgical osmolality exert a strong effect on brain water,
unit for advice (Waldmann, 1998) and initial fluid resuscitation is probably best
• Glasgow Coma Scale, which indicates the achieved with hypertonic saline (Prough, 1996)
degree of injury (Box 15 . 1) . whose sodium ions do not cross the blood-brain
402
barrier, do not risk brain swelling, and do not tissue and other vital organs. Prophylactic anti
cause renal dysfunction as seen with repeated biotics may increase the virulence of infection
mannitol administration (Qureshi et al., 1998). and subsequent mortality (Demling, 1990).
Rapid maintenance of cerebral perfusion without Although steroids such as dexamethasone reduce
fluid overload is sometimes achieved with vasogenic oedema around brain tumours, they
inotropes. are unable to reduce traumatic cerebral oedema
because intracellular fluid is inaccessible (Punt,
Nutrition 1989).
Nutritional support is needed because energy
expenditure may be doubled for up to 4 weeks Mechanical ventilation
(Borzotta, 1994) and a hypermetabolic state may Intubation may be needed to maintain a clear
persist for a year (Woodward, 1996). Swallow airway. IPPV may be needed to regulate an
ing problems require a speech-language referral. unstable breathing pattern, ensure oxygenation,
Paralytic ileus may be a hindrance during the control ICP or manage chest complications.
first fortnight but enteral feeding should be Paralysis reduces oxygen consumption but its
started when possible because IV feeds can routine use has been questioned since Hsiang
increase cerebral oedema and cause neuronal (1993) found that it can increase complications.
damage from hyperglycaemia and lactic acidosis Hyperventilation is sometimes imposed to
(Woodward, 1996). A stable blood sugar is lower PaC02, induce cerebral vasoconstriction
required to prevent hypoglycaernia (Adam and and lower intracranial blood volume. The effect
Osborne, 1997, p. 250). is instant but not sustained because over the next
6-24 hours buffering of respiratory alkalosis
Temperature control relaxes the cerebral vessels. Over-enthusiastic
Temperature must be tightly regulated. A hyperventilation can cause cerebral ischaemia
pyrexia of 10 can raise cerebral metabolism by (Ruta, 1993), as signalled by slowing of the
up to 10% (Vos, 1993) and increase fluid EEG. PaC02 must not be allowed to drop below
requirements. Hypothermia causes arrhythmias, 3 . 3 kPa (25 mmHg).
shifts the oxygen dissociation curve to the left, High PEEP risks hypotension and further
and if it causes shivering, increases oxygen impairment of venous outflow from the brain.
consumption up to fivefold (Frost, 1996). High frequency ventilation may be beneficial in
eliminating BP fluctuations and maintaining
Drug therapy venous return.
Judicious doses of the osmotic diuretic mannitol
decrease blood viscosity and enhance cerebral Physiotherapy
blood flow (Waldmann, 1998) but can cause The hallmark of physiotherapy is maximum
dehydration. Sedatives reduce brain metabolism, involvement and minimum intervention. Involve
but monitoring is required to ensure that they do ment is by:
not reduce CPP (Papazian, 1993), especially in
• frequent assessment to assist delicate risk!
hypovolaemic patients. For pain, opioids can be
benefit decisions
used so long as MAP is maintained (Suarez,
• supervision of handling to minimize ICP
1999) , but Entonox is contraindicated (Moss
disturbance.
and McDowall, 1979). Anaesthetic agents may
be used to reduce cerebral metabolism. Intervention is unWIse in the presence of
Phenytoin is used to control seizures which cardiovascular instability, hypotension or ICP
could otherwise cause cerebral hypoxia. Vaso above 15 mmHg (Paratz, 1993). If it is essential,
constrictor drugs increase CPP but may impair a drug to moderate ICP should be given before
oxygenation to areas around contused brain hand. Treatment can be timed to follow withdra-
------ 403
wal of CSF. Quiet explanations are required for Manual hyperinflation

all patients, however deeply comatose. Stress Ersson et al. ( 1 990) found that patients are
reduction strategies have shown beneficial effects exposed to equal risks of impaired CPP with
(Chudley, 1994). both MH and suction, and should always be
sedated beforehand. If MH is essential, it should
Assessment be brief and avoid disturbance to PaC02•
Sa02 is the main guideline because its assess
ment requires no handling and is continuous and Manual techniques
instant. Any sign of impending chest complica If these are essential, percussIOn should be
tions requires preventive action. Observation of rhythmic, smooth and gentle, and vibrations
BP, ICP and ETC02 is required prior to and should be fine and avoid affecting intrathoracic
throughout treatment. In the absence of an ICP pressure. A vibrator can be used.
monitor, signs of a raised ICP are :
• i pupil size Suction
• pupil unresponsive to light Elevation in ICP during suction can be dramatic
• ! consciousness (Rudy, 199 1), mild (Brucia, 1996), transient, or,
• change in vital signs, breathing pattern or in a third of patients, prolonged beyond 15
muscle tone minutes (Kerr et at., 1996). Variations in
• vomiting. response are due to the degree of hypoxia and
impairment of venous outflow from coughing
If the patient is not intubated, a mmItra
and mechanical stimulation. If suction is
cheostomy is advisable if suction is necessary.
indicated, the following precautions are advised:
Nasal suction is contraindicated in the presence
of: • rest from previous activiry
• watery CSF leaking from the nose or ear, • 100% oxygen before and afterwards
indicating a connection between the subar • head kept strictly in alignment
achnoid space and nasal passages, thus • tracheal tube stabilized throughout
risking infection • contact with the carina avoided (Brucia,
• severe epistaxis, indicating tissue disruption 1996)
and risking the catheter entering the sinuses. • avoidance of more than one suction pass at a
time, and use of manual hyperventilation to
Positioning reduce ICP when necessary (Crosby and
Turning is safe with ICP < 15 (Chudley, 1994). Parsons, 1992) .
Patients should be log-rolled slowly using a
turning sheet, with one person solely responsi Exercise
ble for maintaining head alignment. A kinetic Extreme hip flexion should be avoided in the
bed may be used (Tillett, 1 993). Accurate posi acute stage. If flaccidiry is present with no
tioning in side-lying with neutral head position altered muscle tone, it may be best to avoid any
aids prophylactic chest care. However, for movements in the first few days. If spastic
patients with unstable ICP and low risk of lung patterning develops, appropriate posItIoning
complications, it is best to leave the patient must be maintained and factors that increase
supine in the early stages if there is a suitable tone avoided, e.g. pain, anxiery, infection,
mattress for preventing pressure sores. Neck pressure under the feet and the weight of
flexion must be prevented by using a thin bedclothes. Staff and carers should be taught
pillow or none at all Oones, 1995b). Calf positioning and handling to encourage inhibitory
pressure should be avoided because DVT is a control over spasticity. If increased tone or
significant risk (Gersin, 1994). clonus is identified, immediate splinting and
404 ------
stretching to maintain dorsiflexion has been The disease is punctuated by myasthenic and
recommended (Moseley, 1997), before range of cholinergic crises, which are treated by increased
movement is lost. Early attention to range of drugs for the former, and atropine to counteract
movement is essential because the majority of overadministration of drugs for the latter.
head-injured patients have been found to have Intensive care is required after thymectomy,
long-term contractures (Watkins, 1999). during crises or if bulbar weakness threatens the
airway. Physiotherapy includes clearance of the
Teamwork excess bronchial secretions stimulated by anti
Pre-planning is needed to avoid a cumulative rise cholinesterase.
in ICP. Most teams arrange physiotherapy,
nursing and other interventions as far apart as Botulism
possible, although some find it best to do every Botulism, affects the neuromuscular junction. It
thing at once and then let the patient settle. Co is an infection derived from contaminated food
ordinated teamwork is especially important in or surgical wound infection. Bulbar and respira
the first vulnerable week. tory muscles may become paralysed, and
Head injury can impede identification of pain. sometimes IPPV is required for several months.
Pain limits rehabilitation, increases depression
and if neglected may become chronic (Lahz, Tetanus
1996). The physiotherapist is the most likely The tetanus bacillus produces one of the most
team member to detect and report pain. lethal poisons known. It is a common resident of
Rehabilitation starts in the ICU. MacKay superficial soil and enters the body through a
(1992) has shown that length of coma can be cut wound. It infects any dead tissue and spreads to
to a third by a multidisciplinary programme the central nervous system, leading to muscle
after the immediate acute period, using orienta rigidity, autonomic instability and sometimes
tion, sensory stimulation, exercise and family convulsions. Patients experience pain, stiffness
involvement. Long-term rehabilitation allows and inability to open their mouth (lockjaw).
cognitive improvement to continue for up to 10 Spasms of the larynx or diaphragm are life-threa
years (Prough, 1996). tening and require intubation and IPPV respec
The persistent vegetative state cannot be tively. Sedation and sometimes muscle relaxants
diagnosed for at least a year after injury, but are needed. Risks are contractures, aspiration,
patients are subject to considerable misdiagnosis DVT and cardiovascular complications.
(Watson et al. , 1999).; Potential for improve Recovery occurs over 6 weeks, but residual
ment remains, and our limited ability to find stiffness is common.
evidence of a functioning mind does not
preclude its existence. Critical illness neuropathy
A self-limiting neuropathy occurs to varying
Myasthenia gravis degrees in some patients, precipitated by
This progressive autoimmune disorder affects metabolic upset, paralysing and steroid drugs,
the neuromuscular junction and weakens and immobility (O'Leary and Coakley, 1996). In
muscles in proportion to their use. It is confined particular, it has been found in 70-80% of
to the eye muscles in 200/0 of patients (Oh, patients with sepsis or multisystem failure
1997, p. 434), and for others the limb and trunk (Hund, 1999). Failure to recognize the condition
muscles are usually affected asymmetrically. The leads to misjudgement of weaning ability.
patient may complain of fatigue rather than Recovery is usually complete but residual
weakness. Treatment is by anticholinesterase peroneal weakness may occur. Physiotherapy is
drugs, steroids, occasionally plasmapheresis, and needed little and often to optimize musculoskele
thymectomy via sternotomy (Nilsson, 1997). tal function without exhausting the patient.
--
-- 405
CHEST TRAUMA
Penetrating Injuries can cause blood loss,

infection and haemopneumothorax (blood and
air in the pleura). Haemoglobin in a trauma
patient needs to be above 10 g/ 100 mL for
adequate oxygen delivery (Nolan, 1996).
Penetrating injuries, e.g. stab wounds, require
a programme of chest mobility and exercise, as
described by Senekal and Eales ( 1994). Before
mobilizing patients who have a haemothorax or
haemopneumothorax, they should be asked to
clear some of the blood from the pleural space
by positioning themselves with the chest drain
dependent for a few minutes.
Blunt Injuries, e.g. from road traffic
accidents, spread force over a wide area from
compression, shearing and tension, often
causing rib fractures and lung contusion. Full
cervical protection should be maintained after
blunt trauma until comprehensive radiographs
have been examined by a senior orthopaedic Figure 15.7 Multiple rib fractures following a road traffic
surgeon (Nolan, 1997). accident. On the right, ribs 4-6 are fractured laterally and
If the abdomen sustains blunt trauma, the ribs 6- 1 I posteriorly. On the left, the first rib is fractured.
diaphragm may rupture, usually on the left There is a right pneumothorax and chest drain.
because the liver buttresses the right side.
Diaphragmatic rupture causes abdominal viscera
to herniate into the chest, and surgical repair is injury. Lower rib fractures may be accompanied
required. The diagnosis is often missed but the by intra-abdominal injury.
X-ray shows a displaced hemidiaphragm. An incompetent segment of chest wall that is
large enough to cause paradoxical breathing and
Rib fracture impair respiration is called a flail segment
A third of patients with traumatic rib fractures (Figure 15 . 8 ) . This requires at least two ribs to
develop pulmonary complications (Ziegler, be fractured in more than one place. Paradoxical
1994). Pain causes a restrictive defect, exacer movement may not be apparent in the first day
bated if there is chest wall derangement. Compli or two if muscle spasm stabilizes the chest wall.
cations include pneumothorax (sometimes under
tension), surgical emphysema and haemothorax. Assessment
Each pleural space can hold about 2 L of blood, Palpation elicits exqulSlte pain and is not
so an average adult, whose blood volume IS necessary, but crepitus may be felt by laying the
5-6 L, can exsanguinate into the thorax if hand gently over the tender area. The X-ray may
haemorrhage is uncontrolled. underestimate the presence and extent of rib
The commonest locations are the third to fractures by 5 0% (Mayberry, 1997), especially if
tenth ribs, often laterally where there is no they are anterior. A line of fractures suggests
muscle protection (Figure 15.7). Fractures of the single trauma whereas scattered fractures suggest
well-protected first three ribs indicate great force repeated injury as with alcoholism, or bony
and are often accompanied by intrathoracic weakness as with malignancy. Cough fractures
406 ------
CHEST TRAUMA
Inspiration Expiration
Figure '5.8 Flail chest caused by fractured ribs. The unstable segment is sucked in on inspiration and pushed out on
expiration.
may occur in frail patients or those with osteo

Assessment
porosis. Hyperflexion over a seat belt may cause
Signs of contusion are dyspnoea and bloody
transverse sternal fracture.
secretions. Peripheral ground-glass mottling
develops on X-ray over 1 2-48 hours, or immedi
Treatment
ately if severe, followed by absorption of the
Early regional pain control is essential, usually
infiltrates after 3-5 days or progression to
by a thoracic epidural. If chest drains are used
ARDS. Perfusion of unventilated lung leads to
for pneumothorax or haemothorax, local anaes
shunt and hypoxaemia.
thetic can be administered through the drain.
TENS may be helpful (Sloan et at. , 1986) and
Entonox can be administered if there is no pneu Treatment
mothorax. A cough belt or towel supports IPPV may be needed if hypoxaernia is refractory
coughing. to oxygen therapy or CPAP' If secretions are
Once pain is controlled, regular incentive present, contused lungs do not take kindly to
spirometry is advisable. If gas exchange is percussion and vibrations. Mechanical vibrators
impaired, CPAP or BiPAP provides pneumatic may help, and an oscillating bed has been found
stabilization. Minitracheostomy may be required to reduce chest infections (Fink et at. , 1 990). If
for sputum retention. Soft tissue injuries are frank bleeding is present, suction is contraindi
usually present and will need attention. Early cated unless breathing is obstructed by secre
mobility is to be encouraged. tions.
Lung contusion Fat embolism

Shearing or crushing forces lead to pulmonary Trauma or orthopaedic surgery may cause fat to
laceration and a form of 'blood pneumonia' be released from bone marrow into the circula
known as contused lung. Blood-filled alveoli tion, leading to capillary inflammation and
cause shunt, VA/Q mismatch and hypoxaemia. occlusion. Organs with a high blood flow are
Lung compliance is reduced and oedema particularly affected, including the lungs, which
develops over 48 hours. may develop ARDS. Warning signs are breath-
--
-- 407
lessness, agitation, tachycardia, pyrexia and 1998), and diaphragm splinting often leads to
cyanosis within 72 hours of trauma. The risk is basal atelectasis, consolidation, pleural effusion
increased if fractures are not immobilized and respiratory failure.
because movement precIpItates intravascular Treatment is by intravenous hydration,
entry of the fat embolus. Treatment is aimed at analgesia by the epidural route (if not contraindi
maintenance of gas exchange, vital functions and cated by coagulation problems), nutrition by
hope. long nasoenteral tube, support as required
including IPPV, and surgery if there is infection.
Physiotherapy is aimed at maintaining lung
SYSTEMS FAILURE
volume, mainly by positioning in side-lying and
preferably with the help of a rotating bed.
Disseminated intravascular coagulation Precautions relate to haemodynamic and electro
(DIC) lyte upset.
The normal response to tissue damage is a
contained explosion of thrombin to initiate Collagen vascular disease
coagulation and limit blood loss. This can The following autoimmune disorders may lead
become uncontained after severe damage such as to multisystem failure:
burns, brain or spinal cord injury, fat embolism,
• Goodpasture's syndrome, which can cause
any form of shock, and sometimes the drug
nephritis and lung haemorrhage
Ecstasy. This leads to DIC, in which liberated
• Wegener's granulomatosis, which is a triad
thromboplastin activates uncontrolled coagula
of upper respiratory tract lesions, pulmonary
tion and blocks vessels with clumps of platelets
disease and glomerulonephritis
and fibrin, causing ischaemia and organ damage.
• polyarteritis nodosa, which causes inflamma
When clotting factors and platelets have been
tion and necrosis of arteries, leading to
depleted, bleeding can occur from the slightest
ischaemia of any organ
trauma, including suction. Fourrier ( 1 992)
• systemic lupus erythematosus (SLE), which
describes multisystem failure and death as
involves chronic inflammation of many
common outcomes of DIC, sometimes referred
systems including skin, nervous system,
to as 'Death Is Coming'.
kidney and blood vessels.
Acute pancreatitis Severe collagen vascular disease is suspected if
An inflamed pancreas can be caused by gall there are blood-stained secretions on suction,
stones, alcoholism, drug reaction or eating spontaneous bleeding or abnormal clotting
disorder. A fifth of patients with acute pancreati studies. It will not resolve until the trigger
tis develop a severe attack with 25% mortality mechanism is removed, and treatment is aimed
(Reece-Smith, 1 997). Activated pancreatic at the underlying condition, along with modifica
enzymes autodigest pancreatic tissue and set off tion of the immune response with steroids,
a cascade of ischaemia, inflammation, vasodila restoration of haemostasis and suppo.rt of failing
tion, increased capillary permeability and DIe. systems. Nasopharyngeal suction is contraindi
Progressive liquefaction of the pancreas may cated, and tracheal suction requires extra
occur, leading to abscess formation and sepsis. caution because of the risk of bleeding.
Patients suffer paralytic ileus, which increases
the risk of aspiration because of delayed gastric Kidney failure
emptying, a rigidly distended abdomen and The kidney fails acutely in response to hypoten
continuous epigastric pain, worse in supine. sion, hypoxia or multisystem failure, and is a
Diaphragmatic dysfunction is compounded by its measure of severity of the underlying condition.
proximity to the inflamed pancreas (Matuszczak, Acute renal failure occurs in 3 0% of critically ill
408
MULTISYSTEM FAILURE
patients (Galley, 2000) and is associated with pressure throughout the portal system. Dilated
complex multisystem problems. It is suspected if surface blood vessels . in the lower oesophagus
urine output drops or urea and creatinine levels may cause oesophageal varices. Severe bleeding
rise. Patients in renal failure can be supported in from the varices requires insertion of a Sengsta
several ways: ken tube via the nose or mouth into the
stomach, usually for several days, from which
• Continuous haemofiltration or haemodiafil
balloons are inflated to apply pressure to the
tration removes toxins and excess fluid
bleeding points. Oesophageal varices are a
slowly and allows control of BP, electrolytes,
contraindication to physiotherapy because of the
medication and nutntlon (Kutsogiannis,
tendency to bleed. More precautions for treating
2000) . Moderate anticoagulation is required
patients with liver disease are on page 1 1 4 .
but a specialist renal unit is not necessary.
Fulminant hepatic failure occurs i n people
• Intermittent haemodialysis is faster but can
with previous normal liver function and is most
cause BP disturbance, pulmonary and
commonly caused by paracetamol overdose.
systemic inflammatory changes, wheezing,
After a quiescent 24 hours, patients develop a
hypoxaemia due to capillary blockage and
raised ICP, low potassium and blood sugar, and
bleeding due to anticoagulation. Vascular
present a hyperdynamic picture of high cardiac
access is commonly by an arteriovenous
output and low systemic vascular resistance.
fistula at the wrist.
Handling and suction should be minimal and
• Peritoneal dialysis risks infection, impairs
the patient usually remains supine. Transplant is
basal ventilation and is now little used.
the treatment of choice, otherwise patients may
Physiotherapy should coincide with the end
die from cerebral oedema, hypotension or
of the emptying cycle to ensure free
sepSIS.
diaphragmatic movement.
Liver transplantation requires a 'Mercedes
Physiotherapists must develop a healthy Benz' double subcostal incision and laparotomy,
respect for the renal vascular catheter or necessitating close attention to pain relief. Post
'vascath', as disconnection leads to major blood operative complications include right basal
loss. Other precautions are to be watchful of atelectasis, pleural effusion, liver rejection and
fluid volume changes or hypertension and to be the effects of immunosuppressive drugs. Rehabi
aware of the risk of bleeding as patients are litation is surprisingly rapid once the toxin
anticoagulated. Details of kidney disease are on producing liver has been removed. Some patients
page 1 14. are so poisoned by their own liver that it is
removed even if no donor is immediately
Liver failure available.
Liver cells are vulnerable to hypoxia. Acute liver
failure leads to multisystem involvement but
MULTISYSTEM FAILURE
support of these systems may allow the liver to
recover or permit survival until a donor organ is Bacteraemia: viable bacteria in blood.
available for liver transplant. DIC often occurs Infection : invasion of normally sterile host tissue
because impaired clearance function of the liver by microorganisms.
allows activated factors to rampage through the Septicaemia: systemic infection III which
body. Kidney failure occurs in 5 0% of patients pathogen is present in blood.
with liver failure, although blood urea is not Endotoxin : toxin released by Gram-negative
raised because of reduced urea production by the bacteria as they disintegrate.
failing liver. Sepsis: systemic response to infection, manifest
Cirrhosis may obstruct the portal vein and by two or more of the following:
create portal hypertension, transmitting back temperature > 3 8 ° or < 3 6°C
409
CHAPTER 1 5 DISORDERS I N INTENSIVE CARE PATIENTS
HR > 90/min stimulate excess mtnc oxide production which

RR > 20/min or PaC02 < 4.3 kPa (32 mmHg) augments uncontrolled vasodilation and in
WBC > 1 2 000 effect reduces circulating blood volume,
Systemic inflammatory response syndrome creating a 'functional haemorrhage'. High
(SIRS) : generalized inflammatory response, cardiac output therefore cannot sustain an
manifest by two or more of the above: adequate BP. Hypoxia-damaged tissues cannot
Sepsis syndrome: SIRS caused by infection. extract sufficient oxygen, as shown by S�02
Multisystem failure: systems failure caused by rising to 85% or more. Patients are pyrexial,
direct insult or SIRS, in which homeostasis flushed, tachypnoeic, hypotensive and have a
cannot be maintained without intervention. bounding pulse. Vasopressors may compromise
Also known as multiple organ failure or regional blood flow.
multiple organ dysfunction syndrome. Other types of shock are anaphylactic shock,
Shock: failure of oxygen supply to meet oxygen an allergic reaction by more than one system,
demand. and neurogenic shock following nervous system
damage and loss of sympathetic tone. Both are
Most deaths in surgical ICUs are due to multi
characterized by widespread vasodilation and
system failure (Deitch, 1 999). Once three or
hypotension.
more organs have failed, mortality is over 90%
Shock follows a characteristic sequence:
(Molnar and Shearer, 1 998).
1. inadequate tissue perfusion
Shock 2. anaerobic metabolism
In contrast to the layperson's shock-horror 3. lactic acidosis
understanding of the term, shock occurs when 4. metabolic acidosis
the reserve capacity of tissue respiration is 5. cellular damage
exhausted. Once oxygen delivery (D02) can no 6. organ failure.
longer satisfy oxygen consumption (V02), a
cascade of damaging events ensues. Causes of multisystem failure
Hypovolaemic shock is caused by loss of fluid, Shock either causes multisystem failure directly,
e.g. haemorrhage or burns. Early physiological or becomes part of the process of a catastrophic
compensation is by redistribution of fluid from event that makes excessive demands on oxygen
extravascular to intravascular space, and consumption, e.g. :
selective vasoconstriction to non-vital systems. A
young person can lose 3 00/0 of his/her blood and • prolonged hypotension
still maintain BP and HR (Adam and Osborne, • sepsis
1 997, p. 3 3 5 ) . Hypovolaemic shock is identified • aspiration
by the signs on page 3 62. Cardiac output is • over-transfusion
compromised, (pp. 1 13 , 3 8 1 ) . • smoke inhalation
Cardiogenic shock i s caused b y sudden heart • head injury
failure, as in severe myocardial infarction. It is • near-drowning
characterized by high CVP, low cardiac output • fat embolism
and pulmonary oedema. • pulmonary embolism
Septic shock occurs when sepsis-induced • lung contusion
hypotension is unresponsive to fluid resuscita • poisoning/drug abuse
tion. Sepsis causes a fever which resets the • peritonitis
hypothalamic thermostat, leading to peripheral • acute pancreatitis
vasodilation in an attempt to lose heat, thus • cardiopulmonary bypass
depleting perfusion to the viscera. Endotoxins • multisystem disease
410
MULTISYSTEM FAILURE
• DIC (p. 408) Circulating catecholamines may Increase

• immunosuppression following trauma or cardiac output and total body blood flow but
surgery (Wichmann et at. , 1 998). deranged autoregulation sends the circulating
blood to resilient tissue such as skin and muscle
Interaction of these predisposing factors can at the expense of needy systems such as the gut
blur cause and effect, e.g. the inflammatory and liver. Maldistribution of the circulation and
response can activate the coagulation process, defective microvasculature leads to progressive
and shock can stir up immunochaos. Multisys failure of other systems. Those most related to
tem failure is usually established within 24 hours mortality are the kidney and liver. Those most
of injury (Cryer et aI. , 1 999). relevant to the physiotherapist are the haemato
logical and respiratory systems, leading to DIC
Pathophysiology of multisystem failure and acute respiratory distress syndrome (ARDS).
If an amputated limb is reimplanted after a
Medical management of multisystem failure
delay, it releases endotoxins which invade the
body and set off an inflammatory domino effect. Any potential septic focus needs treatment to
Re-amputation is required to prevent the rest of prevent further stimulation of the inflammatory
the body becoming poisoned. This analogy response, e.g. removal of dead bowel or stabili
represents multisystem failure, but treatment IS zation of fractures. The main aim is then to
not so simple. restore normal homeostasis and sustain tissue
Hypoperfusion and reperfusion activate a perfusion rather than focus on a single system (a
deadly cascade of mediators from damaged cells, tyre blowout that wrecks a car is not corrected
creating 'rogue inflammation'. This subverts the by replacement of the tyre) . Ventilatory and
normal healing function of inflammation, haemodynamic support aims at maintaining D02
escapes the usual control mechanisms and so that gastric intramucosal pH remains above
exacerbates rather than repairs injury. Autodes 7.35 (Oh, 1 997, p. 735). The balance between
truction leads to increased permeability of beneficial and damaging interventions is a fine
epithelium. one, and a formidable array of options can
The main culprit is the gut, whose vulnerability improve oxygen delivery but cannot directly
to hypoperfusion has earned it the name 'engine assist oxygen extraction and has not notably
of multisystem failure' (Botterill and MacFie, reduced mortality.
2000). Just 1 hour of gut ischaemia can cause cell D02 is promoted by respiratory support,
necrosis, loss of mucosal integrity and leakage of inotropic support and vasodilators. V02 is
gut bacteria into the circulation (Brown, 1 994). reduced by respiratory support, sedation,
Patients are in effect poisoning themselves, which paralysis and avoidance of stress or pyrexia.
explains why 50% of patients have no identifiable Support may include packed red blood cell trans
septic focus (Deitch, 1 999). The main victim is fusion or haemofiltration to wash out circulating
the lung, because of its large vascular component, mediators (Lingnau, 1 995). Lactate-induced
now poisoned and permeable. metabolic acidosis can usually be corrected by
Hypoxia is caused by: manipulation of IPPV in order to affect PaC02,
but a pH of less than 7.2 requires haemofiltra
• refractory hypoxaemia tion. Severe sepsis can increase energy expendi
• reduced gas diffusion at tissue level because ture by 500/0 (Bruder, 1 998) and nutritional
of interstitial oedema support is essential, preferably enterally to
• impaired oxygen extraction due to damaged stabilize the gut lining. However, the septic
cells response hinders the utilization of nutrition, as
• excess oxygen consumption due to a twice shown by high nitrogen excretion and relentless
normal metabolic rate. muscle wasting (Green et aI. , 1 995).
41 1
Skilled fluid management is required because syndrome, shock lung, white lung or, because it
transfused fluid tends to escape into the leaky was first described in soldiers salvaged from the
lung, while inadequate circulating volume Vietnam battlefields, Da Nang lung. ARDS
hinders D02• Renal impairment complicates the shows a Pa02:FI02 ratio of less than 26 kPa
picture. Adequate volume is guided by a CVP of (200 mmHg).
1 0- 1 2 cmH20 and PAWP of about 1 8 cmH20
for optimum cardiac output. Pathophysiology
Antibiotics are usually prescribed, but may Lung tissue can be injured directly, e.g. by
exacerbate symptoms because destroyed bacteria aspiration, contusion or smoke inhalation. It can
release more endotoxin (Tangredi, 1998). be injured indirectly by toxins let loose by multi
Steroids may be helpful if initiated early and if system failure. As a result, both alveolar and
there is Gram-negative septicaemia (Lefering, vascular functions of the lung are ravaged by
1 995). inflammatory mediators. The resulting sieve-like
alveolar-capillary membrane allows flooding of
Physiotherapy the alveoli, leading to massive pulmonary
Critical illness neuropathy develops in 70% of oedema, which almost drowns the patient. A
patients (O'Leary and Coakley, 1 996). Meningo lung up to quadruple its normal weight causes
coccal septicaemia can have severe musculoskele compression atelectasis (Pelosi and Gattinoni,
tal and neurological consequences, and 1 996) in dependent regions (Figure 1 5 .9).
hypoperfusion to the peripheries can lead to Invading plasma proteins deplete surfactant,
necrosis and gangrene. If fingers are affected, the exacerbate atelectasis, increase shunt and widen
hand needs to be carefully splinted in a func PA-a02. Vascular injury leads to pulmonary
tional position to optimize circulation and hypertension, which exacerbates oedema
prevent contractures. Passive movements require formation and inhibits right ventricular function.
extreme care to protect the skin. The waterlogged and inflamed lungs become
progressively and unevenly damaged. Some lung
tissue is necrotic and consolidated, with the
ACUTE RESPIRATORY DISTRESS SYNDROME
consistency of liver. Some is collapsed but poten
Acute lung injury is parenchymal lung injury tially recruitable. Some is still undamaged and
leading to alveolar-capillary membrane leak and compliant, but this functioning tissue may only
non-cardiogenic pulmonary oedema. Pa02:F[02 make up one-third of the normal lung capacity
ratio is less than 40 kPa (300 mmHg). The (Slutsky, 1 993).
severest form is acute respiratory distress This so-called 'baby lung' creates a restrictive
syndrome (ARDS), also known as leaky lung defect that worsens as the basic framework of
Opening pressure
em H20
Normal ----_-\ �.------ 0
Small airway
��illiilliiii
collapse
Alveolar coli
Consolidation __ 00
Figure 15.9 Diagram illustrating how the greater weight of dependent lung causes progressively greater opening pressures
downwards. (From Gattinoni, L. , quoted by Sykes, K. and Young, G. D. ( 1 999) Respiratory Support in Intensive Care , BMJ
Publishing, London.)
412
the lung, which has been intact during the florid of the syndrome is less obvious if IPPV is
oedema phase, is remodelled and weakened by already in place.
the inflammatory process. Fibrosis sets in within X-ray si�ns lag behInd clinical signs by 24-48
2 weeks (Ryan and Higgins, 1 998). Non-homo hours. Then diffuse bilateral 'snowstorm' infil
genous loss of elasticity causes uneven distribu trates develop, with sparing of the costophrenic
tion of expiratory time as alveoli empty at angles (Figure 1 5 . 1 0) . After a week, a finer
different speeds, contributing to intrinsic PEEP, consolidation becomes apparent, corresponding
overdistension of alveoli and a 1 2% incidence of to fibrosis. Recovery brings resolution, except in
barotrauma (Du et at. , 1 997). 20% of patients who manifest residual opacities,
When oxygen delivery (D02) decreases to a fibrosis and hyperinflation (Wiener, 1 9 9 1 ) . CT
critical level, oxygen extraction cannot increase scanning shows the opacity of atelectasis in
to compensate, and oxygen consumption ("V02) dependent regions if the patient's position has
drops linearly with D02 (Wong, 1 998). not been regularly changed, and sometimes baro
trauma in non-dependent regions (Figure 1 5 . 1 1 ) .
Clinical features Breath sounds are surprisingly normal, with
Following the provoking insult, there is a just a harsh edge to them. Pulmonary artery
latent period of 1-3 days before signs become catheterization shows a high PAP, reflecting
apparent. Respiratory distress develops over pulmonary hypertension. PAWP (p. 329) is
the next 24 hours as patients struggle to normal because ARDS is not a condition of
breathe through lungs that feel like a wet generalized overhydration, in contrast to cardio
sponge. Both Pa02 and PaC02 drop. Diagnosis genic pulmonary oedema, which causes a high
is usually when virulent hypoxaemia develops PAWP. S�02 is usually reduced as a result of
and, in the spontaneously breathing patient, hypermetabolism, but may be increased if
PaC02 rises as the patient tires. Development hypoxic cells are unable to extract oxygen.
Figure 15. 10 Image of lungs affected by ARDS.
------ 413
Figure 15. 1 1 CT scan of a patient with ARDS, showing dense areas of atelectasis in dependent regions and barotrauma
represented by a pneumothorax in the right anterior region.
Medical treatment improves gas exchange, reduces intrinsic

The cornerstone of management is meticulous PEEP and distributes inspired air more
supportive care. Non-invasive ventilation is evenly. Levels over 15 cmH20 prevent
helpful in the early stages (Rocker et ai. , 1 999), progressive loss of lung compliance asso
but intubation and mechanical ventilation are ciated with low-volume ventilation (Cereda,
often necessary. IPPV has been described as both 1 996). However, if overdistension occurs
a good friend and a secret killer (Pelosi and and compliance worsens, it can damage
Gattinoni, 1 996). It reduces the work of rather than protect the lung. High PEEP is
breathing but squeezes the bulk of the inspira less helpful as fibrosis sets in.
tory gas into healthy and fragile functioning lung • Pressure control ventilation limits peak pres
tissue. This creates stretching forces that can sure and may prevent over-distension of
cause structural damage indistinguishable from compliant areas of lung.
the disease process itself (MacIntyre, 1 996). The • Other options are inverse-ratio ventilation,
risk is reduced by finely tuned synchrony of airway pressure release ventilation and high
ventilator-assisted breaths with patient effort, frequency ventilation (Campbell et aI. ,
and maintenance of lung volume within a 2000).
narrow range. Atelectasis is reduced by PEEP,
Pharmacotherapy includes the following:
and overdistension reduced by various ventila
tory manoeuvres such as those described below. • Surfactant replacement early in the disease
process (Schermuly, 2000).
• Low tidal volumes can allow permissive • Inhaled nitric oxide, distributed to well
hypercapnia (Hickling, 1 994) . High PaC02 ventilated regions, which dilates pulmonary
is well tolerated if established over several vessels and improves VA/Q match (Stewart
days but is inadvisable in patients with intra and Zhang, 1 999).
cranial lesions or metabolic acidosis. • Inhaled �2-agonists which may improve lung
• Judiciously applied PEEP stabilizes alveoli, compliance (Moriiia, 1 997).
414 ------
• Steroids are sometimes given In the later alveoli posteriorly, because of the configuration
stages but tend to encourage infection in of the chest and position of the heart, and in
critically ill patients (Bass et ai., 1997). prone these alveoli are uppermost and recruita
• Supplemental oxygen is limited to 60% if ble. Ventilation becomes more even because the
possible, to prevent oxygen toxicity. Hypox heart is supported by the sternum and there is
aemia is more responsive to PEEP than high less parenchymal distortion (yang, 1 9 9 1 ) .
FI02 levels. Perfusion i s also more uniform in prone (Marini,
1 999). VA/Q is better matched and oxygenation
Extracorporeal gas exchange, a last resort,
improved. The following claims have been
allows reduced minute volume and lower FI02
reported after proning patients with ARDS :
to be delivered but causes bleeding in 75 0/0 of
patients (Anderson, 1 994). • i lung volume by 5 7% (Rialp et ai. , 1 997)
• 1 need for PEEP (Lim et al. , 1 999)
Physiotherapy • i PaO2 by between 2.7 kPa (20 mmHg) and
6.2 kPa (47 mmHg)
The physiotherapist may not be informed that
• i Pa02:F]02 ratio by between 6 . 7 kPa
ARDS is developing because it is a syndrome
(5 0 mmHg) and 1 3 .3 kPa ( 1 00 mmHg)
rather than a disease and the patient already has
• i normal VA/Q units by 12%
a diagnosis. The condition is suspected if a
• 1 shunt by 1 1 % (Wong, 1 999)
patient with relevant predisposing factors shows
• 1 barotrauma (Du et ai. , 1 997)
tachypnoea and severe hypoxaemia, or if a venti
• i drainage of secretions (Kesecioglu, 1 997)
lated patient develops high airway pressures or
• 1 length of leu stay (Gosheron, 1 998).
the ventilator is changed from volume control to
pressure control. Oxygenation is greater if pressure on the
Like the medical management, physiotherapy abdomen is minimized by using an air-fluidized
aims to maximize D02 while causing the least bed or supporting the chest and pelvis with
harm. Gratuitous increase in stress and energy pillows. Improvement is usually apparent within
expenditure must be avoided. The main respira 1 5 minutes but responses vary. If there is no
tory problem is reduced lung volume. Secretions benefit within an hour, the patient is best
are usually of little note. returned to the previous position (Pilbeam,
1 998, p. 159). A positive response is most likely
Positioning before fibrosis begins developing.
Positioning has a marked influence on gas Benefits may be partially lost on returning to
exchange because of the unevenly damaged supine and some patients are best left in prone
lungs (Tobin, 1 994). Side-lying reduces lung for extended periods on a skin-friendly mattress.
densities in the uppermost lung (Brismar, 1 9 85) They are returned supine if required for various
but reinforces compression in the dependent procedures, and at night if sufficient skilled staff
lung (Du et ai. , 1 997), and must be changed are not available. During periods in supine, the
regularly. Right-side-lying may be more benefi physiotherapist can make a full assessment and
cial for cardiac output than left-side-Iying maintain range of movement to all j oints,
(Wong, 1 998). Regular position change in a including elbow, hip and shoulder which can
kinetic bed can reduce atelectasis and improve develop contractures if prone is prolonged
gas exchange (Hormann, 1 994). Patients vary in (Wong, 1 999). Practical obstacles such as
their response and it is best to be guided by the abdominal surgery, spinal Injury, unstable
monitors. fractures or frequent seizures can contraindicate
A more dramatic improvement in Sa02 can be the prone position.
found in two-thirds of patients by gently turning Three or four staff are required for the turn,
them prone (Lim et ai. , 1999). There are more including an intensivist or experienced nurse at
------ 415
(d)
Figure 15.12 T uming a patient prone. (a) The patient is pulled to the side of the bed on the old sheet over a glide sheet.
(b) A clean sheet is laid under the patient. (c) The patient is rolled prone over hislher neutrally-positioned arm. (d) The patient
is pulled to the middle of the bed on the clean sheet over the glide sheet. (From Kesecioglu, J . ( 1 997) Prone position in
therapy-refractory hypoxaemia. Curro Opin. Anaesthesia , 1 0, 92- 1 00)
416
the head of the bed to protect the airway and Head and arm positions are alternated 2-
neck lines (Figure 1 5 . 1 2) . A suggested procedure hourly. Volume of feed may need to be reduced
is described below. in case of regurgitation. Pressure areas now
1 . Inform patient, with reassurance that s/he

Head semi·rotated
will be safe. to left
2. Secure eye protection.
3. Disconnect and plug lines as feasible,
redirect others in axis of body. Chest drains
Dorsum
will need long tubing. of left
4. Check that team members understand the hand
vulnerability of the shoulder joint. Both shoulders

slightly elevated
5. Slide the patient to the edge using a glide
sheet.
Right shoulder
6. Place pillows at pelvis and chest level, but semi·internally
close enough to avoid lumbar lordosis. rotated
7. Place patient's hand under the hip, with

elbow straight and shoulder in neutral.
8. Roll patient over this arm and into prone, so Palm of
right hand
that pelvis and chest rest on pillows and
abdomen is free of pressure.
9. Reconnect lines.
1 0. Ensure that no joint is at end-range,
especially the lumbar spine and neck. The
neck must be slightly flexed and only half
rotated. Slight neck flexion can be
facilitated by overhanging the head at the
end of the bed, supported on a cushioned
table. A pillow or horseshoe headrest
allows the tracheal tube to be unrestricted
but secure.
1 1 . Check that the ulnar nerve IS not ___ Semi-dorsiflexed
ankles
overstretched and shoulder j oint remains
near-neutral (Figure 1 5 . 1 3 ). Either the arm
to which the head is turned can be semi
flexed, or both elbows extended and Figure I S. 1 3 Suggested posrtion for a proned patient.
shoulders internally rotated. Pillows are arranged around the tracheal tube to maintain a
12. Ensure that women's breasts and men's clear airway and prevent obstruction, Pillows support (a)
upper chest to ensure support for head of humerus and
genitals are not compressed.
slight protraction of shoulder girdle, (b) pelvis to prevent
1 3 . Place pillow under shins to prevent peroneal extension of lumbar spine and (c) shins to prevent
nerve stretch, positioning the pillow to pronation, The head of the left humerus may need extra
avoid knee and toe pressure from mattress. support, e,g, by a flattened rolled bandage or comer of a
14. Tilt the bed head-up to about 200 in order pillow, Right dorsum and left palm are rested against the
bed , To change position, the upper part of the patient is
to prevent facial oedema and potential eye
raised, with due consideration for the patient's joints, airway
damage. and lines, and with manual handling technique agreed in
1 5 . Suction airway because the turn often advance, The head is then semi-turned to the opposrte side
mobilizes secretions. and arms re-arranged,
------ 417
include ears, cheeks, knees and toes. Potential been found i n 27% o f survivors due to distres
cardiac arrest must be planned for and a sing experiences in the ICU (Schelling, 1 998).
protocol prepared for rapid return to supine This is a reminder to keep stress reduction at the
(Sun, 1 992). centre of ARDS management.
Some clinicians find that placing 5 kg
sandbags on the chest of a supine patient may
POISONING AND PARASUIClDE
have similar results to the prone position. This
causes greater abdominal excursion and it is Complications of poisoning include arrhythmias
thought that this chest compression reduces the due to the toxin or metabolic upset, fluid
risk of barotrauma to upper lung regions while depletion due to vomiting or diarrhoea, and
directing ventilation to dependent lung. respiratory compromIse due to ventilatory
depression, upper aIrways obstruction or
Manual hyperinflation pulmonary oedema. If gastric lavage is
MH is undertaken warily because of the vulner attempted, it can cause aspiration, distress and
ability of the 'baby lung'. If it is considered laryngeal spasm, and it may increase drug
essential because of a defined localized atelectasis absorption by forcing gastric contents into the
or secretions that cannot be cleared by other small bowel (Valladares, 1 996).
means, it must be brief. In the early stage of Deaths from poisoning remain steady at 4000
disease before damage is severe, Enright ( 1 992) a year in the UK Oones and Volans, 1999).
has demonstrated that positioning, MH, vibra Some poisoning is accidental but most is self
tions and suction can cause sustained improve inflicted. Health staff have shown negative
ment in D02 for patients with atelectasis or attitudes to parasuicide patients (Guy lay, 19 89),
sputum retention, with no evidence of baro including judgements about attention-seeking.
trauma. However, these patients are often at the
If MH is anticipated, the X-ray should be extremes of depression or desperation and over
examined for any precursors to a pneumothorax 90% have diagnosable psychiatric illness
such as thin-walled air cysts beneath the visceral (Urbaitis, 1 999). The professional approach is to
pleura or linear streaking towards the hilum withhold personal judgement and care for the
(Albelda, 1 9 8 3 ; Haake et at. , 1 9 8 7) . Disconnec patient in such a way that s/he believes life to be
tion for suction should be avoided when possible worth living after all. This may help reduce the
(Schwartz, 1 9 8 7) by using a closed-circuit 1 % of patients who will go on to kill themselves
catheter. within a year (Kapur et at. , 1 998).
Successful suicides are 'a permanent solution
The past 20 years have shown no reduction in to a temporary problem' (Guylay, 1 989) and
mortality from ARDS, and up to 70% of patients relatives bereaved by suicide find recovery more
still perish, half from sepsis and a tenth from difficult than from non-suicide bereavements.
respiratory failure (Wong, 1 998). People with The care they receive in the first hours can have
trauma-induced ARDS are most likely to survive, a profound impact on their grief (Odell, 1 997).
while those with an infective aetiology do less
well (Wyncoll and Evans, 1 999). Survivors show
SMOKE INHALATION
a remarkable capacity to regenerate lung tissue
and many become symptom-free over time, but Smoke inhalation is the primary cause of fire
it is recommended that rehabilitation is related deaths (Flynn, 1 999). The addition of
continued because 5 0% experience respiratory smoke inhalation to a burn increases mortality
symptoms, sometimes including severe breath by 20%, or 60% if pneumonia develops (Papini,
lessness (Smith and Sinclair, 1996) and depres 1999). The heat from inhaled smoke is filtered
sion (Bowton, 1999). Post-traumatic stress has by the upper airways at the expense of bronchos-
418
SMOKE INHALATION
pasm, mucosal swelling, pulmonary oedema, • humidified oxygen, at 1 00% if carbon

paralysis of cilia and ulceration. Toxins, steam monoxide has been inhaled
and crack cocaine can overwhelm the filtering • CPAP if the face is not burned, or IPPV with
properties of the airways and penetrate to PEEP, followed by extubation over a
alveoli, where they destroy surfactant and burn fibreoptic bronchoscope in case of oedema
lung tissue (Haponik, 1 992). Upper airway • supplementary feeding, preferably enteral to
obstruction is the most treatable respiratory preserve the gut lining. Hypermetabolism
complication, but if intubation is delayed, can last for weeks, break down protein and
asphyxia may occur from face and neck oedema. waste muscle (Nguyen, 1996).
Secondary damage arises from the inflamma
Other options are hyperbaric oxygen, inhaled
tory response to injured tissue which increases
llltnc oxide (Papini, 1 999) to assist gas
vascular . permeability. This exacerbates
exchange, and a simple form of hypnosis to
pulmonary oedema, which can halve lung
augment pain relief (Ohrbach, 1 998). Pain relief
compliance and quadruple respiratory resistance
is a priority, especially as pain experienced in
(Papini, 1 999). Pulmonary oedema is difficult to
hospital is a stronger predictor of adjustment
control because of the fluid requirements of
after discharge than burn size (Ptacek et at. ,
surface burns. Oxygen delivery is impaired by
1 995). Prophylactic antibiotics are not recom
shock, inflammatory mediators and inhaled
mended but bacterial infection is likely after day
carbon monoxide. Carbon monoxide famously
2 or 3, and cultures should be obtained at the
binds to haemoglobin 200 times more strongly
earliest indication of infection (Papini, 1999).
than oxygen, and also shifts the oxygen disso
Oximetry is falsely normal because the oximeter
ciation curve to the left, which hinders loading
cannot distinguish oxyhaemoglobin from
of oxygen from the lungs and interferes with
carboxy haemoglobin. Large mucus casts may
unloading of oxygen to the tissues. Infection is
require bronchoscopy or occasionally lavage.
commonly transmitted to the denuded airways
Respiratory physiotherapy is aimed at main
from the hospital environment, infected burns
taining lung volume and clearing thick and
or endogenous sepsis. The stages of lung injury
prolific secretions caused by airway damage.
are:
Lavish humidification is needed. Precautions are
1. bronchospasm (first 12 hours) the following.
2. pulmonary oedema (6- 1 2 hours post-burn) • Treatment should be little and often because
3. bronchopneumonia ( > 60 hours post-burn) of the importance of prophylaxis and the
Wheeze and sooty sputum may not appear for inevitable fatigue.
24 hours, and X-ray signs of pulmonary oedema • Percussion and vibrations should be avoided
are not apparent for some days. Severe injury is over chest burns, whether dressed or not. If
indicated by dyspnoea and cyanosis. Later devel manual techniques are essential, a vibrator is
opments may include restricted expansion due to reasonably comfortable.
a tight armour of scarring around the chest, and • If suction is necessary, it should be gentle,
various effects of epithelial damage such as long minimal and scrupulously aseptic to prevent
term hyperreactivity, tracheal stenosis or bronch further mucosal damage.
iectasis (Tasaka et at. , 1995). • Patients need extra attention to communica
Medical treatment is based on: tion if facial oedema affects vision or speech.
• If there is oedema around the head or neck,
• pain management (Wu et ai. , 1 999) postural drainage is contraindicated and
• judicious fluid administration, both crystal patients are often nursed upright.
loid to resuscitate the interstitial space and • If hoarseness, voice change or stridor
colloid for the intravascular space develops, nasopharyngeal suction is contrain-
------ 419
CHAPTER 1 5 DISORDERS IN INTENSIVE CARE PATIENTS
dicated and the patient's condition should be

reported because intubation will be required. Day I
Subjective:
Two-hourly exercises are required for burned
pain and breathlessness.
limbs, especially the hands (Keilty, 1 993), using
Objective:
Entonox or other analgesia. Provision of a 'Burn
pale, sweaty, rapid breathing, flail segment on R,
Intensive Care Gym' provides the opportunity
other respi ratory observations normal.
for patients to improve their functional status
and take responsibility for self-management Questions
(Gripp et aI. , 1 995).
I . Problems?
2. Plan?
NEAR-DROWNING
Near-drowning I S defined as submersion Day 2

followed by survival for 24 hours, then dete X-ray shows white-out on R.
rioration. Death from pulmonary complications pH 7.48, Pa02 6.7 kPa, PaC02 3.9 kPa, HCO)- 24.
can occur, especially with 'wet drowning', which I ntu bated and ventilated --+ blood gases
leads to pulmonary oedema, inactivation of normalized.
surfactant, bronchospasm, hypoxaemia and
cerebral oedema. If water is swallowed, there is Questions
a high incidence of vomiting, sometimes I . Percussion note?
followed by further aspiration. Frequent 2. Breath sounds?
physiotherapy to clear the airways may be 3 . Explain PaC02.
needed for at least 48 hours in order to prevent 4. Explain white-out on R.
atelectasis. 5. Explain Pa02.
'Dry drowning' accounts for 1 0% of near 6. Why was the patient mechanically venti lated
drowning admissions and is caused by laryngos when he stil l had one fully functioning young
pasm in a panicking victim, leading to apnoea lung?
and hypoxaemia. Fluid is not aspirated and the 7. Problems?
airways rarely need clearance by physiotherapy. 8. Plan?
Hypothermia, defined as core temperature
below 35°C, commonly occurs with near Day 3
drowning. Resuscitation attempts should be Epidural in place.
prolonged and nobody considered dead until Weaned and extubated .
they are warm and dead. Patients are given Subjective:
warmed humidified oxygen, warmed IV fluids, Fatigue.
warm blankets (not space blankets, which Objective:
simply prevent heat loss) and sometimes cardio Crackles on auscultation.
pulmonary bypass.
Questions
I . Problems?
2. Plan?
Identify each day's problems and plans for this 25- Day 4
year old male hit by scaffolding (Figure 1 5 . 1 4),
which fractured his 6th and 7th ribs on the right Questions
(imperceptible on X-ray). I . Consolidation? atelectasis?
420
CASE STUDY
(a)
(c) (d)
Figure 1 5. 1 4 X-rays of Mr CA. (a) Day I . (b) Day 2. (c) Day 3. (d) Day 4 .
2 . Lobe(s) affected? 2. . Liaise reo analgesia.

3. Problems? • Position for optimum pain relief and
4. Plan? respi ratory function.
• Regular i ncentive spirometry.
Id41g.,�M''·eMIiii).ij • Assess frequently until analgesia adequate, then

initiate more active measures, e.g. mobilization.
Day , Day 2
I . Pain -> potential for respiratory complications I . Percussion note dull on R.
------ 42 1
2. Breath sounds ! on R. • i R hemidiaphragm suggests lower lobe

3 . PaC02 ! because of breath lessness. atelectasis.
4. White-out sudden, therefore may be due to 3 . ! lung volume as above.
aspiration. (A haemothorax would have 4. Mobil ize and rehabil itate to ful l function.
produced a stony dull percussion note.)
5. . i shunt on R.
• Pain -> shallow breathing -> increased dead
space.
6. A young man should be able to accommodate LITERATURE APPRAISAL
loss of gas exchange in one lung, but not the Comment on the rationale and evidence for
added problem of restricted breathing due to 'chest physical therapy' in the following patient.
pain.
7. • I nadequate pain relief The indications for [chest physical therapy]
• ! volume R lung included . . . lung contusion . . . .
8. • Refer to acute pain team for regional
analgesia Treatment times . . . averaged 6 7 min . . .
• Positioning left-side-Iying [followed by increased] QJQ/ in [50%] of
• Deep breathing and incentive spirometry as the contusion patients . . . .
patient is able
• If adeq uate analgesia not forthcoming, The long-term clinical effect of these
consider I PPB with Entonox changes is unknown.
• Obtain sputum sample. Crit. Care Med. 198 5 ; 13 : 483-486
Day 3
I . • Fatigue
• ! volume R middle and lower lobes.
2. . Liaise with team to ensure rest and sleep Over an hour of postural drainage, percussion,
• Physiotherapy as yesterday but little and vibration and suction is unlikely to be indicated
often, and co-ord inated with rest and sleep. for any condition, let alone lung contusion.
• ACBjAD + other techniques for clearance of Indeed, manual techniques are contraindicated
secretions with lung contusion because of the risk of
• Daily written regime of frequent position bleeding.
change, including sitting out, plus brief Bleeding into alveoli is not cleared by techni
mobilization if patient willing. ques aimed at airways.
Objectively, this technique appeared
Day 4 damaging by increasing the shunt (QJQr) in half
I . and 2. the patients with contusion.
• M iddle lobe consolidation. Subjectively, one can only guess.
422
RECOMMENDED READING
Figure 1 5. 1 5 (a) Figure 1 5. 1 5 (b)
Quiz Fearnhead, L. and Fritz, V. U. ( 1 996) Guillain-Barre

syndrome. S. Afr. J. Physiol. , 52, 85-87.
Firth, J . ( 1 999) Acute renal failure. Medicine, 27(5),
Which is the middle lobe collapse and which
24-3 l .
the ruptured diaphragm? (Figure 1 5 . 1 5 )
Fletcher, S . and Lam, A . M . (2000) Improving
Answer after Recommended Reading. outcome for the injured brain and spinal cord.
Curro Opin. Anaesth., 1 3 , 1 55 - 1 6 0 .
Gill, D. J. and Wells, D . L. (2000) Forever different:
experiences of living with a sibling who has a
RECOMMENDED READING
traumatic brain injury. Rehabil. Nurs. , 25, 48-
Albert, R. K. ( 1 999) Prone position in ARDS. Crit. 52.
Care Med. , 27, 2574-2575 . Gunning, M. P. and Hayes, M. A. ( 1 999) Oxygen
Alderson, J. D. ( 1 999) Spinal cord injuries. Care Crit. transport. Curro Anaesth. Crit. Care, 1 0 , 3 1 9-324.
IlL, 1 5 , 48-52. Horrocks, C. and Brett, S . (2000) Blast injury. Curro
Appleyard, N. ( 1 9 9 8 ) The collagen vascular diseases Anaesth. Crit. Care, 1 1 , 1 1 3-1 1 9 .
in critical care. Care Crit. Ill, 1 4 ( 1 ), 29-3 3 . Johnson, J. and Silverberg, R . ( 1 9 95) Serial casting o f
Bernal, W. and Wendon, J. (2000) Acute liver failure. the lower extremity t o correct contractures during
Curro Opin. Anaesth., 12, 1 1 3-1 1 8 . the acute phase of burn care. Phys. Ther. , 75, 262-
Bulger, E . M . (2000) Rib fractures in the elderly. J. 266.
Trauma, 48, 1 040- 1 04 3 . Keilty, S. E. J. ( 1 9 9 3 ) Inhalation burn injured patients
Cubukcu, A., Paksoy, M. and Ganiillii, N. N. (2000) and physiotherapy management. Physiotherapy,
Traumatic rupture of the diaphragm. Int. J. Clin. 79, 87-90.
Pract. , 54, 1 9-2 l . Kennedy, D. D., Fletcher, N. and Hinds, C. (2000)
Dhond, G. R . and Dob, D. P . (2000) Critical care of Neuromuscular dysfunction in critical illness.
the obstetric patient. Curro Anaesth. Crit. Care., Curro Opin. Anaesth., 1 3 , 93-9 8 .
1 1 , 86-9 l . Kulkarni, V. and Webster, N. ( 1 996) Management o f
Edwards, J . D . ( 1 997) Oxygen transport in the sepsis. Care Crit. Ill, 1 2, 1 22- 127.
critically ill. Br. J. Intens. Care, 7, 23-29. Levy, B . D . , Kitch, B . and Fanta, C. H . ( 1 99 8 )
423
CHAl'TER 1 5 DISORDERS IN INTENSIVE CARE PATIENTS
Medical and ventilatory management of status Wake, D. ( 1 995) Near drowning. Intens. Crit. Care
asthmaticus. lntens. Care Med. , 24, 1 05-1 1 7 . Nurs., 1 , 40-43 .
McColl, M. A . (2000) Changes i n spiritual beliefs Waldmann, C. S. ( 1 99 8 ) Management of head injury
after traumatic disability. Arch. Phys. Med. Rehab. , in a district general hospital. Care Crit. Ill, 14, 65-
8 1 , 8 1 7-823 . 69.
McCord, M. ( 1 999) Respiratory failure: after the
lCU. Crit. Care Clin. N. Am., 1 1 , 48 1-49 1 .
Mergener, K. and Baillie, J . ( 1 99 8 ) Acute pancreatitis.
Br. Med. J. , 3 16, 44-4 8 . Response to quiz
Pickford, A . and Criswell, J. (2000) Review of
gunshot injuries. Care Crit. Ill, 1 6, 28-32. (a) The curved line on the right is the
Pinsky, M. R. ( 1 994) Through the past darkly: ruptured diaphragm, indicating severe
ventilatory management of patients with COPD.
abdominal trauma. The curved border on
Crit. Care Med. , 22, 1 7 1 4- 1 7 1 7.
the right is the upper edge of the liver.
Price, P. (2000) The Glasgow Coma Scale in intensive
Between these two is lung tissue (in front
care. Nurs. Crit. Care, S, 1 70- 1 7 3 .
Stiller, K. and Huff, N. ( 1 999) Respiratory muscle
and behind the ruptured diaphragm) and
training for tetraplegic patients: a literature displaced abdominal contents.
review. Austr. J. Physiother. , 45, 29 1 -3 00. (b) The curved line on the right is the
Tansley, P. D. T. ( 1 9 9 8 ) Chest trauma. Care Crit. Ill, horizontal fissure, displaced downwards by
14, 260-265 . the collapsed middle lobe. The increased
Vandevoort, M . ( 1 999) Nutritional protocol after density reflects loss of middle lobe volume.
acute thermal injury. Acta. Chir. Belg., 99, 9- 1 6 .
424
16 PHYSIOTHERAPY FOR CHILDREN AND INFANTS
SUMMARY
Physiotherapy for children • Indications

• Introduction • Precautions
• Aspects of assessment • Assessment
• Aspects of treatment • Methods to increase lung volume
• Asthma • Methods to decrease the work of breathing
• Chest infections • Methods to clear secretions
• Fatigue, sleep apnoea, hyperventilation • Developmental management
syndrome Modifications for specific neonatal disorders

• Surgery • Meconium aspiration
• Dying children • Intraventricular haemorrhage
The neonatal ICU • Respiratory distress syndrome
• Introduction • Chronic lung disease of prematurity
• Care of the parents Emergencies in the neonatal unit

• Management of pain and stress • Sudden hypoxaemia
• Temperature and fluid regulation • Apnoeic attacks
• Oxygen therapy • Pneumothorax
• Feeding • Cardiorespiratory arrest
• Humidification Mini case study

• Mechanical ventilation Literature appraisal
• Neonatal support systems Recommended reading
Physiotherapy for neonates
control over what is done to them. Teenagers in

PHYSIOTHERAPY FOR CHILDREN
particular need autonomy because they are
extra-sensitive to peer pressure and often feel
Introduction they have outgrown the paternalistic environ
Adult patients can say to themselves: 'I under ment of paediatric units.
stand that I am not in hospital for the rest of my Children appreciate having the same
life, that my family will visit, that the nasty physiotherapist throughout their stay. Those
things they are doing to me are for my own over 3 years old should be included when their
good'. Young children do not have these treatment in discussed in their presence.
resources of reasoning and may be overwhelmed Children need their own toys and belongings,
by bewilderment, uncertainty about the and all but the sickest are best dressed in their
behaviour expected of them and sometimes day clothes. Hospitalized children, like adults,
feelings that they are abandoned or being commonly adopt the sick role and may show an
punished. Despite progress in humanizing chil exaggeration of the behaviour patterns that they
dren's experience in hospital, long-term normally use to cope with stress.
emotional disturbance can still occur. Children Parents require confidence in their own
need to be listened to, believed and given some competence, and acknowledgement that they are
--
-- 425
CHAPTER 16 PHYSIOTHERAPY FOR CHILDREN AND INFANTS
the experts on their children, especially as they

may be more effective than health workers in
the identification of their child's problems
(Roberts, 1996). Siblings require involvement
because they may feel a variety of responses,
including jealousy, anxiety, isolation and guilt.
And if their brother or sister is disabled, they are
likely to suffer bullying at school (Miller, 1996).
Aspects of assessment
Parents should be welcomed during assessment
and treatment. If this causes the child to express
anxiety more noisily than when unaccompanied,
this is healthier than withdrawal. For any
anxious patient, but particularly the young, it is
advisable to avoid touch until a modicum of
trust has been established. If the child's favourite
toy, TV programme, food or game is listed
Figure 1 6. 1 Retractions indicating respiratory distress. A
above the bed, these can be used to engage the = intercostal; B = subcostal. C = substernal. (From
child's interest. Assessment can be done on the Wilkins, R. L. . Krider, S. J. and Sheldon, R. L. (1995) Clinical
parent's lap, with a description of what is being Assessment in Respiratory Care. Mosby, Toronto, with
examined and why. If an intravenous needle is permission. )
present, it can inhibit children from moving and
they should be reassured that it will be
supported throughout. If a nil-by-mouth sign is tory distress are:
present, the child may be distressed and not
• i RR
understand why s/he is so thirsty.
• asynchronous breathing, shown by a seesaw
Children have a high respiratory rate (RR)
motion between chest wall and abdomen
because of the extra metabolism needed for
• nasal flaring
growth and the relatively large metabolically
• apnoea associated with bradycardia or
active brain and viscera. Vital signs are shown in
pallor.
Table 16.l.
In young children and babies, laboured Before auscultation, children can be given the
inspiration is shown by chest recession (retrac opportunity to see and feel the stethoscope, and
tion) because of the compliant chest wall (Figure use it to listen to themselves or a doll. The
16.1). Laboured expiration is shown by diaphragm or bell should be warmed before use.
grunting, which acts as a form of CPAP to splint Breathlessness can hamper communication,
open the narrow airways. Other signs of respira- interfere with sleep and affect eating or
Table 1 6. 1 Age-related vital signs (Prasad and Hussey, 1995 )
Newborn 1-3 yean l-7yean Over 7yean
RR 40-60 20-30 20-30 15-20

P.02 60-90 80-100 80-100 80-100
HR 100-200 100-180 70-150 80-100
BP 60/30-90/60 75/45-130/90 90/50-140/80 90/50-140/80
426 ------
drinking. Alert children in respiratory distress Some modifications of the techniques described
assume a position that promotes airway patency in Chapters 6-8 are discussed below. Treatment
and they should be allowed to maintain this should not be straight after a meal.
position. Deterioration in gas exchange may be
indicated by pallor, sweating, restlessness, Methods to increase lung volume
agitation, glazed eyes and, in ventilated children, Young children need particular attention to
fighting the ventilator. Hypoxaemia must be maintenance of lung volume because lack of
excluded before sedating an unsettled child. elastic tissue in immature lungs means that they
Cyanosis is a severe sign. Atelectasis of the left share with elderly people a tendency for airway
lower lobe may be missed on a portable X-ray closure at low lung volumes.
film because it is hidden by the heart. Two-year-olds can do breathing exercises if
taught imaginatively. The use of paper mobiles,
Aspects of treatment bubble-blowing, blowing through a straw or
Clear, honest and simple explanations should be blowing a tissue will utilize the deep breath that
given to the child before treatment, including is taken before blowing out. Paediatric incentive
demonstrations on a teddy, descriptions of what spirometers are often popular. Abdominal
the treatment will feel like, how long it will last breathing can be taught by placing a favourite
and reassurance that it can be stopped tempora toy on the abdomen, 'like a boat on the sea'.
rily by request at any time. Resistance to Crying upsets the flow rate without increasing
treatment can often be overcome by giving the volume (Figure 16.2) and should be avoided,
child a choice, e.g. whether to keep the TV on or particularly in children with stridor.
off, have incentive spirometry or a walk outside, When positioning for gas exchange, the distri
have curtains open or closed. Requests to stop bution of ventilation is opposite to the adult
treatment must be respected, and if further pattern. The compliant chest wall and lack of
treatment is refused despite cajoling, distraction, connective tissue support for the small airways
joking and enlisting the help of parents or a play inhibits flow to the more compressed dependent
therapist, serious thought should be given to regions, directing ventilation preferentially to
whether the benefits of continuing treatment upper regions. Airway closure occurs above
outweigh the effects of enforcement. resting lung volume until the age of 6 or 7
Babies can be given rattles and toys to watch Games, 1991) and poor ventilation to lower
during treatment. For children, hand puppets regions may predominate for the first 10 years of
can be used to give instructions, story-telling can life (Davies et at., 1990). In the presence of
be used so that the child looks forward to the unilateral lung pathology, gas exchange varies
next instalment in the next physiotherapy and oximetry is the best guide.
sessIOn. For spontaneously breathing children, CPAP
In the UK, a child's consent to treatment is (p. 156) is used if adequate oxygenation cannot be
required if s/he is of 'sufficient understanding to maintained with oxygen therapy. CPAP is suited
make an informed decision' (Children Act, to children to compensate for their floppy chest
1989). Children of school age are presumed walls. Administration can be by face mask, which
competent for this purpose (Rylance, 1996) is not easy to seal, or a short soft nasal prong
unless there is a specific reason otherwise. (Morley, 1999). A starting pressure of 5 cmH20 is
Children should not simply be deemed to be used, and gradually increased until grunting stops
competent if they agree, and incompetent if they or oxygenation is optimum. Pressures above
disagree. Hall (1994) claims that health workers 10 cmH20 bring a risk of gastric distension or
now have a legal obligation to believe their possible pneumothorax. For intubated children,
younger patients. After age 16, full adult rights CPAP in the form of PEEP is always required
apply and parental consent is not required. because the tracheal tube prevents grunting.
------ 427
CHAPTER 16 PHYSIOTHERAPY FOR CHILDREN AND TNFANT�
(a) Inspiration
little and often, and physiotherapy must be
30
avoided after eating.
20
Percussion is sometimes more soothing than
c 10 vibrations. Huffing can be encouraged by
E
:::J 0 blowing cotton wool or using the story of the
;:
0
u: -10 big bad wolf who 'huffed and puffed and blew
the house down'. From age 4-5 years children
-20
Times
can do aspects of ACB and AD (p. 194), but are
-30
Expiration unable to put it together consistently until 6-7
years and may not actually do it when on their
(b) Inspiration own.
30 Wheelbarrow races and games incorporate
20 exercise and position change. Wind instruments
c
10 use the principles of PEP (p. 198). Families can
E 0 be encouraged to use swimming and biking as
:::J
;:
0
-10 treats.
u: -20 Coughing can be encouraged by laughter and
Times
-30 rewarded by earning a star on a cough score
-40 sheet. Coughing with a protruded tongue helps
Expiration to prevent swallowing. In the first year of life,
coughing can sometimes be stimulated at the
Figure 1 6.2 Breathing pattern of (a) a 2-year-old child at neck by finger pressure sideways during exhala
rest and (b) a 20-rnonth old child while crying (left halD and tion against the trachea below the thyroid
sobbing (right halD. (Frorn Nikander, K. (I 997) Adaptive cartilage. This must be gentle to avoid bradycar
aerosol delivery. Eur. Resp. Rev., 7, 385-387)
dia.
Nasopharyngeal suction is unnecessary if the
child is coughing effectively, even if secretions
are swallowed. When suction is necessary, the
Methods to clear secretions procedure on page 205 is followed, using water
Postural drainage can be enjoyable over a bean soluble jelly or the child's saliva as lubricant, and
bag or on the helper's lap in a rocking chair. For catheter sizes as in Table 16.2.
infants, who spend much time supine, the sitting It is advisable to advance the catheter only
position is included to drain the apical segments until a cough is stimulated, or, for intubated
of the upper lobes, with particular attention to patients, not more than 1 cm beyond the end of
the right upper lobe. the tracheal tube (Riston, 2000). Excessive
Many young children have undiagnosed suction pressure causes greater mucosal damage
gastro-oesophageal reflux, which usually clears
spontaneously within 12 months (Nelson, 1998).
For children in whom this is suspected, prone Table 1 6.2 Suggested catheter sizes for the non
and left-side-Iying give some protection (Ewer et intubated child
al., 1999) because the greater curvature of the
stomach provides an enhanced reservoir 1\ge Catheter size (FG)
capacity. The head should generally be raised to Neonate 5
30° and the head-down tilt is usually contraindi 6 months 6
cated (Button et aI., 1997). However, children 1 year 8
2 years 10
vary in the position at which reflux occurs, and 6 years 12
symptoms should be checked. Feeds are given
428
(Czarnik et al., 1991) and does not appear to need for education is underlined by the child's
remove more secretions (Howard, 1994). There fear about the disease. Two-thirds of children
is little research evidence of the pressure at outgrow their asthma (Sears, 1994), and it is
which damage occurs, but Parker (1998, p. 338) thought to be more than coincidence that this is
recommends 10-20 kPa (75-150 mmHg). Mini at a time when they outgrow their fears
tracheotomy has been used for children from 12 (Gillespie, 1989). Education is therefore the key,
years old who need repeated suction (Allen and including the following suggestions:
Hart, 1988).
If a sputum specimen is required, children • use of colourful diaries and stickers, avail
under the age of 4 can rarely expectorate. A able from asthma organizations or manufac
cough swab may be successful, in which the turers (Appendix C)
child coughs and secretions are collected from • practice in using inhalers, preferably in front
the back of the throat by a swab and sent to of a group to improve confidence at school,
microbiology in a sterile container. A specimen and, for children over 6 years, practice in
of nasopharyngeal aspirate may be requested in monitoring peak flow
order to obtain epithelial cells for diagnostic • hard, enjoyable, controlled physical activity
purposes. This entails nasal suction to the post because the majority of children with asthma
nasal pathway, as judged by using a length of are deconditioned and associate exercise
catheter that has been measured from nose to with anxiety (Clark, 1999)
ear. Specimens are often unhelpful because of • healthy eating, especially fresh fruit (Foras
oral contamination, and even secretions from tiere et al., 2000)
intubated children usually carry pathogenic • prevention, including environmental and diet
bacteria from the larynx and trachea (Hjuler, modification from infancy in the case of
1995). atopic families (Brewin, 1998).
Some couples need to begin prevention before

Asthma
birth. Children born to an atopic couple have a
Asthma is the most frequent cause of respiratory 45% chance of developing asthma, sensitization
symptoms in childhood (Battistini et aI., 1993). beginning from 22 weeks gestation (Brewin,
Some 10% of children are affected (Deaves, 1998). Avoidance of smoking by pregnant
1993), twice as many as any other chronic mothers is essential (young, 2000).
illness, and morbidity and mortality are increas Chromones (p. 133) are effective in 70% of
ing worldwide (Fawcett, 1995). The disease is children, in which case steroids can often be
both under- and overdiagnosed. One study avoided (Korhonen et aI., 1999). Theophylline is
showed that children consulted a general practi not advisable for children (Goodman, 1996),
tioner on average 16 times before asthma was and �2-agonists, including the slow-acting
diagnosed (Levy and Bell, 1984). Another varieties, should be used intermittently and not
showed that self-limiting infections are often regularly (Bisgaard, 2000). Inhalers need to cope
misdiagnosed as asthma and lead to unnecessary with children's lack of co-ordination, short
medication (Stein, 1999). A simple screening inspiratory time, reduced ability to breath-hold
method is to take the peak flow before and after and low inspiratory flow rate. Infants inspire at a
a 6-minute exercise test, a drop of more than flow rate below 10 L/min (Wildhaber, 1996).
15% within 10 minutes indicating asthma (Jones The following are suitable:
and Bowen, 1994). Details of asthma are given
in Chapter 3, with aspects related to children • inhaler with spacer and mask: 0-2 years
described below. • inhaler with spacer: 3 years upwards
Rehabilitation programmes have shown • dry powder inhaler (which needs a higher
positive results (Baan-Slootweg, 1997), and the inspiratory flow rate): 5 years upwards
------ 429
• metered dose inhaler: 10 years upwards Table 1 6.3 Croup and epiglottitis
(Cogswell, 1994).
Croup Epiglottitis
Large-volume spacers may need to be tipped,
Age 6 months to 3 years 2-6 years
mask downwards, during inhalation to allow the Aetiology Viral Bacterial
valve to open. If the mask is frightening, the Onset Over days Over hours
parent can support it on the child's face, or the Temperature < 3S,SOC > 3S,SOC
Cough Barking Minimal
cheek can first be stroked gently with the mask. Stridor If severe only Yes
In countries where spacers are not available, a Voice Hoarse Weak
sealed 500 mL plastic bottle is a substitute (Zar Can drink Yes No
Active Yes No
et al., 1999). If nebulizers are used, they can be
tried on a teddy first, and some children can use
them when asleep. Comprehensive instructions
and regular checks are needed to ensure reliable
fulminant infection of the soft tissues around the
technique (Kamps, 2000). Absorption of aeroso
entrance to the larynx. The child presents with
lized drugs is reduced with crying (Iles et al.,
tachypnoea and severe sore throat so that swal
1999).
lowing saliva is difficult and drooling occurs.
The child usually sits upright or in a 'tripod'
Chest infections position with neck extended and arms providing
Risk of infant infections 1S reduced by breast support for the accessory muscles. Prompt
feeding (Wright, 1989) and increased by treatment is required, including intubation if
parental smoking (Couriel, 1994). Young steroids are unable to maintain a patient airway.
children react more severely to respiratory Table 16.3 charts the differences.
infection than adults because of their narrow Physiotherapy is not indicated in the acute
airways, but if segmental atelectasis occurs, it phase for non-intubated babies, but may be
usually clears spontaneously (Simoes, ( 1999). required if symptoms persist, or for intubated
Some infections are associated with a higher babies if there are excessive secretions.
incidence of COPD in adult life (Shaheen et al.,
1994). Inappropriate use of antibiotics is particu Bronchiolitis
larly condemned in children because of the asso Bronchiolitis is inflammation of the bronchioles
ciation with multiresistant infections (Arason, due to viral colonization of the bronchiole
1996). Urban children have on average 5-8 mucosa. It is the commonest respiratory tract
respiratory infections a year, each lasting about a illness of infancy (Cade et aI., 2000), and is most
week (Horton, 1996). The more severe infec usual in those born prematurely. Ciliary damage,
tions are described below. excess mucus and mucosal oedema lead to
airway obstruction and hyperinflation. Signs are
Croup and epiglottitis excess oral secretions, wheeze, fine crackles, and
Croup is an acute syndrome of upper airways breathlessness with chest retractions,. indicating a
obstruction usually caused by laryngotracheo fivefold or more increase in the work of
bronchitis. Humidification is commonly applied breathing (Milner and Murray, 1989). Gas
but it is unclear how a mist might reduce an trapping may prevent sternal recession, unlike
inflammatory obstruction. Croup is usually croup or pneumonia. Admission to hospital is
benign and self-limiting. Severe disease accompa required if the infant is too breathless to manage
nied by stridor requires hospitalization, fluids a cough or has a RR above 50/min (Isaacs,
and steroids (Griffin, 2000). 1995).
Epiglottitis is a less common but more vicious Treatment is by hydration, humidity, oxygen,
form of upper airway obstruction caused by maintenance of the head-up position, minimal
430
handling and occasionally heliox (Paret et at.,

1996). Bronchodilators are rarely helpful, but if Fatigue, sleep apnoea, hyperventilation
prescribed should be nebulized with oxygen syndrome
because they can worsen hypoxaemia in wheezy Sleep apnoea and hyperventilation syndrome can
infants (Rakshi, 1994). Antibiotics (Roosevelt, both occur in children, and either may manifest
1996) and steroids (Simoes, 1999) are consid as chronic fatigue or attention-deficit disorder.
ered ineffective, but benefits have been claimed Enlarged tonsils can cause obstructive sleep
for Chi�ese herbs (Kong et at., 1993). The apnoea, leading to snoring, failure to thrive,
acute illness subsides suddenly in about a week, enuresis and behavioural problems (Lamm et at.,
with recovery over 2-3 weeks, but 70% of 1999). Management of sleep apnoea is as for
infants experience recurrent cough and wheeze adults, including CPAP when necessary
(Cade et at., 2000). (McNamara, 1999). Hyperventilation syndrome
Physiotherapy is not recommended routinely is commonly undiagnosed (Enzer, 1967).
(Nicholas et at., 1999) and tends to cause desa
turation and increased wheeze in the acute stage. Surgery
If sputum retention becomes a problem, percus
sion in modified side-to-side positions is Preoperative management
indicated, with suction if necessary. Close Preoperative information reduces a child's
evaluation is required by assessing post distress (LaMontagne, 1996), and advice on
treatment wheeze, oxygen saturation and how breathing and mobility leads to more rapid
the child settles. recovery (Carmini et at., 2000). Parents have not
always explained the operation to the child.
Pneumonia Without explanation, the boundary between
The clinical course of pneumonia is more acute reality and fantasy can be blurred, e.g. the
than in adults, with chest recession and RR distinction between anaesthesia and death.
above 50 sometimes seen. Rapid breathing may Children have been known to mistake a bone
be the only sign (Ralafox, 2000), but slow marrow test for a 'bow-and-arrow test' or a dye
laboured breathing can be an indication of very injection for a 'die injection'. Preoperative stress
severe pneumonia. Physiotherapy is occasionally is greatest in younger children (Aono et at.,
needed in the later stages if the child is unable to 1997).
clear airway debris. Preoperative explanations are helped by
pictures, rehearsal of procedures, visits to
Pertussis (whooping cough) hospital facilities and encouragement to discuss
This is a lower respiratory tract infection charac the experience with children who have had the
terized by coughing spasms that terminate in a same operation. Physical sensations and their
'whoop' as air is gasped into the lungs, or in reasons should be explained. Truth is essential
younger children by vomiting and apnoea. The because if the child's trust is shaken, co
disease can be lengthy (hence the nickname operation is lost. Parents require highly detailed
'100-day cough') and coughing severe, leading explanations (Kain et at., 1997).
sometimes to airway damage and bronchiectasis Children should be allowed oral fluids 2
in later life. Physiotherapy is only required if hours before surgery to reduce the risks of dehy
there is sputum retention, and treatment must dration, nausea and hypoglycaemia (Phillips et
avoid any stimulus that irritates the sensitive at., 1994). Excessive food starvation can be
airways and sets off more coughing. harmful (Veall, 1995). Early milk-feeding post
operatively helps reduce crying (Gunawardana,
Cystic fibrosis 2000).
For cystic fibrosis, see page 87. Separating a screaming child from its parent
431
at the door of the operating room is no longer adults (Twycross, 1998), but meticulous
acceptable, and a parent should be present prescription is required.
during induction of, and emergence from, anaes • Children may nulllmize complaints if
thesia (Hall et ai., 1995). analgesia is administered by the dreaded
needle.
Pain management • Children are easily held down by force.
Postoperative pain management for children is • Some health staff do not realize that pain is
characterized by doctors under-prescribing and experienced from birth, and indeed before
nurses under-administering (Hall, 1994). Young birth (McCullagh, 1996). There is evidence
children can undergo intubation and chest drain of synapses in a fetus as young as 8.5 weeks'
insertion without medication, and older children gestation, and response to tactile stimuli at 5
have described the pain of medical procedures as weeks gestation (McCullagh, 1996). Invasive
the worst aspect of their condition (yaster, procedures during the first trimester of preg
1995). Fulton (1996) has named this 'institu nancy have been linked to impaired lung
tional violence' and describes children's subse function and increased respiratory symptoms
quent behaviour as similar to that after non after birth (Greenough and Yiiksel, 1997).
accidental injury. Untreated pain has detrimental
The low priority given to children's pain is
effects on short- and long-term clinical outcomes
reinforced by some medical textbooks, e.g.
(Chambliss, 1997), and could bring prosecution
'. . . these patients vigorously object to having an
if applied to animals. Children with neurological
arterial puncture done even if they are relatively
impairment are at particular risk (Pederson and
sick. Because of this, more than one person is
Bjerke, 1999). The causes of poor pain manage
usually required to obtain the sample' (Deming,
ment in children are legion:
1995, p. 2 13). This demonstrates little
• Children's subjective complaints may not be awareness of the ethical, legal and humane
taken seriously. Health staff tend to rely on considerations in relation to forcibly holding
assumptions and personal beliefs when asses down a child to inflict pain.
sing children's pain (Beyer and Byers, 1985). Parents' opinions must be actively sought
• Distinguishing pain from agitation is challen because they tend to assume that everything to
ging in young children, and children may minimize pain is done automatically. For older
not express pain in terms that are easily children, it is better to ask the child because
understood by adults. Absence of crying does parents may underestimate their child's pain (St
not indicate absence of pain. Laurent-Gagnon, 1999). Self-report also gives an
• Doctors' anxieties about drug side effects indication of the associated fear (Manne et al.,
have led to children being described as 'ther 1992). Children over 7 can use a visual analogue
apeutic orphans' (yaster, 1995). Opiates scale. Those over 3 can use colour intensity
cause no more respiratory depression than in scores, face scales (Figure 16.3) or charts with
@'-lO b
!\
Figure 1 6.3 Faces scale for pain assessment in children. (From Carter, B. (1994) Child and Infant Pain, Nelson Thomes.)
432
body outlines. Prelingual and non-verbal sion, attempted suicide and post-traumatic stress
children can be observed for signs of withdrawal, disorder (yule, 1999). Children tend to mistake
face and body reactions, irritability, pallor, flashbacks for reality and keep their feelings to
momentary breath-holding, prolonged sleeping, themselves so as not to upset their parents.
or in older babies who are experienced in
hospital procedures, an expression of frozen Dying children
watchfulness. Physiological measures such as Children have a right to grieve. They have the
changes in RR, heart rate, BP and Sa02 can be capacity to do so, and begin to develop an
used as adjuncts but are not specific as indicators understanding of death from the age of 2-3
of pain and not sustained with continued pain. years (Sheldon, 1998). They may be prevented
Children fear injections more than anything from this necessary process because of a
else in hospital (Twycross, 1998) and a painless natural desire by others to protect them from
route of administration is required. An exception suffering. Children understand more than they
is the rectal route because absorption is slow and can articulate and usually know if they are
variable, it can be perceived as abusive, and going to die (Purssell, 1994). Evasion can leave
there has been one known fatality (Gourlay and them with a sense of bewilderment, betrayal
Boas, 1992). Children can use patient-controlled and fantasies that are more frightening than
analgesia from the age of 4, TENS (Lander, reality.
1993), and 'fentanyl lollipops' (Chambliss, Many children are able to take decisions
1997). about whether to have active or supportive
Nausea needs treating because it can lead to therapy (Purssell, 1994). Communication with
dehydration, wound disruption and later re dying children should be based on honesty. If
admission (Paxton, 1996). If sedation is death is compared to sleep, for example, they
required, doses should normally be greater than may develop an unhealthy fear of bedtime.
recommended (Murphy, 1997). Both sedation As well as experiencing the adult responses to
and opioids need to be reduced gradually dying, children carry the burden of their parents'
(Fonsmark et ai., 1999). grief. Parents may carry the burden of being
avoided by their friends. Siblings have been iden
Postoperative management tified as the most unhappy of the family
Children waking up in an intensive care unit are members (Harding, 1996) and show double the
subject to extra fears, especially if explanations risk of psychological disturbance (Black, 1998).
are not full and clear. Nasogastric tubes can They may be shunned by friends, worry about
increase the work of breathing and increase their own vulnerability, and be confused by a
apnoeas (Oberwaldner, 2000) and for long-term mixture of what they have been told, overheard,
enteral feeding, gastrostomy feeds are more observed and imagined. Siblings should not be
effective (Cosgrove, 1997). Apnoeas are fed 'Susie-is-going-away-on-a-Iong-trip' euphe
common in preterm infants (Levin, 1999). misms or they may wait for her return. When
Children like to be touched as little as asked about their own needs, siblings have
possible after surgery. If coughing is necessary, requested information, open family communica
they prefer to splint the incision themselves by tion and active involvement in the dying child's
leaning forward with their arms crossed or care (Harding, 1996). Sheldon (1998) details
hugging a teddy bear. Children must not be storybooks and workbooks that assist communi
discouraged from crying nor told to be brave. If cation.
they are 'difficult', it is usually because they are The quality of care for the child has a major
frightened. impact on the family's bereavement (Stead,
Child survivors of road accidents show a high 1999). Symptoms such as fatigue may not be
incidence of long-term effects, including depres- treated, even when the cause is anaemia, depres-
------ 433
sion or malnutrition. The fact that 75% of placenta to gas exchange in the lung. Premature
children with cancer now survive has led to a babies have the added shock of being displaced
tendency for aggressive treatment to take prece foetuses. They are delivered into a world against
dence over palliation even when there is little which they have limited defence mechanisms,
hope of cure (Wolf et ai., 2000). One study and sometimes without the basic capacity for
found that half the children who died in hospital respiration, kidney function or temperature
were mechanically ventilated for their final 24 control.
hours (Wolf et ai., 2000). The lower the gestational age, the more
Comprehensive support for the family, keenly sensitive are premature babies to their
including contact after the death, helps reduce environment. The immature cochlea is particu
the high incidence of distress, divorce and larly sensitive to noise levels, and a noisy envir
sibling neglect that tends to accompany the onment can cause hypertension, raised
death of a child. It is unhelpful to tell parents intracranial pressure, hearing loss (Mishoe,
that they will get over their child's death because 1995) and disturbed breathing (Figure 16.4). A
it is rarely true. Parents may find some ease in neonatal intensive care unit (NICU) provides the
reflecting that it may have been better to have technology and skill to care for sick babies,
loved and lost a child than not to have had the preterm or term. It is not always their ideal
child at all. environment, with its bright lights, chorus of
noises, frequent disturbances and resistant
bacteria (Man et ai., 2000).
THE NEONATAL leu Central to a baby's universe is his/her mother,
and infants recognize physical separation from
Introduction birth (Christensson, 1995). Bonding between
child and mother is hindered by the barrier of
The emergence of the baby into the outside
the incubator and the mother's reticence in
world is perhaps the most cataclysmic event
disturbing equipment. NICU 'graduates' run an
of its life.
above-average risk of language delay Gennische
West, 1995
and Sedin, 1999), educational handicap (Saigal,
The sharp intake of breath that adults take in 2000) and abuse in later life (Anon, 1985).
response to sudden cold is thought to be a Attention has now focused on optimizing the
physiological memory of the first breath. All environment and the bond between parents and
babies have undergone the trauma of birth and child. Parents need to be involved in the care
the complex transition from respiration via the and comfort of their baby, and babies need to
! ':fb:'! • -t . . --jf- ..
I
----:--�--:----!-iI--.-+-..
---. . -. - ..
I I
i-Re��r��L6��+r--"��-;�
, 1
Figure ' 6.4 The effect of noise on the breathing pattern of a premature infant. (From Long, J. G., Lucey, J. F. and Philip,
A G. S. (1980) Noise and hypoxemia in the intensive care nursery. Pediatrics, 65, 143-145, with permission.)
434
THE NEONATAL leu
hear and feel their mother. Handling by health and preterm infants are at extra risk of
staff can destabilize preterm infants (Murphy, atelectasis.
1991), but stroking and gentle handling have • Peripheral airways are narrow and contribute
shown beneficial effects (Harrison, 1996) and up to 400/0 of total airways resistance from
handling by the mother can reduce stress and birth to about age 5, leaving young children
oxygen consumption (Ludington, 1990). Moni prone to obstructive diseases of the small
toring provides feedback. airways such as bronchiolitis Games, 1991).
Babies are known as neonates for the first • Blood pressure regulation is unrefined.
month of life, and neonates born before 37 • The normal respiratory rate in infants and
weeks' gestation are considered preterm. children has an extensive range that is more
Respiratory problems are the commonest cause responsive to disease and emotion than that
of morbidity and mortality (Wilson, 1992). of adults.
Problems are more abrupt than in adults because • Most babies are able to breathe through
of their different respiratory systems, as their mouths but are preferential nose
described below. breathers because their large tongues narrow
the oropharynx (Sporik, 1994).
• The immature respiratory centre causes irre
gular breathing patterns and occasional Care of the parents
periods of apnoea. I longed as I have never longed for anything
• For the first year of life, the intercostal so badly, to hold her ... to put her face
muscles are immature, the ribs cartilaginous against mine, whisper that I was here, that
and horizontal, and the rib cage nearly three it was all right .... I stroked her hand with
times as compliant as the lung (Papasta my finger .. . and feeling her minute pink
melos, 1995). The diaphragm does most of fingers holding so hard to mine, I was hit
the work of breathing despite containing less sideways and bowled over by the purest,
fatigue-resistant fibres than adults and tenderest, most passionately committed love
working at a disadvantage because of its I have ever felt . . ..
horizontal angle of insertion. Work of I couldn't bear to ... not be able to help
breathing is 2-3 times that of adults her myself at all .... It hurt me so much, to
(Hoffman, 1995). By 2 years old, the bucket see her weak, in distress and apparently
handle action has developed and the rib cage struggling so hard.... I wanted to drag
and lung become equally compliant (Papasta everything away from her, every bit of
melos, 1995). By 3 years old, when more machinery, to pick her up and hold her to
time is spent upright, rib cage configuration my breast, even if it meant that she died in
is oblique rather than horizontal. a few minutes. That would be better than
• Response to heavy work loads is an having her suffer this, the pain, fear, noise,
increased rate rather than increased depth of bewilderment, being surrounded and
breathing. handled by strangers....
• Hypoxaemia tends to cause bradycardia Every time I touched her, she relaxed and
rather than tachycardia. Immature myocar the monitors showed it, her heart rate
dium has less capacity to increase stroke settled, her limbs were calmer, her eyes
volume, and bradycardia may reduce cardiac searched less frantically about... .
output. I had never held her to me and I ached to
• Collateral ventilation is not established until do so, she seemed so alone in there amongst
age 2-3 years, leaving the lungs vulnerable all the wires and drips and tubes and
to atelectasis. Maturity of the surfactant monitors.
system occurs at about 35 weeks' gestation, Hill, 1989
435
• Dimmed lights at night encourage sleeping

Management of pain and stress
and weight gain. Ear muffs decrease episodes
Evolution has not yet caught up with the of desaturation, crying and intracranial
survival of premature babies. Sky (1990) hypertension. Other beneficial influences are
suggests that they are hyperconscious and only the mother's voice, a soft blanket or sheep
gradually develop mechanisms for filtering the skin (Sparsholt, 1989), 'silent' rubbish bins,
sensory inputs that await them in life. Pain quiet radios, swaddling in 'cosy nests' or
causes greater long-term harm to infants than to other positioning aids, and 'I am sleeping till
older children, and even greater damage to . . . pm' signs (Hutchon, 2000). Periods of
preterm infants (Larsson, 1999), increasing undisturbed sleep reduce risks of hypox
morbidity and mortality (Lancet, 1992), and can aemia, hypertension and apnoea (Cole et at.,
cause hypersensitivity to subsequent pain 1990).
(Barker, 1995). At the same time, the capacity to • Skin contact with the mother and hearing
communicate appears not to have evolved at this the mother's voice lead to a reduction in
stage (Hadjistavropoulos, 1997), which is why oxygen consumption (Ludington, 1990) and
specific assessment tools are necessary (Blauer, pain (Gray et at., 1999).
1998). • Visiting should be unrestricted and include
Premature infants exist in a precarious grandparents and siblings Gohnstone, 1994).
metabolic milieu, and loud voices, knocking the • Intubation upsets BP, HR and Sa02, and the
incubator or even rearranging a limb can lead to child must be premedicated (Bhutada et aI.,
bradycardia, disorganized breathing and 2000). Heelsticks are thought to be more
hypoxia. Pain or stress causes hypertension, painful than venepuncture, especially the
hypoxaemia and hypercapnia (Wessel, 1993). heel squeeze (Lindh, 1999) and they should
Suggestions to reduce stress during physiother be accompanied by skin anaesthesia Gain,
apy are the following. 2000). One blood sample should be used for
multiple measurements as well as blood
• Light and noise can be reduced by partially gases, and a long intravenous line is prefer
covering the incubator during treatment and able to frequent attempts at venous access
keeping sounds to a minimum (Cole et at., (Chiswick, 1999). When required, neonates
1990), apart from talking to the infant. benefit from epidural analgesia (Ochsen
Equipment should not be put on the incu reither, 1997), and premature neonates can
bator. Heat loss must be avoided, especially be given intravenous opioids (Franck, 1998).
from the head. • A stressed parent means a stressed baby, and
• Restraints should be avoided unless essential parents benefit from help to cuddle their
(Sparsholt, 1989). child when attached to awesome equipment,
• Procedures that cause crying should be mini advice on baby massage, and a rocking chair
mized because they predispose to irregular and other comforts for them and their child.
breathing, apnoeic episodes, pulmonary
hypertension and hypoxaemia (Murphy, Rocking beds have been advocated for babies
1991). because of their positive effects on ventilation,
• If sedation is required, propofol can be used feeding, crying and length of hospitalization
for brief procedures (Erb and Frei, 1996). (Sammon, 1994).
The relevance of mother-baby contact was
A team approach to stress reduction results in highlighted by Kennell ( 1999), when an episode
a more stable cardiopulmonary system, with of staff shortage obliged mothers to provide 24-
benefits lasting for months after discharge hour care for their premature infants. Outcomes
(Mann, 1986). Examples are described below. were reduced infection, improved weight gain,
436 ------
THE NEONATAL ICU
increased breast-feeding, quicker development

and, for the mothers, more rapid recovery from Feeding
childbirth. So keen were the babies on the low The effort to co-ordinate breathing, suckling and
technology approach that they even preferred swallowing can reduce 5a02 in premature infants
unwashed to washed nipples. Gale and Vanden (Pickler, 1996), and extra oxygen may be
Berg (1998) took this a step further with required during feeds even if a feeding tube is in
'kangaroo care', when equipment shortage led to place (Shiao, 1995). Preterm infants need
mothers incubating preterm babies next to their preterm formula rather than standard formula in
skin. Outcomes were similar to the first study, order to maintain brain growth and prevent
plus improved sleep, oxygenation and muscle long-term cognitive dysfunction (Lucas et aI.,
tone, greater stability and reduced mortality. 1998).
Snuggling next to the mother's breasts is a
baby's ideal ecological niche. Humidiflcation
Hot-water humidification IS required for
Temperature and fluid regulation intubated infants, and often for spontaneously
The more immature the baby, the less efficient is breathing infants because their small nasal
heat conservation because of scant subcutaneous passages and airways block easily. Heat
fat, fragile skin, inability to sweat or shiver and a moisture exchangers may increase the work of
large surface area in relation to body mass. Up breathing and at present do not supply the
to 50% of calorie intake may be used for main warmth to prevent loss of body heat. Ultrasonic
tammg body temperature. Warmth from humidification can be hazardous in intubated
overhead radiant heat allows easier access to the babies (Tamer, 1970).
baby than an incubator, but promotes water loss.
Both dehydration and fluid overload are risky Mechanical ventilation
for an immature kidney.
If neither oxygen nor CPAP are able to maintain
oxygenation, mechanical ventilation may be
Oxygen therapy needed. Tracheal tubes are uncuffed until up to
Supplemental oxygen is given via a Perspex head 10 years of age, allowing a slight air leak and
box or, for longer-term use, a nasal cannula or less risk of mucosal damage. The mucosa is
catheter (Coffman and McManus, 1984). vulnerable because the subglottic area is the
Hyperoxia or fluctuations in FI02 can lead to narrowest part of the airway and young children
retinopathy of prematurity (Cunningham, 1995) tend to move their necks more than adults.
due to excessive oxygen pressures reaching the Elaborate systems for endotracheal tube fixation
retinal artery. This causes constriction, prolifera are required to prevent such a heavy contraption
tion and fibrosis of the delicate retinal capil from becoming disconnected from such a tiny
laries, leading to blindness. Oximetry cannot nose. Pressure-controlled ventilators are used for
detect hyperoxia, and 5a02 should be kept infants up to 1 year old, so that high peak
between 87% and 92% in preterm infants to aIrway pressures are avoided and flow can
allow a margin of safety. The oximeter probe increase automatically to compensate for the
site must be changed 4-hourly. With transcuta cuff leak.
neous monitoring, Prc02 should be kept at 6.7- The high compliance of the chest wall and
10.7 kPa (50-80 mmHg) and PrcC02 at 5.3- low collagen and elastic content of lung tissue
7.3 kPa (40-55 mmHg). Control of oxygen afford little protection against overdistension,
therapy is essential because lack of oxygen can and a quarter of ventilated babies develop some
also worsen retinopathy of prematurity form of barotrauma (Parker and Hernandez,
(Stephenson, 2000). 1993). The following may occur.
------ 437
• Pulmonary interstitial emphysema (PIE) is physiotherapist, neonatal nurse or in part by the

identifiable radiologically as lucent streaks parent. The maxim that routine treatment is
radiating from the hila, representing air in taboo is never more apt than in the NICU. The
the interstitium. Unlike air bronchograms, approach is to assess, identify any problems, and
the streaks do not branch or taper. Exten balance up the benefits and risks of intervention.
sion of PIE to the periphery can lead to
pneumothorax. Indications
• Pneumothorax is suspected if there is rapid Physiotherapy may be needed if there are excess
deterioration without obvious cause. secretions that cannot be cleared by humidifica
tion and suction, or if there is poor gas
Babies with respiratory distress syndrome are
exchange, increased work of breathing or radi
particularly at risk of PIE because of their lack
ological evidence of atelectasis. Treatment may
of surfactant. Babies with more compliant lungs
be indicated after extubation if airway irritation
are more at risk of pneumothorax (Chatburn,
has created excess secretions. Neonates who
1991). A pneumothorax is treated by chest tube
have aspirated meconium need treatment unless
drainage, but PIE is difficult to treat and causes
contraindicated.
up to a third of ventilated low-birth-weight
babies to develop chronic lung disease of prema Precautions
turity (Coghill et at., 1991). These complications
Because of the poorly developed defences of
may be reduced with a low tidal volume, or by
neonates, all health workers should wash their
using high-frequency ventilation or negative
hands meticulously and avoid the NICU if they
pressure ventilation (Samuels and Southall,
have an infection. Physiotherapy is contraindi
1989).
cated for neonates who are hypothermic, show
PEEP (p. 353) is used in all neonates at 2-
cardiac instability (unless this is due to hypoxia),
5 cmH20 but is specifically required if Pa02 is
have an undrained pneumothorax or are
< 6.7 kPa (50 mmHg) at FI02 > 0.6 (Pilbeam,
producing fresh bloodstained secretions.
1998, p. 360). Following extubation, subglottic
Treatment should be scheduled before feeds or
oedema may develop immediately or over 24
over 1 hour afterwards. If physiotherapy is
hours. In premature infants on prolonged IPPV,
necessary within these times, the gastric contents
airway damage from the tracheal tube and
can be aspirated by syringe via the nasogastric
suction can lead to tracheobronchial stenosis
tube before treatment, and replaced afterwards.
(Brownlee, 1997).
If the infant is receiving phototherapy for
jaundice, it can be removed temporarily for
Neonatal support systems treatment; when replaced, protective eye shields
If bronchodilation is required, preterm and term must be put back.
infants on IPPV can respond to inhaled broncho Infant and monitors should be observed
dilators delivered by nebulizer or inhaler and before, during and after treatment. Large swings
spacer (Sivakumar et at., 1999). Advanced in BP are particularly damaging for preterm
support systems (Chapter 12) are more estab paralysed infants (Bohin, 1995 ). Casual handling
lished for neonates than for adults (Barrington et should be avoided and physiotherapy sessions
ai., 1999). structured so that the infant is rested before and
afterwards. Cumulative procedures or major
disturbances such as suction can reduce Pa02 by
PHYSIOTHERAPY FOR NEONATES
as much as 5.3 kPa (40 mmHg) (Speidel, 1978).
The main role of the physiotherapist is to judge Lights should be no brighter than needed for
if and when intervention is appropriate. safe observation. Oxygen desaturation may be
Treatment itself may be carried out by the caused by suction, or may be an indication for
438
suction. It can also be caused by the head falling necessary not just over the chest but also to
into flexion and obstructing the upper airway. check for abdominal distension, which can be
disabling in a baby dependent on the diaphragm
Assessment to breathe.
Not all neonates need hands-on assessment. The X-ray findings may indicate atelectasis or
nurse will have information on secretions and consolidation, with the right upper and middle
response to interventions. Intubated neonates lobes needing special attention because of their
need a check on their humidifiers. Other details tendency to collapse (Figure 16.5). Neonates
are below. have a large thymus, which looks similar to right
Notes, charts and reports give information on upper lobe consolidation. Air bronchograms
birth and other history, weight gain or loss, projected through the heart shadow may not be
response to. handling and suction, results of the significant but are pathological when seen
last suction, mode and frequency of feeds and peripherally. Any sign of PIE (p. 438) contraindi
whether the baby has rested since the last inter cates manual hyperinflation.
vention. The Apgar score gives an indication of
birth asphyxia through heart rate, respiratory Methods to increase lung volume
effort, reflex irritability, muscle tone and colour.
A recent history of self-limiting bradycardia or Positioning
periods of apnoea suggests that suction might be Spontaneously breathing neonates, especially
needed. Much reliance is placed on this informa when premature, benefit from raising the head
tion because of the limitations of clinical and of the mattresS' to ease the load on the
subjective assessment. Arterial blood gas values diaphragm and lessen the risk of gastrooesopha
correlate with those of capillary blood that has geal reflux.
been warmed to 'arterialize' it, usually taken Side-lying allows greater diaphragmatic
from the heel. excursion than supine. If there is a pneu
Monitors indicate physiological distress, mothorax or unilateral PIE, side-lying with the
shown by bradycardia (HR < 90/min), tachyp affected lung dependent may assist absorption of
noea or apnoea. A respiratory rate of more than the unwanted air (Swingle et al., 1984), under
60 may predict hypoxia in infants (Rajesh et al., cover of monitoring. When infants are in side
2000). Worsening oxygenation may be a sign of lying, they respond best when the trunk and
accumulating secretions or infection. Normal limbs are supported in a flexed position.
Sa02 is 97-100% and must not fall below 93%. The prone position puts unmonitored
Preterm infants have a left-shifted dissociation neonates at risk of sudden infant death
curve because of foetal haemoglobin, and desa syndrome or cot death (Hallsworth, 1995).
turation may reflect a lower Pa02 than in adults. However, prone is not contraindicated in the
Breath sounds at the mouth of an intubated supervised environment of the ICU, and in
infant include the slight hiss of the intentional preterm infants has been shown to stabilize the
air leak. Upper airway obstruction with a mucus chest wall and increase Sa02 (Dimitriou, 1996),
plug increases this sound when air is forced out so long as the endotracheal tube is long enough
past the tracheal tube. If this is reduced after to avoid displacement (Marcano, 2000). Prone
physiotherapy, it may indicate a good outcome. neonates require the head of the mattress to
Auscultation of the chest seems to pick up remain raised.
every sound in the NICU. Rapid shallow Precautions to observe when positioning a
breathing, or ventilator noise and other referred neonate are to monitor the effects of handling,
sounds, can thwart the listener. Wheezes and avoid any pull on the tracheal tube and check
crackles are transmitted throughout the chest, for change in air leak around the tracheal tube
and may be easier to feel than hear. Palpation is· after position change.
439
Figure 1 6.S (a) Right upper lope collapse.

(b) Right upper and middle lobe consolidation
and collapse.
• hyperinflation conditions such as meconium

Manual hyperinflation aspiration and bronchiolitis
The younger the child, the less advisable it is to • prematurity, because the risk of pneu
use manual hyperinflation (MH) because of the mothorax is too great
risk of pneumothorax. Contraindications are • infants whose RR is over 40/rnin, because it
similar to adults, with three additions: is impossible to achieve an effective hyperin
flation.
440
The indication for MH is loss of lung volume Percussion and vibrations

that does not respond to posltloning or Manual techniques are fruitful in neonates
clearance of a mucus plug. A 500 mL bag is used because of the compliant rib cage. Percussion is
for infants and a l L size for children. These usually well tolerated and may be soothing. It can
bags have an open tail which is squeezed be performed with a soft-rimmed face mask,
between finger and thumb to regulate the using firm pressure directly on the skin and
pressure more sensitively than a valve. A taking care to stay within the surface markings of
suggested technique is as follows: the little lungs. Vibrations with the finger tips can
be applied on every second or third expiration.
1. Incorporate a manometer in the circuit to Contraindications include those on page 193
check pressures (Howard and Koniak, 1990). plus risk of intraventricular haemorrhage and
2. Check monitors. rickets. Monitors should, as always, be observed
3. Turn oxygen flow to 6 L/min (although gas throughout because some neonates respond
flow to the infant is controlled manually). poorly. If manual techniques are essential in
4. Bag-squeeze using fingers rather than the preterm babies, they must be as delicate as
whole hand, interspersing each hyperinflation possible while maintaining effectiveness, and the
with three or four tidal breaths. head must be supported throughout. It is
5. Control pressure so that the chest rises only advisable to liaise with a paediatric respiratory
slightly more than during IPPV, and the physiotherapist before using manual techniques
manometer indicates a rise of no more than with premature babies because of the risk of
5 cmH20 above the peak airway pressure for causing a form of brain damage similar to
infants and 10 cmH20 for older children 'shaken baby syndrome' (Harding et ai., 1998).
(Parker, 1998).
6. Maintain some positive pressure at the end of Suction
expiration to mimic PEEP and prevent airway Secretions in the endotracheal tube can double
collapse. airflow resistance (Chatburn, 1991), and shallow
7. Between watching the manometer and suction is indicated for intubated neonates as
monitors, observe the patient. required. Deeper suction should only be used if
necessary because it can cause bradycardia,
Methods to decrease the work of breathing arrhythmias, atelectasis, abrupt peaks in blood
pressure, raised intracranial pressure (Durand et
Work of breathing is increased by stress (Wessel, al., 1989) and pneumothorax (Vaughan et al.,
1993). Measures to reduce stress are described 1978). Figure 16.6 shows how the blood
on page 436. Positioning head up, as described pressure of a baby increased by 20 mmHg during
above, decreases the work of breathing. endotracheal suction.
For non-intubated infants, positioning and
percussion may shift secretions so that they are
Methods to clear secretions swallowed. If not, suction may be necessary. The
techniques described on pages 205 and 429, are
Postural drainage modified by the following:
Unstable preterm neonates who cannot tolerate
handling should not have their position changed • Have the baby in side-lying and wrapped up
for treatment. Other babies can be treated in comfortably but firmly.
alternate side-lying. If the head-down tip is • For preterm infants, preoxygenate by no
necessary, observation and monitoring should be more than 10% to avoid retinopathy of
continuous because of the baby's reliance on prematurity (Parker, 1998).
diaphragmatic function. • Set the vacuum pressure (p. 429).
441
1 00
90
80 Hypertension
during suction
70
60
!
a..
!Il 50
20
10
2 3 4 5
Minutes
Figure 1 6.6 Hypertension in an infant during suction. (From Mcintosh, N. (1989) MARY - a computerised neonatal
monitoring system. tnt. Care Clin. Manit., 1 0, 272-282)
• Use a size 5-6 FG catheter. blunt the stress response (Hickey et at.,
• Observe monitors. 1985).
• Suction the nasopharyngeal airway, passmg 4. Preoxygenate by increasing the ventilator
the catheter only as far as stimulates a FI02 by 10-200/0, but observe oximeter to
cough. monitor the response (Hodge, 1991).
• Suction the nostrils afterwards. 5. Avoid deep suction. The catheter should not
• Invite the parent to cuddle the baby. advance more than 1-2 em beyond the end
of the tracheal tube (Vaughan et at., 1978).
For ventilated infants, tracheal suction is
Its length can be checked against the length
required if the recent history suggests that
of an equivalent-sized Err, which is usually
suction is productive, or if monitors indicate
taped to the outside of the incubator for
hypoxaemia. It may not be possible to feel or
emergencies, or a calibrated catheter can be
auscultate for the presence of secretions. Modifi
used (Kleiber et at., 1988).
cations to the above protocol are described
6. Ensure catheter diameter is less than half the
below.
diameter of the airway (Bertone, 1988):
1. Avoid suction if the temperature is below 5 FG for ETT size 2.5 mm
36°C or there are signs of decreased cardiac 6 FG for Err size 3 mm
output or shock (pallor or cyanosis, 8 FG for Err size 3.5 mm.
sweating, decreased peripheral temperature). 7. For postoperative infants, ensure that
2. Lubrication is not necessary in intubated someone supports the wound.
babies. 8. Draw up normal saline into a syringe,
3. Liaise with medical staff about the disconnect the infant from the ventilator,
advisability of predosing with a drug to instil saline down the tracheal tube (0.5 mL
442
MODIFICATIONS FOR SPECIFIC NEONATAL DISORDERS
for pre term neonates, 1-3 mL for term because suction-induced bronchospasm may
babies), reconnect for a few breaths, then cause obstruction.
disconnect and suction.
9. After reconnection to the ventilator, suction Developmental management
mouth and nostrils.
Nearly 50% of extemely premature babies grow
10. When Sa02 has returned to baseline, turn
up disabled (Christie, 2000), and all premature
the FI02 back to its previous value slowly. If
babies require assessment by specialist collea
the oximeter or other monitors do not show
gues.
that values have returned to baseline, or the
Extended time in prone may lead to a
child does not settle, further suction may be
flattened frog position because of hypotonia, and
indicated, or another problem investigated
this can be avoided by raising the pelvis on a roll
in liaison with the nurse.
(Downs et at., 1991). Passive movements are
Two alternatives have been suggested for normally unnecessary, but for very-Iow-birth
instilling saline. Downs (1989) describes more weight babies, daily gentle exercise can improve
accurate saline delivery, so long as hypoxaemia weight and bone mineralization (Moyer-Mileur,
is not a significant risk: 2000). Monitors should be observed because
handling may destabilize the infant.
1. Inject saline into an unconnected sterile Low-birth-weight babies enjoy waterbeds,
suction catheter until the catheter is filled water pillows, rocking beds and air mattresses
and a drip is visible at the tip. (Long, 1995), and very-Iow-birth-weight babies
2. Disconnect the ventilator and insert the appear to benefit from womb-like swaddling in
catheter into the tracheal tube. flexion (Short et at., 1996).
3. Instil saline directly to the distal end of the
tracheal tube, using the syringe.
4. Withdraw saline, along with some of the
MODIFICATIONS FOR SPECIFIC NEONATAL
mucus, using the syringe.
DISORDERS
5. Disconnect catheter from the synnge,
connect to the suction circuit, suction.
Meconium aspiration
6. Monitor.
Full-term babies who suffer asphyxia during
Prasad and Hussey ( 1995, p. 88) describe prolonged labour may pass meconium (faecal
lavage for mucus plugging, to be carried out material) before birth, then gasp and suck it into
under close monitoring and in association with their mouth. It stays safely there until delivery,
the anaesthetist: but emergence of the chest causes it to be drawn
deep into the lungs by the first breath. This
1. Preoxygenate and sedate.
results in acute obstruction of small airways,
2. Position the baby in the reverse postural
which if complete causes atelectasis, and if
drainage position, i.e. the affected part
incomplete causes hyperinflation. The sticky
downwards.
meconium sets up a chemical pneumonitis which
3. Instil saline, 2-5 mL for infants and lO-
provides an ideal medium for infection.
I S mL for older children.
If labour is prolonged, or monitoring suggests
4. Manually ventilate with tidal volumes.
that the baby is in distress, airway suction during
5. Reposition into postural drainage position.
birth, before delivery of the thorax, reduces
6. Apply manual techniques and MH.
the risk. If aspiration has occurred, IPPV should
7. Suction.
be withheld until the auways have been
8. Monitor.
suctioned so that particulate material is not
Caution should be observed after extubation, forced into distal airways. If mechanical ventila-
443
CHAPTER 16 PHYSIOTHERAPY FOR CHfLDREN AND fNFANTS
tion is initiated, it is like ventilating through fluid and nutrition (Tang, 1997) and respiratory
treacle. support using oxygen, CPAP, IPPV or high
Immediate and intensive physiotherapy is frequency oscillation (Plavka et at., 1999).
needed in the form of postural drainage, percus Normal ventilation pressures for infants are 15-
sion, vibrations and suction. Treatment is 20 cmH20, but infants with RDS require 20-
continued until secretions are free from the dark 40 cmH20. This must be reduced during
colour of meconium. Midwives should be taught recovery to avoid haemodynamic compromise.
this technique unless physiotherapy is available Physiotherapy is limited to advice on position
straight after birth. ing in the early stages, anything more energetic
being unnecessary and sometimes destabilizing.
Intraventricular haemorrhage Periods in alternate side-lying assist secretion
Bleeding into the cerebral ventricles may occur clearance and midline orientation, and help
in the first week of premature life, when swings prevent postural abnormalities. Intubation
in BP or arterial blood gases can cause the fragile irritates the airways and may stimulate excess
capillaries in the ventricles to burst. Precipitating secretions, which need to be cleared in the
factors are pain (Larson, 1999), manual techni recovery phase when the infant is stable, usually
ques, suction, endotracheal obstruction or intu with suction and occasionally with percussion.
bation without sedation (Wren, 1989). If it
occurs, the head-down tip is contraindicated and Chronic lung disease of prematurity
any physiotherapy is to be avoided unless The more premature an infant, the more likely
essential. s/he is to suffer a continuum of lung injury
progressing from RDS, PIE, oxygen toxicity and
Respiratory distress syndrome finally to chronic lung disease of prematurity,
Respiratory distress syndrome (RDS) occurs in also known as bronchopulmonary dysplasia.
premature babies, especially when delivered by This results from the interaction of immature
caesarean section, and is the commonest cause of lungs with high-volume mechanical ventilation,
death in the preterm infant (Wilson, 1992). Lack and is considered present if the infant reaches
of surfactant leads to patchy atelectasis, stiff term age and cannot be discharged from hospital
lungs and increased work of breathing. Alveoli without oxygen or ventilatory support (Verklan,
inflate with difficulty and collapse between 1997).
respiratory efforts. Inflammation interferes with surfactant
Signs of respiratory distress develop in the production and leads to scarring, disordered
first hours of life. Breath sounds are reduced and lung growth, stiff lungs and pulmonary hyper
diffuse fine crackles are heard. The radiograph tension. Signs are persistent respiratory distress
shows hyperinflation with mottling and air and high oxygen requirements. X-ray changes
bronchograms, indicating areas of atelectasis. range from 'grey' lungs to widespread cystic
Distress persists for 24-48 hours, then the areas interspersed with regions of collapse.
condition either stabilizes and improves over Lengthy intubation leads to erosion of the upper
several days as surfactant is produced, or the airway in up to half of patients, often undiag
disease is protracted and severe. Mortality is nosed (Doull, 1997).
50%, but survivors show little morbidity Prevention is by ventilator management to
(Heulitt, 1995). minimize inflation pressures (Greenough, 1990).
Prevention is by prophylactic instillation of Treatment is by diuretics, preferably inhaled
artificial surfactant on delivery of preterm (Prabhu, 1997), bronchodilators and, ironically,
babies, administered in different positions to increasing levels of oxygen and higher inflation
ensure even distribution (Willson, 1998). pressures as the disorder progresses. Failure to
Management is by regulation of temperature, thrive is minimized by adequate nutrition to
444
EMERGENCIES IN THE NEONATAL UNIT
compensate for the high metabolic rate (Martin be caused by a displaced or blocked tracheal
and Shaw, 1997). Long-term hospitalization may tube (unchanged CVP), or barotrauma (i CVP).
be required.
Physiotherapy is indicated if secretions are Apnoeic attacks
present because the lungs are prone to recurrent Respiratory pauses are physiological lulls in
atelectasis and infection. Treatment is avoided or respiration. They may presage pathological
modified if the child is wheezy or has pulmonary apnoea, which lasts more than 20 seconds and
hypertension. When it is necessary, treatment is may be associated with hypoxaemia. Pathologi
preceded by bronchodilators and stopped if cal apnoea may be due to brain-stem immaturity,
wheezing is precipitated. Percussion in alternate upper airway and chest wall instability or gastro
side-lying and sometimes suction can be given, oesophageal reflux (Ewer et aI., 1999). If this
with extra attention to the upper lobes. does not resolve spontaneously, the baby will
Physiotherapy may be required after discharge, need gentle stimulation (Holditch, 1994) or intu
either directly or through parent education. bation.
After long hospitalization, parents need
comprehensive preparation for discharge so that Pneumothorax
they build up confidence and do not feel that Any sudden deterioration in the condition of a
they have 'borrowed' their baby to take home. ventilated infant raises suspicions of barotrauma.
Domiciliary oxygen or non-invasive ventilation A pneumothorax is evident on X-ray, but
may be required (Teague, 1997). For prelingual clinical signs can be elusive. Breath sounds may
children who require a tracheostomy, delayed still be present because sound is transmitted
communication, including hearing loss, can be from the unaffected lung. A tension pneu
prevented by speech-language therapy mothorax causes bradycardia and a plunge in
(Orringer, 1 999). To assist communication, an cardiac output.
uncuffed tube can be occluded with a gloved
hand on expiration if the child is attempting to Cardiorespiratory arrest
talk, laugh or cry. Occlusion must be brief and Most cardiorespiratory arrests in infants and
explained to the child. Toddlers learn to drop children are of respiratory origin. Establishing a
their chin to occlude the tube when they want to patent airway by head positioning may prevent
talk. progress of the event. Care should be taken to
Chronic lung disease of prematurity is avoid pressing on the soft tissues under the chin
survived by 70% of children, but they are left or over-extending the neck because this may
with a risk of cot death and sometimes neurolo occlude the trachea.
gical problems. The lungs can repair as they If an oropharyngeal airway is required, It IS
grow, but it is thought that adult chronic lung not turned upside down for insertion, as in the
disease is in store for many (Cano and Payo, adult. The correct size reaches from the corner
1997). Details of home oxygen for children are of the mouth to the angle of the jaw. In the
given in RCP (1999). NICV, oxygen by bag and mask is available. If
mouth-to-mouth breathing is necessary, both
mouth and nose should be covered with the
EMERGENCIES IN THE NEONATAL UNIT
rescuer's mouth, and gentle puffs given. Parents
are best taught to use the nose only, as they may
Sudden hypoxaemia obstruct the airway when attempting to seal the
A drop in 5a02 may be followed by bradycardia mouth (Wilson-Davis, 1997). The Heimlich
and fighting the ventilator. Manual ventilation manoeuvre is contraindicated in children under
with gentle pressure should be carried out until the age of 3.
the cause is found. If sudden, hypoxaemia could Cardiac arrest is usually systolic and due to
------ 445
respiratory arrest. When assessing for respon

siveness, shaking should be avoided. If artificial
ventilation does not restore the heart beat, chest
compression is started by encircling the chest
with both hands and squeezing the mid-sternum
to a depth of 2 cm, with the thumbs at one
finger's breadth below an imaginary line joining
the nipples, and ensuring that the chest fully re
expands between compressions. The ratio of
breaths to compressions is 1:5 in infants and
children, repeated 20 times per minute. The
easiest pulse to locate is the brachial pulse on the
inside of the upper arm (Zideman, 1994).
This 7-year-old was adm itted after fitting. Identify

what has happened and answer the questions.
HPC: seizure this afternoon -t fall on to head -t
vomited -t respiratory d istress -t intu bated and

Figure 1 6. 7a JW,
ventilated.
CT scan and clin ical assessment shows no
neurological damage.
Ventilated on S I MV with FI02 of 0.4.
Pa02 22.27 kPa ( 1 67 mmHg), PaC02 4. 1 kPa
(30.8 mmHg), pH 7.44, HC03 - 2 1 .8.
Sedated on midazolam.
Extubation planned for tomorrow morning.
Suction non-productive.
Questions
I . Auscultation (Figure 1 6. 7a)?
2. Percussion note?
3. Analysis?
4. Problems?
5 . Goal?
6. Plan?
7. Outcome (Figure 1 6.7b)?
Figure 1 6. 7b JW,
446
RECOMMENDED READING
I;jf14-]��1'g-,;ii�iDiMIiIi)-A statement. A foetus by definition cannot be

demonstrated to consciously appreciate a
sensation.
I . Auscultation Perhaps unreferenced facts and impossible
1 breath sounds L midzone and L lower zone, statements enable the author (and reader ?) to
bronchial breathing L midzone and L lower zone. feel more comfortable in not having to contem
plate a foetus in pain.
2. Percussion note
Dull L midzone and L lower zone.
RECOMMENDED READING
3. Analysis
Alderson, P. (2000) The rise and fall of children's
Atelectasis and consolidation L lung, probably due consent to surgery. Paediatr. Nurs. , 12(2), 6-8.
to aspi ration. Arthur, R. (2000) Interpretation of the paediatric
chest x-ray. Paed. Resp. Rev. 1 , 4 1-5 0 .
4. Problems Askin, D. F. ( 1 997) Interpretation of neonatal blood
1 lung volume on L, gases. Neonat. Network, 16(5), 1 7-2 l .
Inabil ity to clear secretions.
Beeby, P . J . ( 1 99 8 ) Short- and long-term neurological
outcomes following neonatal chest physiotherapy.
5. Goal ]. Pediatr. Child Health, 34, 60-62.
Briassoulis, G. C. (2000) Air leaks from the
L lung cleared and inflated by morning.
respiratory tract in mechanically ventilated
children with severe respiratory disease. Pediatr.
6. Plan
Pulmonol. , 29, 1 27-134.
Saline instil lation to left lung Cantagrel, S. and Cloarec, S . ( 1 999) Consequences of
Postural drainage pulmonary inflations (sighs) on cerebral haemo
Manual hyperinflation dynamics in neonates ventilated by high-frequency
Percussion oscillation. Acta Paediatr. , 88, 1 004- 1 008.
Suction. Chaisupamongkollarp, T. ( 1 999) Prone position in
spontaneously breathing infants with pneumonia.
7. Outcome Acta Paediatr. , 88, 1 033-1034.
Dalton, H. J. and Heulitt, M. J. ( 1 998)
Goal achieved.
Extracorporeal life support in pediatric respiratory
failure. Respir. Care, 43, 966-977.
Eber, E. ( 1 9 97) Bronchoalveolar lavage in children.
Eur. Respir. Monogr. , 5, 1 3 6-1 6 l .
Grasso, M . c., Button, B . M . and Allison, D . J .
Do you agree ? (2000) Benefits o f music therapy as an adjunct to
Unless it can be shown that the fetus has a chest physiotherapy in infants and toddlers with
conscious appreciation of pain . .. the CF. Ped. Pulmonol, 29, 3 7 1 -3 8 l .
responses to noxious stimulation must still Gross, G. W . ( 1 999) Chest imaging in the neonatal
essentially be reflex.
and pediatric ICU. Respir. Care, 44, 1 095- 1 1 26.
Hemmila, M. R. and Hirschi, R. B. ( 1 999) Advances
Do fetuses feel pain? Br. Med. J.(1996),
in ventilatory support of the pediatric surgical
313, 795-799.
patient. Curro Opin. Pediatr. , 1 1 , 24 1-248.
Heulitt, M. J. and Bohn, D. ( 1 99 8 ) Lung-protective
RESPONSE TO LITERATURE APPRAISAL strategy in pediatric patients with ARDS. Respir.
Care, 43, 952-960.
It is not scientific to make an assertion of 'fact' Jacobson, B. ( 1 998) Obstetric care and proneness of
by assumption. offspring to suicide as adults. Br. Med. ]. , 3 1 7,
It is not scientific to make an impossible 1 346-1349.
447
CHAPTER 1 6 PHYSIOTHERAPY FOR CHILDREN AND INFANTS
Joad, J. P. (2000) Smoking and pediatric respiratory advances in neonatology. Arch. Dis. Child. Fetal
health. Clin. Chest Med. , 2 1 , 37-46. Neonat. Ed. , 8 1 , F 1-F4.
Lam, W. H. ( 1 999) Mechanism and management of Russell, R. I. R. ( 1 998) Weaning from mechanical
paediatric head injury. Care Crit. Ill, 1 5 (3), 95- ventilation in children. Care Crit. Ill. , 14, 1 2 1-
98. 1 23 .
Lemons, J. A., Blackmon, L. R. and Kanto, W. P. Shekerdemian, L . ( 1 999) Cardiovascular effects of
(2000) Prevention and management of pain and mechanical ventilation. Arch. Dis. Child. , 80, 475-
stress in the neonate. Pediatrics, 1 05, 454-46 1 . 480.
Long, T . ( 1 995) A critical appraisal o f positioning Sweeney, J. K., Heriza, C. B., Reilly, M. A. and Smith,
infants in the neonatal intensive care unit. Phys. C. ( 1 999) Practice guidelines for the physical
Occup. Ther. Pediatr., 1 5 (3), 1 7-29. therapist in the neonatal intensive care unit.
Marcus, C. L. (2000) Pathophysiology of childhood Pediatr. Phys. Ther. , 1 1 , 1 1 9-132.
obstructive sleep apnoea. Respir. Physiol. , 1 19, T6rnage, C. J. ( 1 999) First week kangaroo care in sick
1 43-154. very preterm infants. Acta Paediatr. , 88, 1402-
Oberwaldner, B. (2000) Physiotherapy for airway 1 404.
clearance in paediatrics. Eur. Respir. j., 1 5 , 1 96- Weir, E. c., Burrow, J. G. and Bell, F. (2000) Existing
204. methods of pain evaluation in children. Br. J. Ther.
O'Callaghan, C. and Barry, P. W. (2000) Asthma drug Rehab. , 7, 4 1 8-423 .
delivery devices for children. Br. Med. j., 320, Young, A. E. R., Manara, A. R. and Burd, D. A. R.
664. ( 1 995) Intensive care management of the child
Rennie, J. M. and Bokhari, S. A. ( 1 999) Recent with severe burns. Care Crit. Ill., 1 1 (3), 93-97.
448
17 EVALUATION OF RESPIRATORY PHYSIOTHERAPY
SUMMARY
Introduction • Successes folder

Definitions Cost effectiveness
Research The audit cycle
• Definitions Education and continuing education
• Problems for respiratory physiotherapy • continuing competency
Literature appraisal • Needs of students and juniors
Standards • Self assessment
Outcome evaluation Mini case study

• Subjective measurement Literature appraisal
• Objective measurement Recommended reading
• one-trurd accept it but get it wrong (Lloyd,

INTRODUCTION
1998).
Respiratory therapy is one of those technical
Effective physiotherapy requires scrutiny of
orphans that grew up eluding the cold eye
the research, development of standards from the
of scientific enquiry.
research, audit to integrate this and other
Hughes, 1980
evidence into practice, and a system of continu
If a patient who is receiving physiotherapy gets ous evaluation so that the process does not
better, is this due to the physiotherapy, the become a luxury to be tagged on at the end if
physiotherapist or divine intervention? The cred there is time.
ibility of respiratory physiotherapy is being
Only about 15% of all contemporary
much challenged in the pages of learned journals
clinical interventions are supported by
and on the shop floor. This we must welcome.
objective scientific evidence that they do
With tongue in cheek, Stiller and Munday
more good than harm.
(1992) commented that 'Some may question the
White, 1988
need for studies, given the generally accepted
and extensive use of chest physiotherapy'. When
this approach is taken seriously, it inhibits DEFINITIONS
progress.
Benchmark: agreed criterion by which a practice
Evaluation is notoriously difficult because
can be judged (Barnard and Hartigan, 1998, p.
literature is scarce and ambiguous, 'chest
119).
physiotherapy' is poorly defined, and variables
Clinical governance: framework to improve
such as simultaneous medical input and the
patient care using evidence-based guidelines
placebo effect upset results. It is also compli
produced by the National Institute for Clinical
cated by evidence that:
Effectiveness. Includes audit, accountability and
• one-third of patients adhere to treatment patient satisfaction (DoH, 1999). If breached,
• one-third reject it outright litigation can be instigated. All breaches
449
CHAPTER 17 EVALUATION OF RESPIRATORY PHYSIOTHERAPY
should be reported to the line manager 1ll a certain patient population, discussion of
writing. physiotherapy management and presentation
Competence: presense of the skills and of the associated literature.
abilities required for safe and effective practice. • Pilot studies are required in advance of more
Criteria: list of what should happen for a ambitious projects in order to refine metho
standard to be achieved. This is checked against dology and uncover potential flaws.
clinical records during a criterion-based audit • Single case studies are a quantitative
(Barnard and Hartigan, 1998, p. 27). approach in which treatment periods are
Evidence-based practice: clinical decision alternated with non-treatment periods.
making based on the systematic search for, Patients act as their own controls and a large
appraisal of and use of current evidence. Where homogeneous group of patients is not
there is lack of objective evidence, clinical needed (Sim, 1995).
expertise can be included in the definition • Controlled trials include a group of subjects
(Partridge, 1996; Parmar, 1998). Clinical who do not receive the treatment under
expertise is a tool to be nurtured mindfully, not investigation so that the outcome is attribu
used as anecdotal justification. table to the topic being investigated.
Guideline: written framework in which scien • Randomized controlled trials allocate subjects
tific knowledge is analysed and translated into a randomly so that any difference in outcome
usable format to assist clinical decision-making can be explained only by the treatment
(Harrison, 1998). Requires references, explana (Roberts, 1998).
tion of reasoning, and grading of recommenda • Blind trials keep subjects in the dark about
tions and quality of the evidence. Sometimes which side of the study they are participating
suffers from lack of consensus. in, so that the placebo effect is minimized.
Outcome measure: subjective or objective • Double-blind trials prevent investigators
change due to physiotherapy input. Examples of knowing the subjects' allocation.
positive outcomes are reduced breathlessness or
improved exercise tolerance. Outcome measures Secondary research compnses (Bury and
must be appropriate, reliable, valid and respon Mead, 1998, p. 146):
sive (Barnard and Hartigan, 1998, p. 30). • reviews, which summarize the results from
Peer review: review of the work of an indivi
several studies and draw conclusions
dual by those who are equal in grade and speci • systematic reviews, which select and cntI
ality (Barnard and Hartigan, 1998, p. 28). cally appraise relevant research and analyse
Protocol: precise, legally binding instructions
the data
developed from a guideline (Jacyna, 1992). • meta-analysis, which pools studies of similar
Standards: see p. 452.
design.
RESEARCH
Problems for respiratory physiotherapy
Understand information you hear with the When putting results of research into practice,
reasoning of responsibility, not the absence of evidence is not evidence of absence.
reasoning of the reporter. Research in respiratory physiotherapy comes
Hadrar Ali, 598-661 with several obstacles:
Definitions • a host of confounding factors including input

• Case reports provide anecdotal evidence to from other disciplines
generate new ideas (Ernst, 1995). • lack of defined categorization in physio
• Descriptive research combines description of therapy compared to medicine
450
RESEARCH
• shortage of time, money or support • unreferenced factual statements

• ethics. • interpretation Wit)lOut consideration of alter-
native explanations
Ethical considerations have, by definition, no • uncontrolled variables
neat answer. As suggested in the British Medical • jargon obscuring clarity
Journal: 'Can we insist on evidence of effective� • lack of a clear aim
ness from randomized controlled trials for • inadequate definitions, e.g. 'conventional
support services which are of such evident chest physiotherapy', so that reproducibility
human desirability as to render their deliberate is impossible
withholding difficult or unethical?' (Keeley, • physiotherapists used as handmaidens to
1999). collect data rather than as designers of the
Why does irrational clinical behaviour, such study
as clinging to practices shown to be of little • conclusions that 'chest physio-therapy was of
value, persist in the face of ample contrary no value', instead of the inelegant but accu
evidence? rate: 'postural drainage with percussion in
Carr, 1 996 this way for this amount of time for these
patients showed no evidence of improved
mucociliary clearance/greater quantity of
sputum/reduced airflow resistance'.
Why do kamikaze pilots wear helmets?
Examples are given below.
A questioning and indeed a suspicious mind is
necessary when reading articles because research
• Torrington et al. , (1984) imposed 4-hourly
can prove or disprove almost anything. The
IPPB, 4-hourly incentive spirometry, 2-
most prestigious journals publish articles based·
hourly deep breathing and 2-hourly nebuli
on false premises, poor design and with inaccu
zation on obese. postoperative patients. The
rate conclusions. Researchers may be biased
. authors expressed surprise that additional 4-
towards proving their own ideas. Editors may be
hourly PD and percussion increased discom
reluctant to publish negative results. Beware of
fort, fever and cost. Nor did this onslaught
literature that contains:
reduce atelectasis. The study has been much
• extrapolation of results from medical quoted to claim that postoperative
research, e.g. lengthy manual ventilation physiotherapy is unnecessary.
used by anaesthetists is not the same as the • Shapiro et al. (1992) took a leap of faith
brief manual hyperinflation used by when they concluded that 'inspiratory
physiotherapists muscle rest confers no benefit' after
• extrapolation of results from healthy young encasing patients in negative-pressure body
volunteers to people who are ill, e.g. suits overnight. Patients were too uncom
dynamic hyperinflation simulated by using fortable to sleep and found a visit to the
CPAP on normal subjects toilet an ordeal. Perhaps they should have
• extrapolation of results from animals to tried a positive-pressure non-invasive venti
humans, e.g. dogs have a different chest shape lator.
and their pleural space communicates bilater • Ng and Stokes (1992) attempted to evaluate
ally respiratory muscle activity during 'unilateral'
• assessment of more than one technique in chest expansion, but did not distinguish
one study inspiratory and expiratory muscles, used
• lack of distinction between correlation and .'subjective observation' to judge this notor
causation iously ambiguous manoeuvre, and did not
451
CHAPTER 17 EVALUATION OF RFSPIRATORY PHYSIOTHERAPY
explain the physiology or implications in Table 17.1 Standards for mobility: all inpatients
relation to aeration of the lung. I, All patients mobilize daily unless:

• Misuse of references is common. Chuter • it is unsafe.
(1990) claimed that 'diaphragmatic move • it is impossible for practical reasons. e,g, unnavigable lines.
uncontrolled pain,
ments . .. improve ventilation of the lower
lung zones', quoting a reference that was 2, For patients who do not mobilize. the reason is
using deep breathing rather than diaphrag documented. e,g, practical or safety contraindication. patient
refusal (land action taken). staff shortage,
matic breathing.
• Weissman et al. (1984) did not define chest 3, The daily exercise programme is documented;
physical therapy in a paper associating it with • in notes. if given verbally to patient.
• as handout for patient. copied in notes,
major haemodynamic and metabolic stress.
• Researchers sometimes succumb to the temp 4, Documentation demonstrates progression,
tation to use a plethora of interventions.
Alison et al. (1994) claimed triumph for
physical therapy from an uncontrolled trial
patients about limitations and risks of
in which people with an exacerbation of
treatment, provision for patient self-manage
cystic fibrosis benefited from 'rest, intrave
ment and follow-up, liaison with the multidis
nous antibiotics, physical therapy, high
ciplinary team, and maintenance of evidence
calorie diet and regular medical review'.
based practice by training, supervision, case
Maybe it was the rest that was the beneficial
presentations, sharing of information from
agent, maybe the medical review, maybe just
courses and a journal club.
natural recovery from an exacerbation.
All who drink of this remedy recover in a

OUTCOME EVALUATION
short time, except those whom it does not
help, who all die. Therefore it is obvious The distinguishing characteristic of the
that it fails only in incurable cases. professional is that he does what he does
Galen, 2nd century intelligently, not routinely.
Ten Hove, 2001
STANDARDS
The reference point for evaluation is the
The perception is, if chest physiotherapy outcome of treatment. Employers now require
doesn't help, it won't hurt. physiotherapists to justify their time in terms of
Eid,1991 outcomes and cost (Dalley, 1999). Subjective
Evaluation needs standards against which evaluation is by listening to patients and using
outcome can be measured. Standards define the questionnaires. Objective evaluation is by a
expected level of performance. They must be selection of the methods used in assessment.
measurable, understandable, desirable and Like research, the tools for outcome evaluation
achievable. They are usually subject to staffing are based on reliability, validity and attribution.
levels.Standards are only useful if audited and if Unlike research, clinical evaluation can include
audit lends to appropriate change in practice. the complete package of treatment as well as
Staff are motivated by setting their own individual components (Dalley, 1999).
standards. Tables 17.1 and 17.2 give examples.
Other standards could include identification Subjective measurement
of which surgical patients are to be assessed, Patient and physiotherapist may have different
time between referral and assessment for acute views of success. Reduced symptoms may not
and non-acute patients, agreement with affect patient wellbeing, or treatment may
patients of plans and goals, explanation to improve function but not affect symptoms
452
Table 17.2 Some respiratory standards, criteria and measurement
Standard Criteria Measurement
I . Each physiotherapy session is evaluated Written evidence of assessment and evaluation 4-monthly notes audit.
in physiotherapy notes, including response to
treatment and appropriate changes in
treatment. Outcomes recorded. Discharge
summary written.
2. Treatment plan is suited to There is written evidence that the treatment plan 4-monthly notes audit.
the patient's problems relates to the patient's assessment.
3. Each member of the respiratory team There is evidence of regular evaluation of For juniors, I hour review with senior
is responsible for clinical clinical practice. weekly. For seniors, peer support
.
evaluation. quarterly.
4. All patients requiring emergency Relevant staff have ongoing training. Twice-yearly training by senior staff.
physiotherapy out of normal working Staff have access to written guidelines for On-call information in induction pack.
hours receive safe and effective treatment. respiratory problems commonly encountered
out of hours.
Staff work a minimum of one Sat/Sun three Audit of rotas.
times a year.
Staff have access to advice from specialist staff. Yearly on-call audit.
Service use is documented. Yearly audit.
Referrers are provided with written protocol. 6-monthly provision of on-call protocol
to referrers.
Inappropriate referrals are followed up. Yearly audit.
(Duckworth, 1999). Subjective outcomes are Some measurements are valid if taken m the
based on the patient's priorities. Patient surveys context of the full clinical picture:
can be created from quality of life scales or
assessment questionnaires (e.g. pp. 218). They • i oxygenation, i.e. i Pa02, Sa02 or S�02
should guarantee anonymity and confidentiality. • i ventilation, i.e. t PaC02
• increase or maintenance of exercise toler-
Objective measurement
ance, e.g. shuttle test or functional activities
Obstacles to measuring outcome include the • t pain
following: • i independence, e.g. ADL
• Sa02 and other measurements vary with • i well-being, e.g. quality of life scores
factors other than physiotherapy. • increase or maintenance of lung volume (p.
• Postoperative atelectasis may be self-limiting. 163)
• Mouthpieces may interfere with what they • clearance of secretions (p. 209)
are meaSUrIng. • t work of breathing (p. 181)
• Patients and other members of the health • lack of deterioration.
team may be seduced by mechanical aids that
make exotic noises. Box 17.1 is an example of measuring the
• Quality of treatment cannot be assessed from outcome for on-calls. This provides guidance for
the number and length of treatments. on-call staff, an indication of the adequacy of
• Patients with chronic respiratory disease are training and a means of monitoring the appro
notoriously vulnerable to suggestion. priateness of the call. Lack of improvement in
• Respiratory disease is often complicated by the patient does not necessarily mean an inap
multipathology. propriate call out.
453
Box 17.1 On call record
Patient . . . . ... . . .. ... . . . .. .. .. . . . . . .... Date . . . . . ... . . . . . . . . . ... .. . ..... .. . .

Physiotherapist . . . . . . . . . . . ... . . . . . .. .. . . . . . . . . . ... . . . .... ... . . . ...... .... ... .
Called by
Diagnosis
Reason for referral ... . .. ....... ....... . . . .... . . .... . . . . . . . . . .. . .. . .. .. . ......
Problems encountered . . . . ..... . . . . ..... . . . ........ ..... . . . .. . ... . . . . . . .. .... ..
Pretreatment Post-treatment N/A
Breathing pattern
BS
AS
Sa02
CXR
Other
Action t/ or )(
Did not attend Attended
Inappropriate Advice only Appropriate Inappropriate

(state reason) (state reason)
BS = breath sounds; AS = added sounds; N/A = not applicable.
Cost effectiveness is allied to clinical effective

Successes folder ness because time is freed up for further input.
Good research on respiratory physiotherapy is Measures to save time include:
scarce, and it is wise to build up a record of
• handouts for patients to reinforce education
objective proof of success, e.g. before-and-after
• avoiding treatment that is not evidence
auscultation, Sa02 or copies of X-rays. This is a
based
crude measure that does not reflect the effects of
• highlighting relevant events 10 the
education and rehabilitation on quality of life,
physiotherapy notes to assist weekend and
but it comes in handy if challenged by budget
handover staff (this is also a safety factor for
holders.
busy times)
• mobility charts to help involve nursing staff
with rehabilitation
COST EFFECTIVENESS
• assistants supported and valued
Do no harm - cheaply. • journal club to screen more journals than
Hughes, 1 980 one person can read
454
OUTCOME EVALUATION
Box 17.2 Physiotherapy assessment referrals (from Suzanne Roberts, as used at Whittington Hospital, London)
Week Ward Physiotherapist Bleep
Date Name of patient Referrer (print name Physiotherapy problem

and designation) for which assessment
is requested
• educational material, homemade or from An on-call serVlCe is cost-effective if it

organizations (Appendix C), sent to respira prevents deterioration or avoids the need for
tory outpatients before their first appoint more time-consuming intervention. It is not
ment cost-effective if non-respiratory physiotherapists
• to assist the ward report, written referral have not developed the competencies to deal
sheet on wards, pinned up at the nurses' with critically ill patients. Nicholls (1996) puts
station, to be filled out by referring staff and the case for the credibility of respiratory
checked daily by the physiotherapist, e.g. physiotherapy: 'We cannot claim to offer 24-
Box 17.2 hour care for patients while working only eight
• information for nursing and medical staff of them'.
about appropriate referrals, by problem or Short-termism must not intrude on cost-effec
by condition, e.g. Box 17.3 tiveness. Prevention and rehabilitation are
• follow-up telephone calls to outpatients for central to efficient respiratory care.
motivation and support when face-to-face
contact is not essential. Telephone consulta
THE AUDIT CYCLE
tion is becoming increasingly part of the
training of hospital staff in North America People do not resist change. They resist
(Oberklaid, 1998). being changed.
Lloyd, 1 998
Extended care practitioners improve efficiency Research and patient feedback tell us the right
by being trained in skills such as taking capillary thing to do. Audit tells us if we are doing the
blood gases, thus being able to progress right thing right. It entails clinically led peer
treatment without waiting for a doctor. review, which systematically analyses practice
Physiotherapists do not improve efficiency by and outcome against agreed standards, then
learning techniques that are not physiotherapy modifies practice where indicated (Sealey,
skills and do not save physiotherapy time. 1999).
It is cost-effective to spend a few moments Protected time, simple topics and minimal
writing individual daily programmes for patients paperwork are advised. Liaison with the hospi
if this motivates them to do their daily practice. tal's clinical audit department is a useful first
It is cost-effective to reduce a patient's need for step. The topic chosen should have the potential
medication. It is cost-effective to reduce the for improvement and be largely responsive to
need for other services. Heijerman (1992) has physiotherapy, e.g.:
shown that, following rehabilitation, some
people with cystic fibrosis are no longer oxygen • percentage of problems resolved
dependent nor need consideration for transplan • percentage of patients receiving discharge
tation. advice
------ 455
CHAPTER 17 EVALUATION Or RESPIRATORY PHY�IOTHERAPY
Box 17.3 Criteria for respiratory physiotherapy
CRITERIA BY PROBLEM
Sputum retention
Patients who have sputum but are unable to clear their chests independently, e.g. due to weakness,
drowsiness, exhaustion.
Note 1: if a patient is productive of sputum, this may be a good sign (they can clear their own
chests) or a bad sign (they have excess secretions with potential for infection, e.g.bronchiectasis).
Note 2: if a patient is non-productive, this may be a good sign (no secretions) or a bad sign
(sputum retention).
Loss of lung volume
Patients who have atelectasis, e.g. post-op.
Breathlessness
Patients who have acute or chronic breathlessness.
Worsening gas exchange

Patients who have deteriorating blood gases or oxygen saturation.
CRITERIA BY CONDITION
Urgent referral
• person who has aspirated.
Necessary referrals
• person with fractured ribs (adequate analgesia required).
• person with COPD, bronchiectasis, cystic fibrosis or pneumonia.
• person with restrictive disease, e.g. fibrosing alveolitis.
Usual referrals
• person with asthma, unless s/he is mobile, breathing comfortably and has access to an education
programme.
• person with lung abscess, unless abscess is responding to antibiotics and does not require
postural drainage for clearance.

• person with a chest infection, unless s/he is mobile and does not have difficulty clearing
secretions.
• person with pleural effusion or pneumothorax, unless s/he is mobile, has adequate gas exchange
and no chest drain.
Unnecessary referral
• person with pulmonary oedema, unless s/he has another physiotherapy problem.
• percentage of referrals or call-outs consid the outcome or assessment sections of this book.
ered appropriate If the full audit cycle is not completed, the
• percentage of surgical patients discharged exercise is wasted. A typical notes audit would
with preoperative function. comprise the cycle in Figure 17.l.
The following is an example of a biannual
Methods of measurement can be chosen from postoperative audit:
456
TH� AUDIT CYCLE
Choose topic to be measured

and method of measurement
10 r
Rotate auditors, re-audit
01;o. ohao9'
� Define standards
Randomly and anonymously

\
Implement change select physiotherapy notes
�
Discuss and recommend Analyse notes, compare
/
change if required ��_____ practice with tandards
Figure 17.1 Notes audit cycle.
Standard: Patients will be able to climb one shortfall, recommend change, agree who is to
flight of stairs on their fourth postoperative be next auditor and date of the next meeting
day. to monitor change.
Patients: all surgical patients admitted in March
and September who are able to climb one If it is felt that staff shortage is slowing
flight of stairs preoperatively. patient discharges, this could be audited in
Method: stairs assessment on fourth consultation with the hospital discharge officer.
postoperative day. Box 17.4 shows a method of collecting this
Audit meeting: assess notes, identify cause of any information.
Box 17.4 Inpatient delayed discharges
Patient
No . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Ward . . . . . . . . . ..... .. . ....... .. .. . . . ....... . . ........................ .... .
Date considered due for discharge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . .. .
Cause of delayed discharge:

• social services/home circumstances: YIN
• staff shortage: YIN
If yes, which discipline .. .. . . ........... ..... ...... . . .. .... . . ................ .
• other .. .. . .... . . . . . .. . .. . .. . . . . . . .... .... . . . . . .... . . .. ... . . . . . . . .. . . ... . .
Date discharged ................ ........... .. ......... ...................... .
457
Box 17.5 Respiratory team information

EDUCATION AND CONTINUING EDUCATION
There are no known facts, only the present • Wards: locations, specialities, phone
theory of the day numbers, crash trolleys, meetings
Howell, cired byConway, 1 992a • Medical and surgical teams and bleep
numbers
Continuing competency • Referral systems
Juniors abd non-respiratory seniors doing out-of • Team meetings
hours work require updating of their technical, • Pre-tutorial reading material
handling and problem-solving skills. Documenta • Junior responsibilities
tion should demonstrate regular training and • Guidelines, e.g. tracheostomy care, use of
assessment in techniques and clinical reasoning. equipment, infection control
• Assessment sheets, mobility charts
Needs of students and juniors • Patient handouts, e.g. relaxation, pre/post
When educators are more humanistic in their op information, ACB/AD, breathless
training of students, the students become positions, exercise sheets
more humanistic in their care of patients. • Previous junior projects
Williams and Deci, 1 998 • End-of-rotation questionnaires
Learning is improved by autonomy. An autono

mous environment improves problem-solving
Seniors need to ensure competency in the
and achieves a more humanistic approach in
respiratory service. Weekend teams should
learners (Williams and Deci, 1998). It is the
contain a mix of experienced and inexperienced
human qualities of supervisors that are often
staff, if numbers allow. Novices need the oppor
considered of equal or more importance than tunity to shadow the respiratory senior before
clinical skills (Neville and French, 1991).
weekend duties, and access to a mentor during
Students and juniors need:
on-call duties. Learning is facilitated by positive
• clarification of expectations role modelling from a supervisor with the
• assistance in setting feasible objectives and following qualities:
assessing whether these are met • clear setting of priorities
• encouragement to work creatively and not
• enthusiasm, honesty and commitment
become a clone of their senior • respect for juniors so that they in turn
• regular contact with their senior (CSP, 1998)
respect their patients
for feedback, case discussions, trouble
• tolerance of a wide range of normality
shooting and assessing the balance of • avoidance of labelling patients as difficult or
guidance and responsibility
not liked
• praise when due (Jackson, 1999)
• willingness to say 'I don't know'
• correction in a way that does not undermine • constructive relationships with medical and
confidence or belittle them in front of patients
other staff
• space for reflection
• ability to coax the nervous patient, soothe
• enjoyment in their work
the fearful and encourage the weary.
• for senior students, consultation on how
closely they want to be supervised (Onuoha, When asking a patient's permission for
1994) student attendance, it is advisable that the
• encouragement to learn from patients, e.g. student is not present, so that the patient feels
Appendix D free to refuse. Permission should also be sought
• an information folder, e.g. Box 17.5. for the student to read the medical notes
458 --
--
EDUCATION AND CONTINUING EDUCATION
(Wilkie, 1997), and patients advised, when

appropriate, of the student's gender.
Clinical practice is not enough to develop
empathy (Thomson et aI. , 1997) and sensitivity
needs to be facilitated rather than blunted, e.g. if
there has been a ward round in which a patient's
needs have been ignored, debriefing is required
rather than acceptance. Supervisors need to
maintain awareness lest juniors feel obliged to
conform.
Our finest clinicians should analyse their
intuitive process so that they can pass on how
they recognize subtle changes in a breathing
pattern, sense a patient's motivation or adjust •
their treatment in response to barely perceptible -
clues. Figure 17.2 Mr FF.
Self assessment
You may get used to hearing about pain, so
don't let yourself get immune to it . . . when I;ii�iIUdIiii).m;iitiI
you get to that point, you have to stop and
re-evaluate yourself. What has happened to the lungs of this 33-year-old
Askew et ai., 1998 man admitted with food poisoning after eating a
spicy Mexican meal?
We are the most available and abiding judges of
our own work, aided by self-questioning: HPC: Vomiting -> back pain -> collapse.
Subjective: SOB.
• Am I allowing myself to get swamped with
acute respiratory work and not tackling Questions (Figure I 7.2)
prevention or rehabilitation?
I. Auscultation?
• Do I favour patients who are appreciative
2. Percussion note?
and co-operative while neglecting those who
are demanding or depressed?
• Have I achieved the appropriate balance
between patients' needs and my professional
development? Idfi4·]�fi'i.,;ii�i'iMIiii)·A
• How do I handle my mistakes?
Continuing education lays the foundation for Answers

lifelong self-evaluation. It also provides the Vomiting -> ruptured oesophagus -> empyema ->
opportunity for seniors to show that compassion development of gas-forming organism ->
is fundamental to effective respiratory care, not pneumothorax.
an old-fashioned, unscientific luxury reserved for
the naive and uninitiated. I. Auscultation: BS ! L upper zone
2. Percussion note: hyperresonant L upper zone.
Sometimes learning requires courage. To
become a learner is to become vulnerable. Progress
Berwick, 1991 Chest tube drained foul-smelling liquid.
------ 459
C HAIYfER 17 EVALUATION OF RESPIRATORY PHYSIOTHERAPY
Blood gases deteriorated --+ intubation + IPPV Culham, E. (1998) Evidence-based practice and
with pressure support --+ increasing airway professional credibility. Physiother. Ther. Pract.,
pressure --+ pressure control initiated. 14,65-67.
Goldhill,D. (2000) Clinical guidelines in intensive
ARDS developing.
care. Care Crit. Ill, 16( 1),2--4.
Physiotherapy: prone positioning. monitoring.
Hartigan,G. (1995) Choosing a method for clinical
musculoskeletal care.
audit. Physiotherapy, 81,187-188.
Patient improved. recovered. decided to avoid
Johnson,S. c., Dodd,M. E. and Evans,W. (1998)
spicy restaurants. Improving the efficiency of medical respiratory
referrals in a DGH. Physiotherapy, 84,584-589.
ARDS = acute respiratory distress syndrome; BS =
Kitchen,S. S. (2000) Audit: does it really improve
breath sounds; IPPV intermittent positive pressure
=
care? Physiotherapy, 86, 226-228.
ventilation. McGovern, M. C. and Stewart, M. C. ( 1999) Drawing
up clinical guidelines. Int. J. Clin. Pract., 53, 1 18-
120.
Morrel, C. and Harvey,G. ( 1999). The Clinical Audit
LITERATURE APPRAISAL Handbook, Bailliere Tindall, London.
Murray,P. (1999) Fundamental issues in
At last, logic:
questionnaire design. Accid. Emerg. Nurs., 7, 148-
.. . when children share a room (which 153.
implicates both exposure to other children Partridge, C. J. ( 1998) Research in cardiopulmonary
and lower socioeconomic status) . . . . physiotherapy,in Physiotherapy for Respiratory
Br. Med. j. (1989), 299, 949 and Cardiac Problems, 2nd edn,(eds B. A. Webber
and J. A. Pryor), Churchill Livingstone,
Edinburgh.
RESPONSE TO LITERATURE APPRAISAL Pieri-Davies,S., Ewart, K. and Boden, K. ( 1994) On
eall respiratory issues threaten patients (letter).
To cheer us up, this shows lateral thinking In Frontline, July 7.
interpreting results. Price,A. M. and Chalker, M. (2000) Our journey
with clinical supervision in an intensive care unit.
Intens. Crit. Care Nurs., 16,5 1-56.
RECOMMENDED READING
Rogers,R. and Perren,P. (1999) Truth or illusion:
Bithell, C. (2000) Evidence-based physiotherapy. evidence-based practice in the real world. Br.].
Physiotherapy, 86,58-60. Ther. Rehab., 6,275-280.
Case, K.,Harrison, K. and Roskell, C. (2000) Shekelle,P. G., Woolf,S. H. and Eccles, M. ( 1999)
Differences in the clinical reasoning process of Developing guidelines. Br. Med. J., 318,593-596.
expert and novice cardiorespiratory Sim, J. ( 1989) Methodology and morality in
physiotherapists. Physiotherapy, 86, 14-2l. physiotherapy research. Physiother., 75, 237-
CSP ( 1997) Guidelines for Good Practice for the 243.
Education of Clinical Educators, Information Sim, 1. and Hlatky, M. A. (1996) Growing pains of
paper CPD 14, Chartered Society of Physiotherapy, meta-analysis. Br. Med.]., 313,702-703.
London. Tobin,A. and Judd, M. ( 1998) Understanding the
CSP ( 1999) Clinical effectiveness. Frontline, March barriers. Physiotherapy, 84,527-529.
supplement, Chartered Society of Physiotherapy, Wallis, C. and Prasad,A. ( 1999) Who needs chest
London. physiotherapy? Moving from anecdote to
CSP ( 1999) How to get a research grant. Frontline, evidence. Arch. Dis. Child., 80,393-397.
Suppl.1(3),8-9. Williams,S. and Harrison, K. ( 1999)
CSP ( 1999) Setting up a research programme. Physiotherapeutic interactions: a review of the
Frontline, Suppl. 1(3), 16- 17. power dynamic. Phys. Ther. Rev., 4,37-50.
460
GLOSSARY OF ABBREVIATIONS, DEFINITIONS, SYMBOLS AND VALUES
Values in [square brackets] are American. Most values are Airway closure Closure of small airways, common in
approximate. dependent lung regions at end-expiration.
Airways resistance N: 0.5-3 .0 cmH20/Us.
Albumin Plasma protein responsible for providing most
If the definition is not here, see the index.
osmotic pressure in blood. N: 40-60g/L, [4.0-6.0gl
100 mL].
L = litre. A1kalaemia Alkalosis of the blood.
N = normal. Alkalosis pH above 7.45. Respiratory alkalosis is caused by
.Ii = change. malfunctioning respiration. Metabolic alkalosis is caused by
Dot over symbol = value per unit time, e.g. V02 = oxygen malfunctioning metabolism.
consumption. Anabolism Constructive phase of metabolism when simple
Bar over symbol mean value, e.g. v, mixed venous.
= substances become complex living matter.
6
Jl-Micro- prefix indicating 10- , i.e. x 0.00000 I . Anaerobic threshold (AT) Highest O2 consumption during
Jlm See Micrometer. exercise, above which sustained lactic acidosis occurs.
/!VI/!P Change in volume in response to change in pressure, Measured by expired gas. Exercise training can increase AT
i.e. compliance. by 25-40%.
A Alveolar, e.g. PA02. Anastomosis Surgical union of tubular structures.
a Arterial, e.g. Pa02. Angina Crushing dull chest pain due to impaired blood
AAA Abdominal aortic aneurysm. supply to the myocardium, worsened with exertion or
ABG Arterial blood gas. stress.
ABPA Allergic bronchopulmonary aspergillosis. Angioplasty Invasive but non-surgical dilation of coronary
Absorption atelectasis Alveolar collapse due to either artery stenosis, using catheter via femoral puncture, or
resorption of air distal to a bronchial obstruction or excess laser.
administration of O2, which is then absorbed. Anoxia Synonymous with hypoxia, but implying a more
ACB Active cycle of breathing. complete O2 lack.
ACE inhibitors Angiotensin converting enzyme inhibitor Antibody Substance produced by interaction of antigen with
drugs. body's defences. Also known as immunoglobulin.
Acidaemia Acidosis of the blood. Antigen Allergen, i.e. irritant that elicits an immune
Acidosis pH below 7.35. Respiratory acidosis is caused by response.
malfunctioning respiration. Metabolic acidosis is caused by AP Anteroposterior.
malfunctioning metabolism. APACHE Acute Physiology And Chronic Health Evaluation:
Acinus Portion of lung participating in gas exchange, supplied scoring system to measure severity of illness, using
by a primary respiratory bronchiole. predictor variables such as diagnosis, age and physiological
ACPRC Association of Chartered Physiotherapists in measures.
Respiratory Care. APTT See Clotting studies.
AD Autogenic drainage. Apgar score Scoring system to measure birth asphyxia, using
Adherence Degree to which patient behaviour coincides a combination of heart rate, respiratory effort, muscle tone,
with clinical recommendations, also known as patient reflex irritability and colour.
compliance but with less implication of obedience. Apneustic breathing Prolonged inspiration, usually due to
ADL Activities of daily living. brain damage.
Adult respiratory distress syndrome Old terminology for Apnoea Absence of breathing for more than 10 seconds.
acute respiratory distress syndrome. Arteriovenous oxygen difference Difference between O2
Adventitious sounds Added sounds on auscultation. delivered to and returning from tissues. Calculated from
Aetiology Cause. arterial and mixed venous blood samples. Related to
Aerophagia Gas in the stomach. metabolic rate.
Aerosol Suspension of solid or liquid particles, e.g. pollen, Ascites Fluid in the abdominal cavity.
dust, smoke, mist, viruses, therapeutic aerosol for Aspiration ( I ) Inhalation of unwanted substances (e.g. gastric
humidification and drug delivery. acid, sea water) into lungs; (2) therapeutic removal of fluid
Air trapping Retention of inspired gas in poorly ventilated or gas from a cavity such as the pleural space.
areas of lung. Asystole No heartbeat.
Airway ( I ) Path that air travels from atmosphere to alveoli; Auscultation Use of stethoscope to hear sounds from a
(2) device to hold natural airway open for relief of body cavity.
obstruction or to allow I PPV. Base deficit Negative base excess.
461
GLOSSARY
Biot's respiration Irregular cycles of deep gasps and Chylothorax Effusion of chyle from thoracic duct into pleural
apnoea. space.
BiPAP Bilevel positive airways pressure. CI See Cardiac index.
BIPAP Biphasic positive airways pressure. Circadian Over 24 hours.
Bleb Collection of extra-alveolar air under visceral pleura (see Closing capacity Lung volume at which airway closure
also Bulla). begins, as a result of narrowing of dependent airways as
Blood culture Blood taken from a pyrexial patient to identify lung deflates. Rises with age as small airways narrow,
microorganisms. equalling FRC at an average 44 years in supine and 66
Bohr effect Reduced availability of O2 from oxyhaemoglobin years in standing.
in regions of low PC02. Closing volume Closing capacity minus residual vulume.
Bohr equation Difference between end-tidal and arterial Increases (becomes a greater proportion of FRC) with small
PC02. Calculates physiological dead space. airways disease, smoking, obesity and extremes of age. N:
BOOP Bronchiolitis obliterans organizing pneumonia. Occurs 10% of VC in young people with normal lungs. Age 65:
secondary to lung or bone marrow transplant, drug 40% of VC.
reaction, aspiration or collagen vascular disease. Clotting studies
Bradypnoea Slow breathing. • AG (activated clotting time) N: 100-140 s.
Bronchiole Airway unsupported by cartilage. • APTT (activated partial thromboplastin time) N: 30-
Bronchomalacia Disorder characterized by degeneration of 40s.
elastic and connective tissue of trachea and bronchi. • Bleeding time N: 3-9 min.
Bronchopleural fistula Communication between lung and • FOPs (fibrinogen degradation products) N: < 10 mg/mL.
pleura, caused by thoracic surgery, trauma, mechanical • Fibrinogen level N: > 150 mg/dL.
ventilation or pulmonary disease. • INR (international normalized ratio) N: 1-104. Higher
Bronchorrhoea Excess bronchial secretions. means increased clotting time and risk of bleeding.
Bronchospasm Abnormal contraction of smooth bronchial • KPTT (kaolin partial thromboplastin time) N: < 7 s
muscle, causing narrowing of airway. above control.
BTS British Thoracic Society. • Platelet count N: 140 000-400 000/mm3 Risk of
Buffer Substance that binds or releases hydrogen ions in bleeding with suction: < 50 000/mm3. Spontaneous
order to keep pH constant. bleeding: < 20 000/mm3
Bulla Collection of air in lung tissue which is more than I cm • PT (prothrombin time) N: 12-15 s.
in diameter, caused by alveolar destruction. • PTT (partial thromboplastin time) N: 12-30 s.
CABG Coronary artery bypass graft. CMV (I) Controlled mandatory ventilation or conventional
Cachexia Emaciation due to catabolism of body protein and mechanical ventilation, (2) cytomegalovirus (virus in the
fat, caused by malnutrition, malignancy, some chronic herpes group).
diseases. CO (I) Cardiac output, (2) carbon monoxide.
Calcium N: 2.2-2.6 mmol/L. CO2 Carbon dioxide.
Catabolism Metabolic process releasing energy and CO2, COAO Chronic obstructive airways disease.
Co02 See Oxygen content. Coagulation See Clotting studies.
Cardiac enzymes Enzymes released from damaged heart Collateral ventilation Exchange of inspired gas between
muscle after myocardial infarction. adjacent lung units.
Cardiac index Cardiac output;body surface area. N: 2.5- Colonization Presence and multiplication of microorganisms
2
3.5 Umin/m Highest at age 10, then decreasing with age. without necessarily causing tissue damage.
Cardiac output (CO or Q) Blood ejected by left ventricle Colostomy Surgical creation of opening into large bowel.
per minute, i.e. heart rate x stroke volume. N: 4-8 Umin at Coma Unrousable unconsciousness.
rest, up to 25 Umin on exercise. Compliance of lung Change in volume in response to
Cardioplegia Cooling of heart to reduce metabolic rate change in pressure. N static compliance: 200 mUcmH20.
during surgery. N dynamic compliance: 180 mUcmH20. N compliance in
Catabolism Destructive phase of metabolism, when large patient on IPPV: 35-50 mUcmH20.
molecules are converted into small molecules. Compliance of lung measured on IPPV Tidal volume/
Catecholamine Compound having sympathomimetic action, (plateau airway pressure - PEEP).
e.g. adrenaline. Consolidation Replacement of alveolar air by substance of
CCF Congestive cardiac failure. greater density than air.
CF Cystic fibrosis. Contralateral Opposite side.
CFA Cryptogenic fibrosing alveolitis. COPO Chronic obstructive pulmonary disease.
Chest wall Structures outside lung that are involved in Cough syncope Loss of consciousness for a few seconds
breathing movements, i.e. rib cage, diaphragm and following cough. Sometimes occurs in middle-aged men
abdominal wall. with COPD. Benign except while driving.
462
GLOSSARY
CPAP Continuous positive airways pressure. Eosinophilia Excess eosinophils. Indicates allergic state, e.g.
CPR Cardiopulmonary resuscitation. extrinsic asthma.
Creatinine Electrolyte in plasma or urine, formed from Eosinophils Inflammatory cells associated with
muscle breakdown and excreted by kidneys. N in plasma: hypersensitivity reactions. i in allergy, e.g. extrinsic
50-100 nmol/L [0.6-1.2 mgt I OOmL]. i in hypovolaemia or asthma.
kidney failure, ii in septic shock. Epiglottis Cartilage that diverts food to oesophagus by
Cryptogenic Of unknown cause. closing over trachea.
Cryptogenic organizing pneumonia See BOOP. ERCP Endoscopic retrograde cholangiopancreatography:
CSF Cerebrospinal fluid. procedure for detection and treatment of gallstones.
CT Computed tomography. ER02 Oxygen extraction ratio.
CVP Central venous pressure. N: 1 -7 mmHg or 5-12 cmH20. Erythrocytosis Polycythaemia.
C,,02 See Mixed venous oxygen content. ETC02 End-tidal CO2. N: 4-6%.
CXR Chest X-ray. Err Endotracheal tube.
Cytokine Inflammatory product. Eucapnia Normal PaC02.
Cytomegalovirus Virus to which immunocompromised Extracorporeal Outside the body.
people are susceptible. Fatigue Abnormal tiredness after normal activity, or
DB Deep breathing. decreased energy that prevents activity that needs sustained
Deglutition Swallowing. effort.
Delirium Condition of disorientation, fear, misperception, FBC Full blood count.
hallucination. FDPs See Clotting studies.
DH Drug history. FEF2S_7S Forced expiratory flow in middle half of expiration.
DIC Disseminated intravascular coagulation. FEFso As above.
DNR Do not resuscitate. FET Forced expiration technique.
002 See Oxygen delivery. FEV I Forced expiratory volume in I second.
Doppler Use of changes in frequency of light and sound FFP Fresh frozen plasma. Frozen within 6 hours of donation.
waves to monitor relative motion. Contains all clotting factors at normal concentration.
Duty cycle (T.ITTOT) Ratio of inspiratory time to total FH Family history.
respiratory cycle time. Short TI in relation to TTOT indicates F102 Fraction of inspired oxygen.
tVT and i dead space, suggesting inspiratory muscle First-pass metabolism Metabolism of a drug other than
fatigue. See also Tension-time index. systemically, due to insufficient absorption or metabolism by
DVT Deep vein thrombosis. gut or liver before drug enters systemic circulation.
Dysphagia Difficulty swallowing. Fluid compartments Extracellular space ( 1 4 L) and
ECC02R extracorporeal CO2 removal. intracellular space (28 L). Extracellular space is subdivided
ECG Electrocardiogram. into vascular (4 L) and interstitial (10 L) spaces.
ECMO Extracorporeal membrane oxygenation. Fluid overload 10% or greater increase in weight due to
-ectomy removal. fluid.
EEG Electroencephalogram: electric potential of brain cells FRC Functional residual capacity.
recorded as brain waves. FUO Fever of unknown origin.
EIA Exercise-induced asthma. FVC Forced vital capacity.
Eisenmenger's syndrome Pulmonary vascular disease with GCS Glasgow Corna Scale.
cyanosis due to extrapulmonary shunt in which congenital Generations Branches of tracheobronchial tree, numbering
heart disease causes a systemic-to-pulmonary circulation between I0 and 23.
connection. Glottis Opening between vocal cords.
Elastance Opposite of compliance. Glucose level in blood N: 3.0-5.5 mmol/L. i in stress, ii
EMD Electromechanical dissociation: dissociation of electrical in diabetes mellitus, t in liver failure or starvation.
and mechanical activity of the heart, represented by clinical GOR Gastro-oesophageal reflux.
signs of cardiac arrest with normal ECG. Causes include Gram-negative pathogenic bacteria Virulent organisms
tension pneumothorax, cardiac trauma or severe electrolyte that thrive in moist environments, e.g. Haemophilus,
or acid-base imbalance. Leads to cardiac arrest. Klebsiella, Pseudomonas, Salmonella.
Encephalopathy Damage to the structure or function of Haematocrit Concentration of red blood cells in blood. N
brain tissue. in women: 36-46%, N in men: 40-50%. Anaemia:
Endotoxic shock Septic shock. < 36%. Polycythaemia: > 55% .
Endurance Capacity of muscle to sustain contraction. Haemoglobin Respiratory pigment in red blood cells that
Enteral Via the gut. combines reversibly with oxygen. N in women: I 1.5-
Entrainment Dilution of a gas stream or aerosol with 15.5gtI00mL, N in men: 14.0-18.0gtI00mL. tin
external gas such as room air. anaemia, i in polycythaemia.
463
GLOSSARY
Hamman's sign Crunching sound synchronous with heart Iatrogenic Causing or exacerbating harm by medical
beat, indicating pneumomediastinum. intervention.
Harrison's sulcus Deformity of the thorax in children ICP Intracranial pressure.
caused by pull of diaphragm on ribs that are either not yet ICU I ntensive care unit.
calcified or weakened by rickets. Idiopathic Of unknown cause.
Hartmann's solution Fluid and electrolyte replenisher. I:E See Inspiratory:expiratory ratio.
Hb Haemoglobin. Ileostomy Surgical creation of opening into ileum.
HCOl - Bicarbonate ion concentration. Ileus Gut obstruction, e.g. due to paralytic ileus.
HDU High dependency unit. Immotile cilia syndrome Primary ciliary dyskinesia.
Hepatomegaly Enlarged liver. Immunoglobulin Antibody. Examples in respiratory
HFJV High-frequency jet ventilation. secretions: IgA, IgE, IgG, IgM.
HFO High-frequency oscillation. IMV Intermittent mandatory ventilation.
HFPPV High-frequency positive pressure ventilation. Infarct Death of tissue due to lack of blood supply.
HFV High-frequency ventilation. Infection Presence of microorganisms or their products in
Hiccup Involuntary clonic spasm of intercostals and normally sterile tissue (see also Sepsis).
diaphragm followed by abrupt glottic closure, of unknown Infiltrate Fluid, cells or other substance in fluid or tissue
aetiology. space, e.g. pulmonary interstitial infiltrate
= fluid between
Hickman line Central venous access line, e.g. for capillary and alveolus, showing on X-ray as diffuse
chemotherapy. shadowing.
Histotoxic Tissue-poisoning. INR See Clotting studies.
HIV Human immunodeficiency virus. Inspiratory capacity Volume inspired during maximum
H:L ratio ratio of power in high and low frequency bands of inspiration from resting end-expiratory position.
electromyogram of respiratory muscle. � with respiratory Inspiratory:expiratory ratio Duration of inspiration
muscle fatigue. relative to expiration.
HLT Heart lung transplant. Inspiratory force See MIP.
HME Heat-moisture exchanger. Inspissated Thick.
HR Heart rate. N: 60- 1 �O/min. Intracranial hypertension i ICP.
HRCT High resolution computed tomography. Intrapulmonary pressure Alveolar pressure.
Humoral Non-cellular. Intrathoracic pressure Pleural pressure.
Hyperdynamic Status signalling onset of septic shock: IPPB Intermittent positive pressure breathing.
galloping pulse, pyrexia, shaking chill, flushing of skin, high IPPV Intermittent positive pressure ventilation, i.e. mechanical
cardiac output, unstable BP. ventilation.
Hyperkalaemia i potassium. Ipsilateral Same side.
Hypermetabolism i basal energy expenditure by more IRT Immune reactive trypsin: antibody identified in CF
than 1 0%. screening.
Hypernatraemia i serum sodium. IRV Inspiratory reserve volume.
Hyperosmolar Containing a high concentration of IS Incentive spirometry.
osmotically active ingredients. Isotonic Exerting the same osmotic pressure, for example,
Hyperoxia Abnormally high oxygen tension in blood. isotonic saline contains salt equal to that in body.
Hyperreactivity Heightened sensitivity to variety of stimuli. Isotonic exercise Active exercise with movement, force of
Present in airways with asthma. Sometimes present with contraction remaining constant.
COPD, bronchiectasis, CF, sarcoidosis, LVF. IV Intravenous.
Hyperthermia Core temperature> 40.5°C. JVP Jugular venous pressure.
Hyperventilation CO2 removal in excess of CO2 K Potassium.
production, causing PaC02 < 4.7 kPa (35 mmHg). Kartagena's syndrome Triad of bronchiectasis, sinusitis and
Hypogammaglobulinaemia � gamma globulin in blood, situs inversus, associated with primary ciliary ·dyskinesia.
associated with � resistance to infection. Kerley B lines Thin 1 -2 cm horizontal lines on X-ray that
Hypokalaemia � potassium. abut the visceral pleural surface, representing engorged
Hyponatraemia � sodium. lymphatics and thickened interlobular septa, indicative of
Hypopnoea Shallow slow breathing. pulmonary oedema. Become visible when the pulmonary
Hypoventilation CO2 production in excess of CO2 artery wedge pressure exceeds 25 mmHg.
removal, causing PaC02> 6.0 kPa (45 mmHg). kPa kilopascal.
Hysteresis Difference in compliance between inspiration and KTPP See Clotting studies.
expiration. Kussmaul breathing Deep sighing breathing often seen in
IABP Intra-aortic balloon pump. patients with metabolic acidosis.
464
Gl.O�SARY
Kyphoscoliosis Anteroposterior and lateral curvature of MEP Maximal expiratory pressure. N: 1 00 cmH20.
spine. Inadequate cough: < 40 cmH20.
Lactate (in blood) Serum lactate. N: < I mmol/L. Severe mEq Milliequivalent, i.e. one-thousandth of molecular weight
oxygen debt and poor prognosis: 2.5-3.0. of substance.
Lactic acidosis Elevation of blood lactate due to insufficient mEq/L Milliequivalents per litre of solution. Electrolyte
oxygen in tissues for body's needs, causing metabolic concentration, also expressed as mmol/L.
acidosis. See also Anaerobic threshold. MET Metabolic energy expenditure. Metabolic unit
Laparoscopy Minimal access incision through abdominal representing oxygen consumed at rest. Basal metabolism
wall. consumes I MET, eating consumes 2 METs, dressing
Laparotomy Full surgical incision through abdominal wall. consumes 3 METs, vacuuming consumes 5 METs, brisk
Laplace's law Pressure developed by diaphragmatic 30-60 min walk consumes 9- 1 0 METs. N: 3 . 5 ml oxygen/
contraction directly proportional to the tension developed kg body weight/min.
in its fibres and inversely proportional to its radius of Metabolism Chemical processes of body, comprising
curvature. anabolism and catabolism. Varies with healing, activity level
Laminar Streamline. and temperature.
Larynx Cylindrical tube connecting pharynx and trachea, Metastasis Ability of cells to spread through bloodstream or
formed by cartilages and containing vocal cords. lymphatics.
Leukocyte White blood cell. MH Manual hyperinflation.
Leukocytosis i white blood cells. MI See myocardial infarction.
LFT ( I ) Lung function test (2) liver function test. Micrometre (J.tm) One millionth of a metre.
Locked-in state Total paralysis below third cranial nerve, Micron Old term for micrometre (see above).
with patient partially or fully aware. Miliary TB Homogenous TB of lung manifest by mottling on
LTOT Long-term oxygen therapy. X-ray.
LVEDP Left ventricular end-diastolic pressure. MIP Maximum inspiratory pressure: assessment of respiratory
LVEDV Left ventricular end-diastolic volume. Determinant of muscle strength. N : - 1 00 to -130 cmH20 (men), - 70 to
preload. Depends on venous retum to L ventricle, - 1 00 cmH20 (women). Typical value for hypercapnic
circulating blood volume and efficiency of left atrial COPD: - 55 (men), - 40 (women). Poor weaning
contraction. Measured, by assumption, from PAWP, which outcome: - 20. Inadequate cough: - 0-20.
relates to LVEDP. Mixed venous blood Blood in pulmonary artery.
LVF Left ventricular failure. Mixed venous oxygen content (Hb x S,,02 x 1 .39) +
Lymphocyte Small leukocytes comprising 25% total white (P,,02 x 0.023).
blood cell count. Mixed venous oxygen saturation N: 75%.
-lysis Breakdown. MMEF Maximum mid-expiratory flow.
MAP See Mean arterial pressure. mmHg Millimetres of mercury.
Mast cells Connective tissue cells involved in hypersensitivity mmol Millimole: One one-thousandth (0.00 I ) of molecular
reactions. Release histamine in response to specific stimuli. weight of substance.
i in asthma. MMV Mandatory minute ventilation.
MeV See Mean corpuscular volume. MODS Multiple organ dysfunction syndrome (multisystem
MOl Metered dose inhaler. failure).
Mean arterial pressure Average pressure pushing blood Mucoactive Affects quality or quantity of mucus.
through systemic circulation, i.e.: (systolic BP + (diastolic Mucokinetic Accelerates mucus transport.
BP x 2))!3. N: 80- 1 00 mmHg. Compromised circulation to Mucolytic Destroys mucin in mucus gel.
vital organs: < 60 mmHg. Compromised circulation to Mucoviscidosis Cystic fibrosis.
injured brain: < 80 mmHg. MV Minute ventilation or volume (see VE)
Mean corpuscular haemoglobin Amount of Hb in red Mycoplasma pneumonia Atypical pneumonia which affects
blood cells. otherwise healthy people rather than the chronically ill or
Mean corpuscular volume Size of red blood cells. t(small elderly.
RBCs): iron deficiency. i (large RBCs): vitamin BI 2 or folate Myocardial infarction Death of a portion of heart muscle
deficiency. due to myocardial ischaemia.
Mediastinum Part of thoracic cavity between the pleural Na See Sodium.
sacs containing the lungs. Contains all the thoracic viscera Neutropenia t neutrophils, i.e. < 1 .5 x 1 0 .
9
except the lungs. Neutrophil White blood cell used for phagocytosis of
MEFso Maximum expiratory flow in mid-expiration. bacteria but which in excess releases tissue-damaging
Mendelson's syndrome Aspiration of gastric contents into enzymes as part of uncontrolled inflammation.
lungs. Neutrophilia i neutrophils.
465
G LOSSARY
NFR Not for resuscitation. Oxygen transport Oxygen transported from lungs to
NHS National Health Service. mitochondria.
NICE National Institute for Clinical Excellence. Oxygen uptake Oxygen consumption.
NICU Neonatal intensive care unit. Ozone Gas that provides a protective layer to earth's
NIPPV Nasal (or non-invasive) intermittent positive pressure atmosphere but at ground level causes inflammation in
ventilation, i.e. non-invasive ventilation. hyperreactive airways.
NIV Non-invasive ventilation. Pso P02 at which 50% of haemoglobin in blood is saturated
NO Nitric oxide. with oxygen. N : 27-28 mmHg.
Nociceptive Painful. PA Posteroanterior.
Normocapnia Normal PaC02 . PA-aOl Alveolar-arterial oxygen gradient, i.e. difference in
O2 Oxygen. partial pressures of PA02 and Pa02. Indicates gas exchange
Occupational lung disease Disease due to inhalation of efficiency but varies with F102. N on room air: 0.7-2.7 kPa
dust, particles, fumes or gases while working. (5-20 mmHg), reflecting normal anatomical shunt. i with
OER See Oxygen extraction ratio. VAiQ mismatch or diffusion impairment, i on exercise, i in
OHFO Oral high frequency oscillation. the elderly, i on supplemental oxygen; for example, on
Oliguria 1 urine output, i.e. < 20 mlJh (normal SO-60 mlJh). 1 00% oxygen PA-a02 = 3 .3-8.6 kPa.
Operation Surgery plus anaesthesia. Pack years Average number of packs smoked daily
Orthostatic Relating to the erect position. multiplied by years smoked, e.g. smoking I pack/day for 30
Orthotopic transplantation Replacement of recipients' years = 30 pack-year history.
organ with that of donor. Packed cell volume Equivalent to haematocrit. N: 0.36-
-oscopy Visual examination of the interior of an organ. 0.46 (women), 0.40-0.50 (men). i in polycythaemia, 1 in
Osmolality Number of osmotically active particles per anaemia.
kilogram of solvent. PaC01 Partial pressure of CO2 in arterial blood. N: 4.7-
Osmolar load Osmolality of solution x volume infused. 6.0 kPa (35-45 mmHg).
Osmolarity Number of osmotically active particles per litre Palliation Alleviation of symptoms.
of solution. PA01 Partial pressure of oxygen in alveoli.
-ostomy Formation of artificial opening to skin surface. Pa01 Partial pressure of oxygen in arterial blood. N: 1 1 -
-otomy Incision. 1 4 kPa (80- 1 00 mmHg).
Oxygen consumption Amount of oxygen consumed by Pa01:F,01 Ratio of Pa02 to inspired oxygen. Estimates
tissues each minute, i.e. CI x (Ca02 - C(02) x 1 0 mUmin/ shunt; similar to PA-a02 but easier to use. N: 40 kPa
2
m . N at rest: 200-250 mUmin (if contributing values (300 mmHg).
normal, i.e. CO 5 Umin, Hb 1 5 g/100 mL, Sa02 97%, Sv02 PAOP Pulmonary artery occlusion pressure ( PAWP).
=
75%). Critical illness: 600 mllmin. Maximum on exercise in PAP Peak airways pressure ( peak inspiratory pressure).
=
unfit male: 3600 mUmin. Maximum on exercise in frt male: PAP Pulmonary artery pressure. N: 1 0-20 mmHg (systolic
5000 mUmin. 22, diastolic 1 0, mean 1 5). Pulmonary hypertension:
Oxygen content Total amount of oxygen in blood, i.e. 25 mmHg.
(Hb x Sa02 X 1 .39) + (p.o2 x 0.023). N in arterial blood: Paralytic ileus Decrease or absence of peristalsis.
1 7-20 mU I 00 mL. Parenchyma Foamlike substance comprising the gas
Oxygen cost of breathing Energy requirements of exchanging part of lung, made up of alveoli, small airways,
respiratory muscles. Provides indirect measure of work of capillaries and supporting tissue.
breathing. N : I mL/L of ventilation. Parenchymal lung disease Disease affecting parenchyma,
Oxygen delivery (002) Volume of oxygen presented to e.g. interstitial lung disease, pneumonia, TB, ARDS.
2
tissues, i.e. CI x Ca02. N: 550-650 mUmin/m May be Parenteral Other than through the gut.
elevated in hyperdynamic states. Pathogen Bacteria, viruses, etc. that can cause disease.
Oxygen demand Oxygen needed by cells for aerobic PAWP Pulmonary artery wedge pressure. N: 5- 1 5 mmHg.
metabolism, estimated by V02. Pulmonary congestion: 20 mmHg. Pulmonary oedema:
Oxygen extraction Oxygen transferred from blood to 25 mmHg.
tissues, i.e. Ca02 difference between arterial and mixed Paw Mean airway pressure.
venous blood, equivalent to VOYD02. PC Pressure controlled ventilation.
Oxygen extraction ratio Ratio of oxygen consumption to PCA Patient controlled analgesia.
oxygen delivery (V02/D02), indicating efficiency of tissues in PCIRV Pressure-controlled inverse-ratio ventilation.
extracting oxygen. Calculation: (Ca02-Cv02)/Ca02. N : PCP Pneumocystis corinii pneumonia.
25%. High oxygen extraction to meet excess metabolic PCV See packed cell volume.
needs: > 35%. Maximum OER: 60-70% for most PCWP Pulmonary capillary wedge pressure ( PAWP).
=
tissues. PO Postural drainage.

Oxygen flux Percentage of oxygen that reaches tissues. Pdi Transdiaphragmatic pressure.
466
GLOSSARY
PE Pulmonary embolus, Ptc02 Transcutaneous oxygen tension,

PEEP Positive end-expiratory pressure, PTT See Clotting studies,
PEFR Peak expiratory flow rate, Pulmonary hypertension i pulmonary artery pressure, i,e,
PEma>< Maximum expiratory pressure at mouth, See MEP, > 25 mmHg (mean) at rest or 30 mmHg on exercise in
PEP Positive expiratory pressure, presence of cardiac output below 5 Umin,
Percussion (therapeutic) Clapping chest wall to loosen Pulmonary osteoarthropathy Pain and swelling of
secretions; (diagnostic) tapping chest wall to identify density joints associated with lung, liver and congenital heart
of underlying tissue, disease,
Percutaneous Through the skin, Pulmonary vascular resistance N: 25- 1 25 dyn,s,cm-
5
Petechiae Small skin haemorrhages, Pulse pressure Difference between systolic and diastolic
pH Inverse of log of hydrogen ion concentration, Measure of pressures: indicates blood flow, N: 40--70 mmHg, i with
hydrogen ions in solution, hypertension, ! with poor stroke volume, Dangerously low
Phlebotomy Therapeutic withdrawal of blood, tissue perfusion: 20 mmHg,
PICU Paediatric intensive care unit. Pulsus paradoxus Weaker pulse on inspiration than
PIE Pulmonary interstitial emphysema, expiration caused by expansion of pulmonary vascular bed
PIF Peak inspiratory flow, N: 40--50 Umin, Breathlessness or on inspiration, i,e, excess negative pressure in chest, e,g,
exercise: up to 200 Umin, severe acute asthma, hypovolaemic patient on I PPV, cardiac
PIFR Peak inspiratory flow rate ( peak inspiratory flow),
= tamponade, N: 1 0 mmHg, higher value indicating laboured
Pima>< Maximum inspiratory pressure at the mouth, See breathing,
MIP, Pump, ventilatory/respiratory Components of breathing
PIP Peak inspiratory pressure, mechanism, comprising respiratory centres, muscles and
Plasma colloid osmotic pressure N: 3.4 kPa (26 mmHg), nerves of respiration, chest wall.
Risk of pulmonary oedema: 1 .45 kPa ( I I mmHg), Purulent Containing pus,
Plasma osmolarity N: 280--300 mosmol/L, PVD Peripheral vascular disease,
Plasmapheresis Plasma exchange, PyC02 Mixed venous CO2 tension, N: 6, I kPa (46 mmHg),
-plasty Reconstruction, Py02 Mixed venous oxygen tension, N: 4,7-5.3 kPa,
Platelet count See Clotting studies, Minimum acceptable: 3,7 kPa (28 mmHg),
Platypnoea Difficulty breathing while sitting up, Pyothorax Large empyema,
Plethoric Florid complexion due to excess red blood cells, Q Volume of blood,
PM Passive movements, QALY Quality-adjusted life-year,
PN Percussion note, QOL Quality of life,
Pneumectomy Lung volume reduction surgery (cf, Q Volume of blood per unit time,
pneumonectomy, see index), Q02 Oxygen delivery (alternative abbreviation: 002),
Pneumomediastinum Air in mediastinum, Q. Shunted blood,
Pneumonitis Inflammation of lung tissue due to chemical or QT Cardiac output,
physical insult, QJQt Shunt fraction,
Pneumopericardium Air in pericardium, Radiolabelling Monitoring mucus clearance by inhalation of
P02 Partial pressure or tension of oxygen, radiolabelled aerosol and following up its clearance by
Polycythaemia Excess red blood cells due to late-stage lung gamma camera,
disease, cyanotic congenital heart disease, high-altitude living RAP Right atrial pressure,
or sleep apnoea, Raynaud's phenomenon of the lung Vasospasm in the
Polysomnography Recording of physiological parameters lungs associated with Raynaud's syndrome,
during sleep, RCV Respiratory syncytial virus,
Polyuria i urine output, i,e, > 1 00 mUh, RDS Respiratory distress syndrome,
POMR Problem oriented medical record, Relative humidity N in ambient air: 25-50%, N in upper
Postural hypotension Drop in BP of more than 5 mmHg trachea: 95%,
on moving to upright position, REM Rapid-eye-movement phase of sleep cycle,
Potassium (I<) Electrolyte in plasma or urine, N in plasma: Resection Surgical cutting out.
3 ,5-5,0 mmol/L, Resistance to gas flow through airways Spontaneous
Poudrage Pleurodesis, ventilation: 0,6-2.4 cmH20/L/s, COPD: 13- 1 8 cmH20/L/s,
PS Pressure support ventilation, During I PPV: 6 cmH20/L/s,
Psittacosis Infectious disease of birds transmitted to humans, Respiratory inductive plethysmography Spirometry for
causing atypical pneumonia, ventilated patients, including measurement of lung volume
PT See Clotting studies, to detect intrinsic PEEP,
PTCA Percutaneous transluminal coronary angioplasty, Respiratory quotient (RQ) Ratio of CO2 produced to O2
PtcC02 Transcutaneous CO2 tension, consumed, Provides a measure of energy consumption,
467
GLOSSARY
Usually < 1 .0 because expired minute volume is slightly less output) x 79.9. N: 800- 1 400 dyn.s.cm-5 Septic shock:
than inspired minute volume, less CO2 being excreted than < 300.
O2 absorbed. N: 0.7- 1 .0, depending on food eaten before Tamponade Fluid in the pericardium.
test. RQ of carbohydrate oxidation: 1 .0. RQ of fat TED Thromboembolic disease.
oxidation: 0.7. Tension-time index (TT) Measurement of muscle fatigue.
RFT Respiratory function test. Quantifies relationship between load and capacity. Indicates
Rhinitis Inflammation of mucus membrane of nose, either proportion of muscle's maximum capacity that can be
seasonal (hayfever) or perennial. sustained indefinitely. Diaphragmatic TT (TTdi) = (mean Pd,
Rhonchi Low-pitched snoring-like wheeze on auscultation, per breath/max Pdi) x T1/TTOT' TT beyond which fatigue
often related to airway secretions. occurs: 0. I S.
Rigors Bone-shaking, teeth-rattling chills. Thoracentesis Thoracocentesis, i.e. withdrawal of fluid from
ROM Range of motion pleural cavity.
RPE Rate of perceived exertion Thoracoplasty Surgery used historically for pulmonary TB,
RR Respiratory rate N: 10-20/min. involving rib resection and localized lung collapse to allow
RTA Road traffic accident. healing.
RV Residual volume. Thoracoscopy Minimal access incision through chest wall .
Sa02 Saturation of haemoglobin with oxygen in arterial blood. Thoracotomy Full surgical incision through chest wall.
N: 95-98%. Thrombocytopenia 1 platelet count.
SGAW Specific airways conductance. Thrombolysis Dissolution of thrombus.
SH Social history. TIA Transient ischaemic attack.
Shunt N: 2% of cardiac output. T.ITTOT See Duty cycle
Silent lung zone Small airways where airflow resistance is TLC Total lung capacity.
difficult to measure so that damage may not be detectable TLCO Total lung transfer capacity for carbon monoxide.
in early obstructive airways disease. TPN Total parenteral nutrition, i.e. food administered
SIMV Synchronized intermittent mandatory ventilation. intravenously.
Sinus arrhythmia Acceleration of pulse with respiration, Tracheal sounds Sounds heard on auscultation at
common in children. suprasternal notch or side of neck.
Sinusitis Inflammation of sinus cavities of face. If chronic, may Tracheal tube Endotracheal or tracheostomy tube.
cause or exacerbate some pulmonary diseases. Trendelenburg position Head down tilt.
Situs inversus Transposition of organs in chest and Tonicity Osmotic equivalence of fluids. isotonic fluids have
abdomen to the opposite side, e.g. heart on right side. same osmolality as serum or plasma, hypotonic fluids have
SLE Systemic lupus erythematosus. less, hypertonic fluids have more.
Small airways Terminal and respiratory bronchioles, i.e. Torr Measurement of pressure used in USA, equivalent to
< I mm diameter. Unsupported by cartilage, therefore mmHg.
influenced by transmitted pleural pressures. TTdi Diaphragmatic tension-time index. See tension-time
SOB Shortness of breath. index.
SOOB Sit out of bed. TTOT Total respiratory cycle.
Sodium (Na) Electrolyte in plasma or urine. N in plasma: Turbulent flow Flow that is not smooth or laminar, resulting
1 35- 1 47 mmol/L [ 1 35- 1 47 mEq/L]. in eddy currents which reduce the volume of gas moved
Somatization Distress expressed as a physical symptom. per unit of time per pressure gradient.
Splanchnic Related to viscera. Tusk mask Oxygen delivery system in which two 20 cm
Sp02 Oxygen saturation by pulse oximetry, equivalent to lengths of corrugated tubing are fitted to exhalation ports of
Sa02' oxygen mask to trap oxygen during exhalation and recycle it
Stent Device for maintaining patency of obstructed to patient during next inhalation (Hnatiuk, 1 998).
structure. Tussive Related to cough.
Sternotomy Surgical cutting through the sternum. Us & Es Urea and electrolytes.
Strength Ability of muscle to create force. Upper respiratory tract Nose (or mouth), pharynx and
Stroke volume Volume ejected from ventricle with each larynx.
beat. Dependent on preload, afterload and contractility. Urea Electrolyte in plasma or urine, formed from protein
Normally the same for each ventricle. N: 60- 1 30 mL. breakdown and excreted by kidneys. N in plasma: 3-
Subcutaneous emphysema Surgical emphysema. 7 mmol/L. Dehydration:> 8. Hypovolaemia: > 1 '8 . Kidney
Surfactant Phospholipid protein complex that lines alveoli. failure: 55.
SVR See Systemic vascular resistance. Urine output N : I mL/h/kg, average 50-60 mL/h. Renal
Sv02 See Mixed venous oxygen saturation. failure: less than half normal.
Syncope Transient loss of consciousness, e.g. faint. V Volume of gas.
Systemic vascular resistance (MAP - CVP!cardiac v Venous.
468
GLOSSARY
Valsalva manoeuvre Forced expiration against closed v Mixed venous.

glottis. Accompanies heavy resistance exercise requiring V Volume of gas per unit time, i.e. flow.
stabilization of the thorax. V50 Flow rate half-way through expiration.
VAP Ventilator-associated pneumonia. VP)Q Ratio of alveolar ventilation to perfusion. N: 0.8 (4 U
VAS Visual analogue scale. min for alveolar ventilation, 5 Umin for perfusion).
Vascath Vascular catheter, usually connecting patient to renal VC02 CO2 production. Mean fraction of expired CO2 x VE.
support. N: 200 mUmin at rest, increasing by 7% for each 1°C rise
Vasopressor Drug that causes vasoconstriction of capillaries in body temperature.
and arteries. VE (Expired) minute volume/ventilation. Also abbreviated as
VATS Video-assisted thoracoscopic surgery. MV. Expired gas is usually measured (more CO2 is
VC ( I ) Vrtal capacity; (2) volume-controlled ventilation. produced than O2 consumed).
VCIRV Volume-controlled inverse-ratio ventilation. V02 Oxygen consumption.
Vo Volume of dead space gas. N: for anatomical VD: 2 ml/kg V02l002 See Oxygen extraction ratio.
body weight. V02max Oxygen consumption at maximum exertion,
VoIVT Dead space in relation to tidal volume, calculated by reflecting aerobic capacity. Increases with frtness, declines
the Bohr equation. N : 0.3-0.4, i.e. 30-40%, depending on with advancing age but rate of decline is slower in physically
position. Critical increase: 0.6. active people. N: > 25 mL/kg/min, or 25 times resting
Venous return Blood returning to right atrium. level. See also Anaerobic threshold.
VF Ventricular fibrillation. WBC See White blood cell count.
VT Tidal volume. N: 7 mL/kg for spontaneously breathing WCPT World Confederation of Physical Therapy.
people, 7- 1 0 mL/kg for ventilated patients, up to 1 2 mL/kg Well-year of life Outcome measure incorporating morbidity
in acute respiratory failure. and mortality; for example, if disease halves quality of life
Venesection See Phlebotomy. for 2 years, patient has lost one full well-year.
Venous admixture Mixing of shunted venous blood with
9
White blood cell count N: 4- 1 0 x 1 0 /L [4 000-- 1 0 000/
oxygenated blood, i.e. mixture of 'true' shunt, which mm3]. Bacterial infection: > 1 0 OOO/mm] Vulnerability to
completely bypasses the pulmonary capillary bed, and infection: < 4000/mm]
'effective' shunt due to Ii,,/Q mismatch. N: 5% of cardiac WOB See Work of breathing.
output. Work of breathing N: 0.3-0.5 kg.m/min.
Venous thromboembolism Combined PE and DVT. Xenotran5plant Cross-species transplant.
469
ApPENDIX A: TRANSATLANTIC DICTIONARY
British North American

I st floor 2nd floor
Accident and Emergency (A&E) Emergency Room (ER)
Adrenaline Epinephrine
ASAP (as soon as possible) Stat
Cardiac arrest Code
Chest drains Chest tubes
Community care Home care
Consultant Staff person
ECG EKG
Entonox Nitronox
Frame/Zimmer Walker
Frusemide Furosemide
General practice Primary care/family practice
Hospital Health Sciences Centre/Facility
Housemanlwoman Intern
Hyoscine Scopolamine
Lignocaine Lidocaine
mmHg (unit of pressure) torr
Nil by mouth NPO (nil per as)
Paracetamol Acetaminophen
Passive movements Range of motion
Patient's notes Patient's chart
Peak expiratory flow rate Maximum expiratory flow rate
Pethidine Meperidine
Queue Line up
Referral Consult
Registrar Resident
Respiratory physiotherapist Part physical therapist, part respiratory therapist
RTA (road traffic accident) MVA (motor vehicle accident)
Salbutamol Albuterol
Sluice Utility room
Speech-language therapist Speech pathologist
Splint Cast
Stick Cane
Theatre Operating room (OR)
Trachy (tracheostomy) Trache
Walk or mobilize Ambulate
Ward Floor
4 70 --
--
ApPENDIX B: POSTURAL DRAINAGE POSITIONS
I. Upper lobes 4. Lower lobe

I (a) Apical segments of both upper lobes - sitting upright 4(a) Apical segments of both lower lobes - prone, head
I (b) Posterior segment of right upper lobe - left-side-Iying, turned to side
turned 45° towards prone 4(b) Anterior basal segments of both lower lobes - supine,
I (c) Posterior segment of left upper lobe - right-side-Iying, foot of bed raised 46 cm
turned 45° towards prone, shoulders raised 30 cm 4(c) Posterior basal segments of both lower lobes - prone,
I (d) ,Anterior segments of both upper lobes - supine head turned to side, foot of bed raised 46 cm
2. Middle lobe 4(d) Medial basal segment - right-side-Iying, foot of bed
Lateral and medial segments - supine, quarter turned to raised 46 cm
left, foot of bed raised 35 cm 4(e) Lateral basal segment - left-side-lying, foot of bed
3. Lingula raised 46 cm
Superior and inferior segments - supine, quarter turned to
right. foot of bed raised 35 cm (Reproduced with permission from Downie, P. A. (ed.) ( 1 987)
Cash 's Textbook of Chest Heart and Vascular Disorders for
Physiotherapists, Faber, London.)
L (a)
I (d)
�
4 (a) 4 (b) 4 (c)
4 (e)
471
ApPENDIX C : RESOURCES
ACPRC (Association of Chartered Physiotherapists in • Alison Gates, Churchill Hospital, Oxford. Tel: 0 1 865
Respiratory Care), c/o Chartered Society of 74 1 84 1 , bleep 5058
Physiotherapy, see below • Lynne Gumery, Birmingham Heartlands Hospital.
Action for Sick Children, Argyle House, 300 Kingston Tel: 0 1 2 1 424 2000, bleep 2742
Rd , Wimbledon, London SW20 8LX. Tel: 020 8542 • Melanie Liley, Nottingham University. Tel: 0 I 1 5 840
4848; fax: 020 8542 2424; e-mail: action-for-sick 4880
children-edu@msn.com • Paula McNaughton, Solihull Hospital. Tel: 0 1 2 1 7 1 I
Action for Victims of Medical Accidents, 44 High St, 4455, page 1 039
Croydon, Surrey CRO I YB. Tel: 020 8686 8 3 3 3 ; fax; • Maureen Rowatt, Glasgow Victoria Infirmary. Tel:
020 8667 9065; website: www .avma.org.uk 0 1 4 1 20 1 6000, bleep 3435
Air pollution information, tel: 0800 5 56677. Bird ventilator: EME, 60 Gladstone Place, Brighton BN2
Alzheimer's Disease Society, Gordon House, 1 0 3QD. Tel :0 1 273 645 1 00; fax : 0 1 273 645 1 0 I ; website:
Greencoat Place, London SW I P I PH . Tel: 020 7306 www . eme-med.co.uk
0606; fax: 020 7306 0808; email: Breathe Easy Clubs

info@alzheimers.org.uk; website: • SW EnglandlS Wales: susan@blfsw.fsnet.co.uk
www.alzheimers.org.uk • South : blf85@yahoo.com
American Association for Respiratory Care, I I 030 • London: blf@britishlungfoundation.com
Ables Lane, Dallas, TX 75229, USA. Tel: + I 972 243 • E/W Midlands: 0 1 2 1 6272260
2272; fax: + I 972 484 2720; e-mail: info@aarc.org; • E Anglia/N Home Counties:
website: www . aarc.org blf@britishlungfoundation.com
• Clinical Practice Guidelines, $35 • NW England/N Wales:
American Lung Association and American Thoracic daphne@blfnw.freeserve .co.uk
Society, 1 740 Broadway, New York, NY 1 00 1 9-4374, • N E EnglandIYorks: margaretbn@currantbun .com
USA. Tel: + I 2 1 2 3 1 5 8700; e-mail: info@lungusa.org; • Scotland: redballoon@blfscotland.org.uk
website: www .lungusa.org British Cardiac Patients Association (BCPA Zipper
ASH (Action on Smoking and Health), 1 02 Clifton St, Club, 6 Rampton End, Willingham, Cambs CB4 5JB).
London EC2A 4HW. Tel: 020 7739 5902; fax: 020 Helpline 0 1 223 846845
76 1 3 053 1 ; website: www .ash.org.uk; e-mail: British Heart Foundation, 1 4 Fitzhardinge St, London
action .smoking. health@dial. pipex.can (campaigning W I H 4DH. Tel: 020 7935 0 1 85 ; website:
organization, not for smoking cessation advice). www. bhf.org.uk
Government official helpline for those needing advice: British Lung Foundation, 78 Hatton Gardens, London
0800 1 69 0 1 69 EC I N 8JR. Tel: 020 783 I 583 I ; fax: 020 783 1 5832;
Asthma and Allergy Foundation of America, 1 23 3 website: www . lunguk.org
20th Street N W , Suite 402, Washington, DC, USA. Tel: • self-help groups, see Breathe Easy Clubs, above
+ I 202 2650265. • travel insurance
Asthma booklets and diaries: • Lung and Asthma Information Agency -
• National Asthma Campaign see below. epidemiological database for health staff
• Allen & Hanburys, Uxbridge, Middlesex UB I I I BT. British Thoracic Society Tel: 020 783 1 8778; fax 020
Tel: 020 8990 9888; fax : 020 8990 432 1 ; website: 783 1 8766; www . brit-thoracic. org. uk.
www . glaxowellcome .co.uk. Canadian Lung Association, Suite 908, 75 Albert St,
Asthma Society of Canada, PO Box 2 1 3, Station K, Ottawa, Ontario KIP 5E7. Tel: + I 6 1 3 237 1 208.
Toronto, Ontario M4P 2G5. Tel: + 1 4 1 6 977 9684. Cancer booklets on breathlessness: Institute of Cancer
Audiovisual Medical Library (Graves), 20 I Felixstowe Research, Royal Marsden Hospital, London SW3 6JJ .
Rd , I pswich I P3 9BJ. Tel: 0 1 473 7260 1 2; website: Tel: 020 7352 8 1 7 1 ; website:
www .namron.demon.co.uk www . royalmarsden.org.uk/patientinfolindex.asp
Autogenic drainage specialist physiotherapists: Cancer support groups

• Christine Atkinson, Hull Royal Infirmary. Tel: 0 1 482 • BACUP (British Association of Cancer United
674539 Patients), 3 Bath Place, London EC2A 3 DR. Tel:
472
APPENDIX C: RESOURCES
020 76 1 3 2 1 2 1 : fax : 020 7696 9002: freeline no.: 4 1 4969: fax: (general) 0 1 279 635232, (respiratory)
0808 800 1 234: e-mail: info@cancerbacup.org.uk: 0 1 279 456304: website: www . clement-clarke .com
website: www .cancerbacup.org.uk Footdrop silicone orthoses: Dorset Orthopaedic Co.

• Cancerlink, I 1 -2 1 Northdown St, London N I Ltd , I I Headlands Business Park, Salisbury Road ,
9BN. Tel: 020 7833 28 1 8 : fax: 020 7833 4963: Ringwood, Hants BH24 3PB. Tel: 0 1 425 480065:
helpline: 0808 2080000 (Mon, Wed , Fri 0900- fax: 0 1 425 480083 : website:
1 700): e-mail: cancerlink@cancerlink.org: website: www . dorset-ortho.co.uk
www.cancerlink.org Glossopharyngeal breathing video: B. A Webber,

Cancer websites Sunnybank, The Platt, Amersham, Bucks H P7 OHX.
• www.cancerfatigue.org Tel: 0 1 494 725724. £.20
• www. webhealing.com Guillain-Barre Syndrome support group, LCC Offices,
• www.scu.edu/Hospice Eastgate , Sleaford , Lincs NG34 7EB. Helpline 0800
• www.langara.bc.ca/vnc/suffer2.htm 374803 (24 hours). Tellfax: 0 1 529 3046 1 5 : website:
Carers National Association, 20 G lasshouse Yard, www.gbs.org.uk
London EC I A 4JS. Tel: 020 7490 88 1 8 : fax: 020 7490 Headway (head injuries organization), 4 King Edward
8824 Court, King Edward St. Nottingham NG I I t!N. Tel:
Chartered Society of Physiotherapy, 1 4 Bedford Row, 0 1 1 5 9240800: fax: 0 I 1 5 9584446
London WC I R 4ED. Tel: 020 7306 6666: fax: 020 Hospices www. hospiceinformation.co.uk
7306 66 1 I : e-mail: csp@csphysio .org.uk: website : Humidifiers:
www.csp.org.uk • Sunrise Medical, Wollaston, W . M idlands DY8 4PS.
Chest drain booklet Sherwood Davies Geck. Tel: 0 1 329 Tel: 0 1 384 446688: fax: 0 1 3 84 446699: website:
224 1 1 4: fax 0 1 329 224390. www.sunrisemedical .com
Cinnamon Trust (residential homes that welcome pets), • Fisher & Paykel, 1 6 Cordwallis Park, Clivemont Rd ,
Foundry House, Foundry Square, Hayle, Cornwall Maidenhead, Berks SL6 7BU. Tel : 0 1 628 626 1 3 6:
TR27 4HE. Tel: 0 1 736 757900: fax 0 1 736 7570 1 0: fax: 0 1 628 626 1 46: website: www.FPHcare.com
website: www.cinnamontrust.co.uk • I ntersurgical , Crane House, Molly Millars Lane,
Continence Foundation, 307 Hatton Square, Wokingham, Berks, RG4 1 2RZ. Tel: 0 I 1 8
1 6 Baldwins Gardens, London EC I N 7RJ . Tel: 020 9795579: fax: 0 I 1 8 9656356: website:
7404 6875: helpline: 020 783 1 983 1 (Mon-Fri 0930- www . i ntersurgical .co.uk.
1 630): website: • Kendall, 1 54 Fareham Road , Gosport, Hants PO 1 3

www .continence .foundation@dial .pipex.com OAS. Tel: 0 1 329 224 1 1 4: fax: 0 1 329 224390:
Cough 10k (coughing aid for postoperative patients) website : www .tyco.com (also video)
Hawksley & Sons, Marlborough Road, Lancing, West • Medicaid, Heath Place, Bognor Regis, West Sussex
Sussex BN I 5 8TN. Tel: 0 1 903 7528 1 5 : fax: 0 1 903 P022 9SL. Tel: 0 1 243 846 1 1 1 : fax: 0 1 243 846 1 00:
766050: website: www . medic-aid.com
e-mail: enquiries@hawksley.co.uk: website: Incentive spirometers:

www.hawskley.co.uk • Kendall, see Humidifiers
Cystic Fibrosis Guidelines Clinical Guidelines for • I ntersurgical, see Humidifiers (also filters for
Physiotherapy Management of Cystic Fibrosis (200 I ). Eds incentive spirometers)
Gumery LB, Pryor, J . , Prasad , S. A , Dodd , M. Available Information for patients:
from Chartered Society of Physiotherapy. • J. A. M. A. Patient Pages website: www.ama
Cystic Fibrosis Research Trust and Association of assn .orgiconsumer.htm
Cystic Fibrosis Adults, I I London Rd , Bromley, Kent • see Support groups
B R I I BY. Tel: 020 8464 72 1 1 : fax: 020 83 1 3 0472: Inhaler tester for assessing inspiratory flow: Clement
website: www . cftrust.org.uk. Clarke , see Flutter
Elder Abuse helpline, 0800 73 1 4 1 4 1 ( 1 000- 1 630). Inspiratory muscle trainers:
Facial disfigurement support network (Let's Face It), 1 4 • Clement Clarke, see Flutter
Fallowfield, Yateley, Hants GU46 6 LW. Tellfax: 020 • Medicaid, see Humidifiers
8952 4990: www . letsfaceitforce9.co.uk • Henleys, 39 Brownfields, Welwyn Garden City,
Flutter video and information: Clement Clarke, Herts AL7 I AN . Tel: 0 1 707 333 1 64 : fax: 0 1 707
Edinburgh Way, Harlow, Essex CM20 2TT. Tel: 0 1 279 334795: website: www. henleysmed.com.
------ 473
APPENDIX C: RESOURCES
• Sunrise Medical, see Humidifiers patient education): Lane Fox Unit, St Thomas' Hospital,
• Tangent Healthcare, 74 Roman Bank, Long Sutton, London SE I 7EH . £ 1 2 each
Lincs PE 1 2 9LB. Tellfax: 0 1 945 880008; website: Non-invasive ventilators:
www .ultrabreathe.com. • AirMed, 33 Half Moon Lane, Heme Hill, London
Kolaczkowski video: Waldemar Kolaczkowski, SE24 9JX. Tel: 020 7737 588 1 ; fax: 020 7737
Physiotherapy Dept, St Michael's Hospital , Toronto , 5234; website: www . airmedltd.com
Ontario, Canada. £50 • Medicaid, see Humidifiers

Laryngectomy support group: National Association of • PneuPAC, Bramingham Business Park, Enterprise
Laryngectomee Clubs, 6 Rickett St, London SW6 I RU. Way, Luton, Beds LU3 4BU . Tel: 0 1 582 430000;
Tel: 020 73 8 1 9993 ; fax: 020 738 1 0025. fax: 0 1 582 43000 I ; website: www. pneupak.co.uk.
Listening books for housebound people: 1 2 Lant St, • ResMed, 67B Milton Park, Abingdon, Oxon OX I 4
London SE I I QH . Tel: 020 7407 94 1 7; fax: 020 7403 4RX. Tel: 0 1 23 5 862997; fax: 0 1 235 83 1 336;
1 377; website: www . listening-book.org.uk website: www.resmed .com.au
Liver patients support group : The British Liver Trust, Oscillator: Hayek, Breasy Medical Equipment Ltd , 9
Central House, Central Avenue, Ransomes Europark, Burroughs Gardens, London NW4 4AU. Tel: 020 8203
I pswich I P3 9QG . Tel: 0 1 473 276326; fax : 0 1 473 6877; fax: 020 8203 4758.
276327; website: www .britishlivertrust.org.uk. Oxygen equipment:
Mallinckrodt (tracheostomy tubes, suction catheters, • Oxygen Therapy Company, Shearwater House,
ventilators, oximeters, heat-moisture exchangers), 1 0 Ocean Way, Cardiff CF I 5HF. Tel: 0800 373580;
Talisman Business Centre, London Rd , Bicester, fax: 0 1 222 488255; e-mail:
Oxfordshire OX26 6HR. Tel: 0 1 869 322700; fax: bucklei@oxygentherapy.co.uk (Uving with Oxygen
0 1 869 3 2 1 890; website: www .mallinckrodt.com. booklet, liquid oxygen, concentrators, holiday
Manometer for testing bag-squeezing pressures: Vital oxygen service)
Signs, The Sussex Business Village, Lake Lane, Famham, • BOC Customer Service Centre, Priestley Road,
W. Sussex P022 OAL. Tel: 0 1 243 555300; fax: 0 1 243 Worsley, Manchester ME28 2UT. Tel: 0800 I I I
555400; website: www .vital-signs.com. 333.
Minitracheostomy: SIMS Portex Ltd , Hythe, Kent, CT2 1 • ATS Medirent. Tel: 0 1 344 477777; fax: 0 1 344
6J L. Tel: 0 1 303 26055 1 ; fax: 1 0303 265560; website: 477789 (liquid oxygen rental)
www . portex.com (also videos) • Life Support Ltd , 4 Stavely Road , Dunstable,
Motor Neurone Disease Association, PO Box 246, Beds LU6 3QQ. Tel: 0 1 582 6626 1 6;
Northampton N N I 2PR. Tel: 0 1 604 250505; fax : fax: 0 1 582 665289 (portable oxygen-conserving
0 1 604 624726, helpline 08457 626262; 24 hrs 0 1 64 cylinders)
22269; e-mail: enquiries@mndassociation .org; website: • Omnicare. Tel: 0500 823773.
mndassociation .org • Sunrise Medical, see Humidifiers
• Breathing Space Kit to reduce fears in final stages of Oximeters (portable) for exercise:
disease • Life Support Ltd , see Oxygen equi pment finger
• leaflets on communication, swallowing, oximeter
physiotherapy, dying • Stowood Scientific Instruments, Royal Oak Cottage,
• Resource file £ I 0 Beckley, Oxford OX3 9UP. Tellfax: 0 1 865 358860;
Myasthenia Gravis Association Tel : 0 1 33 2 2902 1 9 . website: www .stowood.co.uk (wrist oximeter).
National Asthma Campaign , Providence House, • Sunrise Medical, see Humidifiers
Providence Place, London N I ONT. Tel: 020 7226 • see Mallinckrodt (belt oximeter)
2260, helpline 08457 0 I 0203 (Mon-Fri 0900- PEP devices:
2 1 00); fax: 020 7704 0740; website: • Astra T ec, Brunei Way, Stonehouse, Glos G I 0 3SX.
www .asthma.org.uk. Tel: 0 1 453 79 1 763 ; fax: 0 1 453 79 1 00 1 ; website:
National Heart, Lung and Blood Institute , Building www .astratecuk.com
3 1 , Room 4A 1 8 , National Institutes of Health, Bethesda, • Astra Tec Inc, 1 000 Winter St, Suite 2700,
MD 20982, USA. Website: nhlbi .nih .gov Waltham, MA 02 1 54, USA
NICE National Institute for Clinical Excellence: • Henleys, see Inspiratory muscle trainers
www .nice.org.uk • Medicaid, see Humidifiers
Non-invasive ventilator videos (for staff training and Polio support group: British Polio Fellowship, Eagle Office
4 74
APPEND I X C: RESOURCES
Centre , South Ruislip, M iddlesex HA4 6SE. Tel: 020 fax: 020 7490 2686; e-mail: strok@stroke.org. uk;
8842 1 898; fax: 020 8842 0555; e-mail: website: www .stroke .org. uk.
british . polio@dial.pipex.comlinfo@britishpolio.org • booklet on swallowing

• list of articles on exercise and post-polio Suction videos:
syndrome • Maersk Medical, Thomhill Rd, North Moons Moat,
Postoperative pain video and booklet: I nstitute of Health Redditch , Worcs B98 9 N L. Tel: 0 1 527 64222; fax:
and Community Studies, UK. lA5 0 1 527 592 1 I I ; website: www. maersk-medical.com
Primary ciliary dyskinesia family support group, 67 • Vygon, Bridge Road, Ci rencester, Glos GL7 I PT.
Evendons Lane, Wokingham, Berks RG4 1 4AD; Tel: 0 1 285 65705 1 ; fax: 0 1 285 650293 ; e-mail:
www. p-c-d.org.uk (also video). vygon@vygon .co.uk
Quality of Life assessment: www . qlmed.org. Support groups website (2000 UK groups):
Quit (smoking cessation), Victory House, 1 70 Tottenham www .surgerydoor.co . u k
Court Road , London W I T 7NR,. Tel: 020 7388 5775, Swallowing booklets: see Motor Neurone Disease
helpline 0800 002200; fax: 020 7388 5995; website : Association and Stroke Association
www. quit.org.uk Thermocydopad (back pad), Niagara Therapy UK Ltd ,
Shuttle audio tape and booklet, Sally Singh, Pulmonary Middleton House, 43-49 High Street, Horley, Surrey,
Rehabilitation Dept, University Hospital of Leicester, RH6 7BN. Tel: 0 1 293 787040; fax: 0 1 293 782 006; e
G roby Road , Leicester LE3 9QP. Tel: 0 1 1 62 87 1 47 1 mail: Cctherapy@niagaraholdings.co.uk
Spinal Injuries Association, Newpoint House, 76 St Tracheostomies in children: Aid for Children with
James Lane, London N I 0 3DF. Tel: 020 8444 2 1 2 1 ; Tracheostomies, 2 1 5a Perry St, Billericay, Essex CM 1 2
fax: 020 8444 376 1 ; e-mail: sia@spinal .co.uk; website: ONZ. Audiotape from Mallinckrodt
www. spinal.co.uk Tracheostomy audiotapes and booklet: see Mallinckrodt
Stroke Association, Stroke House, 1 23- 1 37 Whitecross Yankauer substitute with soft tip - Meddis. Tel: 0 1 49 1
St, London EC I Y 8JJ . Tel: 020 7566 0300; 825500; fax 0 1 49 1 826600, ngough@meddis.co.uk.
4 75
ApPENDIX D: ARTICLES ON PATIENTS' EXPERIENCES
Bevan, P. G. ( 1 964) Cholecystectomy in a surgeon. Lancet, i, Marsh, B. ( 1 986) A second chance. Br. Med. }. , 292, 675-676.
2 1 4- 2 1 5. Moore, T. ( 1 99 1 ) Cry of the Damaged Man. Picador, Sydney.
Bevan, J. R. ( 1 969) Polyneuropathy. Lancet, i, 1 3 1 0. Neuberger, J. ( 1 99 1 ) The patient's viewpoint. Respir. Med. ,
Bowes, D. ( 1 984) The doctor as patient: an encounter with 8S(suppl. B), 53-56.
Guillain-Barre syndrome. Can. Med. Assoc. ). , 1 3 1 , 1 343- Nicholson, E. M. ( 1 975) Personal notes of a laryngectomee.
1 348. Am. ). Nurs., 7S( 1 2), 2 1 57-2 1 58.
Brooks, D. H. M. ( 1 992) Living with ventilation: confessions of Nursing Times ( 1 98 1 ) Who am I? Where am I? Why do I hurt
an addict. Care Crit. 11/, 8, 205-207. so much? Nurs. Times, 77( 1 5), 633-635.
Carter, B. ( 1 995) An asthmatic in 'Wonderland': a patient's Oermann, M. H. ( 1 983) Mer a tracheostomy: patients describe
perspective. Accid. Emerg. Nurs., 3, 1 39- 1 4 1 . their sensations. Cancer Nurs. , 6, 36 1 -366.
Castledine, G . ( 1 993) A personal view of asthma. Br } Nurs. ,
. . Peloquin, S. M. ( 1 995) The depersonalization of patients. Am. ).
2, 9 1 9. Occup. Ther. , 47, 830-837.
Clark, K. J. ( 1 985) Coping with Guillain-Barre syndrome. Intens. Pisetsky, D. S. ( 1 998) Doing everything. Ann. Intern. Med., 1 28,
Care Nurs., I , 1 3- 1 8. 869-870.
Cornall, A. ( 1 995) Pulmonary rehabilitation: a patient's Redfern, S. ( 1 985) Taking some of my own medicine. Care Crit.
experience. ACPRC ). , 26, 1 0- 1 I . 11/, 1 , 6-7.
Farrow, J . ( 1 995) Cystic fibrosis - it's a funny name. Respir. Dis. Rosen, A. ( 1 998) Last on the list. Br. Med. ). , 3 1 6, 1 324- 1 325.
Pract. , 1 2( I ), 5-6. Ruiz, P. A. ( 1 993) The needs of a patient in severe status
Gandy, A. P. ( 1 968) An attack of tetanus. Lancet, ii, 567-568. asthmaticus. Intens. Crit. Care Nurs., 9, 28-39.
Gordon, S. ( 1 998) Letter to a patient's doctor. Ann. Intern. Shovelton, D. S. ( 1 979) Reflections on an intensive therapy unit.
Med., 1 29, 333-334. Br. Med). , ii, 737-738.
Heath, J. V. ( 1 989) What the patients say. Intens. Care Nurs. , S, Standing, C. ( 1 987) The treatment of our son with cystic
1 0 1 - 1 08. fibrosis.). Roy. Soc. Med., 80(suppl. 1 5), 2-4.
Holden, T. ( 1 980) Patiently speaking. Nurs. Times, 76(24), Stead, C. E. ( 1 999) Sudden infant death syndrome (5IDS) on
1 035- 1 036. the 'other side'. Accid. Emerg. Nurs., 7, 1 70- 1 74.
Houston, J. E. ( 1 988) Physiotherapy from a patient's point of Thomson, L. R. ( 1 973) Sensory deprivation: a personal
view. S. Afr. ). Physiother., 44, 38-4 1 . experience. Am. ). Nurs. , 73 , 266--268.
Jablonski, R. S. ( 1 994) The experience of being mechanically Ulbright, G. F. ( 1 986) Laryngectomy rehabilitation: a woman's
ventilated. Qual. Health Res. , 4, 1 86-207. viewpoint. Women Health, I I , 1 3 1 - 1 36.
Khadra, M. H . ( 1 998) What price, compassion? Med. ). Austr. , Villaire, M . ( 1 995) ICU from the patient's point of view. Crit.
1 69, 42-3 . Care Nurse, I S( I ), 80-87.
Kinnear, W. J. M. ( 1 994) A patient's view of living with a While, A. ( 1 985) Personal view. Br. Med. ). , 29 1 , 343.
ventilator, in Assisted Ventilation at Home - a Practical Wilkinson, J. ( 1 987) The experience and expectations of parents
Guide, Oxford Medical Publications, Oxford, ch. 8, pp. 85- of a child with cystic fibrosis. ). Roy. Soc. Med., 80(suppl.
93. 1 5), 7-8.
Lancet ( 1 969) At the receiving end. Lancet, ii, I 1 29- 1 1 3 1 . Zimmerman, M. D., Appadurai, K. and Scott, J. G. ( 1 997)
Lancet ( 1 969) Cardiac arrest. Lancet, ii, 262-264. Survival. Ann. Intern. Med. , 1 27, 405-408.
Lawrence, M. ( 1 995) The unconscious experience. Am. ). Crit.
Care, 4, 227-232.
4 76
APPENDIX E: REFERENCES ON OUTCOME MEASURES FOR
PULMONARY REHABILITATION
Outcomes bulletted Gallefoss, F. and Bakke, p, S. ( 1 999) How does patient

education and self-management among asthmatics and
ACCP/AACVPR ( 1 997) Pulmonary rehabilitation: joint ACCP/ patients with COPD affect medication? Am. j. Respir. Crit.
AACVPR evidence-based guidelines, Chest, 1 1 2, 1 363-
Care Med. , 1 60, 2000-2005.
1 396,
• 1 �2-agonist medication.
• ' l SOB, 1 hospital days and 1 total no,
hospitalizations Garrod, R. ( 1 998) The pros and cons of pulmonary
rehabilitation at home. PhYSiotherapy, 84, 603-607.
Ambrosino, N, and Foglio, K, ( 1 996) Selection criteria for
• J ET by 24%
pulmonary rehabilitation. Respir. Med. , 90, 3 1 7-322,
• elderly people: t flexibility, strength, fitness Giddings, D. j . ( 1 994) Outcome evaluation of a respiratory
rehabilitation program. Physiother. Can. , 46(2suppl.), 8 1
Bax, j. ( 1 997) Long-term effects of an out-patient pulmonary
• J ET, i ADL
rehabilitation programme in patients with asthma and
COPD. fur. Respir. j. , 1 0, 4S8S. Griffiths, T. L., Gregory, S. E. and Ward, S. A ( 1 996) Effects of
• t ET and t QoL, still maintained after 3 years a structured domiciliary exercise training programme on
quality of life and walking tolerance in patients with severe
Bendstrup, K. E. ( 1 997) Out-patient rehabilitation improves
COPD. fur. Respir. j. , 9(23), I 44s.
activities of daily living, quality of life and exercise tolerance
in COPD. fur. Respir. j. , 1 0, 280 1 -6. • severely impaired patients: i ET, i QoL
• i ADL, QoL, ET Griffiths, T. L., Burr, M. L. and Campbell , I. A (2000) Results at
Cambach, W" Wagenaar, R. C. and Koelman, T. W. ( 1 999) I year of outpatient pulmonary rehabilitation: a randomised
The long-term effects of pulmonary rehabilitation in patients controlled trial. Lancet, 3 55, 362-368.
with asthma and COPD. Arch. Phys, Med. Rehabil. , 80, • 1 hospitalisations by half
1 03- 1 1 1 .
Haas, F. and Axen, K. ( 1 99 1 ) Pulmonary Therapy and
• J ET, i QoL Rehabilitation, Williams & Wilkins, Baltimore, MD, p. 336.
Celli, B, R. ( 1 995) Pulmonary rehabilitation in patients with • cost savings > $2600 per patient/year
COPD. Am. j. Respir. Crit. Care Med. , 1 52, 86 1 -864,
Haggerty, M, C. ( 1 999) Functional status in pulmonary re
• J ET, i QoL
habilitation participants. j. Cardiopulmonary Rehabil. , 1 9 , 35-
Clark, C. j., Cochrane, L. and Mackay, E. ( 1 996) Low intensity 42,
peripheral muscle conditioning improves exercise tolerance • J ET, i functional status
and breathlessness in COPD. fur. Respir. j. , 9, 2590-2596.
• i endurance, i ADL, 1 SOBOE Heijerman, H. G. M. ( 1 992) Long-term effects of exercise
training and hyperalimentation in adult CF. Int. j. Rehabil.
Didour, M. ( 1 997) Effects of lung cycle ergometer training in Res. , 1 5, 252-257.
elderly patients with bronchial asthma. fur. Respir. j. , 1 0, • CF: transplantation no longer needed in some
458S, patients
• elderly patients with asthma: J ET, t QoL
Hodgkin, j. E., Bartolome, R. , Celli, B, R., Connors, G. L.
Flanigan, K. S. ( 1 99 I) Outcome of a 3-day pulmonary (2000) Pulmonary Rehabilitation: Guidelines to Success, 3rd
rehabilitation programme. Respir. Care, 36, 1 27 1 . edn. Lippincott Williams & Wilkins, Philidelphia, PA
• short programme: i ADL, i confidence. • 1 costs, 1 hospitalisations
Foglio, K., Bianchi, L. and Bruletti, G. ( 1 999) Long-term
Lacasse, Y., Wong, E. and Guyatt, G. H. ( 1 996) Meta-analysis
effectiveness of pulmonary rehabilitation in patients with
CAO. fur. Respir. j. , 1 3 , 1 25- 1 32. of respiratory rehabilitation in COPD. Lancet, 348, I I 1 5-
1 1 1 9.
• i QoL, maintained I year after rehabilitation
• 1 4 trials showed i ET, i QoL
Fulambarker, A, Lund, 0 , and Chandok, S, ( 1 995) Effect of
pulmonary rehabilitation on hospital days of COPD patients. Make, B, ( 1 990) Pulmonary rehabilitation - what are the
Chest, I 1 4S, outcomes? Respir. Care, 35, 329-33 1 ,
• 1 admissions, 1 length of stay • literature review of outcomes
477
ApPENDIX E: REFERE CES ON OUTCOME MEASURES FOR PULMONARY REHABILITATION
Make, B. ( 1 994) Collaborative self-management strategies for outcomes in patients with COPO. Ann. Intem. Med. , 1 22 ,
patients with respiratory disease. Respir. Care, 39, 566- 823-832.
577. • 1 symptoms, i ET
• i workload by 30%, i V02 max by 9.2%, i 6 -
Schleifer, T. J. ( 1 994) Patient responsibility in an innovative
minute distance by 2 1 %, i ADL, i social and
COPO therapy program. Physiother. Can. , 46(2suppl.), 8 1 .
emotional function • for severe disease: i ADL, 1 exacerbations, 1
Murray, E. ( 1 993) Anyone for pulmonary rehabilitation? anxiety
Physiotherapy, 79, 705-7 1 0. Sridhar, M. K. ( 1 997) Pulmonary rehabilitation. Br. Med. j. , 3 1 4,
• i IT, 1 hosp, 1 symptoms, 1 anxiety and 1 36 1 .
depression, i QoL • i QoL, i IT, 1 SOB, i control
Novitch, R. S. ( 1 995) Pulmonary rehabilitation in patients with Tanaka, M. ( 1 999) Paced breathing exercises for patients with
interstitial lung disease. Am. j. Respir. Crit. Care Med. , 1 5 1 , chronic respiratory failure. WCPT Proc. , p. 3 1 2.
A684. • RR 1 from 2 1 /min to 1 6/min average
• interstitial lung disease: i IT and arm ergometry.
Votto, J . , Bowen J. and Scalise, P. ( 1 996) Short-stay
Ojanen, M . ( 1 993) Psychosocial changes in patients participating comprehensive inpatient pulmonary rehabilitation for
in a COPO rehabilitation program. Respiration, 60, 96- 1 02. advanced COPO. Arch. Phys. Med. Rehabil. , 77, I I 1 5-
• i well-being, 1 symptoms 1 1 1 8.
• i 1 2-minute distance by 66%, ADL i by 39%, SOB
Parker, L. and Walker, J . ( 1 998) Effects of a pulmonary 1 by 65%
rehabilitation program on physiologic measures, quality of
life and resource utilization. Respir. Care, 43, 1 77- 1 82. Young, P., Oewse, M . and Fergusson, W. ( 1 999)
• i QoL, 1 costs Improvements in outcomes for COPO attributable to a
hospital-based respiratory rehabilitation programme. Austr.
Revill, S. M . , Morgan, M. O. L. and Singh, S. J. ( 1 999) The NZj. Med. , 29, 59-66.
endurance shuttle walk. Thorax, 54, 2 1 3-222. • 1 need for steroids, 1 hospitalisations
• i endurance
ADL = activities of daily living; ET exercise tolerance; QoL
= =
Ries, A. L., Kaplan, R. M. and Limberg, T. M. ( 1 995) Effects of quality of life; RR respiratory rate; SOB
= = shortness of
pulmonary rehabilitation on physiologic and psychosocial breath; SOBOE shortness of breath on exertion.
=
478
ApPENDIX F: CONVERSIONS
Conversion of kilopascals (kPa) to millimetres of

mercury (mmHg)
Multiply by 7.5. i .e. mmHg = kPa x 7.5.
mmHg kPa
3.8 0.5
7.5 1 .0
15 2.0
22.5 3.0
26.3 3.5
30 4.0
33.8 4.5
37.5 5.0
45 6.0
48.8 6.5
52.5 7.0
60 8.0
67.5 9.0
75 1 0.0
82.5 1 1 .0
90 1 2.0
97.5 1 3 .0
1 00 1 3.3
1 05 1 4.0
1 12 1 5.0
1 20 1 6.0
1 28 1 7.0
1 35 1 8.0
1 42 1 9.0
1 50 20.0
225 30.0
300 40.0
Conversion of millimetres of mercury (mmHg) to

centimetres of water (cmH20):
Divide by 0. 1 33 .
mmHg cmH20
5 6.8
10 1 3.6
20 27.2
30 40.7
40 54.3
4 79
ANNOTATED BIBLIOGRAPHY
AACVPR ( 1 998) Guidelines for Pulmonary Instructions for Surgical Patients, Saunders,
Rehabilitation Programs, 2nd edn, American London.
Association of Cardiovascular and Pulmonary • Information sheets to photocopy for patients
Rehabilitation, Illinois. French, W. A. (2000) Case Profiles in Respiratory
• Comprehensive, detailed documentation Care, 2nd edn, Delmar, Canada.
Adam, S. K. and Osborne, S. ( 1 9 97) Critical Care • Aimed at respiratory therapists: case studies,
Nursing: Science and Practice, Oxford University thought-provoking questions
Press, Oxford. Fried, R. ( 1 999) Breathe Well and Be Well, John
• Detailed anatomy and physiology, flow charts Wiley, New York
on pathology, definitions, nursing procedures • Populist guide to mind-body interaction
explained Frownfelter, D. L. and Dean, E. ( 1 996) Principles and
Aloan, C. A. and Hill, T. V. ( 1 995) Respiratory Care Practice of Cardiopulmonary Physical Therapy, 3rd
of the Newborn Child, 2nd edn, J. B. Lippincott, edn, Mosby, Chicago, IL.
Philadelphia, PA, 592 pp. • American approach, detailed
• Diseases, assessment, physiotherapy, oxygen, Goetzman, B. W. and Wennberg, R. P. ( 1 999)
IPPV, home care Neonatal Intensive Care Handbook, 3rd edn,
Anderson, I. D. ( 1999) Care of the Critically III Surgical Mosby, St Louis, MO.
Patient, Edward Arnold, London, 224 pp. • Diseases, procedures, oxygen, CPAP, IPPV
• Respiratory failure, shock, sepsis, multiple Grace, P. A. and Borley, N. R. ( 1 999) Surgery at a
injuries, nutrition, pain management Glance, Blackwell, Oxford
Bird, B., Smith, A. and James, K. ( 1 998) Exercise • Two pages per topic, includes diagrams
Benefits and Prescription. Stanley Thomes, Habel, A. and Scott, R. ( 1998) Notes on Paediatrics:
Cheltenham. Cardiorespiratory Disease, Butterworth
• Application to different conditions Heinemann, London.
Bourke, S. J. and Brewis, R. A. L. ( 1 998) Lecture • Concise
Notes on Respiratory Medicine, Blackwell Science, Hodgkin, J. E., Bartolome, R., Connors, G. L. and
Oxford, 2 1 6 pp. Celli, B. R. (2000) Pulmonary Rehabilitation:
• Accessible style, clearly written. Guidelines to Success, 3rd edn, Lippincott
Bradley, D. ( 1 998) Hyperventilation Syndrome, Williams & Wilkins, Philadelphia, PA.
revised edn, Kyle Cathie, London. Jefferies, A. and Turley, A. ( 1999) Crash Course:
• Readable and informative, essential reading for Respiratory System, Mosby, London.
patients • Bullet lists, flow charts, condensed
Brostoff, J. and Gamlin, L. ( 1 999) Asthma: The information, easy reading, few references
Complete Guide. Bloomsbury, London. Kinnear, W. J. M. ( 1997) Lung Function Tests: A
• Comprehensive guide for patients Guide to their Interpretation, Nottingham
Cairo, J. M. and Pilbeam, S. P. ( 1 999) McPherson's University Press, Nottingham.
Respiratory Care Equipment, 6th edn, Mosby, St • Commonly used tests plus blood gases,
Louis, MO. exercise testing, respiratory muscle function
• Clinically oriented Kinnear, W. J. M., Johnston, I. D. A. and Hall, I. P.
Corne, J., Carroll, M., Brown, I. and Delany, D. ( 1 999) Key Topics in Respiratory Medicine, Bios
( 1 997) Chest X-ray Made Easy, Churchill Scientific Publications, Oxford.
Livingstone, Edinburgh. • Diseases, symptoms, treatments, in
• Pocket-sized, simple, clearly written alphabetical order
Croft ,T. M., Nolan, J. P. and Parr, M. J. A. ( 1 999) Lehrer, S. ( 1 993) Understanding Lung Sounds, 2nd
Key Topics in Critical Care, Bios Scientific edn, W. B. Saunders, London.
Publications, Oxford. • Book and audiotape
• Disorders, symptoms, treatments Levitzky, M. G. ( 1 999) Pulmonary Physiology, 5th
Economou, S. G. and Economou, T. S. ( 1999) edn, McGraw Hill, New York.
480
ANNOTATED BIBLIOGRAPHY
• Short, logical, clear between chapters, little information on

Luce, J. M., Pierson, D. J. and Tyler, M. L. ( 1 993) breathlessness management or ADL
Intensive Respiratory Care, 2nd edn, W. B. Singer, M. and Webb, Q. ( 1 997) Oxford Handbook of
Saunders, London. Critical Care, Oxford University Press, Oxford.
• Basic level, well written, poorly referenced • Pocket-size, packed with facts and figures
Lumb, A. B. (2000) Nunn's Applied Respiratory including drugs; useful to keep in the ICU
Physiology, 5th edn, Butterworth-Heinemann, Smith, M. and Ball, V. ( 1 998) Cardiovascular/
London. Respiratory Physiotherapy, Mosby, London.
• . Comprehensive respiratory physiology • Emphasis on the acute patient, well illustrated,
Milne, A. ( 1 998) Smoking: The Inside Story, good coverage of research and audit
Woodside, Stafford. Smith, T. ( 1 9 94) Coping with Bronchitis and
• Packed with ammunition to dissuade smokers Emphysema, Sheldon, London.
Morgan, M. and Singh, S. ( 1 997) Practical Pulmonary • For patients, UK approach
Rehabilitation, Edward Arnold, London. Stillwell, S. B. ( 1 998) Quick Critical Care Reference,
• Practical manual 3rd edn, Mosby, St Louis, MO.
Nicholls, A. and Wilson, I. (2000) Perioperative • Tiny book with formulae, normal values,
Medicine, Oxford University Press, Oxford. criteria, diagrams
• High-risk surgical patients with medical Sykes, K. and Young, D. ( 1999) Respiratory Support
diseases, pocket size in Intensive Care, 2nd edn, BMJ Publishing,
Oh, T. E. ( 1 997) Intensive Care Manual, 4th edn, London.
Butterworth-Heinemann, London. • Invasive and non-invasive ventilation
• large, international perspective, clearly written Timmons, B. H. and Ley, R. ( 1994) Behavioral and
Orenstein, D. M. ( 1 997) Cystic Fibrosis: A Guide for Psychological Approaches to Breathing Disorders,
Patient and Family, 2nd edn, Lippincott-Raven, Plenum Press, New York.
New York. • Comprehensive information on
• Pathology, airway clearance (emphasis on PD hyperventilation syndrome
and manual techniques), organizations Vincent, J. L. (2000) Yearbook of Intensive Care and
Paw, H. G. W. and Park, G. R. (2000) Handbook of Emergency Medici1fe, Springer, New York.
Drugs in Intensive Care, Greenwich Medical • Latest ICU research
Media, London. Weinstock, D. (ed.) ( 1 990) Normal and Abnormal
Payne, R. ( 1 995) Relaxation Techniques, 2nd edn, Breath Sounds, Springhouse Audio, Pennsylvania.
Churchill Livingstone, Edinburgh. • Includes audiotape
• Practical approach covering 18 techniques West, J. B. ( 1 999) Respiratory Physiology, 6th edn,
Pilbeam, S. P. ( 1 998) Mechanical Ventilation: Williams & Wilkins, Baltimore, MD.
Physiological and Clinical Applications, Mosby, St • Detailed and clearly written
Louis, MO. Wilkins, R. L., Hodgkin, J. E. and Lopez, B. ( 1 996)
• Clear descriptions, easy reading, American Lung Sounds, 2nd edn, Mosby, Toronto
terminology • Includes audiotape or CD
Pryor, J. A. and Webber, B. A. (eds) ( 1998) Physio Wilkins, R. L., Krider, S. J. and Sheldon, R. L. (2000)
therapy for Respiratory and Cardiac Problems, 2nd Clinical Assessment in Respiratory Care, 4th edn,
edn, Churchill Livingstone, Edinburgh. Mosby, Toronto.
• Particularly good on ventilators, monitors, • Physiology, pathology, assessment and
paediatrics, hyperventilation syndrome monitoring, strong on clarity and definitions
Ries, A. L. and Moser, K. M. (2000) Shortness of Williams, S. J. ( 1 993) Chronic Respiratory Illness,
Breath: A Guide to Better Living and Breathing, Routledge, London.
6th edn, Mosby, St Louis, Missouri. • Social and practical problems, symptom
• For patients, practical, lively pictures management
Simonds, A. K., Muir, J. F. and Pierson, D. J. ( 1 996) Wood, K. J. ( 1 998) Critical Thinking Cases in
Pulmonary Rehabilitation, BMJ Publications, Respiratory Care, F. A. Davies, Philadelphia, PA.
London. • Questions and answers, 'thought prompts',
• Clearly written, well-referenced, some overlap flowcharts, problem-based
481
REFERENCES
AARC ( 1 992) Clinical Practice Guideline: exercise Akyiiz, G. ( 1 993) Transcutaneous nerve stimulation in
testing for evaluation of hypoxaemia. Respir. Care, the treatment of pain and prevention of paralytic
3 7, 907-9 1 2 . ileus. Clin. Rehabil. , 7, 2 1 8-22l.
AARC ( 1 993a) Clinical Practice Guideline: Albelda, M. ( 1 983) Ventilator-induced subpleural air
intermittent positive pressure breathing. Respir. cysts. Am. Rev. Respir. Dis., 127, 360-3 65.
Care, 3 8 , 1 1 89-1 1 94. Alderson, J. D. ( 1 999) Spinal cord injuries. Care Crit.
AARC ( 1 993b) Clinical Practice Guideline: directed Ill, 15, 48-52.
cough. Respir. Care, 3 8 , 495-499. Alessi, C. L. ( 1 999) A randomised trial of a combined
Abbott J., Dodd, M. and Bilton, D. ( 1 994) Treatment physical activity and environmental intervention in
compliance in adults with CF. Thorax, 49, 1 1 5- nursing home residents. ]. Am. Geriatr. Soc., 47,
1 20. 784-79 l .
Abelson, J. L. ( 1 996) Respiratory psychophysiology Alison, J . A., Donnelly, P . M . and Lennon, M. ( 1 994)
and anxiety. Psychosomatic Med. , 5 8 , 3 02-3 1 3 . The effect of a comprehensive intensive inpatient
Aboussouan, L . S . ( 1 997) Effect o f noninvasive treatment program on lung function and exercise
positive-pressure ventilation on survival in capacity in patients with CF. Phys. Ther. , 74, 583-
amyotrophic lateral sclerosis. Ann. Intern. Med. , 593.
127, 450-454. Allan, A. J. ( 1 998) Permissive hypercapnia. Care Crit.
ACCP/AACVPR ( 1 997) Pulmonary rehabilitation: Ill, 14, 233-236.
joint ACCP/AACVPR evidence-based guidelines. Allen, J. K. ( 1 990) Physical and psychosocial
Chest, 1 12, 1 3 63-1396. outcomes after coronary artery bypass graft
Acosta, F. ( 1 988) Biofeedback and progressive surgery. Heart Lung, 1 9, 49-54.
relaxation in weaning the anxious patient. Heart Allen, S. ( 1 996) Management of tbe patient with
Lung, 1 7, 299-3 0 l . asthma. Curro Opin. Anaesth. , 9, 254-258.
ACPCF (Association o f Chartered Physiotherapists in Allen, S. ( 1 998) The use of the Respicair bed. Care
Cystic Fibrosis), personal communication. Crit. Ill, 14, 1 27-1 3 l .
Adam, S. K. and Osborne, S. ( 1 9 97) Critical Care Allen, P. W. and Hart, S . M. ( 1 988) Minitracheotomy
Nursing. Oxford Medical. in children. Anaesthesia, 43, 760-76 l .
AHFS ( 1 999) Drug information. American Hospital Allen, G . M., Hickie, I . and Gandevia, S . C . ( 1 994)
Formulary Service, p. 2378. Impaired voluntary drive to breathe: a possible
Ahmedzai, S. ( 1 988) Respiratory distress in the link between depression and unexplained
terminally ill patient. Respir. Dis. Pract., 5 (5), 20- ventilatory failure in asthmatic patients. Thorax,
26. 49, 8 8 1-884.
Ahmedzai, S. ( 1 997) Palliation in non-malignant Allen, c., Glasziou, P. and Mar, C. D. ( 1 999) Bed
disease, in Practical Pulmonary Rehabilitation, (eds rest: a potentially harmful treatment needing more
M. Morgan and S. Singh), Chapman & Hall, careful evaluation. Lancet, 354, 1229-1233.
London. Allison, S. ( 1 995) A study of the sociological
Ahmedzai, S. and Davis, C. ( 1 997) Nebulised drugs in consequences of COAD. Physiotherapy, 8 1 , 457.
palliative care. Thorax, 52(suppl. 2), S75-S77. Allison, S. S. and Yohannes, A. M. ( 1999)
Ahrens, T. ( 1 999a) Continuous mixed venous Consequences of COPD in community-based
monitoring. Crit. Care Nurs. Clin. North Am. , patients. Physiotherapy, 85, 663-668.
1 1 ( 1 ), 33-48. Almirall, J., Gonzalez, C. A. and Balanzo, X. ( 1 999)
Ahrens, T. ( 1 999b) Pulse oximetry. Crit. Care Nurs. Proportion of community-acquired pneumonia
Clin. North Am. , 1 1 (1 ) , 87-98. cases attributable to tobacco smoking. Chest, 1 1 6,
Aiping, J. ( 1 994) Analysis of therapeutic effects of 3 75-379.
acupuncture on abstinence from smoking. J. Trad. Ambrosino, N., Nava, S. and Torbicki, A. ( 1 993)
Chinese Med. , 14, 5 6-63 . Haemodynamic efects of pressure support and
Aitkenhead, A. R. ( 1 989) Analgesia and sedation in PEEP ventilation by nasal route in patients with
intensive care. Br. J. Anaesth. , 63, 1 96-206. stable COPD. Thorax, 48, 523-528.
482
REFERENCES
d'Amours, R. H. ( 1 996) Postoperative pain following two different types of physiotherapy.

management. j. Orth. Sports PT, 24, 227-234. Chest, 1 14, 1 71-1 77.
Amyes, S. G. B. (1995) Antibiotic resistance in the Appleyard, N. and Sherry, K. ( 1998) Plasmapheresis
ICU. Br. J. Intensive Care, 5, 263-270. in the ICU. Care Crit. Ill, 14, 207-2 1 1.
Anand, K. J. S. (1998) Analgesia and sedation for Arafa, O. E., Pedersen, T. H. and Svennevig, J. L.
ventilated children and infants. Respir. Care, 43, (1998) Intraaortic balloon pump in open heart
942-951. operations. Ann. Thorac. Surg. , 65, 741-747.
Andersen, J. B., Qvist, J. and Kann, T. ( 1 979) Arason, V. A. ( 1996) Do antimicrobials increase the
Recruiting collapsed lung through collateral carriage rate of penicillin resistant pneumococci in
channels with PEEP. Scand. J. Respir. Dis. ,60, children? Br. Med. j., 313, 3 8 7-3 9 1 .
260-266. Arbour, R . (1998) Aggressive management of
Andersen, J. B., Olesen, K. P. and Eikard, B. ( 1980) intracranial dynamics. Crit. Care Nurse, 1 8 (3), 30-
Periodic CPAP by mask in the treatment of 40.
atelectasis. Eur. j. Respir. Dis. , 6 1 , 20-25. Arens, R., Gozal, D. and amlin, K. J. (1994)
Anderson, H. L. ( 1994) Extracorporeal life support Comparison of high frequency chest compression
for respiratory failure after multiple trauma. j. and conventional chest physiotherapy in
Trauma, 37, 266-274. hospitalized patients with CF. Am. j. Respir. Crit.
Anderson, H. R., Spix, C. and Medina, S. (1997) Air Care Med. , 1 05, 1 1 54-1 157.
pollution and daily admissions for COPD. Argyropoulou, P. (1993) Buspirone effect on
Eur.Respir.J. , 18, 1064-71. breathlessness and exercise in patients with
Andersson, H. I. ( 1 998) Widespread musculoskeletal COPD. Respiration, 60, 2 1 6-220.
chronic pain associated with smoking. Scand. j. Aris, R. M. (1998) Increased rate of fractures and
Rehabil. Med. , 30, 18 5-191. severe kyphosis: sequelae of living into adulthood
Andn!asson, B., Jonson, B. and Kornfalt, R. (1987) with CF. Ann. Intern. Med. , 128, 1 8 6-193.
Long-term effects of physical exercise on working Aronsson, B., Perk, J. and Torstensson, O. ( 1 996)
capacity and pulmonary function in CF. Acta Activities of daily living, an important target in
Paediatr. Scand. , 76, 70-75. pulmonary rehabilitation. Eur. Respir. j., 9(23)
Angus, R. M. (1 996) Comparison of the acute effects 380s.
on gas exchange of nasal ventilation and Arthur, H. M., Daniels, C. and McKelvie, R. (2000)
doxapram in exacerbations of COPD. Thorax, 5 1, Effect of a preoperative intervention on
1048-1 050. preoperative and postoperative outcomes. Ann.
Anon (1 985) Neonatal intensive care, Care Crit. Ill, 1 , Int. Med. , 1 33, 253-262.
3. Arrucio, H. and Pereira, M. ( 1 990) Cardiac
Antman, K . and Chang, Y . (2000) Kaposi's sarcoma. arrhythmias in critically ill patients. Crit. Care
New. Eng. j. Med. , 342, 1027-1 038. Med. , 1 8 , 1 3 83-13 88.
Anto, J. M. and Sunyer, J. ( 1997) Thunderstorms: a risk Arunabh, M. D. (2000) Management of acute
factor for asthma attacks. Thorax, 52, 669-670. exacerbations in COPD. Curro Opin. Pul. Med. , 6,
Anup, R., Aparna, V. and Pulimood, A. (1999) 122-126.
Surgical stress and the small intestine. Surgery, Ashby, E. C. ( 1 995) Posture, blood velocity in femoral
125, 560-569. vein and prophylaxis of DVT. Lancet, 345, 4 1 9-
Anzueto, A. ( 1 992) Resistive breathing activates the 42 1 .
glutathione redox cycle and impairs performance Ashour, M . ( 1 996) Hemodynamic alterations in
of rat diaphragm. J. App!. Physio!., 72, 529-534. bronchiectasis. J. Thorac. Cardiac Surg. , 1 12, 328-
Anzueto, A. (1999) Muscle dysfunction in the ICU. 334.
Clin. Chest Med. , 20, 43 5-452. Ashutosh, K. (1997) Clinical and personality profiles
Aono, J., Ueda, W. and Kataoka, Y. (1997) and survival in patients with COPD. Chest, 1 1 1,
Differences in hormonal responses to preoperative 95-98.
emotional stress between preschool and school Askew, R., Kibelstis, C. and Overbaugh, S. (1998)
children. Acta Anaesthesiol. Scand., 41, 229-23 1 . Physical therapists' perception of patients' pain
App, E . M., Kieselmann, R . and Reinhardt, D . (1998) and its effect on management. Physiother. Res.
Sputum rheology changes in CF lung disease Int., 3, 37-57.
483
RFFERENCES
Atkinson, G. ( 1 997) Air pollution and exercise. Sports Haemodynamic measurements in critically ill
Exercise Injury, 3, 2-8 . patients. Anaesth. Intensive Care, 27, 33-37.
Austan, F. ( 1 996) Heliox inhalation in status Baldwin, D. R. ( 1 994) Effect of addition of exercise to
asthmaticus. Heart Lung, 25, 1 55-157. chest physiotherapy on sputum expectoration and
Austin, J. H. M. and Ausubel, P. ( 1 992) Enhanced lung function in adults with CF. Respir. Med. , 88,
respiratory muscular function in normal adults 49-53.
after lessons in proprioceptive musculoskeletal Baldwin, D. R . ( 1 997) Non-invasive ventilation for
education. Chest, 1 02, 486-490. acute exacerbations of COPD. Br. Med. ]., 314,
Averns, H. L. ( 1 996) Smoking and outcome in 1 63-1 64.
ankylosing spondylitis. Scand. ]. Rheumatol. , 25, Balfour, C. ( 1 993) Physiotherapists and smoking
1 3 8- 142. cessation. Physiotherapy, 79, 247-250.
Axen, K. ( 1 99 1 ) Training for strength and endurance, Balfour-Lynn, I. ( 1 999) Difficult asthma. Arch. Dis.
in Pulmonary Therapy and Rehabilitation, (eds F. Child. , 80, 20 1-6.
Haas and K. Axen) Williams & Wilkins, Balfour-Lynn, I. M., Prasad, S. A. and Laverty, A.
Baltimore, MD, pp. 2 1 1 and 336. ( 1 998) A step in the right direction: assessing
Azar, G. ( 1 996) Neither dopamine nor dobutamine exercise tolerance in CF. Pediatr. Pulmonol. , 25,
reverses the depression in mesenteric blood 278-284.
flow caused by PEEP. J. Trauma, 40, 679- Banasik, J. L. and Emerson, R. J. ( 1 996) Effect of
686. lateral position on arterial and venous blood gases
Baan-Slootweg, O. H. van der ( 1 997) Evaluation of in postoperative cardiac surgery. Am. J. Crit. Care,
the effects of an out-patient pulmonary 5, 1 2 1 - 1 26.
rehabilitation programme for asthmatic children. Banner, A. S . ( 1 994) Theophylline: should we discard
Eur. Respir. ]., 10, 459s. an old friend? Lancet, 343, 6 1 8 .
Babineau, T. J. ( 1 994) Time to consider early gut Banner, M . J., Kirby, R. R. and Blanch, P . B.
feeding. Crit. Care Med. , 22, 1 9 1 - 1 92. ( 1 996) Differentiating total work of breathing
Bach, J. R. ( 1 993) Airway secretion clearance by into its component parts. Chest, 109, 1 14 1-
mechanical exsufflation. Arch. Phys. Med. Rehabil., 1 143 .
74, 1 70-1 77. Barbato, M. P. ( 1 998) Death is a journey to be
Bach, J. R. ( 1 994) Update and perspectives on undertaken. Med. J. Austr. , 1 68 , 296-297.
noninvasive respiratory muscle aids. Chest, 105, Bargon, J., Dauletbaev, N., Kohler, B. et al. ( 1 999)
1 23 0-40. Prophylactic antibiotic therapy is associated with
Bach, J . R. and Haas, F. ( 1996) Pulmonary an increased prevalence of Aspergillus colonization
rehabilitation. Phys. Med. Clin. North Am. , 7, in adult cystic fibrosis patients. Respir. Med. 93,
205-462. 835-83 8.
Bach, J. R. and Moldover, J. R. ( 1 996) Barker, D. P. ( 1995) Exposure to invasive procedures
Cardiovascular, pulmonary and cancer in neonatal lCU admissions. Arch. Dis. Child., 72,
rehabilitation. Arch. Phys. Med. Rehabil., 77, S45- F47-F48 .
S5 l . Barker, M . ( 1 998) Who are we? What are we moving?
Bachrach, L . K., Loutit, C . W . and Moss, R. B . ( 1 994) Cardiorespiratory Conference, National Heart and
Osteopenia in adults with cystic fibrosis. Am. J. Lung Institute, London.
Med. , 96, 27-34. Barnard, S. and Hartigan, G. ( 1 998) Clinical Audit
Badr, M. S., Grossman, J. E. and Weber, S. A. ( 1 994) in Physiotherapy, Butterworth-Heineman,
Treatment of refractory sleep apnea with Oxford.
supplemental CO2• Am. ]. Respir. Crit. Care Med. , Barnes, T. A. ( 1994) Core Textbook of Respiratory
1 50, 5 6 1-564. Care Practice, Mosby, London.
Baharloo, F . ( 1 999) Tracheobronchial foreign bodies. Barnes, P. J. ( 1 995) Chronic obstructive pulmonary
Chest, 1 15, 1 3 5 7- 1 3 62 . disease. Update, 5 1, 9 1 -97.
Bailey, C. R . ( 1 995) The role of CPAP during weaning Barnes, P. J. and Pauweis, R. A. ( 1 994) Theophylline
in cardiac surgical patients. Anaesthesia, 50, 677- in the management of asthma. Eur. Respir. ]. , 7,
68 l . 579-5 9 l .
Baillard, c., Cohen, Y. and Fosse, J . P . ( 1999) Barnitt, R. ( 1 994) Truth telling i n occupational
484
REFERENCES
therapy and physiotherapy. Br. ]. Occup. Ther. , Bronchial asthma in infancy and childhood. Eur.
57, 334-340. Respir. ]. , 3, 3 73-376.
Barr, S. I. (1999) Effects of dehydration on exercise Baublys, A., Kekstas, G. and Vilkelis, S. ( 1997) Early
performance. Can. ]. Appl. Physiol. , 24, 164-172. enteral versus parenteral nutrition. Intensive Care
Barratt, E. (1989) The management of pressure sores. Med. , 23 (suppl. 1), S 139.
Intensive Ther. Clin. Monitoring, 1 0, 255-259. Baudouin, S. V . ( 1 997) Oedema and cor pulmonale
Barratt, T. E. (1 995) Inhaled �-adrenergic receptor revisited. Thorax, 52, 401-402.
agonists in asthma: more harm than good ? Am. ]. Bauer, M. L., McDougal, J. and Schoumacher, R. A.
Respir. Crit. Care Med. , 1 5 1 , 574-577. (1994) Comparison of manual and mechanical
Barrington, K. J., Singh, A. J. and Etches, P. C. ( 1 999) chest percussion in hospitalized patients with CF.
Partial liquid ventilation with and without inhaled ]. Pediatr. , 124, 250-254.
nitric oxide in a newborn piglet model of Baun, M. M. ( 1984) Cumulative effects of 3
meconium aspiration. Am. ]. Respir. Crit. Care sequential endotracheal suctioning episodes. Heart
Med. , 1 60, 1922-1927. Lung, 1 3, 148-1 54.
Barry, P. W. ( 1 994) Inhaled steroid therapy. Curro Baxter, J. N. (1995) Pathophysiology of laparoscopy.
Paediatr. , 4, 114-1 17. Br. ]' Surg. , 82, 1-2.
Barry, P. W. (1 996) Inhalational drug delivery. Baxter, K., Nolan, K. M. and Winyard, J. A. (1993)
Thorax, 5 1 , 835-840. Are they getting enough? Meeting the oxygen
Bartlett, R. H . , Gazzaniga, A. B. and Gerachty, T. R. needs of postoperative patients. Prof. Nurse, 8,
( 1973) Respiratory maneuvers to prevent 3 10-3 12.
postoperative pulmonary complications. ]. A. M. Bartsch, R. ( 1999) Platelet activation with exercise
A. , 224, 10 1 7-102 1 . and risk of cardiac events. Lancet, 354, 1 747-
Barton, J . (2000) Mother knew best. Breathe Easy, 35, 1748.
2. Beards, S. C. and Nightingale, P. (1 994) Aspiration.
Bartter, T. (1994) The evaluation of pleural effusion. Care Crit. Ill, 1 0, 198-202.
Chest, 106, 1209-1 214. Behbehani, N. A. (1999) Myopathy following
Basili, H. R. (1981) Effect of nutritional support on mechanical ventilation for acute severe asthma.
weaning patients off ventilators.]. Parenter. Enter. Chest, 1 15, 1627-163 1.
Nutr. , 5, 1 6 1-163. Behera, D., Bernard, S. and Butler, J. ( 1995) Positive
Basmajian, J. V. (1998) The elixir of laughter in end expiratory pressure reduces bronchial blood
rehabilitation, Arch. Phys. Med. Rehabil. , 79, flow after aspiration. Respiration, 62, 1 0-15.
1597. Bein, T., Metz, C. and Keyl, C. ( 1 996) Effects of
Bass, T. L., Miller, P. K. and Campell, D. B. (1997) extreme lateral posture on hemodynamics and
Traumatic adult respiratory distress syndrome. plasma atrial natriuretic peptide levels in critically
Chest Surg. Clin. North Am. , 7, 429-443 . ill patients. Intensive Care Med. , 22, 651 -655.
Bastow, V. (1996) Personal communication. Bell, P. (1 996) Leaking abdominal aortic aneurysms.
Bastow, M. D., Rawlings, J. and Allison, S. (1983) Care Crit. Ill, 12, 59-63.
Benefits of supplementary tube feeding after Bell, T. (1961) In the Midst of Life, Atheneum, New
fractured neck of femur. Br. Med. ]. , 287, 1 589- York.
1 592. Bellamy, D. (1997) COPD moves into the limelight.
Bateman, J. R. M., Newman, S. P. and Daunt, K. M. Update, 55, 772.
(1979) Regional lung clearance of excessive Bellet, P. S. (1995) Incentive spirometry to prevent
bronchial secretions during chest physiotherapy. acute pulmonary complications in sickle cell
Lancet, i, 294-297. disease. N. Engl. ]. Med. , 333, 699-703.
Bateman, J. R. M., Newman, S. P. and Daunt, K. M. Bellia, V. (1993) Nocturnal asthma. Eur. Respir. Rev. ,
(1 981) Is cough as effective as chest physiotherapy 3, 383-386.
in the removal of excessive tracheobronchial Bellomo, R. ( 1994) Asthma requiring mechanical
secretions ? Thorax, 36, 683-687. ventilation. Chest, 1 05 , 891-896.
Baterman, D. and McLay, J. S. ( 1 999) Clinical Belman, M. J., Brooks, L. R. and Ross, D. J. ( 1 9 9 1 )
pharmacology: the basics. Medicine, 27(3), 1-4. Variability of breathlessness measurement in
Battistini, E., Gianiorio, P. and Girosi, D. ( 1 993) patients with COPD. Chest, 99, 566-571 .
--
-- 485
REFERENCES
Benetti, F., Mariani, M. A. and Sani, G. ( 1 996) Video Bird, J. ( 1 997) Intensive care problems in obstetric
assisted minimally invasive coronary operations patients. Care Crit. Ill, 1 3, 24 1-244.
without cardiopulmonary bypass.]. Thorac. Biro, P. ( 1 997) Comparison of topical anaesthesia
Cardiovasc. Surg. , 1 12, 1478-1484. methods for venous cannulation in adults. Eur.
Begin, P. ( 1 99 1 ) Inspiratory muscle dysfunction and Resp. ]. , 1 , 37-42.
chronic hypercapnia in COPD. Am. Rev. Respir. Bischoff, H. A., Stahelin, H. B. and Urscheler, N.
Dis. , 143, 905-9 1 2. ( 1 999) Muscle strength in the elderly: its relation
Benhamou, D., Muir, J. F. and Radpaud, C. ( 1 997) to vitamin D metabolites. Arch. Phys. Med.
Long-term efficiency of home nasal mask Rehabil. , 80, 54-5 8 .
ventilation in patients with diffuse bronchiectasis Bisgaard, H. (2000) Long-acting �2-agonists in
and severe chronic respiratory failure. Chest, 1 12, management of childhood asthma. Ped. Pulmonol.,
1 259-1266. 29, 22 1-234.
Bennett, N. T. ( 1 99 1 ) Treatment of status asthmaticus Bisson, A., Stern, M. and Caubarrere, I. ( 1 998)
with continuously aerosolized albuterol. Respir. Preparation of high-risk patients for major
Care, 36, 1323. thoracic surgery. Chest Surg. Clin. North Am. , 8,
Bennicke, K. ( 1 995) Cigarette smoking and breast 54 1-555.
cancer. Br. Med. ]. , 3 10, 143 1-143 3 . Black, D. ( 1 998) The dying child. Br. Med. ]. , 3 16,
Bentall, S. ( 1 998) Assessing the risk o f lower limb 1376-1 3 78.
ischaemia in patients undergoing intraaortic Blackie, K. A., Davidson, A. C. and Marsh, M. J.
balloon counterpulsation. Care Crit. Ill, 14, 228- ( 1 999) 'Not for resuscitation': guidelines for
232. decision making and documentation. Int. ]. Clin.
Beratis, N. G. ( 1 996) Increased BP in neonates and Pract., 53, 2 13-2 1 6.
infants whose mothers smoked during pregnancy. Blair, P. S . ( 1 996) Smoking and the sudden infant
]. Pediatr. , 128, 806-8 12. death syndrome. Br. Med. ]., 3 1 3 , 195-198.
Berge, M. ( 1 999) DNase treatment of primary ciliary Blanckenhagen, J. ( 1986) Unheard victims of breast
dyskinesia. Pediatr. Pulmonol. , 27, 59-6 1 . cancer. The Independent, 7 October.
Berti, M . , Fanelli, G. and Casati, A . (2000) Patient Block, S. D. (2000) Assessing and managing
supplemented epidural analgesia after major depression in the terminally ill patient. Ann.
abdominal surgery. Can. ]. Anesth. , 47, 27-32. Intern. Med. , 1 32, 209-2 1 8 .
Bertone, N. (1988) The role of physiotherapy in a Blower, A . C . ( 1 997) I s thirst associated with
neonatal intensive care unit. Austr. ]. Physiother., disability in hospital inpatients ? ]. Hum. Nutr.
34, 27-34. Dietetics, 1 0, 289-293 .
Berwick, D. M. ( 1 99 1 ) The double edge of Bluman, L. G., Mosca, L. and Newman, N. (1998)
knowledge. ]. A. M. A., 266, 84 1-842. Preoperative smoking and postoperative
Bestall, J. c., Paul, E. A., Garrod, R. and Garnham, R. pulmonary complications. Chest, 1 13, 883-889.
( 1 999) Usefulness of the MRC dyspnoea scale as a British Medical Journal ( 1 997) Passive smoking
measure of disability in patients with COPD. [editorial], Br. Med. ]. , 3 15 , 96 1-962.
Thorax, 54, 5 8 1-586. Boezen, H. M. ( 1 998) Breathlessness in elderly
Bevan, P. G. ( 1964) Cholecystectomy in a surgeon. individuals is related to low lung function and
Lancet, i, 2 14-2 1 5 . reversibility of airway obstruction. Eur. Respir. ].,
Biley, F. C. ( 1 989) Stress in high dependency units. 12, 805-8 1 0.
Intensive Care Nurs. , 5, 1 34-1 4 1 . Boghdadi, M. S. ( 1 997) Cocaine: pathophysiology and
Billings, J.A. (2000) Palliative care. Br. Med. ]. , 3 2 1 , clinical toxicology. Heart Lung, 26, 466-483.
555-558. Bohin, S. ( 1 995) Circulatory effects of ventilator and
Bilton, D., Dodd, M. E. and Abbot, J. V. ( 1 992) The end-expiratory pressure in unparalysed preterm
benefits of exercise combined with physiotherapy infants. Acta Paediatr. , 84, 1 300-1304.
in the treatment of adults with CF. Respir. Med. , Bolgiano, C. S. ( 1 990) Administering oxygen therapy.
86, 507-5 1 1 . Nursing, 20, 47-5 1 .
Bio, M. ( 1 998) Positive pressure ventilation in Bolliger, C . T . ( 1 998) Functional evaluation o f the
amyotrophic lateral sclerosis [letter]. Ann. Intern. lung resection candidate. Eur. Respir. ]. , 1 1, 198-
Med. , 128, 6 0 1 . 2 12.
486
REFERENCES
Bonnet, R. ( 1 995) Intractable cough associated with Bourdelles, G. L., Mier, L. and Fiquet, B. ( 1 996)
the supine body position. Chest, 108, 58 1-585. Comparison of the effects of heat and moisture
Bonita, R. ( 1 999) Passive smoking as well as active exchangers and heated humidifiers. Chest, 1 10,
smoking increases the risk of acute stroke. Thorax, 1 294-1298.
8, 156-1 60. Bourke, S. and Boyd, G. ( 1 9 97) Pigeon fancier's lung.
Boots, R. J., Howe, S. and George, N. ( 1 997) Clinical Br. Med. I. , 3 1 5, 70-7 1 .
utiliry of hygroscopic heat and moisture Bower, L . K . ( 1 995) Extracorporeal life support and
exchangers in intensive care patients. Crit. Care high-frequency oscillatory ventilation. Respir.
Med. , 25, 1 707-17 12. Care, 40, 6 1-73.
Borak, J., Sliwinski, P. and Piasecki, Z. ( 1 9 9 1 ) Bowes, D. ( 1984) The doctor as patient: an encounter
Psychological status o f COPD patients o n long with Guillain-Barre syndrome. Can. Med. Assoc.
term oxygen therapy. Eur. Respir. I., 4, 5 9-62. I. , 1 3 1 , 1 343-1368.
Borg, G. A. V. ( 1 982) Psychophysiological bases of Bowler, S. D., Green, A. and Mitchell, C. A. ( 1 998)
perceived exertion. Med. Sci. Sports Exercise, 14, Buteyko breathing techniques in asthma: a
377-3 8 1 . randomised controlled trial. Med. I. Austr. , 1 69,
Bortoluzzi, G . ( 1 994) Facing death: a personal 575-578.
perspective. NZ j. Physiother. , 22, 6-9. Bowton, D . L. ( 1 999) On patients and patience. Crit.
Borzotta, A. P. (1994) Enteral versus parenteral Care Med. , 27, 2573.
nutrition after severe head injury. j. Trauma, 3 7, Boyd, S. ( 1 994) Evaluation of the literature on the
459-468. effectiveness of physical therapy modalities in the
Bosley, C. M. ( 1 996) Psychological factors associated management of children with CF. Pediatr. Phys.
with use of home nebulized therapy for COPD. Ther. , 6, 70-74.
Eur. Respir. I., 9, 2346-2350. Boylan, A. M. (2000) Mesothelioma. Curro Opin.
Bosscha, K., Niewenhujis, V. B. and Vos, A. ( 1 998) Pulm. Med., 6, 1 5 7-163.
Gastrointestinal motility and gastric tube feeding Bracken, M. B., Shepard, M. J. and Holford, T. R.
in mechanically ventilated patients. Crit. Care ( 1 9 97) Administration of methylprednisolone for
Med. , 26, 1 5 1 0-1 5 17. acute spinal cord injury. j. A. M. A., 277, 1 597-
Bostick, J. and Wendelgass, S. T. ( 1 987) Normal 1 504.
saline instillation as part of the suctioning Bradding, P., Rushby, I. and Scullion, J. ( 1 999) As
procedure. Heart Lung, 1 6, 5 3 2-536. required versus regular nebulized salbutamol for
Bosworth, D. G. and Nielson, D. W. ( 1 9 97) the treatment of acute severe asthma. Eur. Respir.
Effectiveness of home versus hospital care in the j. , 1 3 , 290-294.
routine treatment of CF. Pediatr. Pulmonol., 24, Bradley, T. D. ( 1 993) Unexpected presentations of
42-47. sleep apnoea. Br. Med. j., 306, 1 260-1262.
Botman, M. J. ( 1 987) Contamination of small-volume Bradley, D. ( 1994) Hyperventilation Syndrome, Kyle
medication nebulizers. I. Hosp. Infect., 1 0, 204- Cathie, London.
208. Bradley, J., Howard, J. and Wallace, E. ( 1 999)
Bott, J., Keilty, S. E. J. and Brown, A. ( 1 992) Nasal Validiry of a modified shuttle test in adult cystic
intermittent positive pressure ventilation. fibrosis. Thorax, 54, 437-43 9.
Physiotherapy, 78, 93-96. Brandsma, J . W., Robeer, B. G. and van den Heuvel,
Botterill, I. and MacFie, J. (2000) Bacterial transloca S. ( 1 998) The effect of exercises on walking
tion in the critically ill. Care Crit. Ill, 1 6, 6-10. distance of patients with intermittent claudication.
Boulet, L.-P., Milot, J. and Gagnon, L. ( 1999) Long Phys. Ther. , 78, 278-288.
term influence of inhaled corticosteroids on bone Brandstetter, R., Grant, G. R. and Estillo, M. ( 1 998)
metabolism and densiry. Am. j. Respir. Crit. Care Swan-Ganz catheter: misconceptions, pitfalls, and
Med. , 159, 83 8-844. incomplete user knowledge. Heart Lung, 27, 2 1 8-
Bouley, G. H. ( 1 992) The experience of dyspnea 222.
during weaning. Heart Lung, 2 1 , 47 1-476. Brannon, F. J., Foley, M. W. and Starr, J. A. ( 1 998)
Bollert, F. G. E., Paton, J. Y. and Marshall, T. G. Cardiopulmonary Rehabilitation: Basic Theory and
( 1 999) Recombinant DNase in CF. Eur. Respir. I. , Application, F. A. Davis, Philadelphia, PA.
13, 107- 1 1 3 . Branson, R. D. ( 1 993) The nuts and bolts of
487
REFERENCES
increasing oxygenation. Respir. Care, 3 8 , 672- Brimioulle, S., Moraine, ].-]. and Norrenberg, D.
689. ( 1 997) Effects of positioning and exercise on ICP
Branson, R. D. ( 1 996) Comparison of three in a neurosurgical ICU. Phys. Ther., 77, 1682-
humidification techniques during mechanical 1 689.
ventilation. Respir. Care, 4 1 , 809-8 1 6 . Brismar, B. ( 1 985) Pulmonary densities during
Branson, R. D . ( 1 999) Humidification for patients anesthesia with muscular relaxation. Anesthesiogy,
with artificial airways. Respir. Care, 44, 63 0-64 I . 62, 422-428 .
Branson, R . D . , Davis, K . and Campbell, R . S . ( 1 993) Britton, ]. (2000) Interferon gamma- l b therapy for
Humidification in the ICU. Chest, 1 04, 1 8 00- 1 8 05 . cryptogenic fibrosing alveolitis. Thorax, 5 5
Branthwaite, M. A . ( 1985) The intensive care of (suppl. 1 ), 537-540.
asthma. Br. j. Hosp. Med. , 34, 1-8 . Broad, S. H. ( 199 1) An holistic approach to cardiac
Branthwaite, M. A. ( 1 996) Witholding or rehabilitation. NZj. Physiother. , 19, 6-10.
withdrawing intensive care. Br. j. Intensive Care, Brochard, L., Mion, G. and Isabey, D. ( 1991)
6, 5 1-54. Constant-flow insufflation prevents arterial oxygen
Brashear, R. E. (1983) Hyperventilation syndrome. desaturation during suctioning. Am. Rev. Respir.
Lung, 1 6 1 , 257-273 . Dis. , 144, 395-400.
Brath, H., Lahrmann, H. and Wanke, T. ( 1 997) The Brodner, G. ( 1997) Pain management in patients
effect of lung transplantation on the neural drive undergoing thoracic surgery. Curro Opin. Anaesth.,
to the diaphragm in patients with severe COPD. 1 0, 54-59.
Eur. Respir. j. , 10, 424-429. Bromley, I. ( 1 998) Tetraplegia and Paraplegia,
Braun, N. M. T., Faulkner, ]. and Hughes, R. L. Churchill Livingstone, Edinburgh.
( 1983) When should respiratory muscles be Brooks, D. H. M. ( 1 990) The route to home
exercised? Chest, 84, 76-84. ventilation. Care Crit. Ill, 6, 96-97.
Breslin, E. H. ( 1 992) The pattern of respiratory Brooks-Brunn, ]. A. ( 1 995) Postoperative atelectasis
muscle recruitment during pursed lip breathing. and pneumonia. Heart Lung, 24, 94-1 12.
Chest, 1 0 1 , 75-78. Broomhead, C. ]. ( 1 995) Physiology of postoperative
Breslin, E. H. ( 1 996) Respiratory muscle function in nausea and vomiting. Br. j. Hosp. Med. , 53, 327-
patients with COPD. Heart Lung, 25, 271-285. 330.
Breslin, E. H., Garoutte, B. C. and Carrieri-Kohlman, Brown, S. E. ( 1983) Prevention of suction-related
V. ( 1 990) Correlations between dyspnea, arterial oxygen desaturation. Chest, 83, 621-
diaphragm and sternomastoid recruitment during 628 .
inspiratory breathing. Chest, 98, 298-302. Brown, K. K. ( 1 994) Septic shock. Am. j. Nurs., 94,
Breslin, E., van der Schans, C. and Breukink, S. 20-27.
( 1 998) Perception of fatigue and quality of life in Brown, M. A. and Halonen, M. ( 1999) Perinatal
patients with COPD. Chest, 1 14, 958-964. events in the development of asthma. Curro Opin.
Brett, A. and Sinclair, D. G. ( 1 993) Use of continuous Pulmonary Med. , 5, 4-9.
positive airway pressure in the management of Browning, D. ( 1 992) Treatment of acute severe
community acquired pneumonia. Thorax, 48, asthma assisted by hyperthermia. Anaesthesia, 47,
1280-128 I . 223-225 .
Brevinge, H . ( 1 995) Exercise capacity i n patients Brownlee, K. G. ( 1 997) Paediatric bronchoscopy.
undergoing proctocolectomy and small bowel Arch. Dis. Child. , 77, 272-275 .
resection for Crohn's disease. Br. j. Surg. , 82, Brucia, ]. ( 1 996) The effect of suction catheter
1 040- 1 045. insertion and tracheal stimulation in adults
Brewin, A. ( 1 998) Allergy avoidance. Nurs. Stand. , with severe brain injury. Heart Lung, 25, 295-
12(32), 49-53 . 303.
Briars, G. and Warner, ]. ( 1 993) Cystic fibrosis. Bruder, N. ( 1 998) Influence of body temperature,
Practitioner, 237, 765-770. with or without sedation, on energy expenditure
Bright, L. D. ( 1 995) Deep vein thrombosis. Am. j. in severe head-injured patients. Crit. Care Med. ,
Nurs. , 95, 48-49. 26, 568-572.
Bright, P. ( 1 996) The diagnosis of occupational Bruera, E. ( 1 997) Cancer pain management. Acta
asthma. Thorax, 5 1, 857-863. Anaesth. Scand. , 41, 146-153.
488
REFERENCES
Bruera, E. ( 1 998) Proctolysis for dehydration of Are frequent inner cannula changes necessary?
terminally ill cancer patients. j. Pain Symptom Heart Lung, 27, 5 8-62.
Man., 15, 2 1 6-2 1 9 . Burstal, R., Wegener, F. and Hayes, C. ( 1 998)
Bruera, E . , deStoutz, N . and Velasco, A . ( 1 993) Subcutaneous tunnelling of epidural catheters.
Effects of oxygen on dyspnoea in hypxaemic Anaesth. Intensive Care, 26, 1 47-1 5 l .
terminal cancer patients. Lancet, 342, 13-14. Bury, T. J . and Mead, J . M. ( 1998) Evidence-based
Brusasco, V. and Fitting, J. W. ( 1 998) Lung Healthcare: A Practical Guide for Therapists.
hyperinflation in airway obstruction. Eur. Respir. Butterworth-Heineman, London.
j., 9, 2440. Bush, A., Cole, P. and Hariri, M. ( 1 998) Primary
Bruton, A., Conway, J. and Holgate, S. T. ( 1 999) ciliary dyskinesia: diagnosis and standards of care.
Weaning adults from mechanical ventilation. Eur. Respir. ]., 12, 982-988.
Physiotherapy, 8 5 , 652-66 l . Busse, W. W. ( 1 995) Stress and asthma. Am. ]. Respir.
Bryce, T . N . (2000) Pain after spinal cord injury. Crit. Care Med. , 1 5 1, 249-252.
Phys. Med. Rehab. Clin. N. Am. , 1 1 , 1 57-1 6 8 . Butland, B. K., Strachan, D. P. and Anderson, H. R.
BTS ( 1 990) Guidelines for management o f asthma in ( 1 999) Fresh fruit intake and asthma symptoms in
adults. Br. Med. j. , 3 0 1 , 797-800. young British adults. Eur. Respir. j. , 1 3 , 744-750.
BTS ( 1 993) Guidelines for management of asthma: a Butler, S. G. and Sutherland, R. J. ( 1 998) Current
summary. Br. Med. j. , 306, 776-782. airway clearance techniques. NZ Med. ]., 1 1 1 ,
BTS ( 1994) Guidelines for the measurement of 1 83-1 86.
respiratory function. Respir. Med. , 8 8 , 1 65-194. Button, B. M., Heine, R. G. and Catto, A. G. ( 1 994)
BTS ( 1 997) Instructions for patients using home Postural drainage exacerbates gastroesophageal
nebulizers. Thorax, 52(suppl. 2), S 1 7 . reflux in patients with lung disease. Pediatr. Res. ,
Buccheri, G. ( 1 998) Depressive reactions t o lung 36, 2.
cancer are common and often followed by poor Bye, P. T. P., Alison, J. A. and Regnis, J. A. ( 1 997)
outcome. Eur. Respir. ]., 1 1, 1 73-178. Exercise performance and rehabilitation in cystic
Buckley, F. P. ( 1 997) Anesthetic risks related to fibrosis. Crit. Rev. Phys. Rehabil. Med. , 9, 1-3 3 .
obesity. Curro Opin. Anaesth., 10, 240-243 . Bynum, L. J., Wilson, J. E . and Pierce, A . K . ( 1 976)
Buckman, R. ( 1 996) Talking to patients about cancer. Comparison of spontaneous and positive-pressure
Br. Med. ]., 3 1 3, 699-700. breathing in supine normal subjects. j. Appl.
Buff, D. D., Bavli, S. Z. and Bloch, M. H. ( 1 995) Physiol. , 4 1 , 341-346.
Circadian patterns of emergency asthma Cade, A., Brownlee, K. G. and Conway, S. P.
presentations. Respir. Care, 40, 624-630. (2000) Randomised placebo controlled trial of
Burdet, L. ( 1 997) Thermogenic effect of nebulized corticosteroids in acute respiratory
bronchodilators in patients with COPD. Thorax, syncytial viral bronchiolitis. Arch. Dis. Child. ,
52, 1 30-13 5 . 82, 1 26-1 3 0.
Burdon, J. G . W . ( 1 994) Chronic lung disease and the Cahalin, L. P. ( 1 996) Heart failure. Phys. Ther. , 76,
perception of breathlessness. Eur. Respir. j. , 7, 5 16-53 3 .
1 342-1 349. Cahalin, L. P. ( 1 997) Inspiratory muscle training in
Burford, B. W. and Barton, S. J. ( 1 998) Care of the patients with chronic heart failure awaiting cardiac
dying patient, in Physiotherapy for Respiratory and transplantation. Phys. Ther. , 77, 830-83 8 .
Cardiac Problems, 2nd edn, (eds B. A. Webber and Cahalin, L . P . and Sadowsky, H. S. ( 1 995) Pulmonary
J. A. Pryor), Churchill Livingstone, Edinburgh. medications. Phys. Ther. , 75, 3 97-4 14.
Burge, P. S. ( 1 992) Peak flow measurement. Thorax, Caldwell, M. T. P. ( 1 993) Timing of extubation after
47, 903. oesophagectomy. Br. j. Surg. , 80, 1 537-1 539.
Burke, R. P. ( 1 998) Minimally invasive pediatric Callaghan, S . ( 1 998) Evaluating two dressings for the
cardiac surgery. Curro Opin. Pediatr. , 1 0, 5 27- prevention of nasal bridge pressure sores. Prof.
53 l . Nurse, 13, 3 6 1-364.
Burns, S . P. (2000) Sleep apnea syndrome in chronic Callegari, G. ( 1 994) Clinical effects of oscillating
spinal cord injury. Arch. Phys. Med. Rehab. , 8 1 , positive expiratory pressure. Respir. Care, 39,
1334-1339. 1 104.
Burns, S. M., Spillman, M. and Wilmoth, D. ( 1 998) Calverley, P. and Bellamy, D., (2000) The challenge
489
REFERENCES
of providing better care for patients with COPD. Carr, D. B. ( 1 996) Pain therapy. Curro Opin. Anaesth.,
Thorax, 55, 78-82. 9, 4 1 5-420.
Calvo, V., Borro, ]. M. and Morales, P. ( 1 999) Carr, L., Pryor, ]. A. and Hodson, M. E. ( 1 995) Self
antifungal prophylaxis during the early chest clapping. Physiotherapy, 8 1 , 753-757.
postoperative period of lung transplantation. Carrieri, V. ( 1 992) Exercise may result in greater
Chest, 1 1 5, 1 3 0 1- 1 3 04. decreases in anxiety and distress associated with
Cambach, W. ( 1997) The effects of a community dyspnea than in dyspnea intensity. Am. Rev.
based pulmonary rehabilitation programme on Respir. Dis. , 1 45, A765.
exercise tolerance and quality of life. Eur. Respir. Carroll, S. ( 1 989) Antibiotics and respiratory
]., 10, 1 04-1 1 3 . infection. Respir. Dis. Pract., 6, 29.
Cameron, I. R . and Bateman, N . T . ( 1 990) Respiratory Carson, M. M. ( 1 994) Managing pain during
Disorders, Edward Arnold, London, p. 75 . mediastinal chest tube removal. Heart Lung, 23,
Cammarano, W. B., Pittet, ].-F. and Weitz, S. ( 1998) 500-505.
Acute withdrawal syndrome related to the Carter, B. ( 1 995) An asthmatic in 'Wonderland' : a
administration of analgesic and sedative patient's perspective. Accident Emerg. Nurs. , 3,
medications. Crit. Care Med. , 26, 676-684. 1 3 9- 1 4 1 .
Campbell, ]. ( 1 9 99a) Cannabis: the evidence. Nurs. Carter, A. B. and Hornick, D . B. (1 999) Therapy for
Stand. , 1 3, 45-47. ventilator-associated pneumonia. Clin. Chest Med. ,
Campbell, R. S. ( 1 999b) Extubation and the 20, 68 1 -69 1 .
consequences of reintubation. Respir. Care, 44, Casaburi, R. ( 1992) Principles of exercise training.
799-803. Chest, 1 0 1 , 263S-267S.
Campbell, E. ]. M. and Howell, ]. B. L. ( 1963) The Cassel, W., Plock, T. and Becker, C. ( 1 996) Risk of
sensation of dyspnoea. Br. Med. j., ii, 868. traffic accidents in patients with sleep-disordered
Campbell, E. J., Baker, M. D. and Crites, P. ( 1 988) breathing. Eur. Respir. j., 9, 2606-26 1 1 .
Subjective effects of humidification of oxygen for Castledine, G. ( 1993) A personal view of asthma. Br.
delivery by nasal cannula. Chest, 93, 289-293. ]. Nurs. , 2, 9 19.
Campbell, D., Steinmann, M. and Porayko, L. (2000) Castling, D. ( 1 995) Neonatal endotracheal suction. Br.
Nitric oxide and high frequency jet ventilation in a ]. Int. Care, 5 , 2 1 8-22 1 .
patient with bilateral bronchopleural fistulae and Cazzola, M . ( 1 998) Cardiac effects o f formoterol and
ARDS. Can. j. Anaesth. , 47, 53-57. salmeterol in patients suffering from COPD with
Cano, A. and Payo, F. ( 1997) Lung function and preexisting cardiac arrhythmias and hypoxemia.
airway responsiveness in children and adolescents Chest, 1 14, 4 1 1-4 15.
after hyaline membrane disease. Eur. Respir. ]., 10, Celli, B. ( 1993) Respiratory muscle strength after
88 0-8 85. upper abdominal surgery. Thorax, 48, 683-684.
Carella, M. ]. ( 1 999) Improvement in pulmonary and Celli, B. R. ( 1 994) Physical reconditioning of patients
exercise performance in obese patients after with respiratory diseases. Respir. Care. 39, 48 1-
weight loss. Respir. Care, 44, 1 45 8- 1 464. 499.
Carew, ]. F., Kraus, D. H. and Ginsberg, R. ]. ( 1 999) Celli, B. R., Rodriguez, K. S. and Snider, G. L. ( 1 984)
Early complications: recurrent nerve palsy. Chest A controlled trial of IPPB, incentive spirometry
Surg. Clin. North Am. , 9, 597-608. and deep breathing exercises after abdominal
Carmichael, R. ( 1 9 8 1 ) Personal view. Br. Med. j., 282, surgery. Am. Rev. Respir. Dis. , 1 3 0, 1 2- 1 5 .
1388. Cereda, M . ( 1 996) Positive end-expiratory pressure
Carmini, V., Damignani, R . and Brooks, D. (2000) prevents the loss of respiratory compliance during
Preoperatie physiotherapy teaching in paediatric low tidal volume ventilation. Chest, 1 09, 480-
cardiac patients. Physiother. Can. , 42, 3 12-3 14. 485.
Carone, M. ( 1 997) Comparison of invasive and Cerveira, ]. J., Halpern, V. J., Faust, G. and Cohen, ].
noninvasive saturation monitoring in prescribing R. ( 1999) Minimal incision abdominal aortic
oxygen during exercise. Eur. Respir. ]., 1 0, 446- aneurysm repair. ]. Vasco Surg., 3 0, 977-984.
45 1 . Chambliss, R. ( 1 997) Pain management in the
Carr, L . ( 1 993) Manual therapy for patients with pediatric ICU. Curro Opin. Pediatr. , 9, 246-253 .
respiratory disease. ACPRC j. , 23, 13-15. Chan, C. S. ( 1 990) Eucapnia and hypercapnia in
490
REFFRENCES
patients with chronic airflow limitation. Am. Rev. Christen, W. G. ( 1 996) A prospective study of
Respir. Dis. , 1 4 1 , 86 1-865. cigarette smoking and risk of age-related macular
Chang, S.-c., Shiao, G.-M. and Perng, R.-P. ( 1 989) degeneration in men. ]. A. M. A. , 266, 1 1 47-1 1 5 1 .
Postural effect on gas exchange in patients with Christensen, T. and Kehlet, H . ( 1 984) Postoperative
unilateral pleural effusions. Chest, 96, 60-63. fatigue and changes in nutritional status. Br. ].
Charbonneau, M. ( 1 994) Changes in obstructive sleep Surg. , 71, 473-476.
apnea characteristics through the night. Chest, Christensen, E. F., Nedergaard, T. and Dahl, R.
1 06, 1 695-170 1 . ( 1990) Long-term treatment of chronic bronchitis
Charlto,n, A . and White, D . ( 1 996) Smoking and with PEP mask and chest physiotherapy. Chest,
menstrual problems in 1 6-year-olds. ]. Roy. Soc. 97, 645-650.
Health, 89, 1 93-195. Christensson, K. ( 1 995) Separation distress call in the
Chatburn, R. L. ( 1 991) Principles and practice of human neonate in the absence of materal body
neonatal and pediatric mechanical ventilation. contact. Acta Paediatr. , 84, 468-473 .
Respir. Care, 36, 569-595. Christie, B. (2000) Premature babies have high death
Chatham, K. ( 1 995) Respiratory muscle training. Br. ]. and disability rate. Br. Med. ]. , 321, 467.
Ther. Rehabil. , 2, 3 1-36. Chudley, S. ( 1 994) The effect of nursing activities on
Chatham, K. (2000) Individualised fixed load ICP. Br. ]. Nurs. , 3, 454-459 .
inspiratory muscle training responses in a patient Chulay, M . ( 1 988) Arterial blood gas changes with a
with severe restrictive lung disease and an elite hyperinflation and hyperoxygenation suctioning
sportsman. Physiotherapy, 86, 28-30. intervention. Heart Lung, 1 7, 654-66 1 .
Chatham, K., Berrow, S. and Beeson, C. ( 1 994) Chumillas, S., Ponce, J . L . and Delgado, F . ( 1 998)
Inspiratory pressures in adult cystic fibrosis. Prevention of postoperative pulmonary
Physiotherapy, 80, 748-752. complications through respiratory rehabilitation.
Chatila, W., Hall, J. B. and Manthous, C. A. ( 1 995) Arch. Phys. Med. Rehabil. , 79, 5-9.
The effect of pulmonary secretions on respiratory Chung, D. C. ( 1 992). Partially paralyzed: a personal
mechanics in intubated patients. Respir. Care, 40, experience [letter] . Anesthesiology, 77, 1 053-
1 048-1 05 1 . 1 054.
Cheever, K . H . ( 1 999) Reducing the effects o f acute Church, S. E. ( 1 9 9 1 ) Bronchoconstricton caused by
pain in critically ill patients. Dimens. Crit. Care humidified oxygen in asthmatic patients. Thorax,
Nurse, 1 8 , 14-23 . 46, 4 .
Chen, Y., Horne, S. L. and Dosman, J. A. ( 1 993) Body Chuter, T . A . M . ( 1 990) Diaphragmatic breathing
weight and weight gain related to pulmonary maneuvers and movement of the diaphragm after
function decline. Thorax, 48, 375-3 8 0 . cholecystectomy. Chest, 97, 1 1 1 0-1 1 14.
Chen, Y . , Rennie, D. C. and Lockinger, L . A . ( 1 998) Cichero, J. A. Y. and Murdoch, B. E. ( 1 998) The
Effect of environmental tobacco smoke on cough physiologic cause of swallowing sounds.
in children with a history of tonsillectomy or Dysphagia, 1 3 , 3 9-52.
adenoidectomy. Eur. Respir. ]. , 1 1 , 13 1 9-1323. Ciesla, N. D. ( 1 994) Chest physical therapy for the
Cherny, N. I. and Foley, K. M. ( 1 997) Nonopioid adult ICU trauma patient. Phys. Ther. Pract., 3 ,
and opioid analgesic pharmacotherapy of cancer 92- 1 0 8 .
pain. Otolaryngol. Clin. North Am. , 30, 28 1- Ciesla, N. D. ( 1 996) Chest physical therapy for
304. patients in the ICU. Phys. Ther. , 76, 609-625.
Chiswick, M. L. ( 1 999) Assessment of pain in Clague, J. E. and Calverley, P . M. A. ( 1 990)
neonates. Lancet, 355, 6-7. Management of COPD. Hosp. Update, 16, 20-
Chitnavis, B. P. ( 1 998) Intracranial pressure 32.
monitoring. Care Crit. Ill, 14, 80-84. Clark, K. J. ( 1 9 85) Coping with Guillain-Barre
Choi, P. T. L., Yip, G. and Quinonez, L. G. ( 1 999) syndrome. Intensive Care Nurs. , 1, 1 3 - 1 8 .
Crystalloids vs. colloids in fluid resuscitation. Crit. Clark, C. J . ( 1 996) I s pulmonary rehabilitation
Care Med. , 27, 200-2 1 0. effective for patients with COPD? Lancet, 348,
Christen, W. G. ( 1 992) A prospective study of 1 1 1 1.
cigarette smoking and risk of cataract in men. ]. A. Clark, C. J. ( 1 999) Physical activity and asthma. Curro
M. A., 268, 989-993. Opin. Pulmonary Med. , 5, 68-75.
491
REFERENCES
Clark, C. J. and Cochrane, L. ( 1 999) Physical activity Coghill, C. H., Haywood, J. L. and Chatburn, R. L.
and asthma. Curro Opin. Pulmonary Med. , 5, 68- ( 1 9 9 1 ) Neonatal and pediatric high-freguency
75. ventilation. Respir. Care, 36, 596-603.
Clark, C. J., Cochrane, L. and Mackay, E. ( 1 996) Low Cogswell, J. J . ( 1 994) Epidemiology of asthma. Curro
intensity peripheral muscle conditioning improves Paediatr. , 4, 1 3 9-142.
exercise tolerance and breathlessness in COPD. Cohen, D., Horiuchi, K. and Kemper, M. ( 1 996)
Eur. Respir. ]' , 8 , 2590-2596. Modulating effects of propofol on metabolic and
Clarke, S. W. ( 1989) Rationale of airway clearance. cardiopulmonary responses to stressful ICU
Eur. Respir. J. , 2(suppl. 7), 5 99S-604S. procedures. Crit. Care Med. , 24, 6 1 2-6 17.
Clarke, S. W. ( 1 9 9 1 ) Chronic bronchitis in the 1 990s. Coirault, C. ( 1 999) Relaxation of the diaphragm
Respiration, 5 8 (suppl.), 43-6. muscle. ]. Appl. Physio/. , 87, 1 243-1252.
Clarke, J. P., Schuitemaker, M. N. and Sleigh, J. W. Cole, P. ( 1 999) Cardiorespiratory physiotherapy
( 1 998) The effect of intraoperative ventilation conference, London.
strategies on perioperative atelectasis. Anaesth. Cole, J. G., Begish, A. and Judas, M. L. ( 1 990)
Intensive Care, 26, 262-266. Changing the NICU environment. Neonat. Netw. ,
Claxton, A. R. ( 1 997) Evaluation of morphine versus 9, 1 5-23 .
fentanyl. Anesth. Analg. , 84, 509-5 1 4. Collignon, P. (1 994) Intravascular associated sepsis.
Cleland, J. G. F. ( 1 996) Heart failure. Update, 52, Med. ]. Austr. , 1 6 1 , 3 74-378.
658-663. Collins, J. ( 1 9 76) Blood gases, rational oxygen
Clemency, M. V. ( 1997) Do not resuscitate orders in therapy, air flow limitations. Physiotherapy, 62,
the perioperative period. Anesth. Analg. , 84, 859- 48-52.
8 64. Collins, M. A. ( 1 994) When your patient has an
Clifton-Smith, T. ( 1 999) Breathe to Succeed, Penguin, implantable cardioverter defibrillator. Am. ].
New Zealand. Nurs. , 94, 3 4-39 .
Clini, E., Vitacca, M. and Bianchi, L. ( 1 999) Long Collins, F. ( 1 999) The contribution made b y an
term tracheostomy in severe COPD patients. armchair with integral pressure-reducing cushion
Respir. Care, 44, 4 1 5-420. in the prevention of pressure sore incidence in the
Closs, S. J. ( 1 996) Pain and elderly patients. ]' Adv. elderly acutely ill patient. J. Tissue Viability, 9,
Nurs. , 23, 237-242. 133-137.
Coates, A. L. ( 1 992) Oxygen therapy, exercise and Confalonieri, M. ( 1 994) Severe exacerbations of COPD
cystic fibrosis. Chest, 1 0 1 , 2-4. treated with BiPAP. Respiration, 6 1 , 3 1 0-3 16.
Cobb, J. M. T. ( 1 996) Psychosocial stress and Connor, D. F. J. and Muir, J. ( 1 998) Balanced
susceptibility to upper respiratory tract illness. analgesia for the management of pain in an opioid
Psychosomatic Med. 58, 408-4 1 2 . addict. Anaesth. Intensive Care, 26, 459-460.
Cochrane, G . M. ( 1 995) Acute severe asthma. Thorax, Connors, A. F. ( 1 996) Outcomes following acute
5 0, 1-2. exacerbation of severe COPD. Am. J. Respir. Crit.
Cochrane, G. M. ( 1 997) Compliance with nebulized Care Med. , 1 5 4, 959-967.
therapy. Eur. Respir. Rev. , 7, 3 8 3-3 84. Connors, A. F., Hammon, W. E. and Martin, R. J.
Cochrane, G. M., Webber, B . A. and Clarke, S. W. ( 1 980) Chest physical therapy: the immediate
( 1 9 77) Effects of sputum on pulmonary function. effect on oxygenation in acutely ill patients. Chest,
Br. Med. ]. , ii, 1 1 8 1-1 1 83 . 78, 559-564.
Cockcroft, D . W., McParland, C . P. and Britto, S . A. Consroe, P., Musty, R. and Rein, J. ( 1 997) The
( 1 993) Regular inhaled salbutamol and airway perceived effects of smoked cannabis on patients
responsiveness to allergen. Lancet, 342, 833-83 6 . with multiple sclerosis. Eur. Neurol., 38, 44-48.
Cockram, J., Jenkins, S. and Clugston, R . ( 1 999) Conway, J. ( 1 9 92a) Chest physiotherapy - the way
Cardiovascular and respiratory responses to early forward. Physiotherapy, 78, 77-78.
ambulation and stair climbing following coronary Conway, J. ( 1 992b) The effects of humidification for
artery surgery. Physiother. Theory Pract., 1 5 , 3-1 5 . patients with chronic airways disease.
Coffman, J . A . and McManus, K . P. ( 1 984) Oxygen Physiotherapy, 78, 97- 1 0 l .
therapy via nasal catheter for infants with BPD. Conway, S. P. ( 1 997) Recombinant human DNase in
Crit. Care Nurse, 4, 22-23. CF. Arch. Dis. Child. , 77, 1-3.
492
REFERENCES
Conway, S. P. and Littlewood, J. M. ( 1 997) rhDNase glucocorticoid-induced osteoporosis: implications

in CF. Br. J. Hosp. Med. , 5 7, 37 1-372. for patients with respiratory diseases. Thorax, 5 3 ,
Cook, T. M. ( 1 997) Epidural analgesia following 3 3 1 -332.
upper abdominal surgery. Acta Anaesthesio!. Cowley, D. S. ( 1987) Hyperventilation and panic
Scand. , 41, 1 8-24. disorder. Am. J. Med. , 8 3 , 929-937.
Cook, D. J. ( 1 998) Incidence of and risk factors for Cowley, H. C. ( 1 993) Management of liver disease on
ventilator-associated pneumonia. Ann. Intern. ICU. Care Crit. Ill, 9, 1 22-1 27.
Med. , 129, 433-440. Cowling, M. G. (2000) Stenting in the oesophagus.
Cooper, C. ( 1 995) Rheumatoid arthritis, Hosp. Med. , 6 1 , 33-36.
corticosteroid therapy and hip fracture. Ann. Cox, C. and Hayes, J. ( 1 999) Physiologic and
Rheum. Dis. , 54, 49-52. psychodynamic responses to the administration of
Cooper, A. B. ( 1 996) Pulmonary artery catheters in therapeutic touch in critical care. Int. Crit. Care
the critically ill. Crit. Care Clin. , 12, 777-793. Nurse, 1 5 , 3 63-368.
Copestake, A. J. and McConnell, A. ( 1 994) Craig, D. B. ( 1 9 8 1) Postoperative recovery of
Inspiratory muscle training reduces exertional pulmonary function. Anesth. Analg. , 60, 46-52.
breathlessness in healthy elderly men and women. Crane, L. ( 1994) The effect of exercise training on
II Egrepa Conference Proceedings, Scotland. pulmonary function in persons with quadriplegia.
Cormier, Y., Laviolette, M. and Atton, L. ( 1 9 9 1 ) Paraplegia, 32, 435-44l .
Influence o f lung volume o n collateral resistance. Craven, D . E., Lichtenberg, D . A. and Goularte, T . A.
Respir. Physiol. , 83, 1 79- 1 8 8 . ( 1 984) Contaminated medication nebulizers in
Corrado, A . ( 1 996) Intermittent negative pressure mechanical ventilator circuits. Am. J. Med. , 77,
ventilation in the treatment of hypoxic 834-838.
hypercapnic coma in chronic respiratory Creasey, G. ( 1 996) Electrical stimulation to restore
insufficiency. Thorax, 5 1 , 1 077- 1 082. ventilation. J. Rehabil. Res. Develop. , 33, 1 23-1 3 2.
Corris, P. A. ( 1 990) Respiratory failure in COPD. Int. Cregan, P. ( 1 999) Surgery in the information age.
Ther. Clin. Monit. , 1 1, 2, 50-54. Med. J. Austr. , 1 7 1 , 5 1 4-5 1 6 .
Corris, P. A. and Dark, J. H. ( 1 993) Aetiology of Criner, G. J. (2000) Effects o f long-term oxygen
asthma. Lancet, 341, 1 3 69-13 7 l . therapy on mortality and morbidity. Respir. Care,
Corsico, R . ( 1 993) Anti-asthma drugs and quality of 45, 1 05- 1 1 8 .
life. Eur. Respir. Rev. , 3, 366-368. Criner, G. J. and Isaac, L . ( 1 995) Psychological issues
Cosgrove, M. ( 1 997) Experience of percutaneous in the ventilator-dependent patient. Respir. Care,
endoscopic gastrostomy in children with Crohn's 40, 855-865.
disease. Arch. Dis. Child. , 76, 1 4 1-143 . Crockett, A. W. B. ( 1 997) Symptom-free asthma.
Costello, C . M. ( 1 996) Effect of nebulized Update, 5 5 , 463-468.
recombinant DNase on neutrophil elastase load in Crombie, I. K. ( 1 998) Cut and thrust: antecedent
CF. Thorax, 5 1, 6 1 9-623. surgery and trauma among patients attending a
Coultas, D. B. ( 1 998) Passive smoking and risk of chronic pain clinic. Pain, 76, 1 67-1 7 l .
adult asthma and COPD. Thorax, 5 3 , 3 8 1-3 87. Crosby, L. J. and Parsons, L . C . ( 1 992)
Couriel, J. M. (1 994) Passive smoking and the health Cerebrovascular response of closed head-injured
of children. Thorax, 49, 73 1-734. patients to a standardized endotracheal suctioning
Coursin, D. R. and Coursin, D. B. ( 1998) Survivors, and manual hyperventilation procedure. J.
beware of posttraumatic stress disorder. Crit. Care Neurosci. Nurs. , 24, 40-49.
Med. , 26, 834-835. Crowe, J., MacKay, M. and Morris, H. (2000) A
Cousins, N. ( 1 9 8 1 ) Human Options, WW Norton, multi-centre, randomized controlled trial of the
New York, p. 2 1 0. effectiveness of positioning on quadriplegic
Cousins, M. J. ( 1 989) Acute pain and the injury shoulder pain. Physiother. Can., 42, 266-272.
response. Regional Anesthes., 14, 1 62-179. Cruickshank, J. P. and Lumley, K. ( 1 999) Immediate
Covey, L. S. (2000) Advances in non-nicotine management of acute severe asthma in adults. Br.
pharmacotherapy for smoking cessation. Drugs, J. Nurs. , 8, 1 03-1 08 .
59, 1 7-3 l . Cruickshanks, K. J. ( 1 998) Cigarette smoking and
Cowan, S. ( 1 998) Bisphosphonates and hearing loss. J. A. M. A. , 279, 1 7 15-1 7 1 9 .
493
REFERENCES
Cruz, J. ( 1 995) Cerebral blood flow, vascular Dantzker, D. R. ( 1 983). The influence of
resistance and oxygen metabolism in acute brain cardiovascular function on gas exchange. Clin.
trauma. Crit. Care Med. , 23, 1 4 1 2- 1 4 1 7. Chest Med. , 4, 1 49-1 59.
Cryer, H. G., Leong, K. and McArthur, D. L. Dar, K. ( 1 995) Arterial versus capillary blood
( 1 999) Multiple organ failure: by the time you sampling. Br. Med. ]., 309, 24-25 .
predict it, it's already there. ]. Trauma, 46, 597- Dargie, H. J. ( 1 994) Diagnosis and management of
606. heart failure. Br. Med. ]. , 308, 32 1-328.
CSP ( 1 995) Rules of Professional Conduct, Chartered Darin, J. ( 1 982) The need for rational criteria for the
Society of Physiotherapy, London. use of unheated bubble humidifiers. Respir. Care,
CSP ( 1 998) Standards for Newly-qualified 27, 945-947.
Physiotherapists. Chartered Society of Dark, J. H. ( 1 997) Lung: living related
Physiotherapy, London. transplantation. Br. Med. Bull. , 53, 892-903 .
Cunningham, S. ( 1 995) Transcutaneous oxygen levels David, A. ( 1 99 1 ) Positive expiratory pressure, in
in retinopathy of prematurity. Lancet, 346, 1 464- Respiratory Care, (ed. J. A. Pryor), Churchill
1 465. Livingstone, Edinburgh, pp. 5 1-63.
Cupples, S. A. ( 1 99 1 ) Effects of timing and Davies, K. ( 1 994) Prevention of pressure sores. Br. J.
reinforcement of pre-operative education for Nurs., 3, 1 099-1 1 04.
patients having coronary artery bypass graft Davies, C. W. H. ( 1 999) Intrapleural streptokinase in
surgery. Heart Lung, 20, 654-660. the management of malignant multiloculated
Currie, A. E. and Gallagher, P. J. ( 1 988) The pathology pleural effusions. Chest, 1 15 , 729-733 .
of clubbing. Br. ]' Dis. Chest, 82, 3 8 2-3 85. Davies, R . J. O. and Hopkin, J. M . ( 1 989) Nasal
Currie, D. c., Gaskell, M. D. and Cole, P. J. ( 1 986) oxygen in exacerbations of ventilatory failure. Br.
Practice, problems and compliance with postural Med. ]. , 299, 43-44.
drainage. Br. ]. Dis. Chest, 80, 249-253. Davies, H., Helms, P. and Gordon, I. ( 1 990) The
Curtis, J. R. ( 1 994) Emergent assessment and effect of posture on regional ventilation in
management of acute respiratory failure in COPD. children and adults. Thorax, 45, 3 1 3-3 14.
Clin. Chest Med. , 1 5 , 48 1-500. Davies, L., Angus, R. M. and Calverley, P. M. A.
Curtis, K. A., Drysdale, G. A. and Lanza, R. D. ( 1 999) ( 1 999) Oral corticosteroids in patients admitted to
Shoulder pain in wheelchair users with tetraplegia hospital with exacerbations of COPD. Lancet,
and paraplegia. Arch. Phys. Med. Rehabil., 80, 354, 456-460.
453-457. Davis, P. B., Drumm, M. and Konstan, M. W. ( 1 996)
Czarnik, R. E., Stone, K. S. and Everhart, C. C. Cystic fibrosis. Am. J. Respir. Crit. Care Med. , 1 5 4,
( 1 99 1 ) Differential effects of continuous versus 1 229-1256.
intermittent suction on tracheal tissue. Heart Davis, G. and Glaser, R. ( 1 990) Cardiorespiratory
Lung, 20, 1 44- 1 5 l . fitness following spinal cord injury. In: Key Issues
D'Alonzo, G . E . ( 1 995) Measurements o f morning in Neurological Physiotherapy (Eds. Ada, L.,
and evening airflow. Am. ]. Respir. Crit. Care Canning, C.). Butterworth-Heinemann, London.
Med. , 152, 1 097- 1 099. Daviskas, E. ( 1 997) Inhalation of dry-powder
D'Alonzo, G. E., Steinijans, V. W. and Keller, A. mannitol increases mucociliary clearance. Bur.
( 1 995) Measurements of morning and evening Respir. ]' , 10, 2449-2454.
airflow grossly underestimate the circadian Daviskas, E. ( 1999) Inhalation of dry powder
variability of FEV 1 and peak expiratory flow in mannitol improves clearance of mucus 'in patients
asthma. Am. ]. Respir. Crit. Care Med. , 152, 1 097- with bronchiectais. Am. ]. Respir. Crit. Care Med. ,
1 099. 1 5 9, 1 843-1 848.
D'Amours, R. H. ( 1 996) Postoperative pain Davy, K. P. and Seals, D. R. ( 1 994) Total blood
management. ]' Orthop. Sports PT, 24, 227-234. volume in healthy young and older men. J. Appl.
Dalley, J. ( 1 999) Evaluation of clinical practice. Physiol. , 76, 2059-2062.
Physiotherapy, 8 5 , 49 1-497. Dean, E. ( 1 994) Oxygen transport: a physiologically
Dallimore, K., Jenkinsm S. and Tucker, B. ( 1 998) based conceptual framework for the practice of
Respiratory and cardiovascular responses to cardiopulmonary physiotherapy. Physiotherapy, .
manual chest percussion in normal subjects. Austr. 80, 347-354.

Physiother. ]., 44, 267-274. Dean, E. ( 1 997) Oxygen transport deficits in systemic
494
REFERENCES
disease and implications for physical therapy. neonatal and pediatric patients, in Clinical
Phys. Ther. , 77, 1 87-20 1 . Assessment in Respiratory Care, (eds R. L. Wilkins,
Dean, E . and Ross, ] . ( 1 992) Mobilization and R. L. Sheldon and S. ]. Krider), Mosby, Toronto.
exercise conditioning, in Pulmonary Management Demling, R. ( 1 990) Pulmonary dysfunction after
in physical therapy, (ed. C. C. Zadai), Churchill cerebral injury. Crit. Care Med. , 1 8 , 768-774.
Livingstone, Edinburgh. Denehy, L. ( 1999) The use of manual hyperinflation
Dean, N. c., Brown, ]. K. and Himelman, R. B. in airways clearance. Eur. Respir. ]' , 14, 958-
( 1 992) Oxygen may improve dyspnea and 965.
end\uance in patients with COPD. Am. Rev. Denholm, S. W. and Goodwin, H . A. ( 1 995)
Respir. Dis., 146, 94 1-945. Aspiration of foreign bodies. Hosp. Update, 2 1 ,
Deaves, D. M. ( 1993) An assessment of the value of 5 62-5 64.
asthma education in the prevention of childhood Denison, D. M. ( 1 996) Physiological principles, in
asthma. ]. Adv. Nurs. ing, 1 8 , 354-363. Occupational Lung Disease, (ed. W. Raymond
DeBusk, R. F. ( 1 990) Training effects of long versus Parkes), 2nd edn, Butterworth-Heinemann,
short bouts of exercise in healthy subjects. Am. ]. London.
Cardio!. , 65, 1 0 1 0- 1 0 1 3 . Dennison, A., Oakley, N. and Appleton, D. ( 1 996)
Dechman, c., Sato, ]. and Bates, ]. H. T . (1 993) Local anaesthesia for major general surgical
Effect of pleural effusion on respiratory mechanics procedures. Postgrad. Med. ]., 72, 1 05-108.
and the influence of deep inflation, in dogs. Eur. DeRose, ]. ]., Argenziano, M. and EI-Arnir, N. ( 1 998)
Respir. ]., 6, 2 1 9-224. Lung reduction operation and resection of
Decramer, M. ( 1994) Corticosteroids contribute to pulmonary nodules. Ann. Thorac. Surg. , 65, 3 14-
muscle weakness in CAO. Am. ]. Respir. Crit. Care 3 18.
Med. , 150, 1 1-16. Deschamps, c., Pairolero, P. C. and Allen, M. S .
Decramer, M. ( 1997) Hyperinflation and respiratory ( 1 999) Early complications. Chest Surg. Clin.
muscle interaction. Eur. Respir. ]. , 1 0, 934-94 1 . North Am. , 9, 5 8 7-595.
DeGuire, S . , Gevirtz, R. and Kawahara, Y . ( 1992) Deslauriers, ]. ( 1 999) Techniques of pneumonectomy.
Hyperventilation syndrome and the assessment of Chest Surg. C/in. North Am., 9, 437-448 .
treatment for functional cardiac symptoms. Am. ]. DeVito, A. ]. ( 1 990) Dyspnea during hospitalization
Cardio!. , 70, 673-677. for acute phase of illness as recalled by patients
Deitch, E. A. ( 1 999) Prevention of multiple organ with COPD. Heart Lung, 1 9, 1 8 6- 1 9 1 .
failure. Surg. C/in. North Am. , 79, 1471-1488. Dewar, A. L . ( 1 995) Unbearable incidents: failure to
Dekker, F. W., Schrier, A. C. and Sterk, P. ]. ( 1992) endure the experience of illness. ]. Adv. Nurs. , 22,
Validity of peak expiratory flow measurement in 957-964.
assessing reversibility of airflow obstruction. Dexter, F. and Hindman, B. ]. ( 1997)
Thorax, 47, 1 62-1 66. Recommendations for hyperbaric oxygen therapy
DeLateur, B. ]. ( 1 997) Quality of Life: a patient of cerebral air embolism. Anesth. Analg. , 84,
centred outcome. Arch. Phys. Med. Rehabi!' , 78, 1 203-1207.
237-299. Dhand, R. and Fink, ]. ( 1 999) Dry powder inhalers.
Delaunay, L. ( 1995) Laparoscopic cholecystectomy Respir. Care, 44, 940-95 1 .
minimally impairs postoperative cardiorespiratory Dickey, ] . L . ( 1989) Postoperative osteopathic
and muscle performance. Br. ]. Surg. , 82, 3 73-376. manipulation of median sternotomy patients. ].
Delk, K. K., Gevirtz, R. and Hicks, D. A. ( 1 993) The Am. Osteopath. Assoc. , 89, 1 3 09-1 322.
effects of biofeedback retraining on lung function Dicpinigaitis, P. V. ( 1 998) Treatment of chronic
in patients with CF. Chest, 105, 23-28. refractory cough with baclofen. Respiration, 65,
DeLucas, P. ( 1 996) Exercise test in the early diagnosis 86-8 8 .
of interstitial pulmonary diseases. Eur. Resp.]. , Didour, M. ( 1997) Effects of lung cycle ergometer
9(23), 1 4 1 5 . training in elderly patients with bronchial asthma.
DeMeo, M . T . ( 1 992) Nutrition i n acute pulmonary Eur. Respir. ]. , 1 0, 458S.
disease. Nutr. Rev. , 50, 320-328. Diflorio, T. ( 1 999) The effect of midazolam on
Demeter, S. L. ( 1 986) Hyperventilation syndrome and persistent postoperative nausea and vomiting.
asthma. Am. ]. Med. , 8 1,89-94. Anaesth. Intensive Care, 27, 3 8-40.
Deming, D. D. ( 1 995) Respiratory assessment of Dilworth, ]. P. and White, R. ]. ( 1 992) Postoperative
495
REFERENCES
chest infection after upper abdominal surgery. DoH ( 1996.) Guidelines ofAdmission to and Discharge
Respir. Med. , 86, 205-2 10. from Intensive Care and High Dependency Units.
Dimitriou, G. ( 1 996) A comparison of supine and Department of Health, London.
prone positioning in oxygen dependent and DoH ( 1 999) Clinical Governance. NHS Executive,
convalescent premature infants. Br. ]. Intensive Leeds.
Care, 6, 254-259. Donahoe, M. and Rogers, R. M. ( 1 990) Nutritional
Dimond, B . C. ( 1 999) Legal Aspects of Physiotherapy, assessment and support in COPD. Clin. Chest
Blackwell, Oxford. Med., 1 1 , 487-504.
Dimopoulou, 1. ( 1 999) Respiratory function in Donahoe, M., Rogers, R. M. and Cottrell, J. J. ( 1 992)
patients with thalassaemia and iron overload. Eur. Is loss of body weight in COPD patients with
Respir. j. , 1 3 , 602-65 9. emphysema secondary to low tissue oxygenation?
Dinwiddie, R. (2000) Pathogenesis of lung disease in Respiration, 24 (supp!. 2), 33-39.
CF. Respiration, 67, 3-8. Donald, 1. ( 1977) Pain - a patient's view, in Pain:
Dixhoorn, J. van ( 1 986) Behavioral characteristics New Perspectives in Measurement and
predisposing to hyperventilation complaints. Management, (ed. A. W. Harcus), Churchill
Gedrag Gezondheid., 14, 1 69-174. Livingstone, Edinburgh, p. 1 .
Dixhoorn, J. van, Duivenvoordent, H. J. and Staal, J. Donald, K. J., Robertson, V. J . and Tsebelis, K.
A. ( 1 987) Cardiac events after mycardial (2000) Setting safe and effective suction pressure.
infarction: possible effect of relaxation therapy. Intensive Care Med. , 26, 1 5-19.
Eur. Heart ]., 8, 1 2 1 0- 1 21 4 . Donaldson, G. C. ( 1999) Effect of temperature on
Dobb, G. J. and Coombs, L. J. ( 1 98 7) Clinical lung function and symptoms in COPD. Eur.
examination of patients in the ICU. Br. ]. Hosp. Respir. ]' , 1 3 , 844-849.
Med. , 3 8 , 1 02-8. Donner, C. F. and Carone, M. ( 1998) Determining
Dobbs, P. and Coad, N. ( 1 999) The pathophysiology quality of life in COPD patients. RT Int. , 7, 37--43.
and ICU treatment of patients following use of Donner, C. F. and Howard, P. ( 1 992) Pulmonary
ecstasy. Br. ]' Intensive Care, 9, 9-1 3 . rehabilitation in COPD with recommendations for
Dock, W. ( 1 944) The evil sequelae of complete bed its use. Eur. Respir. ]. , 5, 266-275.
rest. j. A. M. A. , 125, 1 083-1085. Dorinsky, P. M., Reisner, C. and Ferguson, G. T.
Dodd, F. M., Simon, E. and McKeown, D. ( 1995) ( 1 999) The combination of ipratropium and
The effect of a cervical collar on the tidal volume alb utero I optimizes pulmonary function testing in
of anaesthetised adult patients. Anaesthesia, 50, COPD. Chest, 1 15, 966-9 7 1 .
96 1 -963. Douglas, N. ( 1 993) Nocturnal asthma. Respir. Dis.
Dodd, M. E. ( 1 9 9 1 ) Exercise in cystic fibrosis adults, Pract., 1 0, 7-9.
in Respiratory Care, (ed. J. A. Pryor), Churchill Douglas, W. E. and Flabouris, A. ( 1 999) Surgical
Livingstone, Edinburgh, pp. 27-50. emphysema following percutaneous tracheostomy.
Dodd, M. E. ( 1996) Nebuliser therapy: what nurses Anaesth. Intensive Care, 27, 69-72.
and patients need to know. Nurs. Stand. , 10(3 1 ) , Doull, I. J. M. ( 1 997) Tracheobronchomalacia in
3 9--42. preterm infants with chronic lung disease. Arch.
Dodd, M. E., Howarth, C. S. and Webb, A. K. ( 1 998) Dis. Child., 76, F203-F205.
A practical approach to oxygen therapy in cystic Dow, L. ( 1 996) Does dietary intake of vitamins C and
fibrosis. j. Roy. Soc. Med. , 9 1 (supp!. 34), 3 0-3 9. E influence lung function in older people? Am. ]'
Dodge, J. ( 1 999) Gastro-oesophageal reflux in infants. Respir. Crit. Care Med. , 154, 1401- 1404.
Acta Paediatr. , 88, 359-370. Downs, J. A. ( 1989) Endotracheal suction: a method
Dodson, L. A., Nathan, N. S. and D'Ambra, M. N. of tracheal washout. Physiotherapy, 75, 454.
( 1 997) New concepts in right heart failure. Curro Downs, J. A., Edwards, A. D. and McCormick, D. C.
Opin. Anaesth., 10, 2 1 -28. ( 1 9 9 1 ) Effect of intervention on development of
DoH ( 1993) The Health of the Nation, Department of hip posture in very preterm babies. Arch. Dis.
Health, London. Child. , 66, 797-8 0 1 .
DoH ( 1 995) Health of the Nation: Nutritional Dresler, C . M . ( 1 996) Smoking cessation and lung
Guidelines for Hospital Catering, Department of cancer resection. Chest, 1 10, 1 1 99-1202.
Health, London. Dreyfuss, D. ( 1995) Mechanical ventilation.with
496
REFERENCES
heated humidifers or heat moisture exchangers. Eaton, J. M. ( 1984) Adult manual resuscitators. Br. j.
Am. j. Respir. Crit. Care Med. , 1 5 1, 986-992. Hosp. Med. , 3 1, 67-703.
Drugs and Therapeutics Bulletin ( 1997) Long-acting Eaton, D., Bannister, P. and Mulley, G. P. ( 1 994)
�rstimulants in asthma. Drugs Ther. Bull., 35, 1- Axillary sweating in clinical assessment of
4. dehydration in ill elderly patients. Br. Med. j. ,
Du, H. L., Yamada, Y. and Suzuki, R. O. S. ( 1 997) 308, 1271.
Beneficial effects of the prone position on the Edington, J., Kon, P. and Martyn, C. N. ( 1 997)
incidence of barotrauma in oleic acid-induced lung Prevalence of malnutrition after major surgery. j.
injury. Acta Anaesthesio/. Scand., 4 1 , 70 1-707. Hum. Nutr. Diet. 1 0, 1 1 1-1 1 6.
Duckworth, M. ( 1 999) Outcome measurement Edmondson, R. ( 1994) The causes and management
selection and typology. Physiotherapy, 85, 2 1-27. of pulmonary embolism. Care Crit. Ill, 10, 26-9.
Dudgeon, D. J. and Lertzman, M. ( 1 998) Dyspnea in Edwards, J. D. ( 1 997) Oxygen transport in the
the advanced cancer patient. j. Pain Symptom critically ill. Br. j. Intensive Care, 7, 23-29.
Manage., 16, 2 1 2-2 19. Efthimiou, J. and Barnes, P. F. ( 1 998) Effect of
Dudley, D. L., Glover, E. M., and Jorgenson, B. N. inhaled corticosteroids on bones and growth. Eur.
( 1980) Psychosocial concomitants to rehabilitation Respir. J., 1 1, 1 1 67-1 1 77.
in COPD. Chest, 77, 544-5 5 1 . Egbert, L. D., Battit, G. E. and Welch, C. E. ( 1 9 64)
Dulfano, M . J . ( 1 973) Physical properties of sputum. Reduction of postoperative pain by
Am. Rev. Respir. Dis. , 107, 1 3 0-133. encouragement and instruction of patients. N.
Duncan, S. R. ( 1 987) Hyperventilation syndrome. Engl. J. Med. , 270, 825-827.
Hosp. Med. , 23, 86-98. Ehrlich, M., Manns, P. J. and Poulin, C. ( 1 999)
Dunlevy, C. D. and Tyl, S. E. ( 1 992) The effect of Respiratory training for a person with C3-C4
oral versus nasal breathing on oxygen tetraplegia. Austr. j. Physiother. , 45, 3 0 1-307.
concentrations from nasal cannulas. Respir. Care, Eid, N. ( 1 9 9 1 ) Chest physiotherapy in review. Respir.
37, 357-360. Care, 36, 270-282.
Dunn, R. B., Walter, J. S. and Walsh, J. ( 1 995) Eigen, H., Clark, N. M. and Wolle, J. M. ( 1987)
Diaphragm and accessory respiratory muscle Clinical-behavioral aspects of CF. Am. Rev. Respir.
stimulation using intramuscular electrodes. Arch. Dis. , 136, 1 5 09-1 5 1 3 .
Phys. Med. Rehabil. , 76, 266-2 7 1 . El-Ansary, D . , Adams, R . and Ghandi, A . (2000)
Durand, M . , Sangha, B . and Cabal, L. A . ( 1 989) Musculoskeletal and neurological complications
Cardiopulmonary and intracranial pressure following CABG. Austr. Physiother. J., 46, 1 9-25.
changes related to endotracheal suctioning in Elborn, J. S. ( 1 996) Nutrition and survival in CF.
preterm infants. Crit. Care Med. , 1 7, 5 06-5 1 0 . Thorax, 5 1 , 971-972.
Duranti, R . ( 1 995) Mechanical loading and control o f Elborn, J. S., Shale, D. J., Britton, J. R. ( 1 9 9 1 ) Cystic
breathing i n patients with severe COPD. Thorax, fibrosis: current survival and population estimates
50, 127-133. to the year 2000. Thorax, 46, 88 1-885.
Durbin, C. G. ( 1 993) Oxygen toxicity in the critically Elborn, J. S., Johnston, B. and Allen, F . ( 1 9 92)
ill patient. Respir. Care, 38, 739-753. Inhaled steroids in patients with bronchiectasis.
Durward, Q. J., Amacher, A. L. and Maestro, R. F. Respir. Med. , 86, 1 2 1-124.
( 1 983) Cerebral and cardiovascular responses to Elborn, J. S., Prescott, R. J. and Stack, B. H . R. (2000)
changes in head elevation in patients with Elective versus symptomatic antibiotic treatment in
intracranial hypertension. j. Neurosurg. , 59, 938- cystic fibrosis patients. Thorax, 55, 355-35 8 .
44. Elia, M . ( 1 995) Changing concepts o f nutrient
Dweik, R. A. and Stoller, J. K. ( 1 999) Role of requirements in disease. Lancet, 345, 1 279-1 282.
bronchoscopy in massive hemotpysis. Clin. Chest Elliott, M. W. ( 1 995) Nocturnal assisted ventilation
Med. , 20, 89-105. using BiPAP. Eur. Respir. j. , 8, 43 6-440.
Dyer, I. ( 1 995) Preventing the ITU syndrome. Elliott, M. W., Aquilina, R. and Green, M. ( 1994) A
Intensive Crit. Care Nurs. , 1 1 , 1 30-1 3 9. comparison of different modes of noninvasive
Eakin, E. G., Resnikoff, P. M., Prewitt, L. M. and ventilatory support. Anaesthesia, 49, 279-283.
Ries, A. L. ( 1 998) Validation of a new dyspnea Ellis, N. ( 1 994) Acupuncture in Clinical Practice,
measure. Chest, 1 13, 6 1 9-624. Chapman & Hall, London.
497
RHERENCES
Ellis, B. ( 1 995) Cardiac transplantation. physiotherapy. Intensive Care Britain, Greycoat,

Physiotherapy, 8 1 , 1 57-1 62. Harley St, London, 1 1 8-123.
Ellis, E. R., Redfern, ]. and Rusterholtz, B. ( 1 999) Enzer, N. B . and Walker, P. A. ( 1 967)
The effects of feedback on the performance of Hyperventilation syndrome in childhood. J.
manual hyperinflation by physiotherapists. WCPT Pediatr. , 70, 521-532.
Proceedings, p. 3 1 . Epstein, C. D. and Henning, R. J. ( 1 993) Oxygen
Elpern, E . H., Scott, M. G . and Petro, L. ( 1 994) transport variables in the identification and
Pulmonary aspiration in mechanically ventilated treatment of tissue hypoxia. Heart Lung, 22, 328-
patients with tracheostomies. Chest, 1 05, 563- 348.
566. Erb, R. and Frei, F. ]. ( 1 996) Sedation in the
Ely, W. E., Johnson, M. M. and Chiles, C. ( 1 996) paediatric ICU. Curro Opin. Anaesth., 9, 239-243 .
Chest X-ray changes in air space disease are Eriksson, L. (1 996) Pulmonary physiology relevant to
associated with parameters of mechanical chest physiotherapy. Israel J. Med. , 32, S 1 1 0-
ventilation. Am. J. Respir. Crit. Care Med. , 154, S 1 14.
1 543-1550. Ernst, E. ( 1 995) What is wrong with anecdotal
Emergency Care Research Institute ( 1 977) Suction evidence? Eur. J. Phys. Med. Rehabil. , 5, 1 45-146.
catheters. Health Devices, 6, 1 32-1 4 1 . Ernst, E. ( 1 998) Complementary therapies for asthma.
Empey, D . ( 1 992) International consensus on J. Asthma, 35, 667-6 7 1 .
diagnosis and treatment of asthma. Respir. Dis. Ersson, U . , Carlson, H. and Mellstrom, A . (1 990)
Pract. , 9, 1 3-20. Observations on intracranial dynamics during
Empey, D. ( 1 993) Tuberculosis - a killer returns. respiratory physiotherapy in unconscious
Respir. Dis. Pract. , 1 0, 4-5. neurosurgical patients. Acta Anaesthesiol. Scand. ,
Emtner, M. ( 1 998) A 3-year follow-up of asthmatic 34, 99-103.
patients participating in a 1 0-week rehabilitation Esteban, A. ( 1 995) A comparison of four methods of
program. Arch. Phys. Med. Rehabil., 79, 5 3 9- weaning. N. Engl. J. Med. , 332, 345-348.
544. Everard, M. L., Clark, A. R. and Milner, A. D. ( 1 992)
Emtner, M., Herala, M. and Stalenheim, G. ( 1 996) Drug delivery from holding chambers with
High-intensity physical training in adults with attached facemask. Arch. Dis. Child. , 67, 580-585.
asthma. Chest, 1 09, 323-330. Everard, M. L., Evans, M. and Milner, A. D. (1 994) Is
Emtner, M., Hedin, A., Sd.lenheim G ( 1 998) tapping jet nebulizers worthwhile? Arch. Dis.
Asthmatic patients' views of a comprehensive Child. , 70, 53 8-539.
asthma rehabilitation programme. Physiother. Res. Everly, G. S. ( 1 989). A Clinical Guide to the
Int. , 3, 1 75- 193. Treatment of the Human Stress Response, Plenum
Enderby, P. ( 1 995) The effect of dairy products on Press, New York.
the viscosity of saliva. Clin. Rehabil. , 9, 6 1 -64. Ewer, A. K., James, M. E. and Tobin, ]. M. ( 1 999)
Eng, P. ( 1 998) Flexible fiberoptic bronchoscopy. Prone and left lateral positioning reduce gastro
Respir. Ther. Int., 7, 33-3 5 . oesophageal reflux in preterm infants. Arch. Dis.
Eng, P. A . , Morton, ] . and Douglass, ]. A . ( 1 996) Child. Fetal Neonat. Ed., 8 1 , F201-F205.
Short-term efficacy of ultrasonically nebulized Fabregas, N. ( 1 996) Diagnosis of ventilator-associated
hypertonic saline in CF. Pediatr. Pulmonol., 2 1 , pneumonia. Curro Opin. Anaesthesiol. , 9, 1 57- 1 6 1 .
77-83 . Fahrenfort, M . ( 1 987) Patient emancipation b y health
Engdahl, O. ( 1 993) Chest radiograph - a poor education. Patient Education Council, USA, 10, 25.
method for determining the size of a Faling, L. ]. ( 1 986) Pulmonary rehabilitation -
pneumothorax. Chest, 103, 26-29. physical modalities. Clin. Chest Med. , 7, 599-6 1 8 .
Engstrom, C. P., Persson, L. 0., Larsson, S. et al. Falk, S. ( 1 997) Lung cancer. Update, 5 5 , 706-7 12.
( 1 996) Functional status and well-being in COPD. Fallowfield, L. ( 1 993) Giving sad and bad news.
Thorax, 5 1, 825-830. Lancet, 341, 476-478.
Enqvist, B. ( 1 997) Preoperative hypnosis reduces Fan, C.-F., Tanhui, E. and Joshi, S. ( 1 997)
postoperative vomiting after surgery of the breasts. Acupressure treatment for prevention of
Acta Anaesth. Scand. , 4 1 , 1 028-1032. postoperative nausea and vomiting. Anesth. Analg. ,
Enright, S. ( 1 992) Cardiorespiratory effects of chest 84, 82 1-825 .
498
REFERENCES
Fanta, C. H. (1 992) Emergency management of acure supplements. Phys. Med. Rehab. Clin. N. Am. , 1 0,
severe asthma. Respir. Care, 37, 55 1-563. 673-697.
Fareed, A. (1 996) The experience of reassurance. J. Fink, J. and Dhand, R. ( 1 999) Bronchodilator
Adv. Nurs. , 23, 272-279. resuscitation in the emergency department. Respir.
Fawcett, D. D. ( 1 995) Inhaled anti-inflammatory Care, 44, 1 3 53-1 374.
agents in childhood asthma. Respir. Care, 40, 1 08- Fink, M. P., Helsmoortel, C. M. and Stein, K. L. (1 990)
1 13 . The efficacy of an oscillating bed in the prevention
Faymonville, M . E. ( 1 997) Psychological approaches of lower respiratory tract infection in critically ill
during conscious sedation. Pain, 73, 3 6 1 -367. victims of blunt trauma. Chest, 97, 1 32-1 37.
Fehrenbach, C. ( 1 998) Chronic obstructive pulmonary Fink, J. B., Krause, S. A. and Barrett, L. ( 1 998)
disease. Prof. Nurse, 13, 771-777. Extending ventilator circuit change interval
Feldman, Z. (1 992) Effect of head elevation on head beyond 2 days. Chest, 1 13, 405-4 1 1 .
injured patients. J. Neurosurg. , 76, 207-2 1 1 . Finlayson, J . M. ( 1 997) The role of exercise in
Feldman, c., Kassel, M. and Cantrell, J . ( 1 999) The rehabilitation after uncomplicated myocardial
presence and sequence of endotracheal tube infarction. Physiotherapy, 8 3 , 5 1 7-523.
colonization in patients undergoing mechanical Fiorentini, A. ( 1 992) Potential hazards of
ventilation. Eur. Resp. J., 13, 546-55 1 . tracheobronchial suctioning. Intens. Crit. Care
Felhendler, D. (1 996) Pressure on acupoints decreases Nurs. , 8, 2 1 7-226.
postoperative pain. Clin. j. Pain, 12, 326-329. Fisher, M. D. ( 1 9 97) Pediatric traumatic brain injury.
Feneck, R. O. (1 996) Cardiac surgery and intensive Crit. Care Nurse, 20, 3 6-5 1 .
care. Br. j. Intensive Care, 6, 1 55-1 6 1 . Fisher, E . B., Haire-Joshu, K . and Morgan, G. D.
Feng, W., Deng, W . W . and Huang, S. G . (1 998) ( 1 990) Smoking and smoking cessation. Am. Rev.
Short-term efficacy of RC-Cornet in improving Respir. Dis. , 142, 702-720.
pulmonary function and decreasing cohesiveness Fitting, J.-W. ( 1 992) Nutritional support in chronic
of sputum in bronchiectasis patients. Chest, 1 1 4, obstructive lung disease. Thorax, 47, 14 1-143 .
320. Fitzgerald, J. M. ( 1 988) Use of oxygen therapy for
Ferdinand, B. (1 998) Postoperative pneumonia. Chest adult patients outside the critical care areas of a
Surg. Clin. North Am. , 8, 529-54 1 . university hospital. Lancet, i, 9 8 1 -983.
Ferguson, J . A. (1992) Pain following coronary artery Fixley, M. S. ( 1 978) Flow dependence of gas
bypass grafting. Intens. Crit. Care Nurs. , 8, 1 53- distribution and the pattern of inspiratory muscle
1 62. contraction. J. App/. Physiol. , 45, 733-74 1 .
Ferguson, M. K. ( 1 999) Preoperative assessment of Flanc, C . ( 1 969) Postoperative DVT, effect of
postoperative risk, Chest, 1 1 5 , 5 8 S-63S. intensive prophylaxis. Lancet, i, 477-478.
Ferguson, A. D., Prescott, R. J. and Selkon, J. B. Flaxman, J. ( 1 978) Quitting smoking now or later.
( 1 996) The clinical course and management of Behav. Ther. 9, 240-270.
thoracic empyema. Q. j. Med. , 89, 285-289. Fletcher, E. C. ( 1 992) A double-blind trial of
Ferrer, M. (1 997) Chronic obstructive pulmonary nocturnal supplemental oxygen for sleep
disease stage and health-related quality of life. desaturation in patients with COPD. Am. Rev.
Ann. Intern. Med. , 127, 1 072-1079. Respir. Dis. , 145, 1 070- 1 076.
Fessler, H. E. ( 1 995) CPAP reduces inspiratory work Flood, P. T. and Partridge, M. R. ( 1 996) Asthma: a
more than dyspnea during hyperinflation. Chest, changing perspective on management. Curro
1 08 , 432-440. Anaesth. Crit. Care, 7, 260-265.
Fiddler, H. and Williams, N. (2000) ECMO: a Flynn, M. B. ( 1 999) Identifying and treating
physiotherapy perspective. Physiotherapy, 86, inhalation injuries in fire victims. Dimens. Crit.
203-208. Care Nurs. , 1 8, 1 8-23.
Fiel, S. B. ( 1 993) Clinical management of pulmonary Foglio, K., Bianchi, L. and Bruletti, G. ( 1 999) Long
disease in CF. Lancet, 34 1 , 1 070-1074. term effectiveness of pulmonary rehabilitation in
Field, S. K. (1 998) Does medical antireflux therapy patients with CAO. Eur. Respir. j. , 13, 1 25-132.
improve asthma in asthmatics with GOR? Chest, Foley, M. P., Prax, B. and Crowell, R. ( 1 996)
1 1 4, 275-283. Cardiorespiratory demands in older adults. Phys.
Fillmore, C. M. ( 1 999) Nutrition and dietary Ther. , 76, 1 3 13-1 3 1 9 .
499
REFERENCES
Fong, S. L. e. ( 1994) Compliance among adults with Practice of Cardiopulmonary Physical Therapy,
CF. Ann. Pharmacother. , 24, 689-69 1 . Mosby, Chicago, IL.
Fonsmark, L., Rasmussen, Y. H . and Carl, P . ( 1 999) Fuhrman, B. P., Hernan, L. J. and Steinhorn, D. M.
Occurrence of withdrawal in critically ill sedated ( 1 998) Partial liquid ventilation and the challenges
children. Crit. Care Med. , 27, 1 96-199. of randomized controlled trials. Respir. Care, 43,
Forastiere, F., Pistelli, R. and Sestini, P. (2000) 1086- 1 09 1 .
Consumption of fresh fruit rich in vitamin C and Fuller, D . , Sullivan, J . and Fregosi, R . F . ( 1 996)
wheezing symptoms in children. Thorax, 5 5 , 283- Expiratory muscle endurance performance after
288. exhaustive submaximal exercise. ]. Appl. Physiol. ,
Forbes, e. ( 1994) Management of deep vein 80, 1495-1 502.
thrombosis. Practitioner, 238, 1 68-175. Fulmer, J. D. and Snider, G. L. ( 1984) ACCP-NHLBI
Fourrier, F. ( 1992) Septic shock, multiple organ National conference on oxygen therapy. Chest, 86,
failure and DIe. Chest, 1 0 1 , 8 1 6-823. 234-247.
Francis, K. ( 1 996) Physical activity in prevention and Fulton, Y. ( 1 996) Children's rights and the role of the
rehabilitation of breast cancer. Crit. Rev. Phys. nurse. Paed. Nurs. , 8, 29-3 1 .
Rehabil. Med. , 8 , 3 23-34 1 . Gale, G . and VandenBerg, K . A. ( 1 998) Kangaroo
Franck, L . S. ( 1 998) The use o f intravenous opioids to Care. Neonat. Netw. , 1 7, 69-7 1 .
provide analgesia in critically ill premature Gallagher, R . ( 1 998) Nicotine withdrawal as an
neonates. ]. Pain Symptom Manage., 1 5 , 4 1-69. etiologic factor in delirium [letter] . J. Pain
Frank, e., Akeson, W. H., Woo, S. L. Y. and Arniel, Symptom Manage., 1 6, 26-27.
D. ( 1994) Physiology and therapeutic value of Gallagher, R. and Trenchard, J. ( 1 986) Movements of
passive joint motion. Clin. Orthoped. Related Res. , Life, Redemptionist Publications, Alton.
1 85 , 1 1 3- 1 24. Gallego, J. and Perruchet, P. ( 1 991) Effect of practice
Fraser, J. and Kerr, J. R. ( 1 993) Psychophysiological on the voluntary control of a learned breathing
effects of back massage on elderly institutionalized pattern. Physiol. Behav. , 49, 3 15-3 19.
patients. J. Adv. Nurs. , 1 8 , 238-245. Galley, H. F. (2000) Can acute renal failure be
Frazer, e. A. ( 1 999) Effect of transcutaneous electrical prevented? ]. Roy. Coli. Surg. Edin., 45, 44-5 0.
nerve stimulation on emesis associated with PCA. Gandy, A. P. ( 1 968) An attack of tetanus. Lancet, ii,
WCPT Proceedings, p. 6 1 . 5 67-568.
Freedberg, P . D., Hoffman, L . A. and Light, W . e. Ganea, G. R. and Bogue, e. W. ( 1 999) Pain
( 1 987) Effect of progressive muscle relaxation on management and weaning from narcotics and
asthma. Heart Lung, 16, 24-30 . sedatives. Curro Opin. Pediatr. , 1 1, 207-2 12.
Freedman, S. ( 19 8 7) Breathlessness and respiratory Gardner, W. N. ( 1 996) The pathophysiology of
mechanics during reflex or voluntary hyperventilation syndrome. Chest, 1 09, 5 1 6-530.
hyperventilation in patients with CAL. Clin. Sci. , Garrod, R. ( 1 998) The pros and cons of pulmonary
73, 3 1 1-3 1 8 . rehabilitation at home. Physiotherapy, 84, 603-
Freeman, J . A. and Armstrong, I . R . ( 1 994) Pulmonary 607.
function tests before and after laparoscopic Garrod, R., Bestall, J. and Garnham, R. ( 1 996)
cholecystectomy. Anaesthesia, 49, 579-5 82. Factors affecting attendance at an outpatient
Freichels, T. A. ( 1 998) Managing mechanical pulmonary rehabilitation programme. Eur. Respir.
ventilation in status asthmaticus. Dimens. Crit. ]., 9 (23), 3 82s.
Care Nurs. , 1 7, 2-7. Garrod, R., Bestall, J. e. and Paul, E. ( 1999)
Fried, R. ( 1 993) The Psychology and Physiology of Evaluation of pulsed dose oxygen delivery during
Breathing, Plenum Press, New York. exercise in patients with severe COPD. Thorax,
Froese, A. B. and Bryan, e. ( 1974) Effects of 54, 242-244.
anesthesia and paralysis on diaphragmatic Garssen, B. ( 1980) Role of stress in the development
mechanics in man. Anesthesiology, 4 1 , 242-255 . of the hyperventilation syndrome. Psychother.
Frost, E. A . M . ( 1996) Management o f post Psychosom., 33, 2 1 4-225.
operative complications. Curro Opin. Anaesth. , 9, Garssen, B. ( 1 983) Agoraphobia and the
48 1-487. hyperventilation syndrome. Behav. Res. Ther. , 2 1 ,
Frownfelter, D. L. and Dean, E. ( 1 996) Principles and 643-649.
5 00
REFERENCES
Gaultier, C. and Crapo, R. ( 1 997) Effects of nutrition, Gillespie, D. J. and Rehder, K. ( 1 987) Body position
growth hormone disturbances, training, altitude and VAiQ relationships in unilateral pulmonary
and sleep on lung volumes. Eur. Respir. ]., 1 0, disease, Chest, 1, 75-79.
291 3-29 1 9. Girard, J. P. and Terki, N. ( 1994) The Flutter as an
Gauwitz, D. F. ( 1 995) How to protect the dysphagic adjunct to drug therapy in the management of
stroke patient. Am. ]. Nurs. , 95, 34-3 8 . bronchial asthma. j. Invest. Allergy Clin.
Gaynor, J. W. ( 1 998) Update o n lung transplantation Immunol., 4, 23-27.
in children. Curro Opin. Pediatr. , 1 0, 256-2 6 I . Girault, C. ( 1 997) Physiological effects and
Geller, M . (2000) Marked peripheral edema optimisation of nasal assist-control ventilation for
associated with montelukast and prednisone. Ann. patients with COPD. Thorax, 52, 690-696.
Int. Med. , 132, 924. Girault, C. ( 1 999) Noninvasive ventilation as a
Gershman, N. H. ( 1996) Comparison of two methods systematic extubation and weaning technique in
of colle<:ting induced sputum. Eur. Respir. j., 9, acute-on-chronic respiratory failure. Am. j. Respir.
2448-2453. Crit. Care Med. , 1 60, 86-92.
Gersin, K. ( 1 994) The efficacy of sequential Girault, c., Muir, J.-F. and Mihaltan, F. ( 1 996)
compression devices in multiple trauma patients Effects of repeated administration of zolpidem on
with severe head injury. j. Trauma, 3 7, 205-208 . sleep, diurnal and nocturnal respiratory function,
Ghoneim, M . M . (2000) Awareness during anesthesia. vigilance and physical performance. Chest, 1 10,
Anesthesiology, 92, 597-602. 1 203- 1 2 1 I .
Giacomo, T. D. ( 1 999) Thoracoscopic resection of Girodo, M., Ekstrand, K . A . and Metivier, G . J .
solitary lung metastases from colorectal cancer is a ( 1 992) Deep diaphragmatic breathing for the
viable therapeutic option. Chest, 1 15 , 1 14 1- 1 143. asthmatic patient. Arch. Phys. Med. Rehabil. , 73,
Giannini, D. and Bacci, E. ( 1 999) Inhaled 7 1 7-720.
beclomethasone dipropionate reverts tolerance to Giroux, ]. M., Lewis, S. and Holland, L. G. ( 1 987)
the protective effect of salmeterol. Chest, 1 1 5 , Postoperative chest physiotherapy for abdominal
629-634. hysterectomy patients. Physiother. Can. , 39, 89-93 .
Gibson, G. J. ( 1 995) Perception, personality and Giuliano, K. K., Bloniasz, E. and Bell, ]. (2000)
respiratory control in life-threatening asthma. Implementation of a pet visitation program in
Thorax, 50(suppl. 1), S2-S4. critical care. Crit. Care Nurse, 1 9, 43-49.
Gibson, G. J. ( 1 996) Pulmonary hyperinflation. Eur. Goldhill, D. R. and Sumner, A. ( 1998) Outcome of
Respir. ]. , 9, 2640-2649. intensive care patients in a group of British ICUs.
Gidding, S. ( 1 994) Active and passive tobacco Crit. Care Med. , 26, 1 33 7-1345.
exposure. Pediatrics, 94, 750-75 I . Golding, J. ( 1 994) The consequences of smoking in
Gift, A. G . ( 1 992) Relaxation to reduce dyspnea and pregnancy. Smoking in Pregnancy Conference,
anxiety in COPD patients. Nurs. Res. , 4 1 , 242- University of Bristol, Bristol, UK.
246. Goldman, J. M. ( 1 986) Effect of abdominal binders
Gilbert, A. (1 996) Anxiety: a risk factor in open heart on breathing in tetraplegic patients. Thorax, 4 1 ,
surgery. ACPRC j., 29, 60. 940-945.
Gilbert, C. ( 1 999) Breathing and the cardiovascular Goldman, J. M., Teale, C. and Muers, M. F. ( 1 992)
system. j. Bodywork Mov. Ther. , 3, 2 15-224. Simplifying the assessment of patients with
Gilbert, V. E. ( 1 989) Detection of pneumonia by chronic airflow limitation for home nebulizer
auscultation of the lungs in the lateral decubitus therapy. Respir. Med. , 86, 33-3 8 .
positions. Am. Rev. Respir. Dis. , 140, 1 0 1 2- 1 0 1 6 . Goldschlager, N . , Epstein, A . E. and Naccarelli, G .
Giles, D. R . ( 1 995) Short-term effects o f postural (2000) Practical guidelines for clinicians who treat
drainage with clapping vs autogenic drainage on patients with amiodarone. Arch. Int. Med. , 1 60,
oxygen saturation and sputum recovery in patients 1 74 1- 1 748.
with CF. Chest, 1 08 , 952-954. Goldstein, R. S. ( 1 995) Home mechanical ventilation.
Gill, ]. and Slater, J. ( 1 9 9 1 ) Building barriers against Chest, 108, 1 5 8 1-1586.
infection. Nurs. Times, 87(50), 53-54. Goldstein, R. (2000) Musculoskeletal conditions after
Gillespie, D. ( 1 989) Let's listen to the children. spinal cord injury. Phys. Med. Rehab. Clin. N.
Respir. Dis. Pract. , 6, 23. Am. , 1 1, 91-1 08.
501
REFERENCES
Goldstone, ]. and Moxham, ]. ( 1 9 9 1 ) Weaning from Graham, A. . N. J., Cosgrove, A. P. and Gibbons, ]. R.
mechanical ventilation. Thorax, 46, 5 6-62. P. ( 1992) Randomised clinical trial of chest
Golster, M. ( 1 995) Blood volume and colloid osmotic drainage systems. Thorax, 47, 46 1-462.
pressure. Crit. Care Med. , 23, A8 8. GRASSIC: Grampian Asthma Study of Integrated
Goodfellow, L. M. ( 1 997) Application of pulse Care ( 1 9 94) Integrated care for asthma. Br. Med.
oximetry and the oxyhemoglobin dissociation j., 308, 559-564.
curve. Crit. Care Nurs. Q., 20, 22-27. Grasso, M. c., Button, B. M. and Allison, D. ].
Goodman, D. C. ( 1996) Theophylline in acute (2000) Benefits of music therapy as an adjunct to
childhood asthma. Pediatr. Pulmonol. , 2 1 , 2 1 1- chest physiotherapy in infants and toddlers with
218. CF. Pediatr. Pulmonol. , 29, 37 1-38 l .
Goodnough, S . K . ( 1 985) The effects of oxygen and Gravil, ] . H., Al-Rawas, O . A. and Cotton, M. M.
hyperinflation on arterial oxygen tension after ( 1 998) Home treatment of exacerbations of
suction. Heart Lung, 14, 1 1-17. COPD by an acute respiratory assessment service.
Gopinath, S. P., Valadka, A. B. and Uzura, M. ( 1 999) Lancet, 3 5 1 , 1 853-1 855.
Comparison of jugular venous oxygen saturation Gray, H. H. ( 1 9 92) Management of pulmonary
and brain tissue POz as monitors of cerebral embolism. Thorax, 47, 825-832.
ischemia after head injury. Crit. Care Med. , 27, Gray, E. ( 1 999) Do respiratory patients receive
2337-2345. adequate analgesia? Nurs. Stand. , 1 3 (47), 32-35.
Gordon, s. ( 1 9 94) What's in a name? J. Emerg. Nurs. , Gray, ]. F., MacIntyre, N. R. and Kronenberger, W.
20, 1 70- 1 7 l . G. ( 1 990) The effects of bolus normal saline
Gordon, K . and Child, A . (2000) Heart failure. Nurs. instillation with endotracheal suctioning. Respir.
Times, 96, 45-47. Care, 35, 785-790.
Gorini, M. ( 1996) Breathing pattern and COz Gray, L., Watt, L. and Blass, E. M. ( 1 999) Skin-to
retention in severe COPD. Thorax, 5 1, 677- skin contact is analgesic in healthy newborns.
683. Pediatrics, 1 05 , e14.
Gosbee, ]. ( 1998) Communication among health Green, M. and Moxham, ]. ( 1 993) Respiratory
professionals. Br. Med. j. , 3 16, 642. muscles in health and disease, in Respiratory
Gosselink, R. ( 1 996) Reliability of a commerciially Medicine: Recent Advances, (ed. P. ]. Barnes),
available threshold loading device in healthy Butterworth-Heineman, London.
subjects and in patients with COPD. Thorax, 5 1 , Green, C. J., Campbell, I. T. and McClelland, P.
60 1-605 . ( 1 995) Energy and nitrogen balance and changes
Gosselink, R., Kovacs, L. and Decramer, M. ( 1 999) in midupper-arm circumference with multiple
. Respiratory muscle involvement in multiple organ failure. Nutrition, 2, 73 9-746 .
sclerosis. Eur. Respir. j. , 1 3 , 449-454. Greenfield, S. M. ( 1 997) Drinking before sedation. Br.
Gosselink, R. A. A. M. ( 1 995) Diaphragmatic Med. j. , 3 14, 1 62.
breathing reduces efficiency of breathing in Greenough, A. ( 1990) Bronchopulmonary dysplasia.
patients with COPD. Am. J. Respir. Crit. Care Arch. Dis. Child. , 65, 1 082-1088.
Med. , 1 5 1 , 1 13 6-1 1 42. Greenough, A. ( 1 995) Nitric oxide - clinical aspects.
Gould, D. ( 1 994) The significance of hand-drying in the Care Crit. Ill, 1 1 , 143-147.
prevention of infection. Nurs. Times, 90, 33-335. Greenough, A. and Yuksel, B. ( 1997) First trimester
Gounden, P. ( 1993) The effect of posture on invasive procedures: effects on symptom status
pectoralis major and latissimus dorsi in expiration and lung volume in very young children. Ped.
in tetraplegia. S. Afr. j. Physiother. , 49, 25-27. Pulmonol. , 24, 4 1 2-422.
Gourlay, G. K. and Boas, R. A. ( 1992) Fatal outcome Greenwald, B. M. ( 1 993) CPAP to treat profound
with use of rectal morphine for postoperative pain hypoxaemia associated with acute severe asthma.
control in an infant. Br. Med. j. 3 04, 766-767. Crit. Care Med. , 2 1 (suppl.) S 154.
Gozzoli, V. (2001) Is it worth treating fever in ICU Greif, R., Laciny, S., Rapf, B. and Hickle, R. S . ( 1 999)
patients? Arch. Int. Med. , 1 6 1 , 1 21-123. Supplemental oxygen reduces the incidence of
Graff, T. D. and Benson, D. W. ( 1 969) Systemic and postoperative nausea and vomiting. Anesthesiogy,
pulmonary changes with inhaled humid 9 1 , 1 246-1252.
atmospheres. Anesthesiology, 30, 1 99-207. Greif, R., Akca, o. and Horn, E. P. (2000)
5 02
REFERENCES
Supplemental perioperative oxygen to reduce the Gunawardana, R. H. (2000) Postoperative crying in

incidence of surgical wound infection. N. Engl. j. infants [letter] . Anaesthesia, 5 5 , 1 97.
Med. , 342, 1 6 1-1 67. Guylay, J. ( 1 989) What suicide leaves behind. Issues
Gribbin, H. R. ( 1 993) Management of respiratory Compo Pediatr. Nurs. , 12, 1 03-1 1 8 .
failure. Br. j. Hosp. Med. , 49, 461-477. Haake, R., Schlichtig, R . and Ulstad, D. R . ( 1 987)
Grief, R. (2000) Supplemental perioperative oxygen Barotrauma. Chest, 9 1 , 608-6 1 3 .
to reduce the incidence of surgical wound Haas, F . and Haas, S . S. ( 1 990) The Chronic
infection. New Eng. j. Med. , 342, 1 6 1 - 1 67. Bronchitis and Emphysema Handbook, John
Griffin, S. (2000) Nebulised steroid in the treatment Wiley, Chichester.
of croup. Br. j. Gen. Pract. , 50, 1 35-14 l . Hadfield, P. J. ( 1 997) Treatment of otitis media with
Griffiths, R. (2000) Breathing circuits and their uses. effusion in children with primary ciliary
Br. j. Periop. Nurs. , 1 0, 55-59. dyskinesia. Clin. Otolaryngol. , 22, 302-306.
Griffiths, R .. D. and Jones, c. ( 1 999) Recovery from Hadjistavropoulos, H. D. ( 1 997) Judging pain in
intensive care. Br. Med. j. , 3 19, 427-429. infants. Pain, 73, 3 1 9-324.
Griffiths, T. L., Gregory, S. E. and Ward, S. A. ( 1 996) Hagarty, E. M. ( 1 996) Use of pulse oximetry to
Effects of a structured domiciliary exercise determine oxygen prescription. Respir. Care, 4 1 ,
training programme on quality of life and walking 3 0-36.
tolerance in patients with severe COPD. Eur. Hagler, D. A. and Traver, G. A. ( 1 994) Endotracheal
Respir. j. , 9(23 ), 144s. saline and suction catheters. Am. ]. Crit. Care, 3 ,
Griffiths, T. L., Burr, M. L. and Campbell, I. A. 444-447.
(2000) Results at 1 year of outpatient pulmonary Hahn, R. G. ( 1 997) Haemodynamics during
rehabilitation: a randomised controlled trial. inhalation of a 50% N20/02 mixture. Acta
Lancet, 355, 362-3 68. Anaesthesio!. Scand., 4 1 , 485-49 l .
Gripp, C. L., Salvaggio, J. and Fratianne, R. B ( 1 995) Hahn, A., Bach, J . R. and Delaubier, A. ( 1 997)
Use of burn intensive care unit gymnasium as an Clinical implications of maximal respiratory
adjunct to therapy. j. Burn Care Rehabil. 16, 1 60- pressure determinations for individuals with
l. Duchenne muscular dystrophy. Arch. Phys. Med.
Groen, J. J. ( 1 979) The psychosomatic theory of Rehabil. , 78, 1-6.
bronchial asthma. Psychother. Psychosom., 3 1 , 3 8- Hall, O. ( 1 9 84) Physical and social problems of CF in
48. the young adult. ACPRC Newsl. , 7, 29-3 3 .
Gross, D. and King, M. ( 1 984) High frequency chest Hall, P. A . and Bowden, M . I. ( 1 996) Introducing an
wall compression. Physiother. Can. , 36, 1 37-1 3 9 . acute pain service. Br. ]. Hosp. Med. , 5 5 , 1 5-17.
Grounds, M . ( 1 997) Can enhancement of Hall, P. A., Payne, F. F. and Stack, C. G. ( 1 995) Parents
cardiovascular physiology reduce surgical mortality in the recovery room. Br. Med. ]. , 3 10, 1 63-1 64.
and morbidity? Br. j. Intensive Care, 7, 97- 1 05 . Hall, J. c., Tarala, R. A. and Tapper, J. ( 1 996)
De Guia, T . S. ( 1 995) Inhaled corticosteroids in Prevention of respiratory complications after
COPD. Chest, 108, 1486-1489. abdominal surgery. Br. Med. j. , 3 12, 148-153.
Guerin, G. ( 1 997) Facial mask noninvasive Hallsworth, M. ( 1 995) Positioning the pre-term
mechanical ventilation reduces incidence of infant. Paed. Nurs. 7, 1 8-20.
nosocomial pneumonia. Intensive Care Med. , 23, Halpern, N. A. ( 1 999) Hearing loss in critical care.
1 024- 1 032. Crit. Care Med. , 27, 2 1 1-2 1 9 .
Guernelli, J., Wainapel, S. F. and Pack, S. ( 1 999) Hamdorf, P . A. ( 1 999) Walking with its training
Morbidly obese patients with pulmonary disease. effects on the fitness and activity patterns of 79-
Am. j. Phys. Med. Rehabil. , 78, 60-65. 9 1 year old females. Austr. NZ j. Med. , 29, 22-28 .
Guglielminotti, J. ( 1 998) Effects of tracheal suctioning Hamilton, L . and Lyon, P . S. ( 1 995) A nursing-driven
on respiratory resistances. Chest, 1 13 , 1335-1 3 3 8 . program to preserve and restore functional ability
Guia, T . S. ( 1 995) Inhaled corticosteroids i n COPD. in hospitalized elderly patients. j. Nurs. Admin.,
Chest, 108, 6, 1486-1489. 25, 3 0-37.
Gumery, L. B., Pryor, J., Prasad, S. A. and Dodd, M. Hamm, H. and Light, R. W. ( 1 997) The pleura: the
(2001) Clinical Guidelines for Physiotherapy outer space of pulmonary medicine. Eur. Respir. j.,
Management of Cystic Fibrosis, CSP, London. 1 0, 2-3 .
503
REFERENCES
Hammon, W. E., Connors, A. F. and McCaffree, D. Harper, R., Brazier, J. E., Waterhouse, J. C. and
R. 1 992 Cardiac arrhythmias during postural Walters, S. J. ( 1 997) Comparison of outcome
drainage and chest percussion of critically patients. measures for patients with COPD in an outpatient
Chest, 1 02, 1 83 6- 1 84 l . setting. Thorax, 52, 879-887.
Hampson, N. B . ( 1 988) Pulse oximetry in severe Harrington, G. R. ( 1 993) Noninvasive monitoring.
carbonmonoxide poisoning. Chest, 1 14, 1036-4 l . Am. j. Med. , 95, 221-227.
Han, J . N., Stegen, K . and Simkens, K . ( 1 9 97) Harris, J. D. ( 1 996) Rib cage and thoracic spine. Phys.
Unsteadiness of breathing in patients with HVS Med. Rehabil. Clin. North Am. , 7, 76 1-77 l .
and anxiety disorders. Bur. Respir. j. , 1 0, 1 67- Harris, P . ( 1 989) Are pulmonary haemodynamics of
1 76. importance to survival in chronic obstructive lung
Hanks, G. W. ( 1 996) Morphine in cancer pain. Br. disease? Bur. Respir. j. , 2(suppl. 7), 674s-677s.
Med. j. , 3 12, 823-826. Harris, M. L. and Moxham, J. ( 1 998) Measuring
Hanley, M. V. and Tyler, M. L. ( 1987) Ineffective respiratory and limb muscle strength using
airway clearance related to airway infection. Nurs. magnetic stimulation. Br. j. Intensive Care, 8, 21-
Clin. North Am. , 22, 1 35-149. 26.
Hanning, C. D. ( 1 992) Prolonged oxygen therapy. Br. Harris-Eze, A. O. ( 1 996) Role of hypoxemia and
j. Anaesth. , 69, 1 15-1 1 6. pulmonary mechanics in exercise limitation in
Hannon, J. c. (2000) The physics of Feldenkrais. j. interstitial lung disease. Am. j. Respir. Crit. Care
Bodywork Mov. Ther. , 4, 1 14-122. Med. , 1 54, 994- 1 00 l .
Hansell, D. M. ( 1 998) Imaging pulmonary embolism. Harrison, D . A . ( 1 993) The performance o f two
Br. Med. j. , 3 16, 490-49 l . intensive care humidifiers at high gas flows.
Haponik, E . F . ( 1 992) Smoke inhalation injury. Anaesthesia, 48, 902-905.
Respir. Care, 3 7, 609-6 17. Harrison, P. ( 1 995) The use of heliox to wean from
Haponik, E. F., Aquino, S. L. and Vining, D. J. ( 1 999) mechanical ventilation. Chest, 108, 1 34S.
Virtual bronchoscopy. Clin. Chest Med. , 20, 201- Harrison, L. ( 1 996) Effects of gentle human touch on
220. preterm infants. Neonat. Netw. , 1 5 , 35-4 l .
Haraldsson, P.-O. ( 1 990) Clinical symptoms of sleep Harrison, L . ( 1998) Clinical guidelines and protocols
apnea syndrome and automobile accidents. ORL, in ITU. Care Crit. Ill, 1 4, 1 55-157.
52, 57-62. Harrison, T. W. ( 1 999) Randomised placebo
Harcus, A. W. ( 1977) Pain - New Perspectives in controlled trial of �-agonist dose reduction in
Measurement and Management, Churchill asthma. Thorax, 54, 98-1 02.
Livingstone, Edinburgh, p. 3 9 . Hartkopp, A., Hansen, H. and Seidenschnur, A.-M.
Harding, J. E., Miles, F. K. I. and Becroft, D. M. o. ( 1 998) Suicide in a spinal cord injured population.
( 1 998) Chest physiotherapy may be associated Arch. Phys. Med. Rehabil. , 79, 1356-1 3 6 l .
with brain damage in extremely premature infants. Harvey, M . A . ( 1 996) Managing agitation i n critically
J. Pediatr. 1 32, 440-444. ill patients. Am. J. Crit. Care, S, 7-1 5 .
Harding, R. ( 1 996) Children with cancer. Prof. Nurse, Hasani, A . , Pavia, D. and Agnew, J. E. ( 1 994)
1 1 , 5 8 8-590. Regional lung clearance during cough and FET.
Harding, S. M., Guzzo, M. R. and Richter J. E. Thorax, 49, 557-5 6 l .
( 1 999) 24-h esophageal pH testing in asthmatics. Hatipoglu, U . S., Laghi, F . and Tobin, M . J. ( 1 999)
Chest, 1 15 , 654-659. Does inhaled albuterol improve diaphragmatic
Hardinge, F. M. ( 1 995) Effects of short term high contractiliry in patients with COPD? Am. j. Respir.
frequency negative pressure ventilation. Thorax, Crit. Care Med. , 1 60, 1 9 16-192 l .
50, 44-49. Hayakawa, H., Sato, A. and Imokawa, S . ( 1 996)
Hardy, K. A. ( 1 994) A review of airway clearance Bronchiolar disease in rheumatoid arthritis. Am. j.
techniques. Resp. Care, 39, 440-455. Respir. Crit. Care Med. , 1 54, 153 1-1536.
Hargreaves, M. R. ( 1 995) Inhaled sodium Hayden, R. A. ( 1 993) Trend-spotting with the S:02
cromoglycate in ACE-inhitor cough. Lancet, 345, monitor. Am. J. Nurs. , 93, 26-33.
13-15. Hazelrigg, S., Boley, T. and Henkle, J. ( 1 996)
Harmer, M. ( 1 9 9 1 ) Postoperative pain relief. Thoracoscopic laser bullectomy. j. Thorac.
Anaesthesia, 46, 1 67-1 68. Cardiovasc. Surg. , 1 12, 3 1 9-327.
504
REFERENCES
HEA ( 1 995) Passive Smoking. Health Education Heslop, A. and Shannon, C. ( 1 995) Assisting patients
Authority, London. living with long-term oxygen therapy. Br. J. Nurs. ,
Hecht, S. ( 1 993) A tobacco-specific carcinogen in the 4, 1 123-1 128.
urine of men exposed to cigarette smoke. N. Engl. Hess, D. (1 994) Inhaled bronchodilators during
J. Med. , 329, 1 543-1546. mechanical vantilation Respir. Care, 39, 1 05-1 2 1 .
Hedenstierna, G. ( 1 997) Lung function during Heulitt, M . J . ( 1 995) Acute respiratory distress
anesthesia. Curro Opin. Anaesthesiol. , 1 0, viii syndrome in pediatric patients. Respir. Care, 40,
Xl. 74-85 .
Hedenstierna, G. ( 1 999) Invited editorial on kinetics Hickey, P . R., Hansen, D. D. and Wessel, D. L.
of absorption atelectasis during anesthesia. J. Appl. ( 1 985) Blunting of stress responses in the
Physiol. , 86, 1 1 14. pulmonary circulation of infants by fentanyl.
Heffner, J. E. ( 1 990) Pulmonary reactions from illicit Anesth. Analg. , 64, 1 13 7- 1 142.
substance abuse. Clin. Chest Med. , 1 1 , 15 1-1 6 1 . Hickling, K. G. ( 1 994) Low mortality in ARDS using
Heffner, J . E . ( 1 996) Advance directive education permissive hypercapnia. Crit. Care Med. , 22,
during pulmonary rehabilitation. Chest, 1 09, 3 73- 1 5 68-1578.
379. Hilbert, G., Gruson, D. and Portel, L. ( 1 998)
Heijden, H. F. M. van der, Dekhuijzen, P. N. R. and Noninvasive pressure support ventilation in COPD
Folgering, H. ( 1 996) Pharmacotherapy of patients with postextubation hypercapnic
respiratory muscles in COPD. Respir. Med. , 90, respiratory insufficiency. Eur. Respir. J., 1 1 , 1349-
5 1 3-522. 1353.
Heijdra, Y. F. ( 1 994) Effects of body position, Hill, L . L . and Pearl, R . G. ( 1999) Combined inhaled
hyperinflation and blood gas tensions on maximal nitric oxide and inhaled prostacyclin. J. Appl.
respiratory pressures in patients with COPD. Physiol. , 86, 1 1 60- 1 1 64 .
Thorax, 49, 453-458 . Hill, S. ( 1 989) Family, Michael Joseph, London.
Heijdra, Y. F. ( 1 996) Nocturnal saturation improves Hindle, T., Dhoot, R. and Georgieva, C. ( 1 996)
by target-flow inspiratory muscle training in Clinical nutrition in NHS hospitals. Br. J. Intensive
patients with COPD. Am. J. Respir. Crit. Care Care, 6, 6 1-65.
Med. , 1 53, 260-265. Hirschberg, A. J. (1 994) Use of doxapram
Hellman, E. A. ( 1 994) Outpatient cardiac rehabilitation hydrochloride as an alternative to intubation for
in elderly patients. Heart Lung, 23, 5 06-5 1 2. COPD patients with hypercapnia. Ann. Emerg.
Henderson, R. C. ( 1 999) Bone mineral content and Med. , 4, 701-703 .
body composition in children and young adults Hjelmqvist, H. (2000) Colloids versus crystalloids.
with CF. Pediatr. Pulmonol., 27, 8 0-84. Curro Anaesth. Crit. Care, 1 1 , 7-10.
Henzi, I. (2000) Dexamethasone for the prevention of Hjuler, I. M. ( 1 995) Bacterial colonization of the
postoperative nausea and vomiting. Anesth. Analg. , larynx and trachea in healthy children. Acta
90, 1 86-1 94. Paediatr. , 84, 566-568.
Hernandez-Reif, M. (2000) High blood pressure and Hnatiuk, O. W. ( 1 998) Delivery of high
associated symptoms reduced by massage therapy. concentrations of inspired oxygen via Tusk mask.
J. Bodywork Mov. Ther. 4, 3 1-3 8 . Crit. Care Med. , 26, 1 032-1035.
Herr, K . A . ( 1 998) Evaluation of the faces pain scale Hodge, D. ( 1 9 9 1 ) Endotracheal suctioning and the
for use with the elderly. Clin. J. Pain., 14, 29-3 8 . infant. Neonat. Netw. , 9, 7-14 .
Herridge, M . S. and Slutsky, A . S . ( 1 996) High Hodgkin, J. E. and Petty, T. L. ( 1 987) Chronic
frequency ventilation. Respir. Care, 4 1 , 3 85-393. Obstructive Pulmonary Disease, W. B. Saunders,
Herring, D., King, A. I. and Connelly, M. ( 1 987) New London.
rehabilitation concepts in management of radical Hodgkin, J. E., Connors, G. L. and Bell, C. W. ( 1 993)
neck dissection syndrome. Phys. Ther. , 67, 1 095- Pulmonary Rehabilitation: Guidelines to Success,
1 099. Butterworth, London.
Hertanu, J. S. and Moldover, J. R. ( 1 996) Hodgkin, J. E., Connors, G. L. C. and Celli, B. R.
Cardiovascular, pulmonary and cancer (2000) Pulmonary Rehabilitation: Guidelines to
rehabilitation. 1 . Cardiac rehabilitation. Arch. Success, 3rd edn. Lippincott, Philadelphia.
Phys. Med. Rehabil. , 77, S3 8-S44. Hodgson, c., Denehy, L. and Ntoumenopoulos, G.
505
REFERENCES
( 1 996) The acute cardiorespiratory effects of Hospital Update ( 1 995) An epidemiological overview
manual lung hyperinflation in ventilated patients. of asthma. Hosp. Update, 2 1 , 3 69.
Eur. Respir. ]. , 9 (suppl. 23), 3 7s. Houtmeyers, E. ( 1 999) Effects of drugs on mucus
Hoffman, G. M. ( 1 995) Airway complications of clearance. Eur. Respir. ]., 14, 452-467.
instrumentation. Respir. Care, 40, 97-107. Houtmeyers, E., Gosselink, R. and Gayan-Ramirez, G.
Hoffmann, B. and Welte, T. ( 1 999) The use of ( 1 999) Regulation of mucociliary clearance in
noninvasive pressure support ventilation for severe health and disease. Eur. Respir. ]' , 13, 1 1 77-1 1 8 8 .
respiratory insufficiency due to pulmonary Howard, F. ( 1 994) Endotracheal suctioning and the
oedema. Intensive Care Med. , 25, 15-20. neonate. Paediatr. Nurs. , 6, 14-17.
Hofman, J. c., Wenger, N. S. and Davis, R. B. ( 1997) Howard, L. and Koniak, D. ( 1 990) Evaluation of
Patient preferences for communication with manometer use in mechanical ventilation of
physicians about end-of-life decisions. Ann. Intern. infants. Heart Lung, 19, 620-627.
Med. , 127, 1-12. Howes, T. Q., Deane, C. R. and Levin, G. E. ( 1 995)
Hogan, W. J. (2000) Life after antireflux surgery. Am. The effects of oxygen and dopamine on renal and
]. Med. , 108, 1 8 1 s-19 1 s. aortic blood flow in COPD. Am. ]. Respir. Crit.
Holden, T. ( 1 980) Patiently speaking. Nurs. Times, Care Med. , 1 5 1, 3 78-383.
76(24), 1 03 5- 1 036. Howie, A. ( 1 999) Rapid shallow breathing as a
Holditch, D. ( 1 994) Pathologic apnea and brief predictive indicator during weaning. Nurs. Crit.
respiratory pauses in preterm infants. Nurs. Res. , Care, 4, 1 7 1 - 1 78.
43, 293-299. Hsia, C. C. W. ( 1 993) Respiratory muscle limitation
Holgate, S. T. ( 1 996) Inhaled sodium cromoglycate. in patients after pneumonectomy. Am. Rev. Respir.
Respir. Med. , 90, 3 8 7-390. Dis. , 147, 744-752.
Holleman, D. R. ( 1995) Does the clinical examination Hsiang, J. ( 1 993) Paralysis for ICP control in severe
predict airflow limitation? ]. A. M. A. , 273, 3 13- head injury. Crit. Care Med. , 2 1 , S23 6.
3 1 9. Hsieh, A. H., Bishop, M. J. and Kubilis, P. S. (1 992)
Holliday, J. F. ( 1 999) Reduction in ventilator Pneumonia following closed head injury. Am. Rev.
response to CO2 with relaxation feedback. Chest, Respir. Dis. , 146, 290-294.
1 1 5 , 1285-1292. Huang, D., Ades, P. A. and Weaver, S. ( 1 990) Cardiac
Holmes, P. W., Barter, C. E. and Pierce, R. J. ( 1 992) rehospitalizations and costs are reduced following
Chronic persistent cough: use of ipratropium cardiac rehabilitation. ]. Cardiopulm. Rehabil., 1 0,
bromide. Respir. Med. , 86, 425-429. 1 08.
Homma, S., Kawabata, M. and Kishi, K. ( 1 999) Hubbard, R., Johnston, I. and Britton, J. ( 1 998)
Successful treatment of refractory bronchorrhea Survival in patients with cryptogenic fibrosing
by inhaled indomethacin. Chest, 1 1 5, 1465- alveolitis. Chest, 1 1 3, 3 96-400.
1468. Hudes, E. T. ( 1 989) Recovery room oxygenation.
Hoozen, B. E. V. ( 1 997) Marijuana. Clin. Rev. Allerg. Can. ]. Anaesth. , 3 6, 20-24.
Immunol., 1 5 , 243-268. Hughes, R. L. ( 1 980) Do no harm - cheaply. Chest,
Hopp, L. J., Kim, M. J. and Larson, J. L. (1 996) 77, 582-5 8 3 .
Incremental threshold loading in patients with Hugli, O. ( 1 996) The daily energy expenditure in
COPD. Nurs. Res. , 45, 1 96-202. stable COPD. Am. ]. Respir. Crit. Care Med. , 153,
Horiuchi, K. ( 1995) Propofol attenuates the metabolic 294-300.
and cardiopulmonary responses to stressful ICU Huib, A. M. K. ( 1 999) Stable chronic obstructive
procedures. Crit. Care Med. , 23, A36 (suppl.). pulmonary disease. Br. Med. ]., 3 1 9, 495-500.
Hormann, C. ( 1 994) Effect of kinetic therapy in Hund, E. ( 1 999) Myopathy in critically ill patients.
patients with severe ARDS. Crit. Care Med. , 22, Crit. Care Med. , 27, 2544-2547.
A87. Hung, C.-H., Chu, D.-M. and Wang, c.-L. ( 1 999)
Horton, R. ( 1 996) How often do children cough? Hypokalemia and salbutamol therapy in asthma.
Lancet, 348, 699-670. Pediatr. Pulmonol. , 27, 27-3 1 .
Hosker, H. S. R. ( 1 995) Assessment and provision of Hunt, D . , Leighton, M . and Reed, G . (1 999)
home nebulizers for COPD. Respir. Med. , 89, 47- Intermittent claudication: implementation of an
52. exercise programme. Physiotherapy, 85, 149-153.
506
REFERENCES
Hurewitz, A. N. ( 1 985) Obesity alters regional Isaacs, D. ( 1 995) Bronchiolitis. Br. Med. J., 3 10,
ventilation in lateral decubitus position. J. Appl. 4-5.
Physiol. , 59, 774-783. Jacavone, J. ( 1 998) Use of pulmonary rehabilition
Hutchon, B. (2000) Cradle philosophy. Ther. Weekly, stretegies to wean a difficult-to-wean patient. Crit.
26, 6. Care Nurse, 1 8 , 29-37.
Hyde, J. A. , Rooney, 5. J. and Graham, T. R. ( 1 996) Jackson, G. ( 1999) Recognising and rewarding good
Fluid management in thoracic trauma. Hosp. performance: the importance of being valued. Int.
Update, 22, 448--452. ]. Clin. Pract., 53, 3 .
Hyde, V. ( 1 999) Constipation and laxative use in Jackson, M., Flower, C . D. R . and 5hneerson, J . M.
older community-dwelling adults. Clin. Effect. ( 1993) Treatment of symptomatic pulmonary
Nurs. , 3, 1 80-80. aspergillomas. Thorax, 48, 928-930.
Ibanez, J., Raurich, J. M. and Abinanda, R. ( 1 9 8 1 ) Jacobsson, C. (2000) How people with stroke and
The effect o f lateral positions on gas exchange in healthy older people experience the eating
patients with unilateral lung disease during process. J. Clin. Nurs, 9, 255-264.
mechanical ventilation. Intensive Care Med. , 7, Jacox, A., Carr, D. and Chapman, C. R. ( 1 992)
23 1-234. Clinician's quick reference guide to postoperative
Iies, R., Lister, P. and Edmunds, A. T. ( 1 999) Crying pain management in adults. J. Pain Symptom
significantly reduces the absorption of aerosolised Manage., 7, 2 1 4-228 .
drug in infants. Arch. Dis. Child. , 8 1, 1 63-1 65 . Jacques, A . ( 1 994) Epidural analgesia. Br. ]. Nurs. , 3,
lng, A. J., Ngu, M . C . and Breslin, A. B. X . (2000) 734-73 8 .
Obstructive sleep apnea and GOR, Am. J. Med. , Jacyna, M. R . ( 1992) Pros and cons of medical audit.
108, 1 20s-125s. Hosp. Update, 1 8 , 5 1 2-5 1 6 .
Ingram, R. H. ( 1 967) Effect of pursed lips expiration Jaffe, A., Bush, A . and Geddes, D. M. ( 1999)
on the pulmonary pressure-flow relationship in Prospects for gene therapy in CF. Arch. Dis.
obstructive lung disease. Am. Rev. Respir. Dis., 96, Child. , 80, 286-289.
3 8 1-3 8 8 . Jain, A. (2000) Local anaesthetic effect of topical
Inman, M . D. ( 1 996) The effect o f regular inhaled amethocaine gel in neonates. Arch. Dis. Child.
albuterol on exercise-induced bronchoconstriction. Fetal Neonat. Ed., 82, F42-F45.
Am. ]. Respir. Crit. Care Med. , 1 53, 65-69. Jalleh, R., Fitzpatrick, M. F. and Jan, M. A. ( 1 993)
Inman, C. L., Warren, G. L. and Hogan, H. A. ( 1 999) Alcohol and cor pulmonale in chronic bronchitis
Mechanical loading attenuates bone loss due to and emphysema. Br. Med. J., 306, 374.
immobilization and calcium deficiency. ]. Appl. James, I. ( 1 9 9 1 ) Respiratory management in
Physiol. , 87, 1 89-195. paediatrics. Care Crit. Ill, 7, 47-50.
Innocenti, D. M. ( 1 966) Breathing exercises in the James, A., Williams, J. and Wilkins, W. E. ( 1 998) A
treatment of emphysema. Physiotherapy, 52, 437- pre-discharge ward for acute medical patients. J.
44 1 . Roy. Coli. Phys. , 32, 23 1-234.
Innocenti, D . M. ( 1 974) Physiotherapy in the Jansen, H. M. ( 1 995) Predisposing conditions to
management of acute asthma. Nurs. Mirror, 139, bacterial infections in COPD. Am. ]. Respir. Crit.
77-79. Care Med. , 1 5 1 , 2073-2080.
Innocenti, D. M. (1 997) Breathing re-education Janson, c. (2000) What characterizes patients who are
[letter]. Physiotherapy, 83, 269. unable to tolerate CPAP? Respir. Med. , 94, 145-
Innocenti, D. M. ( 1998) Hyperventilation, in 149.
Physiotherapy for Respiratory and Cardiac Janssens, J. P. ( 1 998) Transcutaneous PC02 to
Problems, 2nd edn, (eds B. A. Webber and J. A. monitor noninvasive mechanical ventilation.
Pryor), Churchill Livingstone, Edinburgh. Chest, 1 1 3, 768-773.
Ioli, F., Casaburi, R., Patessio, A. and Donner, C. F. Janssens J. P. (2000) Management of dyspnea in
( 1 9 9 1 ) Exercise prescription. Eur. Respir. Rev. , 1 , severe COPD. J. Pain Symptom. Man. 19, 3 78-
486--489. 3 92.
Irwin, R. 5., Boulet, L.-P. and Cloutier, M. M. ( 1998) Janssens, J. P., Pache, J. C. and Nicod, L. P. ( 1 999)
Managing cough as a defense mechanism and as a Physiological changes in respiratory function
symptom. Chest, 1 14, 1 335-1 795. associated with ageing. Eur. Respir. ]. , 13, 1 97-205.
507
REFERENCES
Jantz, M. A. and Pierson, D. J. ( 1 994) Pneumothorax Johnston, I. D. A., Prescott, R. J., Chalmers, J. C. and
and barotrauma. Clin. Chest Med. , 1 5 , 75-92. Rudd, R. M. ( 1 997) British Thoracic Society study
Jarvik, R., Westaby, S. and Katsumata, T. ( 1 998) of cryptogenic fibrosing alveolitis. Thorax, 52, 3 8-
LVAD power delivery. Ann. Thorac. Surg. , 65, 44.
470-473 . Johnstone, M. ( 1 994) Children visiting members of
Jarvis, M. J. ( 1 986) Low cost carbon monoxide their family receiving treatment in ICUs. Intens.
monitor in smoking assessment. Thorax, 4 1 , 886- Crit. Care Nurs. , 10, 289-292.
887. Jokic, R. ( 1 998) Continuous positive airway pressure
Jarvis, M. J. ( 1 995) Smoking cessation. Thorax, requirement during the first month of treatment in
50(suppl. 1 ) , S22-S24. patients with severe OSA. Chest, 1 14, 1 06 1-1069.
Jederlinic, P., Muspratt, J. A. and Miller, M. J. ( 1 984) Jolliet, P. ( 1999) Beneficial effects of helium: oxygen
Inspiratory muscle training in clinical practice. versus air: oxygen noninvasive pressure support.
Chest, 86, 870-873 . Crit. Care Med. , 27, 2422-2429.
Jefferies, A. and Turley, A. ( 1 999) Crash Course: Joly, H. R. and Weil, M. H. ( 1 969) Temperature of
Respiratory System, Mosby, London. the great toe as an indication of the severity of
Jenkin, A. ( 1 996) The nasopharyngeal airway. shock. Circulation, 39, 1 3 1 - 1 3 8 .
Accident Emerg. Nitrs. , 4, 1 6-20. Jones, A . Y . M. and Jones, R . D . (2000) The effect on
Jenkins, S. C, Heaton, R. W. and Fulton, T. J. ( 1 987) sound generation of varying both gas flow rate and
Comparison of domiciliary nebulized salbutamol the viscosity of sputum-like gel. Lung, 1 78, 3 1-40.
and salbutamol from a metered dose aerosol in Jones, P. D. ( 1 985) Microbial contamination of
stable COPD. Chest, 9 1 , 804-807. domiciliary nebulizer equipment. Austr. NZ J.
Jenkins, S. C and Moxham, J. ( 199 1 ) The effects of Med. , 1 5 , 585-589.
mild obesity on lung function. Respir. Med. , 85, Jones, M. J. ( 1 998) Neurophysiological facilitation of
309-3 1 1. respiration. Cardiorespiratory physiotherapy
Jenkins, S. C, Soutar, S. A. and Moxham, J. ( 1 988) conference, London.
The effects of posture on lung volumes in normal Jones, J. (2000) Pet therapy for elderly wins growing
subjects and in patients pre- and post-coronary recognition. Br. Med. J. , 320, 602.
artery surgery. Physiotherapy, 74, 492-496. Jones, c. and Barrett, C. ( 1 995) The role of the
Jennings, P. ( 1 9 92) Coping mechanisms. Pediatr. pharmacist in asthma care. Respir. Dis. Pract., 12,
Nurs. , 4, 1 3 - 1 5 . 25-26.
Jennische, M . and Sedin, G . ( 1999) Speech and Jones, A. and Bowen, M. ( 1 994) Screening for
language skills in children who required neonatal childhood asthma using an exercise test. Br. J.
intensive care. Acta Paediatr. , 8 8 , 975-982. Gen. Pract., 44, 1 27-1 3 1 .
Jette, A. M. ( 1 993) Tobacco use; a modifiable risk Jones, C and Griffiths, R . ( 1 998) Intensive care
factor for dental disease among the elderly. Am. J. follow-up workshop. Br. J. Intensive Care, 8, 1 3 9-
Publ. Health, 83, 1271-1274. 1 40.
Jette, D. u., Manago, D. and Medved, E. (1 997) The Jones, c. and O'Donnell, C. ( 1 994) After intensive
disablement process in patients with pulmonary care - what then? Intens. Crit. Care Nurs. , 10, 89-
disease. Eur. Respir. J., 77, 3 85-394. 92.
Jindani, A. ( 1993) Postoperative cardiac surgical care. Jones, A. L. and Volans, G. ( 1 999) Management of
Br. Heart J., 69, 59-64. self-poisoning. Br. Med. J., 3 19, 1 4 1 4- 1 4 1 7.
Jobst, K., McPherson, K. and Brown, V. ( 1 986) Jones, D. and West, R. ( 1 995) Cardiac Rehabilitation,
Controlled trial of acupuncture for disabling BMJ Publishing, London.
breathlessness. Lancet, ii, 1 4 1 6-14 1 8 . Jones, A., Tse, E. and Cheung, L. ( 1 997) Restoration
Johnson, K. L. ( 1 994) Closed versus open endotracheal of lung volume using the flutter or breathing
.
suctioning. Crit. Care Med. , 22, 658-666. exercise. Austr. Physiother. ]., 43, 1 83-1 8 9 .
Johnson, J. H . and Prins, A. ( 1 9 9 1 ) Prediction of Jones, A., Jones, R. D., Kwong, K. and Burns, Y.
maximal heart rate during a sub maximal work ( 1 999) Effect of positioning on recorded lung
test. J. Sports Med. Phys. Fitness, 3 1 , 44-47. sound intensities in subjects without pulm'onary
Johnson, M. K. (2000) Large lung bullae in marijuana dysfunction, Phys, Ther. , 79, 682-690.
smokers. Thorax, 5 5 , 340-342. Jones, T. R., Allen, A, and Hoy, D. (2000) Mass
508
REFERENCES
psychogenic illness attributed to toxic exposure at Kam, A. c., O'Brien, M. and Kam, P. C. A. ( 1 993)
a high school. N. Eng/. ]. Med. , 342, 96-100. Pleural drainage systems. Anaesthesia, 48, 1 54-
Joorabchi, B. (1 997) Expressions of the 161.
hyperventilation syndrome in childhood. Clin. Kamalvand, K . and Sulke, N . ( 1 999) Recent advances
Pediatr. , 1 6, 1 1 1 0-1 1 15. in the non-surgical management of atrial
Jorm, A. F., Rodgers, B. R. and Jacomb, P. A. ( 1 999) fibrillation. Int. ]. Clin. Pract., 5 3 , 44-46.
Smoking and mental health. Med. ]. Austr. , 170, Kamps, A. W. A. (2000) Poor inhalation technique,
74-77. even after inhalation instructions, in children with
Jounieaux, V. (1995) Oxygen cost of breathing in asthma. Pediatr. Pulmono/. , 29, 3 9-42.
patients with emphysema or chronic bronchitis in Kandioler, D. ( 1 998) Long-term results after repeated
acute respiratory failure. Am. ]. Respir. Crit. Care surgical removal of pulmonary metastases. Ann.
Med. , 152, 2 1 8 1-2 1 84. Thorac. Surg. , 65, 909-9 1 2.
Joynt, G. M. and Lipman, J. ( 1 994) The use of heat Kapur, N., House, A. and Creed, F. ( 1 998)
and moisture exchangers in critically ill patients. Management of deliberate self poisoning in adults.
Care Crit. Ill, 10, 271-274. Br. Med. ]., 3 1 6, 83 1-832.
Jubran, A. ( 1 994) Use of flow-volume curves in Karetzky, M. S. ( 1967) The cause of hyperventilation
detecting secretions in ventilator-dependent and arterial hypoxia in patients with cirrhosis of
patients. Am. ]. Respir. Crit. Care Med. , 150, 766- the liver. Am. ]. Med. Sci, 254, 797-804.
769. Karper, W. B. and Boschen, M. B. ( 1 993) Effects of
Judson, M. A. ( 1 994) Mobilization of secretions in exercise on acute respiratory tract infections and
rcu patients. Respir. Care, 39, 2 1 3-225. related symptoms. Geriatr. Nurs. , 14, 15-18.
Judson, M. A. ( 1 998) Lung transplantation for Katz, J., Clairoux, M. and Kavanagh, B. P. (1 994)
pulmonary sarcoidosis. Eur. Resp. ]. , 1 1, 73 8-744. Preemptive lumber epidural anaesthesia reduces
Juniper, E. F. ( 1 999a) Validation of a standardized postoperative pain. Pain, 5 9, 3 95-403.
version of the asthma qualiity of life questionnaire. Katz, J., Jackson, M. and Kavanagh, B. P. ( 1 996)
Chest, 1 1 5 , 1265-1270. Acute pain after thoracic surgery predicts long
Juniper, M. ( 1 999b) Ventilator associated pneumonia. term post-thoracotomy pain. Clin. ]. Pain., 12,
Care Crit. Ill, 1 5 , 198-20 1 . 5 0-55.
Juniper, M. C . and Davies, C . W. H . ( 1 998) New Katz, M. G., Katz, R. and Schachner, A. ( 1 998)
guidelines for the management of life threatening Phrenic nerve injury after CABG. Ann. Thorac.
asthma. Care Crit. Ill, 1 4, 6 1-63. Surg. , 65, 3 2-35.
Juniper, M. C. and Garrard, C. S. ( 1 997) The chest x Kauffmann, F. ( 1 993) The ageing lung. Respir. Med. ,
ray in intensive care. Care Crit. Ill, 13, 1 98-200. 87, 5-7.
Justins, D. M. and Richardson, P. H. ( 1 9 9 1 ) Clinical Kavanagh, B. P. ( 1 994) Pain control after thoracic
management of acute pain. Br. Med. Bull., 47, surgery. Anesthesiology, 8 1, 737-759 .
56 1-583. Kawagoe, Y . ( 1 994) Hyperinflation with intrinsic
Kain, Z. N., Wang, S. M. and Caramico, L. A. ( 1 997) PEEP. ]. App/. Physiol., 77, 2440-2448.
Parental desire for perioperative information Kawamura, H. ( 1 999) The effects of pre-and
and informed consent. Anesth. Analg. , 84, 299- postoperative contralateral TENS for the phantom
306. limb pain in amputees. WCPT Proceedings, p. 6 1 .
Kakizaki, F., Shibuya, M. and Yamazaki, T. ( 1 999) Keeley, D . ( 1 999) Rigorous assessment o f palliative
Preliminary report on the effects of respiratory care revisited. Br. Med. ]. , 3 19, 1447-1448.
muscle stretch gymnastics on chest wall mobility. Keenan, S. P. ( 1 997) Effect of noninvasive positive
Respir. Care, 44, 409-4 14. pressure ventilation on mortality in patients with
Kallet, R. H. (2000) The effects of pressure control acute respiratory failure. Crit. Care Med. , 25,
versus volume control asisted ventilation on 1685-1 692.
patient work of breathing. Respir. Care, 45, 1 085- Keilty, S. E. J. and Bott, J. ( 1 992) Continuous positive
1096. airways pressure. Physiotherapy, 78, 90-92.
Kam, P. C. A. ( 1 994) Noise pollution in the Keilty, S. E. J. and Moxham, J. ( 1 995) Noninvasive
anaesthetic and intensive care environment. ventilation in acute-on-chronic airways disease.
Anaesthesia, 49, 982-986. Hosp. Update, 2 1 , 1 65-1 7 1 .
509
REFERENCES
Keistinen, T. ( 1 997) Bronchiectasis: an orphan disease hyperinflation as a physiotherapy technique in

with a poorly-understood prognosis. Eur. Respir. intensive care units. Physiotherapy, 78, 747-
]., 1 0, 2784-2787. 750.
Kelley, S. and Jull, G. ( 1 998) Breast surgery and King, J. C. and Nixon, P. G. F. ( 1 988) A system of
neural tissue mechanosensitivity. Austr. cardiac rehabilitation: psychophysiological basis
Physiother. , 44, 3 1-37. and practice. Br. ]' Occup. Ther. , 5 1, 3 78-383.
Kellner, R., Samet, J. and Pathak, D. ( 1992) Dyspnea, King, M., Dasgupta, B. and Tomkiewicz, R. P. ( 1 997)
anxiety and depression in chronic respiratory Rheology of cystic fibrosis sputum after in vitro
impairment. Gen. Hosp. Psychiat. , 14, 20-28. treatment with hypertonic saline alone and in
Kemper, M. ( 1 993) The effects of adding pressure combination with rhDNase. Am. J. Respir. Crit.
support during chest physical therapy. Respir. Care Med. , 156, 1 73-1 77.
Care, 38, 1 245. Kings Fund ( 1 998) Trends in Rehabilitation Policy and
Kennell, J. H. ( 1 999) The humane neonatal care Effective Practice in Rehabilitation, Kings Fund,
initiative. Acta Paediatr. , 8 8 , 367-370. London.
Kerr, G. W. ( 1 998) Neurogenic pulmonary oedema. J. Kinsman, R. A., Yaroush, R. A. and Fernandez, E.
Accident Emerg. Med. , 1 5 , 275-277. ( 1 983) Symptoms and experiences in chronic
Kerr, K. ( 1 999) Exercise - no easy option. bronchitis and emphysema. Chest, 83, 755-76 1 .
Physiotherapy, 85, 1 14-1 1 5 . Kirk, A . J. B . ( 1 986) Minitracheostomy in
Kerr, M., Sereika, S. and Rudy, E . ( 1 996) The effect cardiothoracic practice. Care Crit. Ill, 2, 1 04-1 10.
of neuromuscular blocking agents on ICP response Klech, H. H. ( 1 998) Reduced smoking - an acceptable
to endotracheal suctioning in severe head injured goal for the hopeless heavy smoker? Eur. Respir.
patients. Crit. Care Med. , 24, A24. J. , 1 1 , 263-264.
Kerridge, L H., Pearson, S. A., Rolfe, L E. and Lowe, Klefbeck, B. ( 1 999) Combination of inspiratory
M. ( 1 998) Decision making in CPR. Med. ]. muscle training and assisted ventilation in patients
Austr. , 169, 128- 1 3 1 . with prior polio. WCPT Proceedings, 1 4 1 .
Kesecioglu, J. ( 1997) Prone position in therapy Kleiber, c . , Krutzfield, N . and Rose, E . F. ( 1 988)
refractory hypoxaemia. Curro Opin. Anaesth., 1 0, Acute histologic changes in the tracheobronchial
92- 1 00. tree associated with different suction catheter
Khadra, M. H. ( 1 998) What price, compassion? Med. insertion techniques. Heart Lung, 1 7, 1 0-14.
J. Austr. , 1 69, 42-43. Klein, J. S. ( 1 999) Chest imaging in the surgical ICU.
Khajotia, R. R. ( 1 9 9 1 ) Induced sputum and Respir. Care, 44, 1 078-1 094.
cytological diagnosis of lung cancer. Lancet, 338, Klein, P., Kemper, M. and Weissman, C. ( 1 988)
976-977. Attenuation of the hemodynamic responses to
Kiely, J. L. ( 1 999) Subjective efficacy of nasal CPAP chest physical therapy. Chest, 93, 3 8-42.
therapy in OSA. Eur. Respir. J., 1 3 , 1 086-1090. Klingstedt, c., Hedenstierna, G. and Lundquist, H.
Kiernan, M. ( 1 998) Pressure sores. Br. J. Ther. ( 1 9 9 1 ) The influence of body position and
Rehabil., 5 , 402-405. differential ventilation on lung dimensions and
Kikuchi, R., Watabe, N. and Konno, T. ( 1 994) High atelectasis. Respir. Care, 36, 12.
incidence of silent aspiration in elderly patients Kluft, J., Beker, L. and Castagnino, M. ( 1 996) A
with community-acquired pneumonia. Am. ]. comparison of bronchial drainage treatments in
Respir. Crit. Care Med. , 1 5 0, 25 1-253 . CF. Pediatr. Pulmonol. , 22, 27 1-274.
Kimmel, P . L., Miller, G. and Washington, W . B. Knichwitz, G., Rotker, J. and Mollhoff, T. (1 998)
( 19 8 9) Sleep apnoea syndrome in chronic renal Continuous intramucosal PCOz measurment
disease. Am. J. Med. , 86, 3 08-3 14. allows the early detection of intestinal
King, M. ( 1 985) Clearance of mucus by simulated malperfusion. Crit. Care Med. , 25, 1 5 5 0-1 557.
cough. J. Appl. Physiol. , 5 8 , 1 776-1 782. Kochanek, P. M. ( 1999) Subarachnoid hemorrhage,
King, M. ( 1 9 97) Mucoactive therapy. Pediatr. systemic immune response syndrome and MODS.
Pulmonol. Suppl. , 14, 1 22-123. Crit. Care Med. , 27, 454-455 .
King, M. ( 1 998) Experimental models for studying Kolaczkowski, W . ( 1989) Improvement i n oxygen
mucociliary clearance. Eur. Respir. ]. , 1 1, 222-228. saturation after chest physiotherapy in patients
King, D. and Morrell, A. ( 1 992) A survey on manual with emphysema. Physiother. Can. , 4 1 , 1 8-23.
510
REFERENCES
Koll, U., Matsuda, Y. and Takayanagi, K. ( 1 999) Kuo, C. D., Lin, S. E. and Wang, ]. H. ( 1 9 9 1 )
Assessment of health-related quality of life in Aerosol, humidity and oxygenation. Chest, 99,
patients with chronic respiratory failure. WCPT 1 35 2-1356.
Proceedings, p. 3 1 8 . Kuo, C. D., Shiao, G. M. and Lee, J. D. ( 1 993) The
Koltyn, K . F. and Morgan, W . P. ( 1 992) Efficacy of effects of high-fat and high-carbohydrate diet loads
perceptual versus heart rate monitoring in the on gas exchange and ventilation in COPD patients
development of endurance. Br. J. Sports Med. , 26, and normal subjects. Chest, 1 04, 1 8 9- 196.
132-134. Kutsogiannis, D. ]. (2000) Continuous venovenous
Komara, ]. ]. and Stoller, ]. K. ( 1 995) The impact of a hemodiafiltration for renal failure and sepsis. Can.
postoperative oxygen therapy protocol. Respir. Med. Assoc. ]., 1 62, 537-5 3 8 .
Care, 40, 1 1 25-1 1 29. Kuwahira, I . ( 1 993) Changes i n regional blood flow
Kong, X. T., Fang, H. T. and Jang, G. Q. ( 1 993) distribution and oxygen supply during hypoxia in
Treatment of acute bronchiolitis with Chinese conscious rats. J. Appl. Physiol. , 74, 2 1 1-2 14.
herbs. Arch. Dis. Child. , 68, 468-4 7 l . Kuyvenhoven, M. M. (2000) Antimicrobial agents in
Konrad, F . X. ( 1 993) Bronchial mucus transport in lower respiratory tract infections. Br. J. Gen.
chronic smokers and nonsmokers during general Pract., 50, 1 33-134.
anesthesia. ]. Clin. Anesth. , 5, 375-380. Laatikainen, A. K. ( 1 999) Bone mineral density in
Konstan, M. W. (1 994) Efficacy of the flutter device perimenopausal women with asthma. Am. ].
for airway mucus clearance in patients with CF. J. Respir. Crit. Care Med. , 159, 1 179- 1 1 85 .
Pediatr., 124, 689-693. Lacasse, Y . ( 1 996) Meta-analysis o f respiratory
Konstan, M. W., Byard, P. ]. and Hoppel, C. ( 1 995) rehabilitation in COPD. Lancet, 348, 1 1 1 5- 1 1 1 9.
Effect of high dose ibuprofen in patients with Lacasse, Y., Rousseau, L. and Maltais, F. ( 1 998)
cystic fibrosis. N. Eng!. J. Med. , 332, 848-854. Prevalence and impact of depression in patients
Korhonen, K., Korppi, M. and Remes, S. T. ( 1 999) with severe COPD. Chest, 1 14, 3 1 9.
Lung function in school-aged asthmatic children LaChapelle, D. L., Hadjistavropoulos, T. and Craig,
with inhaled cromoglycate, nedocromil and K. D. ( 1 999) Pain measurement in persons with
corticosteroid therapy. Eur. Respir. ]., 13, 82-86. intellectual disabilities. Clin. J. Pain. 1 5 , 13-23.
Kotloff, R. M. ( 1 998) Comparison of short-term Lagergren, J., Bergstrom, R. and Lindgren, A. ( 1 999)
functional outcomes following unilateral and Symptomatic gastroesophageal reflux as a risk
bilateral lung volume reduction surgery. Chest, factor for esophageal adenocarcinoma. N. Engl. J.
1 13, 890-895. Med. , 340, 825-83 l .
Koufman, J. A. and Burke, A. J. ( 1 997) The etiology Laghi, F . ( 1 995) Weaning from mechanical
and pathogenesis of laryngeal carcinoma. ventilation. Curro Opin. Crit. Care, 1, 7 1 -76.
Otolaryngol. CUn. North Am. , 30, 1-5. Lahz, S. ( 1 996) Incidence of chronic pain following
Koul, B., Solem, ].-0. and Steen, S. ( 1 998) HeartMate traumatic brain injury. Arch. Phys. Med. Rehabil. ,
left ventricular assist device as bridge to heart 77, 889-8 9 l .
transplantation. Ann. Thorac. Surg. , 65, 1 625- Lakhani, M . K . ( 1 996) The dizzy patient. Update, 52,
1 630. 383-3 86.
Kraft, A. R. (1 984) The hyperventilation syndrome. Lalloo, U. G. ( 1 998) Increased sensitivity of the cough
Br. J. Psychiat., 145, 5 3 8-542. reflex in progressive systemic sclerosis patients
Kriimer, B. K., Schweda, F. and Riegger, G. A. ]. with interstitial lung disease. Eur. Respir. J., 1 1,
( 1 999) Diuretic treatment and diuretic resistance 702-705.
in heart failure. Am. ]. Med. , 1 06, 90-96. Lam, S. ( 1 985) Effect of bronchial lavage volume of
Krause, ]. S. (2000) Depression after spinal cord cellular and protein recovery. Chest, 8 8 , 856-859.
injury. Arch. Phys. Med. Rehap. , 8 1 , 1 099- 1 1 09. Lamm, c., Mandeli, ]. and Kattan, M. ( 1 999)
Krishna, G. ( 1 999) Terminal weaning from mechanical Evaluation of audiotapes as an abbreviated test for
ventilation. Crit. Care Med. , 27, 9-1 0. OSA in children. Pediatr. Pulmonol. , 27, 267-272.
Kritz, H. (1 995) Passive smoking and cardiovascular LaMontagne, L. L. ( 1 996) Children's preoperative
risk. Arch. Intern. Med. , 1 5 5 , 1 942-1948. coping and its effects on postoperative anxiety.
Kubler-Ross, E. ( 1 973) On Death and Dying, Nurs. Res. , 45, 141-146.
Tavistock, London. Lan, C. ( 1 996) Cardiorespiratory function, flexibility
511
REFERENCES
and body composition among geriatric Tai Chi and nursing staff attitudes to postoperative opioid
Chuan practitioners. Arch. Phys. Med. Rehabil. , analgesia. Pain, 48, 3 13-3 19.
77, 6 1 2-6 1 6. Lawler, K. ( 1 995) Entonox : too useful to be limited
Lancet (1 992) Pacifiers, passive behaviour and pain. to childbirth? Prof Care Mother Child, S, 19-2 1 .
Lancet, 339, 275-276. Lawrence, M . ( 1 995) The unconscious experience.
Lancet ( 1 9 95a). Pathophysiology and management of Am. J. Crit. Care, 4, 227-232.
sickle cell pain crisis. Lancet, 346, 1408-141 1 . Lawrence, D. and Kakker, V. V. ( 1980) Graduated
Lancet ( 1 995b) Deglamorising cannabis. Lancet, 346, static external compression of the lower limb. Br.
1 24 1 . J. Surg. , 67, 1 1 9-1 2 1 .
Landa, J. F . , Kwoka, M . A . and Chapman, G . A. Laws, A . K . and Mcintyre, R . W . ( 1 969) Chest
( 1 980) Effects of suctioning on mucociliary physiotherapy: a physiological assessment during
transport. Chest, 77, 202. IPPV in respiratory failure. Can. Anaesth. Soc. J.,
Landbo, C. ( 1 999) Prognostic value of nutritional 1 6, 487-492.
status in COPD. Am. J. Respir. Crit. Care Med. , Lazarus, H. R. and Kostan, J. J. ( 1 969) Psychogenic
160, 1 8 5 6- 1 8 6 l . hyperventilation and death anxiety.
Lander, J . ( 1 993) TENS for children's procedural Psychosomatics, 10, 14-22.
pain. Pain, 52, 209-2 1 6. Leach, R. M. ( 1 9 92) Portable liquid oxygen and
Landreneau, R. J., Pigula, F. and Luketich, J. D. exercise ability in severe respiratory disability.
( 1 996) Acute and chronic morbidiy differences Thorax, 47, 78 1-789.
between muscle-sparing and standard lateral Leach, M. ( 1 998) Signs and symptoms of systemic
thoracotomies. J. Thorac. Cardiovasc. Surg. , 1 12, lupus erythematosus. Nurs. Times, 94( 13), 50-52.
1 346-135 l . Leach, R. M. and Bateman, N. T. ( 1 993) Acute
Lane, D . J . ( 1 9 9 1 ) Chronic persistent asthma. Respir. oxygen therapy. Br. J. Hosp. Med. , 49, 637-644.
Med. , 8 5 , 359-3 63. Leach, R. M. and Bateman, N. T. ( 1 994) Domiciliary
Lang, C. ( 1 9 9 1 ) Using relaxation and exercise for oxygen therapy. Br. ]. Hosp. Med. , 5 1 , 47-54.
people living with HIV/AIDS. Physiotherapy, 79, Leach, R. M. and Treacher, D. F. ( 1 998) Oxygen
3 79-3 84. transport 2 - tissue hypoxia. Br. Med. J. , 3 1 7,
Lannefors, L. ( 1 992) Mucus clearance with three chest 1 370- 1 3 73 .
physiotherapy regimes in CF. Eur. Respir. J., 5 , Leary, R., Fellows, I . and Fletcher, S . (2000) Enteral
748-753 . nutrition part 1 . Care Crit. Ill, 16, 22-26.
Lannoo, E. ( 1 998) Cerebral perfusion pressure and Ledson, M. J. ( 1 998) Cross infection between cystic
intracranial pressure. Intensive Care Med. , 24, fibrosis patients colonised with Burkholderia
23 6-24 1 . cepacia. Thorax, 53, 432-436.
Laporte, D . M., Chan, D . and Sveistrup, H . ( 1 999) Lee, S. T. ( 1 989) Intracranial pressure changes during
Rising from sitting in elderly people, part 1. Br. ]. positioning of patients with severe head injury.
Occup. Ther. , 62, 3 6-42. Heart Lung, 1 8 , 4 1 1-4 14.
Lareau, S. C. ( 1 999) Dyspnea in patients with COPD. Lee, L., Friesen, M. and Lambert, I. R. ( 1 998)
Heart Lung, 28, 65-73. Evaluation of dyspnea during physical and speech
Larsson, B. A. ( 1 999) Pain management in neonates. activities in patients with pulmonary diseases.
Acta Paed., 88, 1 3 0 1-1 3 1 0. Chest, 1 1 3, 625-632.
Lascelles, B. D. X . ( 1 997) Post-operative central Lee, B. G., Presneil, J. ]. and Cade, J. F. ( 1 999) Tidal
hypersensitivity and pain. Pain, 73, 46 1-47 1 . volume alteration during mechanical ventilation
Laskiwski, S. ( 1 993) The patient with spinal cord with heliox. Anaesth. Intensive Care, 27, 96.
injury: modifications of hope and expressions of Lefering, R. ( 1 995) Steroid controversy in sepsis and
despair. Can. J. Rehabil. , 6, 143- 1 5 3 . septic shock. Crit. Care Med. , 23, 1924-1303.
Laursen, S. B. ( 1 998) Bi-level positive airway pressure Leger, P. ( 1 994) Nasal intermittent positive pressure
treatment of OSA. Respiration, 65, 1 14-1 1 9 . ventilation. Chest, 105, 1 00-1 05.
Lavie, C. J . , Milani, R . V . and Squires, R . W. ( 1 9 92) Leino, K., Mildh, L. and Lertola, K. (1999) Time
Exercise and the heart. Postgrad. Med. , 9 1 , 1 3 0- course of changes in breathing pattern in
150. morphine- and oxycodone-induced respiratory
Lavies, N. ( 1 992) Identification of patient, medical depression. Anaesthesia, 54, 835-840.
5 12
REFERENCES
Leisure, G. S., Stone, D. J. and Spiekermann, B. F. infiltration prior to arterial puncture. Thorax,
( 1 995) Airway management of the chronically 5 1 (suppl. 3), A67.
intubated patient. Respir. Care, 40, 1 279-1286. Lim, T. K., Ang, S. M. and Rossing, T. H. ( 1 989) The
Leite, J. J. ( 1 995) Role of pulmonary restriction in effects of deep inhalation on maximal expiratory
patients with ankylosing spondilitis Chest, 108, flow during spontaneous asthmatic episodes. Am.
157S. Rev. Respir. Dis. , 1 40, 340-343.
Lenhardt, R. ( 1 997) Assessment of peri operative Lim, C. M., Koh, Y. and Chin, J. Y. ( 1 999)
hypothermia. Curro Opin. Anaesthesiol., 1 0, 454- Respiratory and haemodynamic effects of the
458. prone position. Eur. Respir. j. , 13, 163- 1 6 8 .
Lennard-Jones, J. E. ( 1 992) Positive Approach to Lin, K . H. ( 1 999) Abdominal weight and inspiratory
Nutrition as a Treatment, Kings Fund, London. resistance. Arch. Phys. Med. Rehab., 80, 74 1-745.
Lennie, T. A. ( 1 999) Anorexia in response to acute Lin, V. W. H., Singh, H. and Chitkara, R. K. ( 1 998)
illness. Heart Lung, 28, 3 8 6-40 l . Functional magnetic stimulation for restoring
Lera, S . ( 1 997) Psychological dimensions of coping in cough in patients with tetraplegia. Arch. Phys.
respiratory rehabilitation. Eur. Respir. j. , 1 0, 459s. Med. Rehabil. , 79, 5 1 7-522.
Leslie, K. and Sessler, D. L ( 1 999) Peri-operative Lindeman, C. A. ( 1 9 7 1 ) Nursing intervention with the
hypothermia. Best Pract. Res. Clin. Anesthesiol. , presurgical patient. Nurs. Res. , 20, 3 1 9-332.
13, 349-36 l . Lindgren, L. (1 997) Pain after laparoscopic
Levin, A. ( 1 999) Humane neonatal care initiative. cholecystectomy. Acta Anaesthesiol. Scand., 4 1 ,
Acta Paediatr. , 88, 353-355. 1 9 1 - 1 92.
Levine, P. A. ( 1 997) Management of advanced-stage Lindh, V. ( 1 999) Heel lancing in term new-born
laryngeal cancer. Otolaryngol. Clin. North Am. , infants. Pain, 80, 1 43-148.
30, 1 0 1-1 1 3 . Lindley, C. M., Dalton, J. A. and Fields, S. M. ( 1 990)
Levine, S . ( 1 988) Who Dies? Gateway, Bath, p . 134. Narcotic analgesics. Cancer News, 13, 28-3 8 .
Levitzky, M. G. ( 1 995) Pulmonary Physiology, Lingnau, W. ( 1 995) Continuous hemofiltration
McGraw-Hili, New York. improves multiple organ failure outcome. Crit.
Levy, M. and Bell, L. ( 1 984) General practice audit of Care Med. , 23, A 1 06.
asthma in childhood. Br. Med. j., 289, 1 1 1 5-1 1 1 8 . Link, W. J., Spaeth, E. E. and Wahle, W. M. ( 1 976)
Levy, B . D., Kitch, B. and Fanta, C . H . ( 1 998) The influence of suction catheter tip design on
Medical and ventilatory management of status tracheobronchial trauma and fluid aspiration.
asthmaticus. Intensive Care Med. , 24, 1 05- 1 17. Anesth. Analg. , 5 5 , 290-297.
Lewandowski, K. ( 1 992) approaches to improve Linsenbardt, S. T., Thomas, T. R. and Madsen, R. W.
survival in severe ARDS. In: Vincent, J.L. (ed) ( 1 992) Effect of breathing techniques on blood
Yearbook of Int, Care Emerg. Med, Springer pressure response to resistance exercies. Br. j.
Verlag, Berlin. Sports Med. , 26, 97- 1 00.
Lewis, M. L, Sieck, G. C. and Fournier, M. ( 1 986) Linsenmeyer, T. A. (2000) Sexual function and
Effect of nutritional deprivation on diaphragm infertility following spinal cord injury. Phys. Med.
contractility and muscle fiber size. j. Appl. Rehab. Clin. N. Am. , 1 1, 1 4 1- 1 63 .
Physiol. , 60, 596-603 . Liposky, J. M . ( 1 994) Ventilatory response to high
Li, X. Y. ( 1 996) Mechanisms of cigarette smoke caloric loads. Crit. Care Med. , 22, 796-802.
induced increased airspace permeability. Thorax, Lipworth, B. J. ( 1 995) New perspectives on inhaled
5 1 , 465-47 l . drug delivery. Thorax, 5 0, 1 05-1 1 0 .
Liebeskind, J . C . and Melzack, R. ( 1 987) The Lisboa, c., Villafranca, A. and Leiva, E . ( 1 997)
international pain foundation. Pain, 30, 1-2. Inspiratory muscle training in CAL: effect on
Light, R. W. ( 1 989) Effects of oral morphine on exercise performance. Eur. Respir. j. , 1 8 , 537-
breathlessness and exercise tolerance in patients 542.
with COPD. Am. Rev. Respir. Dis. , 139, 1 26-1 3 3 . Little, S. A., Elkholy, M. M. and Chalmers, G. W.
Light, R . W . ( 1 993) Management of spontaneous ( 1 999) Predictors of nocturnal oxygen
pneumothorax. Am. Rev. Respir. Dis. , 148, 245- desaturation in patients with COPD. Respir. Med. ,
248. 93, 202-207.
Lightowler, J. V. J. ( 1 996) Local anaesthetic Liu, R. ( 1 994) Effects of background stress and
513
REFERENCES
anxiety on postoperative recovery. Anaesthesia, Lumb, A. B. (2000) Nunn's Applied Respiratory

49, 3 8 2-3 86. Physiology, 5th edn. Butterworth-Heinemann,
Liu, C. and Douglas, R. M. ( 1 998) Chinese herbal London.
medicines in the treatment of acute respiratory Lynch, J. J. ( 1 978) The simple art of touching.
infections. Med. j. Austr. , 169, 579-582. Nursing, 8, 32-36 .
Ljubic, S., Metelko, Z. and Car, N. ( 1 998) Reduction Ma, Y . , Li. J. and Lui, Y . ( 1 997) Short wave
of diffusion capacity for carbon monoxide in diathermy for small spontaneous pneumothorax.
diabetic patients. Chest, 1 14, 1 033- 1 03 5 . Thorax, 52, 5 6 1 -562.
Lloyd, G. ( 1 987) Heat and moisture exchangers. Care McCaffery, M. and Ferrell, B. R. ( 1 992) Does the
Crit. Ill, 3, 1 1 0-1 1 3 . gender gap affect your pain control decisions?
Lloyd, S . ( 1 998) Education and adherence t o therapy in Nursing, 92, 49-5 1 .
a clinical setting. Eur. Respir. Rev., 5 8 , 333-3 37. McCallum, T. J. (2000) Fertility in men with cystic
Lock, S. H . ( 1 992) Comparison of liquid and gaseous fibrosis. Chest, 1 1 8 , 1 05 9- 1 062
oxygen for domiciliary portable use. Thorax, 47, McCarren, B. ( 1 992) Dynamic pulmonary
98-1 00. hyperinflation. Austr. Physiother. j., 3 8 , 1 75-1 79.
Locke, C. R., Talley, N. J. and Fett, S. L. ( 1 999) Risk McConnell, A. K., Caine, M. P. and Donovan, K. J.
factors associated with symptoms of GOR. Am. ]. ( 1 998) Inspiratory muscle training improves lung
Med. , 106, 642-649. function and reduces dyspnoea in mild/moderate
Logemann, J. A. ( 1 986) Treatment for aspiration asthmatics. Clin. Sci., 95, 4.
related to dysphagia. Dysphagia, 1, 34-3 8 . McConnochie, K. and Chatham, K. ( 1 99 1 ) Double
Lomholt, N . ( 1 982a) The new N L tracheal suction blind controlled study of inspiratory muscle
catheter. Acta Anaesth. Scand., 26, 4-8. training. Thorax, 46, 755P.
Lomholt, N. ( 1 982b) Design and function of tracheal McCool, F. D. and Tzelepis, G. E. ( 1 995) Inspiratory
suction catheters. Acta Anaesth. Scand. , 26, 1 -3 . muscle training in the patient with neuromuscular
Long, T . ( 1995) The effect o f positioning prematurely disease. Phys. Ther. , 75, 1 006- 1 0 14.
born infants in the neonatal ICU. Phys. Occup. McCowan, c., Neville, R. G. and Thomas, G. E.
Ther. Pediatr. , 1 5 , 1 7-3 1 . ( 1 998) Effect of asthma and its treatment on
Lowell, J . A. ( 1 990) Postoperative fluid overload. Crit. growth. Br. Med. ]., 3 1 6, 668-772.
Care Med. , 1 8 , 728-733 . McCullagh, P. ( 1 996) Determining foetal sentience.
Lowen, A . ( 1 9 9 1 ) Breathing, Movement and Feeling, Hosp. Update, 22, 5-6.
International Institute for Bioenergetic Analysis, McDonald, C. F. ( 1 995) Exertional oxygen of limited
New York. benefit in patients with COPD and mild
Lubel, D. ( 1 989) Falls and the older person. Care hypoxaemia. Am. ]' Respir. Crit. Care Med. , 1 52,
Elderly, 1, 66-67. 1 6 1 6- 1 6 1 9.
Lucas, A., Morley, R. and Cole, T. J. ( 1 998) McEvoy, R. D., Davies, J. H. and Hedenstierna, G.
Randomised trial of early diet in preterm babies ( 1 982) Lung mucociliary transport during high
and later IQ. Br. Med. j. , 1 7, 148 1 -1 487. frequency ventilation. Am. Rev. Respir. Dis. , 126,
Luce, P. J. ( 1 996) Asthma in the elderly. Br. ]' Hosp. 452-45 6.
Med. , 5 5 , 1 1 8- 1 24. McFadden, E. R. ( 1 995) Asthma. Lancet, 345, 1 2 15-
Luce, J. M., Pierson, D. J. and Tyler, M. T. ( 1 993) 1 260.
Intensive Respiratory Care, W. B. Saunders, McFadden, E. R. and Warren, E. L. ( 1 997)
Philadelphia, PA. Observations on asthma mortality. Ann. Intern.
Ludington, S. M. ( 1 990) Energy conservation during Med. , 127, 1 42-1 47.
skin-to-skin contact between infants and mothers. McGrath, P. J. and Frager, G. ( 1 996) Psychological
Heart Lung, 1 9 , 445-45 1 . barriers to optimal pain management in infants
Ludwig, c. ( 1 984) When you learn that you are a and children. Clin. ]. Pain, 12, 1 35-4 1 .
myasthenic. Remedial Ther. , 24 February, 8 . McIlwaine, M., Davidson, A. G . F . and Wong, L . T.
Ludwigs, U. ( 1 998) Pulmonary epithelial permeability K. ( 1 99 1 ) The effect of chest physiotherapy by
and gas exchange. Chest, 1 1 3, 459-466. postural drainage and autogenic drainage on
Lum, L. C. ( 1 9 8 1 ) Hyperventilation and anxiety state. oxygen saturation in CF. Pediatr. Pulmonol. , 6,
]. Roy. Soc. Med. , 74, 1-4. 29 1 .
5 14
REFERENCES
McIlwaine, P. M., Wong, L. T. K. and Peacock, D . availability between Vento lin nebules and
(1 996) Long term comparative trial o f respiratory solution. Chest, 1 1 1 , 204-208.
conventional postural drainage and percussion McNicholas, W. T. ( 1 9 97) Impact of sleep on
versus PEP in the treatment of CF. Israel j. Med. respiratory failure. Eur. Respir. j. , 1 0, 920-933.
Sci., 32(suppl.), S275. McQuellon, R. P. and Hurt, G. J. ( 1997) The
McIlwaine, P. M., Wong, L. T. W. and Peacock, D. psychosocial impact of laryngeal cancer.
( 1 997) Flutter versus PEP. Pediatr. Pulmonol. , Otolaryngol. Clin. North Am. , 30, 23 1-24 1 .
14(suppl.), 299. Mador, M . J . ( 1 9 9 1 ) Respiratory muscle fatigue and
McIntosh, A. ( 1 989) Sleep deprivation in critically ill breathing pattern. Chest, 100, 1 43 0- 1435.
patients. Nursing, 3, 44-45. Mador, M. J., Kufel, T. J. and Pineda, L. A. (2000)
MacIntyre, N. R. ( 1 995) Psychological factors in Diaphragmatic fatigue and high-intensity exercise
weaning from mechanical ventilation. Respir. Care, in patients with COPD. Am. j. Respir. Crit. Care
40, 277-28 1 . Med. , 1 6 1 , 1 1 8-123.
MacIntyre, N . R . ( 1996) Minimizing alveolar stretch Magarian, G. J. ( 1 982) Hyperventilation syndromes.
injury during mechanical ventilation. Respir. Care, Medicine, 61, 2 1 9-235 .
4 1 , 3 1 8-326. Magnussen, H. and Holz, O. ( 1 999) Monitoring
MacIntyre, N. R., Helms, M., Wunderink, R. and airway inflammation in asthma by induced
Schmidt, G. ( 1 999) Automated rotational therapy sputum. Eur. Respir. j. , 1 3 , 5-7.
for the prevention of respiratory complications Maguire, P. ( 1 998) Surgery and loss of body parts. Br.
during mechanical ventilation. Respir. Care, 44, Med. j. , 3 1 6, 1 086- 1 08 8 .
1447-145 1 . Mahadeva, R . , Webb, K. and Westerbeek, R. C.
MacKay, L. E . ( 1 992) Early intervention i n severe head ( 1 998) Clinical outcome in relation to care in
injury. Arch. Phys. Med. Rehabil. , 73, 635-64 1 . centres specialising in CF. Br. Med. j. , 3 1 6, 1 1 7 1 -
MacKeliaig, J . M. ( 1 990) A review o f the 1 175 .
psychological effects of intensive care on the Mahler, D. A. ( 1 990) Dyspnea, Futura Publishing,
isolated patient and family. Care Crit. Ill, 6, 1 00- New York.
1 02. Mahler, D. A. ( 1 995) Changes in dyspnea, health
McKenzie, D. K. ( 1 994) Dynamic changes in the zone status and lung function in chronic airway disease.
of apposition and diaphragm length during Am. j. Respir. Crit. Care Med. , 1 5 1 , 6 1-65.
maximal respiratory efforts. Thorax, 49, 634-63 8. Mahon, J. L. ( 1999) Theophylline for irreversible
McLaren, P. (1991) The right to know. Br. Med. j. , chronic airflow limitation. Chest, 1 15, 3 8-48 .
303, 937-938. Majid, A . A . ( 1 992) Pain control after thoracotomy.
Macklem, P. T. and Eidelman, D. ( 1 990) Chest, 1 0 1 , 98 1-984.
Reexamination of the elastic properties of Mak, V. H. F., Bugler, J. R. and Roberts, C. M.
emphysematous lungs. Respiration, 5 7, 1 8 7-1 92. ( 1 993) Effect of arterial desaturation on 6-minute
McMichan, J. c., Michel, L. and Westbrook, P. R. walk, effort and breathlessness in patients with
( 1 980) Pulmonary dysfunction following traumatic airflow limitation. Thorax, 48, 33-3 8 .
quadriplegia. j. A. M. A., 243, 528-529. Mak, V . H. F., Harvey, C. and Treacher, D. F . ( 1 995)
McNamara, R. M. ( 1 992) Utility of the peak Non-invasive assisted ventilation for respiratory
expiratory flow rate in the differentiation of acute failure for acute severe asthma. ACPRC j. , 26, 22-
dyspnea. Chest, 1 0 1 , 1 29-132. 23.
McNamara, F. ( 1 999) Obstructive sleep apnea in Make, B. M. ( 1 994) Collaborative self-management
infants and its management with nasal CPAP. strategies for patients with respiratory disease.
Chest, 1 16, 1 0-16. Respir. Care, 39, 566-577.
Macnaughton, P. D. ( 1 995) Posture and lung function Mal, H., Rullon, 1. and Mellot, F. ( 1 999) Immediate
in health and disease. Br. j. Intensive Care, 1, 133- and long-term results of bronchial artery
137. embolization for life-threatening hemoptysis.
MacNee, W. ( 1 995) Oxidants/antioxidants in Chest, 1 15 , 996- 1 0 0 1 .
idiopathic pulmonary fibrosis. Thorax, 50, 553- Malfroot, A . and Dab, 1. ( 1 99 1 ) New insights on
558. gastro-oesophageal reflux in CF. Arch. Dis. Child. ,
MacNeish, C. F. ( 1 997) A comparison of pulmonary 66, 1 33 9-1345.
515
REFERENCES
Malmberg, L. P., Tamminen, K. and Sovijarvi, A. R. Marik, P., Hogan, J . and Krikorian, J . ( 1 999) A
A. (2000) Orthostatic increase of respiratory gas comparison of bronchodilator therapy delivered
exchange in hyperventilation syndrome. Thorax, by nebulization and metered-dose inhaler in
55, 295-3 0 1 . mechanically ventilated patients. Chest, 1 15 ,
Man, P., Verhoeven, B . A . N. and Verbrugh, H. A. 1 653-1657.
(2000) An antibiotic policy to prevent emergence Marinho, P. E. M., Brito, E. C. S. and Gusmao, A. L.
of resistant bacilli. Lancet, 3 5 5 , 973-978. ( 1999) Comparative study of the change in
Mange, K., Matsuura, D., Cizman, B. and Soto, H. inspiratory and expiratory muscle strength
( 1 997) Language guiding therapy: the case of between young and elderly subjects by the use of
dehydration versus volume depletion. Ann. Intern. volumetric incentive spirometer. WCPT
Med. , 1 2 7, 848-853 . Proceedings, p. 385.
Mann, N. P . ( 1 98 6) Effect o f night and day on Marini, J. J. ( 1 999) PEEP in the prone position. Crit.
preterm infants. Br. Med. j. , 293, 1 265-1 267. Care Med. , 27, 1-2.
Mann, c., Pouzeratte, Y. and Boccara, G. (2000) Marini, J. J., Tyler, M. L. and Hudson, L. D. (1984)
Comparison of intravenous or epidural patient Influence of head-dependent positions on lung
controlled analgesia in the elderly. Anesthesiology, volume and oxygen saturation in chronic air-flow
92, 433--44 1 . limitation. Am. Rev. Respir. Dis. , 129, 1 0 1-1 05 .
Manne, S. L., Jacobsen, P . B. and Redd, W . H . ( 1 9 92) Marino, J. ( 1 995) Neuromuscular blockade i n the
Assessment of acute pediatric pain. Pain, 48, 45- ICU. Crit. Care Med. , 23, A240.
52. Marino, W. D . , Nyarko, W. C. and Kiyici, N. ( 1 995)
Manning, H. L. ( 1 995) Pathophysiology of dyspnoea. Helium-oxygen mixtures in adult patients with
N. Engl. ]. Med. , 3 3 3 , 1 5 47-1553. COPD and CO2 retention. Chest, 1 08 , 1 07S.
Manning, H. L. (2000) Bronchodilator therapy in Marsh, B. ( 1 986) A second chance. Br. Med. j., 292,
COPD. Curro Opin. Pulm. Med., 6, 99-103. 675-676.
Mansour, V. M. ( 1 998) Panic disorder: coronary Marshall, S. M. ( 1 996) The perioperative management
spasm as a basis for cardiac risk. Med. ]. Austr. , of diabetes. Care Crit. Ill, 12, 64-69.
168, 390-3 92. Marshall, R. and Holden, W. S. ( 1 963) Changes in
Manthous, C. A. ( 1 994) Administration of therapeutic calibre of the airways in man. Thorax, 1 8 , 54-5 8 .
aerosols to mechanically ventilated patients. Chest, Martin, M. and Shaw, N . J . ( 1 997) Feeding problems
1 06, 5 60-5 7 1 . in infants and young children with chronic lung
Manthous, C . A., Hall, J. B. and Melmed, A . ( 1 995) disease. j. Hum. Nutr. Diet., 1 0, 272-275.
Heliox improves pulsus paradoxus and peak Martin, C. J., Ripley, H. and Reynolds, J. ( 1 976)
expiratory flow in nonintubated patients with Chest physiotherapy and the distribution of
severe asthma. Am. j. Respir. Crit. Care Med. , 1 5 1 , ventilation. Chest, 69, 1 74-178.
3 1 0-3 14. Martinez, F . , Epstein, S. and Roe, J. (1991)
Manzano, J. L. ( 1 993) Verbal communication of Determinants of respiratory muscle strength in
ventilator-dependent patients. Crit. Care Med. , 2 1 , CAO. Am. Rev. Respir. Dis. , 1 43, A 1 6 1 .
5 12-5 1 7. Martinez-Moragon, E . ( 1 998) Malignant pleural
Marcano, B. (2000) Cephalad movement of tracheal effusion. Respiration, 65, 1 08-1 1 3 .
tubes due to prone positioning of pediatric Maskell, N., Wells, S . and Meecham Jones, D . J.
patients with ARDS. Chest, 1 1 8, 1 79S. ( 1 999) The value of an intensive physiotherapy
Marcus, C. L. ( 1 992) Supplemental oxygen and course in patients with hyperventilation.· ALAJATS
exercise performance in patients with CF. Chest, Conference, California (abstract), p. 832.
1 0 1 , 52-57. Mason, M. F . ( 1 993) Speech Pathology for
Marcy, T. W. ( 1 994) Respiratory distress in the Tracheostomized and Ventilator Dependent
ventilated patient. Clin. Chest Med. , 1 5 , 55-74. Patients, Voicing, California.
Marik, P. E. ( 1 996a) The cuff-leak test as a predictor Massard, G. and Wihlm, J.-M. ( 1 998) Postoperative
of postextubation stridor. Respir. Care, 4 1 , 5 09- atelectasis. Chest Surg. C/in. North Am., 8, 503-
5 1 1. 528.
Marik, P. E. ( 1 996b) The refeeding syndrome in ICU Mastro, T. D., Fields, B. S. and Breiman, R. F. ( 1 99 1 )
patients. Crit. Care Med. , 24, A84. Nosocomial legionnaires' disease and use of
516
REFERENCES
medication nebulizers. ]. Infect. Dis. , 1 63, 667- Menier, R. J. ( 1 994) Benefits of a multidisciplinary
67l. pulmonary rehabilitation program [letter]. Chest,
Mathewson, H . S. ( 1 993) Combined drug therapy in 1 0 5 , 640-64 l .
asthma. Respir. Care, 3 8 , 1 340. Menkes, H . and Britt, J. ( 1 980) Rationale for physical
Mathewson, H. S. (1 997) Post-myocardial infarction therapy. Am. Rev. Respir. Dis. , 122, 127-132.
drugs. Respir. Care, 42, 5 1 7-5 1 9. Merveille, O. c., Childers, M. K. and Kreimid, M. M.
Mathur, R. (1 999) Cerebral bioenergetics in stable ( 1 999) Weaning from mechanical ventilation in a
COPD. Am. J. Respir. Crit. Care Med. , 1 60, 1 994- general rehabilitation center. Am. J. Phys. Med.
1999. Rehabil. , 78, 85-86.
Mattison, L. E., Coppage, L. and Alderman, D. F. Meythaler, J. M. ( 1 9 97) Rehabilitation of Guillain
( 1 997) Pleural effusions in the medical ICU. Chest, Barre syndrome. Arch. Phys. Med. Rehabil. , 78,
1 1 1 , 1 0 1 8- 1 023. 872-879.
Matuszczak, Y. ( 1 998) Diaphragmatic function is Middleton, P. G., Geddes, D . M. and Alton, E. W.
markedly altered in cerulein-induced pancreatitis. ( 1 993) Effect of amiloride and saline on nasal
Crit. Care Med. , 26, 1327-1 33 l . mucociliary clearance and potential difference in
Maurer, J . R., Frost, A. E . and Estenne, M. ( 1 998) cystic fibrosis and normal subjects. Thorax, 48,
International guidelines for the selection of lung 8 1 2-8 1 6.
transplant candidates. Heart Lung, 27, 223- Mier, A., Laroche, C. and Agnew, J. E. ( 1 990)
229. Tracheobronchial clearance in patients with
Maxam-Moore, V. A. (1 996) The development of an bilateral diaphragmatic weakness. Am. Rev. Respir.
early extubation algorithm for patients after Dis. , 142, 545-546.
cardiac surgery. Heart Lung, 25, 6 1-68. Milgrom, H. and Bender, B. ( 1 997) Nonadherence to
Mayberry, J. c. ( 1 997) The fractured rib in chest wall asthma treatment and failure of therapy. Curro
trauma. Chest Surg. Clin. North Am. , 7, 239- Opin. Pediatr. , 9, 590-595.
256. Milia, C. E. ( 1 998) Risk of death in CF patients with
Mayor, A. H. ( 1 9 97) Magnetic resonance imaging of severely compromised lung function. Chest, 133,
the heart during CPAP via a facemask in normal 1 23 0-1234.
subjects [abstract] . Anesth. Analg. , 84, 1 04. Millard, P. H. ( 1 983) Depression in old age. Br. Med.
Medical Monitor ( 1 992) Maternal smoking increases ]., 287, 3 75 .
squint risk in children. Med. Monitor, 27 Miller, S. ( 1 996) Living with a disabled sibling. Paed.
November, 3 3 . Nurs., 8 , 2 1-24.
Meduri, G. U . ( 1 990) Ventilator-associated Miller, M. R. and Ouanjer, P. H. ( 1 994) Peak flow
pneumonia. Chest, 97, 1208- 1 2 19. meters. Br. Med. ]., 308, 548-549.
Meduri, G. U. ( 1 996) Noninvasive positive pressure Miller, K. M., Perry, P. A. ( 1 990) Relaxation techniques
ventilation via face mask. Chest, 1 09, 1 79- 1 93 . and postoperative pain in patients undergoing
Mehta, A . C. ( 1 999) Airway stents. Clin. Chest Med. , cardiac surgery. Heart Lung, 19, 1 3 6- 1 46.
20, 1 3 9- 1 52. Miller, R. F. and Semple, S. J. G. ( 1 99 1 ) Continuous
Mejia, R. ( 1 999) Target dyspnea ratings predict positive airways pressure for pneumocystis carinii
expected oxygen consumption as well as target pneumonia. Respir. Med. , 85, 1 33-138.
heart rate values. Am. J. Respir. Crit. Care Med. , Miller, S., Hall, D . O. and Clayton, C. B. ( 1 995)
159, 1485-1489. Chest physiotherapy in cystic fibrosis: a
Melamed, S. ( 1 999) Emotional reactivity and comparative study of autogenic drainage and the
debilitating beliefs during hospitalization predict active of breathing with postural drainage. Thorax,
future adjustment to first MI in men. Scand. ]. 50, 165-1 69.
Rehabil. Med. , 3 1 , 23-30. Miller, T. P. and Barbers, R. G. ( 1 999) Management
Melendez, J. A. ( 1 992) Postthoracotomy respiratory of the severe asthmatic. Curro Opin. Pulmonary
muscle mechanics during incentive spirometry. Med. , 5, 5 8-62.
Chest, 1 0 1 , 432-436. Mills, M. E. and Sullivan, K. (2000) Patients with
Mellins, R. B., Zimmerman, B. and Clark, N. M. operable oesophageal cancer: their experience of
(1 992) Patient compliance. Am. Rev. Respir. Dis. , information-giving in a regional thoracic unit. ].
146, 1376-1 3 77. Clin. Nurs., 9, 23 6-246.
517
REFERENCES
Milne, A. ( 1 998) Smoking: The Inside Story, Morgan, M. D . L. ( 1 992) Detection and quantification
Woodside, Stafford. of pulmonary emphysema by computed
Milner, A. D. ( 1 997) The role of corticosteroids in tomography. Thorax, 47, 1001-1 004.
bronchiolitis and croup. Thorax, 52, 5 95-597. Morice, A. ( 1 996) Inhaled therapy for asthma.
Mirski, M. A. ( 1 995) Sedation for the critically ill Update, 52, 592-596.
neurologic patient. Intensive Care Med. , 23, 2038- Morice, A. H. ( 1 998) Asthma. Update, 56, 44-49.
205 3 . Morina, P. ( 1 997) Effects of nebulized salbutamol on
Mishoe, S. C. ( 1 995) Quiet - hospital zone. Respir. respiratory mechanics in ARDS. Intensive Care
Care, 40, 1 1 1 6-1 1 1 7. Med. , 23, 5 8-64.
Misset, B. ( 1 9 9 1 ) Heat and moisture exchanger vs. Morley, C. ( 1 999) Continuous distending pressure.
heated humidifier during long-term mechanical Arch. Dis. Child. Fetal Neonat. Ed., 8 1 , F52-
ventilation. Chest, 1 00, 1 60-163. F56.
Mitchell, A. ( 1 998) Steroids and depression. Br. Med. Morrell, N. W. ( 1 994) Collateral ventilation and gas
j. , 3 16, 244-245. exchange in emphysema. Am. j. Respir. Crit. Care
Mitchell, P. H. and Mauss, N. K. ( 1 978) Relationship Med. , 1 50, 635-64 l .
of patient-nurse activity to rcp variations. Nurs. Morris, C. K. ( 1 99 1 ) Cardiovascular benefits to
Res. , 27, 4-1 0. increased activity. Herz, 16, 222-236.
Mitchell, P. H., Ozuna, J. and Lipe, H. P. ( 1 98 1 ) Morris, J. ( 1 999) The effects of immobilization on the
Moving the patient in bed: effects on rcp. Nurs. musculoskeletal system. Br. j. Ther. Rehabil. , 6,
Res. , 3 0, 2 1 2-2 1 8 . 3 90-393.
Miyahara, Y. ( 1 995) Monitoring o f nocturnal oxygen Morrison, S. A. ( 1 988) Biofeedback to facilitate
desaturation. Respiration, 62, 348-352. unassisted ventilation in individuals with high
Mogan, J., Wells, N. and Robertson, E. ( 1 985) Effects level quadriplegia. Phys. Ther. , 68, 1 378-1380.
of preoperative teaching on postoperative pain. Morrison, R. S., Ahronheim, J. C. and Morrison, G.
Int. j. Nurs. Stud. , 22, 267-285. R. ( 1 998) Pain and discomfort associated with
Mohsenifar, Z., Horak, D . and Brown, H. V. ( 1 983) common hospital procedures. j. Pain Symptom
Sensitive indices of improvement in a pulmonary Manage. , 1 5 , 9 1- 1 0 l .
rehabilitation program. Chest, 8 3 , 1 89-1 92. Morrison, R . S. and Siu, A. L . (2000) A comparison of
Mohsenin, V. ( 1 994) Daytime oxygen saturation does pain and its treatment in advanced demential and
not predict nocturnal desaturation in patients with cognitively intact patients with hip fracture. J. Pain
COPD. Arch. Phys. Med. Rehabil. , 75, 285-289. Symptom. Man. 1 9 , 240-248 .
Molen, B. ( 1 995) Dyspnoea: a study of measurement Mortensen, J., Falk, M. and Groth, S. ( 1 99 1 ) The
instruments. j. Adv. Nurs., 22, 948-956. effects of postural drainage and PEP in cystic
Moller, J. T. ( 1 998) Long-term postoperative fibrosis. Chest, 1 00, 1 35 0- 1 357.
cognitive dysfunction in the elderly. Lancet, 3 5 1 , Moseley, A. M. ( 1 997) The effect of casting combined
857-8 6 l . with stretching on passive ankle dorsiflexion in
Molnar, Z. and Shearer, E. ( 1 998) Venovenous adults with traumatic head injuries. Phys. Ther. ,
haemofiltration in the treatment of sepsis and 77, 240-249.
multiple organ dysfunction syndrome. Br. j. Moser, K. M. ( 1 990) Venous thromboembolism. Am.
Intensive Care, 8, 1 2- 1 8 . Rev. Respir. Dis. , 1 4 1 , 235-249.
Monga, U . , Tan, G . and Ostermann, J . ( 1 997) Moser, D. K. and Dracup, K. ( 1 996) Is anxiety early
Sexuality in head and neck cancer patients. Arch. after myocardial infarction associated with
Phys. Med. Rehabil. , 78, 298-304. subsequent ischemic and arrhythmic events?
Moore, T. ( 1 99 1 ) Cry of the Damaged Man, Picador, Psychosomatic Med. , 58, 395-40 l .
Sydney. Moss, E . and McDowall, D. G . ( 1 979) ICP increases
Moore, F. D. ( 1 994) The effect of length of stay on with 5 0% nitrous oxide in severe head injuries. Br.
complications. Ann. Surg. , 220, 738-739. J. Anaesth. , 5 1 , 757-760.
Morgan, A. D., Peck, D. F. and Buchanan, D. R. Mowatt-Larssen, C. A. ( 1 993) Specialized nutritional
( 1 983) Effect of attitudes and beliefs on exercise support in respiratory disease. Clin. Pharm., 12,
tolerance in chronic bronchitis. Br. Med. j., 286, 278-292.
1 7 1 -1 73 . Moyer-Mileur, L. J. (2000) Daily physical activity
518
REFERENCES
program increases bone mineralization and growth expiration with and without an end-inspiratory
in preterm very low birth weight infants. hold. WCPT Proceedings, p. 36.
Pediatrics, 1 06, 1088- 1092. Myles, W. S. and Maclean, D. ( 1 986) A comparison
Moniche, S., Biilow, S. and Hesselfeldt, P. ( 1 995) of response and production protocols for assessing
Convalescence and hospital stay after colonic perceived exertion. Eur. ]. Appl. Physio/. , 55, 5 85-
surgery with balanced analgesia, enforced oral 587.
feeding and mobilisation. Eur. j. Surg. , 1 6 1 , 283- Nagler, A. ( 1 996) Reduction in pulmonary fibrosis in
288. vivo by halofuginone. Am. ]. Respir. Crit. Care
Muers, M. ( 1 993) Understanding breathlessness. Med. , 1 54, 1 082-1086.
Lancet, 342, 1 190-1 1 9 l . Nance, P. W., Schryvers, O. and Leslie, W. ( 1 999)
Muir, J.-F. ( 1 993) Home mechanical ventilation. Intravenous pamidronate attenuates hone density
Thorax, 48, 1 264-1273 . loss after acute spinal cord injury. Arch. Phys.
Muir, J.-F., Girault, C . and Cardinaud, J.-P. ( 1 994) Med. Rehabil. , 80, 243-25 l .
Survival and long-term follow-up of Napolitano, L . M . ( 1 999) Capnography in critical
tracheostomized patients with COPD treated by care. Crit. Care Med. , 27, 862-863 .
home mechanical ventilation. Chest, 106, 201- Nathan, S. D. ( 1 995) Bronchiolitis obliterans in
209. single-lung transplant recipients. Chest, 1 07, 967-
Muldoon, M. F. ( 1 998) What are quality of life 972.
measurements measuring? Br. Med. j., 3 1 6, 542- Nava, S. ( 1998a) Noninvasive mechanical ventilation
545. in the weaning of patients with respiratory failure.
Mulholland, c . , Lennon, S. and Graham, R. ( 1 994) Ann. Intern. Med. , 1 2 8 , 72 1-728.
Does prone positioning improve oxygen saturation Nava, S. ( 1998b) Rehabilitation of patients admitted
in a patient with CF? Physiother. Theor. Pract., 1 0, to a respiratory intensive care unit. Arch. Phys.
223-233 . Med. Rehabi/. , 79, 849-854.
Mulley, G . ( 1993) Nursing elderly patients out o f bed. Neilly, J. B. ( 1992) Effects of selective sleep
Br. Med. ]., 307, 80. deprivation on ventilation during recovery sleep in
Mulloy, E. ( 1 996) Ventilation and gas exchange normal humans. ]. App/. Physiol. , 72, 1 00-1 09.
during sleep and exercise in severe COPD. Chest, Nelson, H. S. ( 1 995) �radrenergic bronchodilators.
109, 387-394. N. Eng/. ]. Med. , 333, 499-504.
Munday, I. T., Desai, P. M. and Marshall, C. A. Nelson, S. P. ( 1 998) One-year follow-up of symptoms
( 1993) The effectiveness of preoperative advice to of gastroesophageal reflux during infancy.
stop smoking. Anaesthesia, 48, 8 1 6-8 1 8 . Pediatrics, 1 02, 67-74.
Munro, N . C. ( 1 992) Radiological evidence of Nelson, F. V., Zimmerman, L. and Barnason, S.
progression of bronchiectasis. Respir. Med. , 86, ( 1998) The relationship and influence of anxiety
397-40 l . on postoperative pain in the CABG patient. ]. Pain
Munro, N. c., Currie, D . C . and Garbett, N. D. Symptom Manage. , 1 5 , 1 02-109.
(1989) Chest pain in chronic sputum production. Nelson-Piercy, A. ( 1 996) Asthma in pregnancy. Br. ].
Respir. Med. , 83, 339-34 l . Hosp. Med. , 55, 1 15-1 17.
Murch, S . H . ( 1 995) Cellular mediators of lung Neville, S. and French, S. (1991) Clinical education.
damage. Br. j. Intensive Care, S, 27-3 0. Physiotherapy, 77, 3 5 1 -354.
Murphy, F. M. ( 1 9 9 1 ) The high-risk infant. Neville, E., Gribbin, H. and Harrison, B. D . W.
Physiotherapy, 77, 367-370. ( 1 99 1 ) Acute severe asthma. Respir. Med. , 8 5 ,
Murphy, M. S. ( 1 997) Sedation for invasive 463-474.
procedures in paediatrics. Arch. Dis. Child. , 77, Newell, S. Z. ( 1 989) Inspiratory and skeletal muscle
28 1-286. strength and endurance and diaphragmatic
Murray-Parkes, C. ( 1 998) The dying adult. Br. Med. activation in patients with CAL. Thorax, 44, 903-
j. , 3 16, 1 3 13-1 3 1 5 . 9 12.
Muscolino, G . ( 1 997) Pancoast tumours. Thorax, 52, Newman, K. B., Lynch, D . A. and Newman, L. S.
284-286. ( 1994) Quantitative computed tomography detects
Mutatkar, S. S. ( 1 999) Comparison between effect of air trapping due to asthma. Chest, 106, 1 05-1 09.
diaphragmatic breathing exercise with purse lip Ng, G. Y. and Stokes, M. J. ( 1992) EMG recordings
5 19
REFERENCES
of respiratory muscles during unilateral and gastrostomy and nasogastric tube feeding after
bilateral chest expansion. Austr. Physiol. ]. , 38, acute dysphagic stroke. Br. Med. J., 3 12, 1 3-16.
203-208 . Nosworthy, J., Barter, C. and Thomas, S. ( 1992) An
Nguyen, T . T . ( 1 996) Current treatment of severely evaluation of three elements of pulmonary
burned patients. Ann. Surg. , 223, 14-25. rehabilitation. Austr. Physiother. , 38, 1 89-193.
Nicholas, T. E. ( 1 997) Surfactant replacement therapy Noureddine, S. N. ( 1 996) Sleep apnea: a challenge in
in ARDS. Thorax, 52, 1 95-197. critical care. Heart Lung, 25, 3 7-42.
Nicholas, K. ]., Dhouieb, M. O. and Marshall, T. G. Novak, R. A., Shumaker, L. and Snyder, ]. V. (1 987)
( 1 999) An evaluation of chest physiotherapy in the Do periodic hyperinflations improve gas exchange
management of acute bronchiolitis. Physiotherapy, in patients with hypoxemic respiratory failure?
85, 669-674. Crit. Care Med. , 15, 108 1-1085.
Nicholls, D. ( 1 996) The crisis in undergraduate Novitch, R. S. ( 1 995) Pulmonary rehabilitation in
respiratory care. ACPRC J. , 29, 5 l . patients with interstitial lung disease. Am. J.
Nicholson, C . ( 1 993) Are you ready for video Respir. Crit. Care Med. , 1 5 1 , A684.
thoracoscopy? Am. ]. Nurs. , 93, 54-57. Ntoumenopoulos, F. and Greenwood, D. ( 1 996)
Nield, M. A. ( 1 999) Inspiratory muscle training Effects of cardiothoracic physiotherapy on
protocol using a pressure threshold device. Arch. intrapulmonary shunt in abdominal surgical
Phys. Med. Rehabil. , 80, 1 00-1 03 . patients. Austr. ]. Physiother. , 42, 297-303.
Nield, M . (2000) Dyspnea self-management i n African Nunn, J. F., Coleman, A . J. and Sachithanandan, T.
Americans with chronic lung disease. Heart Lung, ( 1 965) Hypoxaemia and atelectasis produced by
29, 50-55. forced expiration. Br. J. Anaesth., 37, 3-1 l .
Nikander, K. (2000) Evaluation of pulsed and breath Nuorti, J. P . (2000) Cigarette smoking and invasive
synchronized nebulization. Pediatr. Pulmonol. , 29, pneumococcal disease. N. Engl. ]. Med. , 342, 68 1-
120-126. 689.
Nikolajsen, L. ( 1 997) The influence of preamputation Nursing Times ( 1 9 8 1 ) Who am I ? Where am I ? Why
pain on postamputation stump and phantom pain. do I hurt so much? Nurs. Times, 77( 15), 633-635.
Pain, 72, 3 93-405. Nuttal, G. A. ( 1 998) No difference exists in the
Nilsson, E. ( 1 997) Intrathecal morphine for post alteration of circadian rhythm between patients
sternotomy pain. Acta Anaesthesiol. Scand. , 4 1 , with and without ICU psychosis. Crit. Care Med. ,
549-556. 26, 135 1-1355.
Ninane, V. ( 1 997) Intrinsic PEEP. Eur. Respir. J., 1 0, Nygren, J., Thorell, A. and Jacobsson, H. (1 996)
5 1 6-5 1 8 . Preoperative gastric emptying. Ann. Surg. , 222,
Ninane, V., Rypens, F . and Yernault, ].-c. (1 992) 728-734.
Abdominal muscle use during breathing in patients Nyren, S. ( 1 999) Pulmonary perfusion is more
with CAO. Am. Rev. Respir. Dis. , 146, 1 6-2 l . uniform in the prone than in the supine position.
Ninane, V., Yernault, ].-c. and deTroyer, A . ( 1 993) J. Appl. Physiol. , 86, 1 135-1 1 4 l .
Intrinsic PEEP in patients with COPD. Am. Rev. Oakley, M . J . , Wheelwright, E. F . and James, P . ] .
Respir. Dis. , 148, 1 03 7-1042. ( 1 998) Pneumatic compression boots for
Nishimura, K. (2000) Clinical course and prognosis of prophylaxis against DVT: beware occult arterial
patients with COPD. Curro Opin. Pulm. Med. , 6, disease. Br. Med. ]. , 3 1 6, 454-455.
127-132. Oberklaid, F. ( 1 998) Twenty-four hour access to
Nolan, ]. P. ( 1 996) Care for trauma patients in the health information and advice. Med. ]. Austr. , 169,
ICU. Curro Anaesth. Crit. Care, 7, 1 3 9-145. 125-126.
Noppen, M., Dhondt, E. and Mahler, T. (1 994) Oberwaldner, B. (2000) Physiotherapy for airway
Successful management of recurrent clearance in paediatrics. Eur. Respir. J., 15, 1 96-
pneumothorax in CF by localized apical 204.
thorascopic talc poudrage. Chest, 106, 262-264. O'Brian, G. M., Furukawa, S. and Kuzma, A. M.
Northridge, D. ( 1 996) Frusemide or nitrates for acute ( 1 999) Improvements in lung function, exercise
heart failure? Lancet, 347, 667-668. and quality of life in hypercapnic COPD patients
Norton, B. ( 1 996) A randomised prospective after lung volume reduction surgery. Chest, 1 15,
comparison of percutaneous endoscopic 75-84.
520 ------
REFERENCES
Ochsenreither, J. M. ( 1997) Epidural analgesia in Orenstein, D. M. and Kaplan, R. M. ( 1 9 9 1 )

infants. Neonat. Netw. , 1 6, 79-84. Measuring the quality of well-being i n C F and
O'Connor, B. J. ( 1 997) Premenstrual asthma: still lung transplantation. Chest, 1 00, 1 0 1 6-1 0 1 8 .
poorly understood. Thorax, 52, 5 9 1 -5 92. Orozco-Levi, M., Torres, A . and Ferrer, M . ( 1 995)
Odderson, I. R. ( 1 995) Swallow management in Semirecumbent position protects from pulmonary
patients on an acute stroke pathway. Arch. Phys. aspiration but not completely from
Med. Rehabil. , 76, 1 13 0-1 1 3 3 . gastroesophageal reflux in mechanically ventilated
Odell, M . ( 1 997) Suicide: a study of grief i n intensive patients. Am. J. Respir. Crit. Care Med. , 152,
care. Care Crit. Ill, 13, 23 8-240. 1 38 7- 1 3 90.
O'Donnell, D. E. ( 1 994) Breathlessness in patients Orringer, M. K. ( 1 999) The effects of tracheostomy
with chronic airflow limitation. Chest, 106, 904- tube placement on communication and
9 1 2. swallowing. Respir. Care, 44, 845-853.
O'Donnell, D. E. ( 1 995) The impact of exercise Osman, L. M. ( 1 997) Quality of life and hospital re
reconditioning on breathlessness in severe CAL. admission in patients with COPD. Thorax, 52, 67-
Am. J. Respir. Crit. Care Med. , 1 52, 2005-2 0 1 3 . 7l.
O'Donnell, D. E . and Webb, K . A . ( 1 992) Ott, A., Siooter, A. J . C . and Hofman, A . ( 1 998)
Breathlessness in patients with severe chronic Smoking and risk of dementia and Alzheimer's
airflow limitation. Chest, 1 02, 824-83 l . disease. Lancet, 3 5 1 , 1 840- 1 843 .
O'Driscoll, B . R. ( 1997) Nebulisers for COPD. Oz, M. c., Argenziano, M. and Rose, E. A. ( 1 997)
Thorax, 52(suppl. 2), S49-S52. What is 'minimally invasive' coronary bypass
Oh, T. E. ( 1997) Intensive Care Manual, 4th edn, surgery? Chest, 1 12, 1409-1 4 1 6 .
Butterworth-Heinemann, London. Paice, J. A . ( 1 998) Barriers t o cancer pain relief. J.
Ohrbach, R., Patterson, D. R. and Carrougher, G. Pain Symptom Manage. , 1 6, 1-9.
( 1 998) Hypnosis after an adverse response to Pal, B. ( 1 998) Following up outpatients by telephone.
opioids in an ICU burn patient. Clin. J. Pain, 14, Br. Med. J., 3 16, 1 647.
1 67-175. Palange, P., Forte, S. and Onorati, P. ( 1 998) Effect of
Ojanen, M. ( 1 993) Psychosocial changes in patients reduced body weight on muscle aerobic capacity in
participating in a COPD rehabilitation program. COPD. Chest, 1 14, 1 2-1 8 .
Respiration, 60, 96- 1 02. Palevsky, P . M . ( 1 996) Hypernatremia i n hospitalized
O'Kroy, J. A. ( 1993) Effects of flow and resistive patients. Ann. Intern. Med. , 124, 1 97-203.
training on respiratory muscle endurance and Paley, C. A. ( 1 997) A way forward for determining
strength. Respiration, 60, 279-283. optimal aerobic exercise intensity? Physiotherapy,
Olds, D. L. ( 1 994) Intellectual impairment in children 83, 620-624.
of women who smoke cigarettes during pregnancy. Palmer, L. B. and Smaldone, G. C. ( 1 998) Secretions
Pediatrics, 93, 22 1-227. in mechanically ventilated patients and duration of
O'Leary, M. J. and Coakley, J. H. ( 1 996) Weakness intubation. Crit. Care Med. , 26, A l 1 2.
and wasting in the critically ill patient. Curro Pankow, W. ( 1 997) Influence of noninvasive positive
Anaesth. Crit. Care, 7, 8 1-8 6. pressure ventilation on inspiratory muscle
Olivier, F. L. ( 1 998) Suggested guidelines for the use activity in obese subjects. Eur. Respir. J., 1 0,
of exercise with adults in acute care settings. 2847-2852.
Physiother. Can., 50, 127-135. Panos ( 1 994) The Smoke Blows South, Briefing Paper
Olsen, M. F., Hahn, I. and Nordgren, S. ( 1 997) 1 3 , Panos, London.
Randomised controlled trial of prophylactic chest Papastamelos, C. ( 1 995) Developmental changes in
physiotherapy in major abdominal surgery. Br. J. chest wall compliance in infancy and early
Surg., 84, 1535-1538. childhood. J. Appl. Physiol. , 78, 1 79-1 84.
Olseni, L. ( 1 994) Chest physiotherapy in COPD: FET Papazian, L. ( 1 993) Effect of bolus doses of
combined with either postural drainage or PEP. midazolam on ICP and CPP in patients with severe
Respir. Med. , 88, 435-440. head injury. Br. J. Anaesth., 71, 267-27 l .
Onuoha, A. R. A. ( 1 994) Effective clinical teaching Papini, R. P. G . ( 1 999) Current concepts in the
from the perspectives of students, supervisors and management of burns with inhalation injury. Care
teachers. Physiotherapy, 80, 208-2 14. Crit. Ill, 15, 6 1-65.
521
REFERENCES
Paratz, J. ( 1993) The effect of respiratory in postoperative coronary artery surgery patients.
physiotherapy on ventilated neurosurgical patients. Physiother. Theor. Pract., 14, 5-12.
Physiother. Theor. Pract., 9, 3-1 1 . Patman, S., Jenkins, S. and Stiller, K. ( 1 999) Manual
Paret, G., Dekel, B. and Vardi, A. ( 1 996) Heliox in hyperinflation: effects on respiratory parameters.
respiratory failure secondary to bronchiolitis. Anaesth. Intensive Care, 27(suppl.), 96.
Pediatr. Pulmonol. , 22, 322-323. Patterson, R., Mazur, N. and Roberts, M. ( 1 998)
Parker, A. ( 1 998) Paediatrics, in Physiotherapy for Hypersensitivity pneumonitis due to humidifier
Respiratory and Cardiac Problems, 2nd edn, (eds J. disease. Chest, 1 1 4, 93 1-933 .
A. Pryor and B. A. Webber), Churchill Patterson, c . , Teale, C. and Dow, L . ( 1 999) D o we
Livingstone, Edinburgh. overlook respiratory symptoms and airflow
Parker, A. and Middleton, P. G. ( 1 998) obstruction in elderly medical admissions [letter] ?
AssessmentPhysiotherapy for Respiratory and Age Ageing, 28, 3 26.
Cardiac Problems, 2nd edn, (eds J. A. Pryor and B. Pavia, D. ( 1 99 1 ) Bronchoalveolar clearance.
A. Webber), Churchill Livingstone, Edinburgh. Respiration, 5 8 (suppl.), 1 3-17.
Parker, J. C. and Hernandez, L. A. ( 1 993) Pavy, T. J. G. and Doyle, D. L. ( 1 996) Prevention of
Mechanisms of ventilator-induced lung injury. phantom limb pain by infusion of local anaesthetic
Crit. Care Med., 2 1 , 1 3 1-142. into the sciatic nerve. Pain, 24, 599-600.
Parker, M. M., Schubert, W. and Shelhamer, J. H. Paxton, D. ( 1996) Treating postoperative nausea in
( 1 984) Perceptions of a critically ill patient children. Hosp. Update, 22, 428-430.
experiencing therapeutic paralysis in an ICU. Payne, R. ( 1 995) Relaxation Techniques, Churchill
Intensive Care Med. , 1 2, 69-7 1 . Livingstone, Edinburgh.
Parmar, M . ( 1 998) Evidence based medicine. Care Peach, H. and Pathy, M. S. ( 1 9 8 1 ) Follow-up study of
Crit. Ill, 14, 2 1 8 . disability among elderly patients discharged from
Partridge, M. R . ( 1 992) Smoking and the young. Br. hospital with exacerbations of chronic bronchitis.
Med. J., 305, 2. Thorax, 36, 5 85-5 89.
Partridge, M. R. ( 1 9 94) Asthma: guided self Pearce, A. C. ( 1984) Smoking and anaesthesia.
management. Br. Med. j. , 3 08, 547-548. Anesthesiology, 6 1 , 5 76-5 84.
Partridge, C. ( 1 996) Evidence based medicine - Pearson, M. G. ( 1 996) Managing asthma. ACPRC j.,
implications for physiotherapy ? Physiother. Res. 29, 5 3 .
Int. , 1 , 69-73. Peche, R. ( 1 996) Sternomastoid muscle size and
Parvez, L., Vaidya, M. and Sakhardande, A. ( 1 996) strength in patients with severe COPD. Am. j.
Evaluation of antitussive agents in man. Pulm. Respir. Crit. Care Med. , 1 5 3 , 422-425 .
Pharmacoi. , 9, 299-308. Pedersen, S. ( 1 996) Inhalers and nebulizers. Respir.
Pasero, C. L. ( 1 994) Avoiding opioid-induced Med. , 90, 69-77.
respiratory depression. Am. j. Nurs. , 94, 25-3 1 . Pederson, C. and Bjerke, T. ( 1 999) Pediatric pain
Pasterkamp, H . ( 1997) Respiratory sounds. Am. J. management. Dimens. Crit. Care Nurs. , 1 8, 42-5 1 .
Respir. Crit. Care Med. , 1 5 6, 974-987. Peek, G . J. ( 1 9 97) Extra-corporeal membrane
Patel, M. ( 1 993) Optimal time for measuring the oxygenation. Br. Med. Bull. , 53, 745-746.
cardiorespiratory effects of PEEP. Chest, 1 04, Peerless, J. R., Davies, A., Klein, D. and Yu, D. ( 1 999)
1 3 9-142. Skin complications in the ICU. Clin. Chest Med. ,
Patel, H. and Yang, K. L. ( 1 995) Variability of 20, 453-467.
intrinsic PEEP. Crit. Care Med. , 23, 1 074- Pehrsson, K. ( 1 994) Quality of life of patients treated
1 079. by home mechanical ventilation due to restrictive
Patel, R. G., Petrini, M. F. and Dwyer, T. M. ( 1 999) ventilatory disorders. Respir. Care, 88, 2 1-26.
Work of breathing during weaning from Pellegrino, R., Rodarte, J. R. and Brusasco, V. ( 1 998)
ventilation. Respir. Care, 44, 42 1-427. Assessing the reversibility of airway obstruction.
Paterson, D. H. ( 1992) Effects of ageing on the Chest, 1 14, 1 607-1 6 1 2.
cardiorespiratory system. Can. J. Sport Sci. , 1 7, Pellegrino, R., Villosio, c., Milanese, U. and Garelli,
1 7 1-177. G. ( 1 999) Breathing during exercise in subjects
Patman, S., Jenkins, S. and Bostock, S. ( 1 998) with mild-to-moderate airflow obstruction. j. Appl.
Cardiovascular responses to manual hyperinflation Physiol. , 87, 1 697-1704.
522
REFERENCES
Pellino, T. A. ( 1 998) Perceived control mediates the dyskinesia to exercise and �ragonist challenge.
relationship between pain severity and patient Eur. Respir. ]., 1 1 , 1 3 89-1 3 9 1 .
satisfaction. ]. Pain Symptom Manage. , 15, 1 1 0- Picardo, C . ( 1 996) Classification of severe asthma
1 1 6. exacerbations. Eur. Respir. ]., 9, 1 1 75-1 1 78 .
Pelosi, P. and Gattinoni, L. ( 1 996) Mechanical Pickler, R . H. ( 1 996) Effects o f nonnutritive sucking
ventilation in ARDS. Curro Opin. Anaesth. , 9, on behavioral organisation and feeding in preterm
5 15-522. infants. Nurs. Res. , 45, 1 3 2-135.
Pelosi, P., Cadringher, P. and Bottino, N. ( 1 999) Sigh Pierart, F., Wildhaber, J. H. and Vrancken, I. ( 1 999)
in acute respiratory distress syndrome. Am. ]. Washing plastic spacers in household detergent
Respir. Crit. Care Med. , 159, 872-880. reduces electrostatic charge. Eur. Respir. ]., 1 3 ,
Pennock, B. E. ( 1 994) Distressful events in the ICU. 673-678.
Heart Lung, 23, 323-327. Pieri-Davies, S., Ewart, K. and Boden, K. ( 1 994) On
Penson, R. T. and Rudd, R. M. ( 1 997) Commentary: call respiratory issues threaten patients (letter).
octreotide and hypertrophic pulmonary Frontline, 7 July.
osteoarthropathy. Thorax, 52, 297-298. Pierson, D. J. and Lakshminarayan, S. ( 1 984)
Pentland, B. ( 1 994) Pain in Guillain-Barre syndrome. Postoperative ventilatory management. Respir.
Pain, 59, 159-164. Care, 29, 603-6 1 1 .
Peper, E. ( 1 992) Fifteen-month follow up with Pietropauli, J. A., Rogers, F . B. and Shackford, S . R.
asthmatics utilizing EMGlincentive inspirometer ( 1 992) The deleterious effects of intraoperative
feedback. Biofeedback Self-reg., 1 7, 1 43-15 1 . hypotension in patients with severe head injuries.
Peruzzi, W. T. ( 1 996) The current status of PEEP. ]. Trauma, 33, 403-407.
Respir. Care, 4 1 , 273-8 1 . Piirilii, P., Sovijiirvi, A. R. A. and Kaisla, T. ( 1 9 9 1 )
Petersen, G . M., Pierson, D . J . and Hunter, P . M. Crackles i n patients with fibrosing alveolitis,
( 1 979) Arterial oxygen saturation during bronchiectasis, COPD and heart failure. Chest, 99,
nasotracheal suctioning. Chest, 76, 283-287. 1 076-1 083.
Peto, R., Speizer, E. and Cochrane, A. L. ( 1 983) The Pilbeam, S. P. ( 1 998) Mechanical Ventilation, Mosby,
relevance in adults of airflow obstruction but not St Louis, MO.
mucus hypersecretion to mortality from chronic Pin, I. ( 1 992) Use of induced sputum to investigate
lung disease. Am. Rev. Respir. Dis. , 128, 491-500. airway inflammation in asthma. Thorax, 47, 25-29.
Petty, T. L. ( 1 990) The national mucolytic study. Pifia IL ( 1 996) Exercise and heart failure. Chest, 1 1 0,
Chest, 97, 75-83. 1 3 1 7-27.
Petty, T. L. and O'Donohue, W. J. ( 1 994) Further Pina, J. S., Behrens, M. L. and Moffit, D. R. ( 1 997)
recommendations for prescribing and research in Are nose clips necessary in adults and children
long-term oxygen therapy. Am. ]. Respir. Crit. performing forced expiratory spirometry ? Respir.
Care Med. , 150, 875-877. Care, 42, 492-497.
Phelan, D. ( 1 995) Hopeless cases in intensive care. Pinney, S., Freeman, L. J . and Nixon, P. G. F . ( 1 987)
Care Crit. Ill, 1 1 , 1 96-1 97. Role of the nurse counsellor in managing patients
Phillips, S. ( 1 993) Zingiber officinale (ginger) : an with the hyperventilation syndrome. J. Roy. Soc.
antiemetic for day surgery. Anaesthesia, 48, 7 1 5- Med. , 80, 2 1 6-2 1 8.
7 1 7. Pitkin, A. ( 1 997) Hyperbaric oxygen therapy in
Phillips, G. D. and Millard, F. J. c. (1 994) The intensive care. Br. ]' Intensive Care, 7, 1 07-1 1 3 .
therapeutic use of ultrasonic nebulizers in acute Pitkin, R . M . ( 1 998) Listen to the patient. Br. Med. ].,
asthma. Respir. Med. , 88, 3 8 7-3 89. 3 1 6, 1 252.
Phillips, S., Hutchinson, S. and Davidson, T. ( 1 993) Plavka, R., Kopecky, P. and Sebron, V. ( 1 999) A
Preoperative drinking does not affect gastric prospective randomized comparison of
contents. Br. ]' Anaesth. , 70, 6-9. conventional mechanical ventilation and very early
Phillips, S., Daborn, A. K. and Hatch, D. J. ( 1 994) high frequency oscillatory ventilation. Intensive
Preoperative fasting for paediatric anaesthesia Br. Care Med. , 25, 68-75.
]. Anaesth., 73, 529-536. Playfair, W. ( 1 8 8 1 ) Notes on the systematic treatment
Phillips, G. E., Thomas, S. and Heather, S. (1 998) of nerve prostration. Lancet, i, 8-9.
Airway response of children with primary ciliary Plaza, V., Serra-BatHes, J. and Ferrer, M. (2000)
523
REFERENCES
Quality of life and economic features in elderly Prescott, E. ( 1 999) Socioeconomic status, lung
asthmatics. Respiration, 67, 65-70. function and admission to hospital for COPD.
Plebani, A. ( 1 9 97) Usefulness of chest physiotherapy Eur. Respir. j., 13, 1 109- 1 1 14.
with PEP in HIV-infected children. Acta Paediatr. , Preston, I. M., Matthews, H. R. and Ready, A. R.
86, 1 195-1 1 97. ( 1 986) Minitracheotomy. Physiotherapy, 72, 494-
Poi, P. J. H., Chuah. S. Y. and Srinivas, P. ( 1 998) 6.
Common fears of patients undergoing Prichard, A. J. N. ( 1 994) Tracheostomy. Care Crit. Ill,
bronchoscopy. Eur. Respir. ]. , 1 1 , 1 147-1 149. 10, 64-69.
Pollack, C. ( 1 999) Cardiorespiratory Physiotherapy Prough, D. S. ( 1 996) Head trauma and brain
Conference, London. resuscitation. Curro Opin. Anaesth. , 9, 1 88-1 93.
Pollock, M. L. and Wilmore, J. H. ( 1 990) Exercise in Pryor, J. A. and Webber, B. A. ( 1 998) Physiotherapy
Health and Disease. W. B. Saunders, London. for Respiratory and Cardiac Problems, 2nd edn,
Poponick, J. M. ( 1 999) Use of a ventilatory support Churchill Livingstone, Edinburgh.
system (BiPAP) for acute respiratory failure. Chest, Ptacek, J. T., Patterson, D. R. and Montgomery, B. K.
1 1 6, 1 66-1 7 l . ( 1 995) Pain, coping and adjustments in patients
Postma, D . S. ( 1 9 9 1 ) Inhaled therapy in COPD. with burns. ]. Pain Symptom Manage. , 10, 446-
Respir. Med. , 85, 447-449. 455.
Postma, D. S. ( 1 998) When can an exacerbation of Punt, J. ( 1 989) Head injury. Care Crit. Ill, 5, 233-
COPD be treated at home? Lancet, 3 5 1 , 1 8 27- 237.
1 828. Purssell, E . . ( 1 994) Telling children about their
Potempa, K. M., Folta, A. and Braun, L. T. ( 1 99 1 ) impending death. Br. ]' Nurs. , 3, 1 1 9-120.
The relationship o f resting and exercise blood Purtilo, R. B. ( 1 976) Similarities in patient response to
pressure in subjects with essential hypertension chronic and terminal illness. Phys. Ther. , 56, 279-
before and after propranolol. Heart Lung, 2 1 , 284.
5 09-5 14. Putensen, C�, Mutz, N. F. and Putensen, G. ( 1999)
Potts, M. ( 1994) Grief has to be. Lancet, 343, 279- Spontaneous breathing during ventilatory support
280. improves ventilation-perfusion distributions in
Powell, K. E. and Pratt, M. ( 1996) Physical activity patients with ARDS. Am. j. Respir. Crit. Care
and health Br. Med. ]. , 3 13 , 1 26-1 27. Med. , 159, 1 241-1248.
Powell-Tuck, J . ( 1 997) Penalties of hospital Quanjer, P. H. ( 1 993) Standardised lung function
.
undernutrition. ]. Roy. Soc. Med. , 90, 8-1 l . testing. Eur. Respir. j., 6(suppl. 1 6), S l .
Powell-Tuck, J . (2000) Malnutrition and pressure Qureshi, A . I., Suarez, J . I . and Bhardwaj, A. ( 1998)
ulcers. Br. ]' Nurs. , 9, 1 94-204. Use of hypertonic (3%) saline/acetate infusion in
Power, C. and Li, L. (2000) Cohort study of the treatment of cerebral edema. Crit. Care Med. ,
birthweight, mortality and disability. Br. Med. ]. , 26, 440-446.
320, 840-8 4 l . Radford, R. ( 1982) A rational basis for percussion
Prabhu, V . G. ( 1 997) Pulmonary function changes augmented mucociliary clearance. Respir. Care, 27,
after nebulized and IV frusemide in ventilated 556-563.
premature infants. Arch. Dis. Child., 77, F32-F35 . Rajagopalan, N., Maurer, J. and Kesten, S. ( 1 996)
Prabhu, M. B., Mink, J . T . and Graham, B. L. ( 1 990). Bronchodilator response at low lung volumes
Effect of a deep breath on gas mixing and predicts bronchiolitis obliterans. Chest, 1 09, 405-
diffusion in the lung. Respir. Physiol. , 79, 1 95- 407.
204. Rajesh, V. T., Singhi, S. and Kataria, S. (2000)
Prasad, S. A. ( 1 993) Current concepts in Tachypnoea is a good predictor of hypoxia in
physiotherapy. ]. Roy. Soc. Med., 86(suppl. 20), acutely ill infants. Arch. Dis. Child. , 82, 46-49.
23-29. Rakshi, K. ( 1 994) Management of acute bronchiolitis.
Prasad, S. A. and Hussey, J. ( 1 995) Paediatric Arch. Dis. Child. , 71, 463-469.
Respiratory Care, Chapman & Hall, London. Ralafox, M. (2000) Diagnostic value of tachypnoea in
Prescott, E. ( 1 998) Smoking and risk of myocardial pneumonia defined radiologically. Arch. Dis.
infarction in women and men. Br. Med. ]. , 3 16, Child. , 82, 4 1-45.
1 043-1 047. Ramonatxo, M., Boulard, P. and Prefaut, C. ( 1 995)
524
REFERENCES
Validation of a noninvasive tension-time index of Reid, P. T. and Rudd, R. M. ( 1 993) Management

inspiratory muscles. J. Appl. Physiol. , 78, 646- of malignant pleural effusion. Thorax, 48, 779-
653. 780.
Rampulla, C. ( 1 992) Dyspnea on exercise. Chest, 1 0 1 , Reid, W. D. and Loveridge, B. M. ( 1 983)
248S-252S. Physiotherapy management of patients with
Ramsay, J. ( 1 994) The psychology of childhood COAD. Physiother. Can. , 35, 183-195.
asthma. Paed. NUTs. , 6, 1 7- 1 8 . Reiland, K. E. (2000) Gastrointestinal surgical
Ramsey, B. W. ( 1 996) Management of pulmonary patients' outcomes influenced by nutrition. AORN
disease in patients with CF. N. Engl. J. Med. , 335, J., 7 1 , 199-204.
1 79-188. Reina-Rosenbaum, R., Bach, J. R. and Penek, J.
Rankin, N. ( 1998) What is optimum humidity? Respir. ( 1 997) The cost/benefits of outpatient-based
Care Clin. North Am. , 4, 32 1-328. pulmonary rehabilitation. Arch. Phys. Med.
Raoof, S., Chowdhrey, N. and Raoof, S. ( 1999) Effect Rehabil. , 78, 240-244.
of combined kinetic therapy and percussion Reisman, J. J. ( 1 988) Role of conventional
therapy on the resolution of atelectasis in critically physiotherapy in CF. J. Pediatr. , 1 13, 632-636.
ill patients. Chest, 1 15, 1 658-1666. Renfroe, K. L. ( 1 988) Effect of progressive relaxation
Ras, G. J., Staden, M. V. and Schultz, C. ( 1994) on dyspnea and state anxiety in patients with
Respiratory manifestations of rigid spine COPD. Heart Lung, 1 7, 408-4 1 3 .
syndrome. Am. J. Respir. Crit. Care Med. , 1 50, Rennie, M . ( 1997) Central dogma unproven. Br. J.
540-546. Intensive Care, 7, 125.
Rastall, M., Brooks, B. and Klarneta, M. ( 1 999) An Rennie, M. ( 1 998) The gut, central as always. Br. J.
investigation into younger and older adults' Intensive Care, 8, 5 .
memory for physiotherapy exercises. Rennie, M . (2000) A rotten culture. Br. J. Int. Care,
Physiotherapy, 85, 1 22-128. 10, 4 1 .
Rawal, N. ( 1 997) Survey of postoperative analgesia Renston, J . P . ( 1 994) Respiratory muscle rest using
following ambulatory surgery. Acta Anaesthesiol. nasal BiPAP ventilation in patients with stable
Scand. , 41, 1 0 1 7-1 022. severe COPD. Chest, 105, 1 053-1060.
Ray, J. F. ( 1974) Immobility, hypoxemia, and Resende, T. L. and O'Neill, P. A. ( 1 992) Effects of
pulmonary arteriovenous shunting. Arch. Surg. , exercise and abdominal massage on constipation
109, 5 3 7-54 1 . and faecal incontinence. Physiotherapy, 78,
RCP ( 1 996) Clinical Guidelines for Cystic Fibrosis 589.
Care, Royal College of Physicians, London. Restrick, L. J., Clapp, B. R. and Mikelson, C. ( 1 997)
RCP ( 1999) Domiciliary Oxygen Therapy Services, Nasal ventilation in pregnancy. Eur. Respir. J., 10,
Royal College of Physicians, London. 2657-265 8 .
Reardon, J. ( 1994) The effect of comprehensive Revill, S. M . , Morgan, M. D. L . and Singh, S. J.
outpatient pulmonary rehabilitation on dyspnea. ( 1 999) The endurance shuttle walk. Thorax, 54,
Chest, 105, 1 046-1052. 2 13-222.
Redfern, S. (1985) Taking some of my own medicine. Rezvani, K. ( 1 996) Ecstasy induced
Care Crit. Ill, 1, 6-7. pneumomediastinum. Thorax, 5 1, 960-9 6 1 .
Reece-Smith, H. ( 1 997) Pancreatitis. Care Crit. Ill, 1 3 , Rhodes, K . ( 1 993) Diuretics i n clinical practice.
135- 1 3 8 . Practitioner, 237, 49-52.
Reed, J. C. ( 1 996) Chest Radiology, Mosby, S t Louis, Rialp, G., Betbes A. J. and Ormaechea, E. ( 1997)
MO, p. 2 1 7. Changes in pulmonary mechanics with change
Rees, J. ( 1987) Cough. Update, 34, 1 1 1 0-1 1 1 9 . from supine to prone in ARDS. Intensive Care
Regnard, C. ( 1997) Mouth care, skin care and Med., 23, S 12.
lymphoedema. Br. Med. J., 3 15, 1 002- 1 005. Ricour, C. ( 19 8 9) Stress-induced disturbances of the
Regnis, J. A. ( 1994) Benefits of nocturnal nasal CPAP gastro-intestinal tract in children. Intensive Care
in patients with CF. Chest, 1 0 6, 1 7 1 7-1724. Med. , 1 5 , S32-S36.
Reick, C. W. ( 1 996) Auto-PEEP associated with Riedler, J. ( 1 996) Inhaled hypertonic saline increases
excessive oxygen flow through five manual sputum expectoration in CF. J. Pediatr. Child
resuscitators. Respir. Care, 4 1 , 1 009-1012. Health, 32, 48-50.
525
REFERENCES
Riegel, B. ( 1 985) A review and critique of the respiratory failure and recovery. Eur. Respir. ].,
literature on preoxygenation for endotracheal 10, 2560-2565.
suctioning. Heart Lung, 14, 507-5 1 8 . Rosenberg, M. ( 1 992) Patient-controlled analgesia. ].
Ries, A. L . ( 1 994) The importance o f exercise in Oral Maxillofacial Surg. , 50, 3 8 6-3 89.
pulmonary rehabilitation. Clin. Chest Med. , 1 5 , Rosenthal, M., Christensen, B. K. and Ross, T. P.
327-337. ( 1 998) Depression following traumatic brain
Ries, A. L. and Moser, K. M. ( 1 996) Shortness of injury. Arch. Phys. Med. Rehabil. , 79, 90-103 .
Breath: a Guide to Better Living and Breathing. Rosenthal, M . H. ( 1999) Intraoperative fluid
Mosby, Missouri. management. Chest, 1 14, 1 06S-1 12S.
Rimm, E. R. ( 1 995) Prospective study of cigarette Rosner, V., Hannhart, B. and Chabot, F . ( 1 999)
smoking, alcohol use and the risk of diabetes. Br. Validity of transcutaneous oxygen/carbon dioxide
Med. ]., 3 1 0, 555-559. pressure measurement. Eur. Respir. ]', 13, 1 044-
Ringbaek, T. J. (2000) Rehabilitation of patients with 1 047.
COPD. Exercise twice a week is not sufficient! Rossi, A. ( 1 994) Effects of PEEP on VA/Q
Respir. Med. , 94, 1 5 0- 1 54. mismatching in ventilated patients with chronic
Ritson, P. (2000) Manual bagging and shallow airflow limitation. Am. ]. Respir. Crit. Care Med. ,
suction. ACPRC Conference, E. Midlands. 149, 1 077-1 084.
Roa, J. ( 1 9 9 1 ) Work of breathing and ventilatory Rossi, A., Appendini, L. and Poggi, R. (1 993) Acute
muscle recruitment during pursed lip breathing. bronchial asthma: indications for intensive care.
Am. Rev. Respir. Dis., 1 43, 4. Eur. Respir. ]., 3, 400-403 .
Roberts, H. ( 1 996) Listen to the parents. Br. Med. ]., Rossoff, L. J. ( 1 995) Is handwashing really needed in
3 1 3, 954-955 . an intensive care unit? Crit. Care Med. , 23, 121 1-
Roberts, I. ( 1 998a) Human albumin administration in 1 2 16.
critically ill patients. Br. Med. ]., 3 1 7, 23. Roth, G. ( 1 990) Maps to Ecstasy, Crucible, London.
Roberts, C. J., Parke, T. J. and Sykes, M. K. ( 1 993) Rothen, H. U. ( 1 993) Re-expansion of atelectasis
Effects of intraoperative inspired gas mixtures on during general anaesthesia. Br. ]' Anaesth., 71,
postoperative nocturnal oxygen saturation. Br. ]. 788-795.
Anaesth., 7 1 , 476-480. Roussos, C. (1 996) Fatigue of the respiratory muscles.
Rochester, D. F. ( 1 992) Nutritional repletion. Sem. Int. Care Med. , 22, 1 34-155.
Respir. Med. , 1 3 , 44. Rowbotham, E. ( 1 9 90) ACPRC Study Day, London.
Rocker, G. M., Mackenzie, M.-G. and Williams, B Rowe, B. H. ( 1 993) Performance of an asthma quality
( 1 999) Noninvasive positive pressure ventilation: of life questionnaire. Am. Rev. Respir. Dis. , 148,
successful outcome in patients with ALI/ARDS. 675-68 1.
Chest, 1 1 5, 1 73-177. Rowlee, S. C. ( 1 999) Monitoring neuromuscular
Roizen, M. F. ( 1 997) Anesthesia and medical disease. blockade in the ICU. Heart Lung, 28, 352-362.
Curro Opin. Anaesth. , 1 0. Royse, C. F. ( 1 997) The effect of supplemental
Rolla, G. ( 1 994) Effect of pleurotomy on pulmonary oxygen on the incidence of hypoxaemia after
function after CABG with IMA. Respir. Med. , 88, premedication in patients undergoing cardiac
4 1 7-420. surgery. Anaesth. Intensive Care, 25, 347-349.
Rollin, B. ( 1 976) First You Cry, New American Rubin, B. K. ( 1 9 97) The classification and use of muco
Library, New York. active medications. Pediatr. Pulmonol., 14, 1 1 8 .
Romand, J.-A. and Donald, F. ( 1 995) Physiological Rudkin, S. T. and White, R. J. ( 1 995) Use of
effects of CPAP in the critically ill. Care Crit. Ill, respiratory specialist nurse in the education and
1 1, 23 9-243 . supervision of patients receiving LTOT.
Roosevelt, G. ( 1 996) Dexamethasone in bronchiolitis. Respiratory Nurses Conference, Warwick.
Lancet, 348, 292-295. Rudy, E. B. ( 1 99 1 ) Endotracheal suctioning in adults
Ropper, A. H., O'Rourke, D. and Kennedy, S. K. with head injury. Heart Lung, 20, 667-674.
( 1 9 82) Head position, ICP and compliance. Ruffolo, c. ( 1 998) Gastric tonometry. Crit. Care
Neurology, 32, 1 288- 1 29 1 . Nurs. Q. , 2 1 , 26-32.
Rosario, N . D., Sassoon, C . S . H . , Chetty, K. G . and Ruggier, R., Bailey, C. R. and Grounds, R. M. ( 1 994)
Gruer, S. E. ( 1 997) Breathing pattern during acute A simple method for maintenance of oxygen
526
REFERENCES
saturation following intravenous induction of Sakakibara, M. ( 1 996) Effect of slowed respiration on

anaesthesia. Anaesthesia, 49, 759-76 l . cardiac parasympathetic response to threat.
Ruiz, P. A. ( 1 993) The needs of a patient in severe Psychosomatic Med. , 5 8 , 32-37.
status asthmaticus. Intens. Crit. Care Nurs. , 9, 28- Sakellari, V. ( 1 997) Hyperventilation effect on
39. postural sway. Arch. Phys. Med. Rehabil. , 78, 730-
Russell, 1. R. (2000) Malnutrition and pressure ulcers. 736.
Br. J. Nurs. , 9, 1 94-204. Salazar, J. ( 1 99 1 ) Exercise physiology, in Pulmonary
Russell, P. O., Epstein, 1. H. and Johnston, J. J. Therapy and Rehabilitation, (eds F. Haas and K.
( 1 988) The effects of physical activity as Axen), Williams & Wilkins, Baltimore, MD, pp.
maintenance for smoking cessation. Addict. 58,63.
Behav. , 13, 2 15-2 1 8 . Salmon, B., Wilson, N. M. and Silverman, M. ( 1 990)
Russo, E . ( 1 998) Cannabis for migraine treatment. How much aerosol reaches the lungs of wheezy
Pain, 76, 3-8 . infants and toddlers? Arch. Dis. Child. , 65, 401-
Russo, P. ( 1 990) Cardiovascular responses associated 403.
with activity and inactivity. In: Key Issues in Salmon, P. ( 1 992) Surgery as a psychological stressor.
Neurological Physiotherapy (Eds. Ada, 1., Stress Med. , 8, 193-198.
Canning, C.). Butterworth-Heinemann, London. Saltin, B., Blomqvist, G. and Mitchel, J. H. ( 1 968)
Rusznak, C. ( 1 9 9 1 ) Influence of salbutamol and Response to bed rest after exercise and after
salmeterol on ciliary beat frequency. Thorax, 46, training. Circulation, 3 8 (suppl. 7), 1-76.
782P. Sammon, M. P. ( 1 994) Entrainment of respiration to
Ruta, T. S . ( 1 993) The effect of acute hypocapnia on rocking in premature infants. J. Appl. Physiol. , 77,
local cerebral blood flow. Anesthesiogy, 78, 1 34- 1548-1554.
140. Samuels, M. P. and Southall, D . P. ( 1 989) Negative
Ryan, C. J. ( 1 998) Matters of life and death. Med. J. extrathoracic pressure in infants and young
Austr. , 1 69, 1 24. children. Br. Med. J., 299, 1 253-1 257.
Ryan, D. and Higgins, B. ( 1 998) Corticosteroid Samuels, S., Samuels, M. and Dinwiddie, R. ( 1 995) A
therapy in late ARDS. Care Crit. Ill, 14, 2-5 . survey of physiotherapy techniques used in
Ryan, C. F. and Love, 1. 1. (2000) Unpredictable specialist clinics for cystic fibrosis. Physiotherapy,
results of laser assisted uvulopalatoplasty. Thorax, 8 1 , 279-283.
55, 399-404. Sandler, H. (1988) The hemodynamic effects of
Ryan, C. F., Road, R. D. and Buckley, P. A. ( 1 993) repeated bed rest exposure. Aviat., Space Environ.
Energy balance in stable malnourished patients Med. , 54, 1 047-1 054.
with COPD. Chest, 103, 1038- 1 044. Sapira, J. D. ( 1 995) About egophony. Chest, 108,
Rylance, G. (1 996) Making decisions with children. 865-867.
Br. Med. J. , 3 12, 794. Sasse, S. A. ( 1 995) Arterial oxygenation time after an
Saag, K. G. ( 1 997) Cigarette smoking and rheumatoid Fi02 increase in mechanically ventilated patients.
arthritis severity. Ann. Rheum. Dis. , 56, 463-469. Am. J. Respir. Crit. Care Med. , 1 52, 148-
Sacchetti, A. ( 1 994) Pediatric analgesia and sedation. 152.
Ann. Emerg. Med. , 23, 23 7-249. Sato, P., Sargur. M. K. and Schoene, R. B. (1 986)
Sahebjami, H. ( 1 993) Anthropometric and pulmonary Hypnosis effect on carbon dioxide
function test profiles of outpatients with stable chemosensitivity. Chest, 89, 828-83 l .
COPD. Am. J. Med. , 94, 469-474. Saudny, H . ( 1 997) Impact of nutritional support on
Sahn, S. A. and Heffner, J. E. ( 1 994) Pulmonary functional status. Am. J. Respir. Crit. Care Med. ,
Pearls II, Mosby, St Louis, MO, p. 162. 1 5 6, 794-799.
Sahn, S. A. and Heffner, J. E. (2000) Spontaneous Savage, J. ( 1 9 92) Advice to take home. Nurs. Times,
pneumothorax. New. Eng. J. Med. , 342, 868-874. 8 8 (38), 24-27.
Saigal, S. (2000) School difficulties at adolescence in a Savci, S., Ince, D. I. and Arikan, H. (2000) A
regional cohort of children who were extremely comparison of autogenic drainage and the active
low birth weight. Pediatrics, 1 05, 325-3 3 l . cycle of breathing in patients with COPD. J.
Saint, S. and Matthay, M. A. ( 1 998) Risk reduction in Cardiopulm. Rehab. 20, 3 7-43.
the ICU. Am. J. Med. , 105, 5 1 5-523. Sawdon, V., Woods, I. and Proctor, M. ( 1 995) Post-
------ 527
REFERENCES
intensive care interviews. Intens. Crit. Care Nurs. , and mortality in older adults. Arch. Int. Med. , 1 60,
1 1, 329-332. 1 76 1- 1 768.
Sawyer, E. H. and Clanton, T. L. ( 1 993) Improved Schwartz, S. Z. ( 1987) Effects of blood volume and
pulmonary function and exercise tolerance with discontinuance of ventilation on pulmonary
inspiratory muscle conditioning in children with vascular pressures. Crit. Care Med. , 15, 671-675.
cystic fibrosis. Chest, 104, 1490-1497. Schwartzstein, R. M. ( 1992) Asthma: to run or not to
Scalvini, S., Porta, R. and Zanelli, E. ( 1 999) Effects of run? Am. Rev. Respir. Dis. , 145, 739-740.
oxygen on autonomic nervous system dysfunction Sciaky, A. J. ( 1 994) Mobilizing the intensive care unit
in patients with COPD. Eur. Respir. J., 1 3 , 1 1 9- patient. Phys. Ther. Pract., 3, 69-80.
1 24. Scum ( 1 9 8 1 ) Simple mechanical method for
Scarlett, J. ( 1 998) Minimally invasive cardiac surgery. decreasing the incidence of thromboembolism.
Crit. Care Nurse, 2 1 , 1 6-23. Am. J. Surg., 141, 5 82-585.
Scheeren, T. ( 1 9 97) Prostacyclin (PGI2). Intensive Scurr, J. H., Robbe, I. J., Ellis, H. and Goldsmith, H.
Care Med. , 23, 146-158. S. ( 1 9 8 1 ) Simple mechanical method for
Scheinkestel, C. D., Bailey, M. and Myles, P. S. decreasing the incidence of thromboembolism.
( 1 999) Hyperbaric or normobaric oxygen for Am. J. Surg. , 1 4 1 , 582-585.
acute carbon monoxide poisoning. Med. J. Austr. , Sealey, C. ( 1999) Two common pitfalls in clinical
1 70, 203-2 1 0. audit: failing to complete the audit cycle and
Schelling, G. ( 1 998) Health-related quality of life and confusing audit with research. Br. J. Occup. Ther.,
posttraumatic stress disorder in survivors of 62, 238-243 .
ARDS. Crit. Care Med. , 26, 65 1-659 . Sears, M. R. ( 1 994) Growing up with asthma. Br.
Schenkel, S. ( 1 996) Oxygen saturation during daily Med. J., 309, 72-73.
activities in COPD. Eur. Respir. J., 9, 2584-25 89. Seiner, S. J. ( 1 999) Treating depression in patients
Scherder, E. ( 1 999) Epilepsy: a possible with cardiovascular disease. Harvard Rev.
contraindication for TENS [letter). J. Pain Psychiat. , 7, 85-93 .
Symptom Manage., 1 7, 1 52-1 5 3 . Senekal, M. ( 1 994) The optimal physiotherapeutic
Schermuly, R . T . (2000) Differential impact of approach to penetrating stab wounds of the chest.
ultrasonically nebulized versus tracheal-instilled S. Afr. J. Physiother. , 5 0, 29-36.
surfactant on VAIQ mismatch. Am. J. Respir. Crit. Senekal, M. and Eales, C. ( 1 994) The optimal
Care Med. , 1 6 1 , 152-159. physiotherapeutic approach to penetrating stab
Schieb, D. A., Protas, E. J . and Hasson, S. M. ( 1 996) wounds of the chest. S. Afr. J. Physiother. , 50, 29-
Special feature: implications of physical restraint 36.
and restraint reduction of older persons. Top. Shah, P. L., Scott, S. F. and Hodson, M. E. ( 1 994)
Geriatr. Rehabi/., 12, 70-83 . Lobar atelectaiss in CF and treatment with
Schleifer, T. J., Gleason, J . and Grady, L. ( 1994) recombinant human DNase. Respir. Med., 88,
Patient responsibility in an innovative COPD 3 1 3-3 1 5 .
program. Physiother. Can. , 46(suppl.), 8 l . Shaheen, S. 0., Barker, D. J. P . and Shiell, A . W.
Schlichtig, R . and Sargent, S . C . ( 1 990) Nutritional ( 1 994) The relationship between pneumonia in
support of the mechanically ventilated patient. early childhood and impaired lung function in late
Crit. Care Clin. , 6, 767-777. adult life. Am. J. Respir. Crit. Care Med. , 149,
Schneiderman, J. (2000) A randomized controlled trial 6 1 6-6 1 9.
of a 3 -year home exercise program in CF. J. Shapiro, S. H., Ernst, P. and Gray-Donald, K. ( 1 992)
Pediatr. , 1 3 6, 3 04-3 10. Effect of negative pressure ventilation in severe
Schonhofer, B., Mang, H. and Haidl, P. ( 1 996) COPD. Lancet, 340, 1425-1429.
Controlled ventilation in conscious patients. Eur. Shapiro, B. A., Warren, J. and Egol, A. B. ( 1 995)
Respir. J., 9, 33 0s. Practice parameters for intravenous analgesia and
Schonhofer, B., Geibel, M. and Sonneborn, M. ( 1 997) sedation. Crit. Care Med. , 23, 1 596-1600.
Daytime mechanical ventilation in chronic Sharkey, R. A. ( 1997) Renal functional reserve in
respiratory insufficiency. Eur. Respir. J., 1 0, 2840- patients with severe COPD. Thorax, 52, 4 1 1-4 15.
2846. Sharma, o . P. ( 1 998) Many faces of pulmonary
Schulz, R. (2000) The association between depression aspergillosis. Eur. Respir. J., 12, 795-7 15.
528
REFERENCES
Sharpe, M. ( 1 998) Putting the rest cure to rest Effect of chest wall vibration on dyspnoea. Am. ].
again. Br. Med. ]. , 3 16, 796. Respir. Crit. Care Med. , 149, 1235-1240.
Sharpe, P. (2000) Cannabis: time for scientific Siddiqui, A. V. (2000) Pulmonary embolism as a
evaluation of this ancient remedy? Anesth. Analg. , consequence of applying sequential compression
90, 237-240. device on legs in a patient asymptomatic of deep
Sharpe, P. and Hanning, C. ( 1 999) Neurological vein thrombosis. Anesthesiology, 92, 8 8 0-882.
sequelae. Best Pract. Res. Clin. Anaesth. , 1 3 , 451- Sigel, B. ( 1973) Compression of the deep venous
463 . system of the lower leg. Arch. Surg. , 1 06, 3 8-44.
Sheldon, F. ( 1 998) Bereavement. Br. Med. ]. , 3 16, Signorile, J. F . ( 1 995) Increased muscle strength in
456-458. paralyzed patients after spinal cord injury. Arch.
Shelledy, D. C. ( 1 995) A comparison of the effects of Phys. Med. Rehabil. , 76, 55-5 8 .
assist-control, SIMV and SIMV with pressure Silkoff, P. E. and Martin, R. J. ( 1 998) Chronobiology
support. Heart Lung, 24, 67-75 . of asthma. Respir. Ther. Int., 7, 2 1-26.
Shelly, M. P. ( 1 992) Intensive care sedation, in Silver, J. A. and Foster, W. M. ( 1 990) Effect of short
Vincent, J. L. (ed) Yearbook of Intensive Care and term vitamin C therapy on mucociliary function.
Emergency Medicine, Springer-Verlag, Berlin. Am. Rev. Respir. Dis. , 1 4 1 , A523.
Shelly, M. P. ( 1 998) Sedation in the lTV. Care Crit. Silver, M. R. ( 1 998) BIPAP: useful new modality or
Ill, 14, 85-8 8. confusing acronym? Crit. Care Med. , 26, 1473-
Shelly, M. P., Lloyd, G. M. and Park, G. R. ( 1 988) A 1474.
review of the mechanisms and methods of Sim, J. ( 1 986) Truthfulness in the therapeutic
humidification of inspired gases. Intensive Care relationship. Physiother. Pract., 2, 1 2 1- 1 27.
Med. , 14, 1-9. Sim, J. ( 1 995) The external validity of group
Shepherd, R. W. ( 1 988) Increased energy expenditure comparative and single system studies.
in young children with CF. Lancet, i, 1 300-1303. Physiotherapy, 8 1 , 263-270.
Sherman, C. B., Hubert, M. and Fogel, B. S. ( 1 9 92) Similowski, T. ( 1 991) Contractile properties of the
Vnrecognized respiratory disease in the elderly. human diaphragm during chronic hyperinflation.
Am. Rev. Respir. Dis. , 145, A763 . N. Engl. J. Med. , 325, 9 1 7-923 .
Shiao, S. Y. P. K. ( 1 995) Nasogastric tube placement. Simoes, E. A. F. ( 1 999) Respiratory syncytial virus
Nurs. Res. , 44, 82-8 8 . infection. Lancet, 354, 847-8 5 1 .
Shikora, S. A . ( 1 996) Enteral nutrition and the Simmonds, P . ( 1 999) Managing patients with lung
critically ill. Postgrad. Med. ]. 72, 3 95-402. cancer. Br. Med. J., 3 19, 527-528.
Shivaram, V., Donath, J. and Khan, F . A. ( 1 987) Simonds, A. K . ( 1 996) Non-invasive Respiratory
Effects of continuous positive airway pressure in Support, Chapman & Hall, London.
acute asthma. Respiration, 52, 1 5 7- 1 62. Simonds, A. K. ( 1 998) Discharging the ventilator
Shneerson, J. M. ( 1996a) Motor neurone disease. Br. dependent patient. Br. ]' Intensive Care, 8 , 47-
Med. ]., 3 13, 244. 51.
Shneerson, J. M. ( 1 996b) Techniques in mechanical Simonds, A. K., Muir, J . F . and Pierson, D . J . ( 1 996)
ventilation. Thorax, 5 1 , 756-76 1 . Pulmonary Rehabilitation, BMJ Publications,
Short, M. A., Brooks-Brunn, J . A. and Reeves, J. London.
( 1 996) The effects of swaddling versus standard Simpson, F. G. ( 1 993) Home nebulizers - do we
positioning on neuromuscular development in very know what we are doing? ACPRC ]. , 22, 3 6-37.
low birth weight infants. Neonat. Netw. , 1 5 , 25- Simpson, K., Killian, K. and McCartney, N. ( 1 992)
31. Randomised controlled trial of weight-lifting
Shum, M. I . D., Lauder, I. and Lam, W . K . ( 1 993) exercise in patients with chronic airflow
Effect of antibiotics on sputum inflammatory limitation. Thorax, 47, 70-75 .
contents in acute exacerbations of bronchiectasis. Sims, S. E. R. ( 1987) Relaxation training as a
Respir. Med. , 87, 449-454. technique for helping patients cope with cancer. ].
SiaHkas, N. M., Mitrouska, I. and Bouros, D. ( 1 999) Adv. Nurs. , 1 2, 583-5 9 1 .
Surgery and the respiratory muscles. Thorax, 54, Sinclair, D . G. ( 1 997) Gastrointestinal permeability
458-465. following cardiopulmonary bypass. Int. Care Med. ,
Sibuya, M., Yamadam, M. and Kanamaru, A. ( 1 994) 23, 5 1 0-5 1 6.
529
REFERENCES
Singer, M. and Little, R. ( 1 999) Cutting edge. Br. Slutsky, A . S. ( 1 993) Mechanical ventilation. Respir.
Med. J., 3 19, 50 1 -305. Care, 38, 1 3 8 9-13 1 9 .
Singer, M. and Webb, Q. ( 1 997) Oxford Handbook of Small, S. P. and Graydon, J. E. ( 1 992) Perceived
Critical Care, Oxford Medical Publications, uncertainty, physical symptoms and negative
Oxford. mood in hospitalized patients with COPD. Heart
Singer, M., Vermaat, J. and Hall, G. ( 1994) Lung, 2 1 , 568-574.
Hemodynamic effects of manual hyperinflation in Smalldone, G. C. ( 1 993) Regional impairment of
critically ill mechanically ventilated patients. mucociliary clearance in COPD. Chest, 1 03,
Chest, 106, 1 1 82- 1 1 87. 1 390-1396.
Singh, S. J., Morgan, M. D. L., Hardman, A. E. and Smedstad, K. G. ( 1 992) Postoperative pain relief and
Rowe, C. ( 1 994) Comparison of oxygen uptake hospital stay after total esophagectomy. Clin. J.
during a conventional treadmill test and the Pain, 8, 149-153.
shuttle walking test in chronic airflow limitation. Smeltzer, S. C . ( 1 996) Expiratory training in multiple
Bur. Respir. J., 7, 2 0 1 6-2020. sclerosis. Arch. Phys. Med. Rehabil. , 77, 909-9 12.
Singh, V. ( 1 990) Effect of yoga breathing exercises on Smith, M. A., Mathewson, J. J. and Ulert, L A. ( 1 996)
airway reactivity in subjects with asthma. Lancet, Contaminated stethoscopes revisited. Arch. Intern.
335, 1 3 8 1-1383. Med. , 1 56, 82-84.
Sinha, S. ( 1 998) Effect of nutritional status on Smith, C. E. and Mayer, L. S. ( 1998) Continuous
vecuronium-induced neuromuscular blockade. positive airway pressure. Heart Lung, 27, 99-1 08 .
Anaesth. Intensive Care, 26, 392-3 95. Smith, H. R. and Sinclair, D. G. ( 1996) Severe
Sisson, R. ( 1 990) Effects of auditory stimuli on pulmonary dysfunction following acute respiratory
comatose patients with head injury. Heart Lung, distress syndrome. Postgrad. Med. J., 72, 555-
19, 3 73-378. 556.
Sivakumar, D., Bosque, E. and Goldman, S. L. ( 1 999) Smith, S., Garnett, P. and Buckley, P. ( 1 997) Delirium
Bronchodilator delivered by metered dose inhaler in the critically ill. Care Crit. Ill, 13, 1 75-178.
and spacer. Paediatr. Pulmonol., 27, 208-2 12. Smith, L E., King, M. A. and Siklos, P. W. L. ( 1 998)
Sivasothy, P., Smith, L E. and Shneerson, J. M. ( 1 998) Treatment of ventilatory failure in the Prader
Mask intermittent positive pressure ventilation in Willi syndrome. Bur. Respir. j. , 1 1, 1 150-1 152.
chronic hypercapnic respiratory failure due to Smith, J. A., Redman, P. and Woodhead, M. A.
COPD. Bur. Respir. j. , 1 1, 34-40. ( 1 999) Antibiotic use in patients admitted with
Sjoland, H., Wiklund, L and Caidahl, K. ( 1 996) exacerbations of COPD. Bur. Respir. j. , 1 3 , 835-
Improvement in quality of life and exercise 838.
capacity after coronary bypass surgery. Arch. Smithard, D. G. ( 1 995) Dysphagia assessment after
Intern. Med. , 1 5 6, 265-2 7 1 . acute stroke. Hasp. Update, 2 1 , 555-560.
Sjostrom, B . , Haljamiie, H. and Dahlgren, L.-O. Smy, J. ( 1 995) How asthma drains the patient'S purse.
( 1997) Assessment of postoperative pain. Acta Asthma J., 1 , 8.
Anaesthesiol. Scand. , 4 1 , 339-344. Snider, G. L. ( 1 995) Withholding and withdrawing
Sky, M. ( 1 990) Breathing. Bear, New Mexico, p. 49. life-sustaining therapy. Am. J. Respir. Crit. Care
Slavin, R. G. ( 1996) ABPA in CF. Pediatr. Pulmonol. , Med. , 1 5 1 , 279-28 l .
2 1 , 1-2. Sommers, M. S . ( 1 9 9 1 ) Potential for injury: trauma
Sliwa, J. A. and Marinko, M. S. ( 1 996) after cardio-pulmonary resuscitation. Heart Lung,
Transcutaneous electrical nerve stimulator-induced 20, 287-295.
ECG artifact. Am. J. Phys. Med. Rehabil. , 75, 3 07- Sonksen, J . ( 1 998) Safer non-cardiac surgery for
3 09. patients with coronary artery disease. Br. Med. J.,
Sliwinski, P. ( 1 994) The adequacy of oxygenation in 3 17, 1400-140 l .
COPD patients undergoing long-term oxygen Soryal, L , Sinclair, E . , Hornby, J . ( 1992) Impaired
therapy. Bur. Respir. j. , 7, 274-278. joint mobility in Guillain-Barn! syndrome. j.
Sloan, J. P., Muwanga, C. L. and Waters, E. A. ( 19 8 6) Neural. Neurosurg. Psychiat., 55, 1 0 14- 1 0 1 7.
Multiple rib fractures: TNS versus conventional Sottile, F. D. ( 1 986) Nosocomial pulmonary infection.
analgesia. J. Trauma, 26, 1 120-1 122. Crit. Care Med. , 14, 265-270.
Siotman, G. J. ( 1 998) Hyperbaric oxygen in systemic Sorahan, T. ( 1 997) Childhood cancer and parental use
inflammation. Crit. Care Med. , 26, 1 932. of tobacco. Br. J. Cancer, 75, 1 34-1 3 8 .
530
REFERENCES
Soutar, A. ( 1 997) Bronchial reactivity and dietary Steinfort, C. L., Smith, M. J. and Harrison, N. K.
antioxidants. Thorax, 52, 1 66-170. ( 1 987) Reactive arthritis in bronchiectasis. Am. J.
Souter, M. J., Andrews, P. J. D. and Pereirinha, M. R. Respir. Dis. , 1 3 5 , A42.
( 1 999) Delayed intracranial hypertension. Crit. Stephenson, J. (2000) Oxygen for preemies. J. A. M.
Care Med. , 27, 1 77-18 1 . A. , 283, .
Spahija, J . A. ( 1 996) Effects o f pursed-lips breathing Sterk, P. J. ( 1994) Improving asthma treatment. Eur.
and expiratory resistive loading in healthy Respir. J., 7, 220-222.
subjects. J. Appl. Physiol. , 8 0 (5), 1 772- 1 784. Sternbergh, W. C. ( 1 998) Abdominal and
Sparsholt, M. ( 1 989) Pain and the special care baby thoracoabdominal aortic aneurysm. Surg. Clin.
unit. Nurs. Times, 8 5 (4 1 ), 6 1-64. North Am. , 78, 827-843.
Speidel, B. D. (1 978) Adverse effects of routine Steven, M. H., Pryor, J. A. and Webber, B. A. ( 1 992)
procedures on preterm infants. Lancet, i, 864-866. Physiotherapy versus cough alone in the treatment
Spence, D.. P. S. ( 1 991) Effect of nebulized salbutamol of cystic fibrosis. NZ J. Physiother. , 20, 3 1-37.
on walking distance. Thorax, 46, 305P. Stevensen, C. J. ( 1 994) The psychophysiological
Spooner, C. (2000) Nedocromil sodium in the effects of aromatherapy massage following cardiac
treatment of exercise-induced asthma. Eur. Resp. surgery. Complement. Ther. Med. , 2, 27-35 .
J. , 1 6, 3 0-37. Stewart, T . D. and Rossier, A . B. ( 1 978) Psychological
Sporik, R. ( 1 994) Why block a small hole? Arch. Dis. considerations in the adjustment of spinal cord
Child. , 7 1 , 393-394. injury. Rehabil. Lit., 39, 75-80.
Spring, C. ( 1 999) The fibre-optic bronchoscope in the Stewart, T. E. and Zhang, H. ( 1 999) Nitric oxide in
ICU. Br. J. Intensive Care, 9, 14-22. sepsis. Respir. Care, 44, 308-3 1 3 .
Squier, H. c., Ries, A. L. and Kaplan, R. M. ( 1 995) Stiller, K . R . and Munday, R . M. (1 992) Chest
Quality of well-being predicts survival in lung physiotherapy for the surgical patient. Br. J. Surg. ,
transplantation candidates. Am. J. Respir. Crit. 79, 745-749.
Care Med. , 152, 2032-2036. Stiller, K., Montarello, J. and Wallace, M. ( 1 9 94) Are
Sridhar, M. K. ( 1 995) Nutrition and lung health. Br. breathing and coughing exercises necessary after
Med. J. , 3 10, 75-76. coronary artery surgery? Physiother. Theor. Pract. ,
Sridhar, K. S., Lobo, C. F. and Altman, R. D. ( 1 998) 10, 143-52.
Digital clubbing and lung cancer. Chest, 1 14, Stiller, K., Mcinnes, M. and Huff, N. ( 1 997) Do
1535-1537. exercises prevent musculoskeletal complications
Stanescu, D. C. ( 1 9 8 1 ) Pattern of breathing and after cardiac surgery? Physiother. Theor. Pract. , 13,
ventilatory response to CO2 in subjects practising 1 17- 1 26.
hatha-yoga. J. Appl. Physiol. , 5 1, 1 625- 1 629. Stolp-Smith, K. A. ( 1 999) Antidepressant exacerbation
Stapleton, J. A., Lowin, A. and Russell, M. A. H. of spasticity. Arch. Phys. Med. Rehabil. , 80, 339-
(1 999) Prescription of transdermal nicotine 342.
patches for smoking cessation in general practice. Stone, K. S. ( 1 9 9 1 ) The effect of lung hyperinflation
Lancet, 354, 2 1 0-2 15. and endotracheal suctioning on cardiopulmonary
Starke, 1. D., Webber, B. A. and Branthwaite, M. A. haemodynamics. Nurs. Res. , 40, 76-80.
( 1 979) IPPB and hypercapnia in respiratory Stone, G., Huggon, A. M. and Nayeem, N. ( 1 999)
failure. Anaesthesia, 34, 283-287. Telephone follow-up of relatives after sudden
Stauffer, J. L. ( 1 999) Complications of endotracheal death. Int. J. Clin. Pract. , 5 3 , 1 07-1 09.
intubation and tracheotomy. Respir. Care, 44, Strachan, D. P. ( 1 9 9 1 ) Ventilatory function and
828-843. winter fresh fruit consumption. Thorax, 46, 624-
Stead, C. E. ( 1 999) Sudden infant death syndrome 629.
(SIDS� on the 'other side'. Accident Emerg. Nurs. , Stradling, J. R., Negus, T. W. and Smith, D. ( 1 998)
7, 1 70-174. Mandibular advancement devices for the control
Stein, R. T. ( 1 999) Respiratory syncytial virus in early of snoring. Eur. Respir. J., 1 1, 447-450.
life and risk of wheeze and allergy by 1 3 . Lancet, St-Laurent-Gagnon, T. ( 1 999) Pain evaluation in
354, 54 1-546. preschool children and by their parents. Acta
Steiner, M. c., Singh, S. and Morgan, M. D. L. Paediatr. , 88, 422-427.
(2000) Stable COPD [letter] . Br. Med. J., 320, Strijbos, J. H. ( 1 996) A comparison berween an
3 1 2. outpatient pulmonary rehabilitation program and
531
REFERENCES
a home-care pulmonary rehabilitation programme. severe cardiogenic pulmonary oedema. Anesth.

Chest, 109, 366-372. Analg. , 84, 1 09 1- 1 096.
Strollo, P. J. ( 1 998) Sleep-disordered breathing. Tamaoki, J . ( 1 992) Effect of indomethacin on
Respir. Care, 43, 42 1-428. bronchorrhea. Am. Rev. Respir. Dis. , 145, 548-
Suarez, J. I. ( 1 999) Narcotics for brain-injured 552.
patients? Crit. Care Med. , 27, 3 62-363. Tamaoki, J. ( 1 994) Effect of long term treatment with
Suda, T. ( 1 995) Hypersensitivity pneumonitis oxitropium bromide on airway secretion in
associated with home ultrasonic humidifiers. chronic bronchitis. Thorax, 49, 545-548.
Chest, 1 07, 7 1 1-7 17. Tamer, M. A. ( 1 970) Hyponatremia secondary to
Suman, O. E. ( 1 995) Airway obstruction during ultrasonic aerosol therapy in the newborn. ].
exercise in asthma. Am. ]. Respir. Crit. Care Med. , Pediatr. , 77, 1 05 1-1054.
1 52, 24-3 1 . Tan, A. K. W. ( 1 995) Incentive spirometry for
Sun, W.-Z. ( 1 992) Successful cardiopulmonary tracheostomy and laryngectomy patients. ].
resuscitation in the prone position. Am. Rev. Otolaryngol. , 24, 292-295.
Respir. Dis. , 77, 202-204. Tang, W. ( 1 9 97) Influence of respiratory distress
Sutcliffe, A. J. ( 1 993) Pain relief for acutely ill and syndrome on body composition after preterm
injured patients. Care Crit. Ill, 9, 266-269. birth. Arch. Dis. Child. , 77, F28-F3 1 .
Sutton, P. P., Lopez, M. T. and Pavia, D. ( 1 985) Tangredi, M . ( 1 998) Septic shock. Am. ]. Nurs. ,
Assessment of percussion, vibratory shaking and 9 8 (3), 46-49.
breathing exercises in chest physiotherapy. Bur. ]. Tannenbaum E. 1. and Davids 1. M. ( 1 995) Cystic
Respir. Dis., 66, 147-152. fibrosis - approaches to management. S. Afr. J.
Sutton, P. P., Gemmell, H. G. and Innes, N. ( 1 988) Physiother. , 5 1 , 2, 27-30.
Use of nebulized saline and nebulized terbutaline Tantucci, C., Duguet, A. and Similowski, T. ( 1 998)
as an adjunct to chest physiotherapy. Thorax, 43, Effect of salbutamol on dynamic hyperinflation in
5 7-60. COPD. Bur. Respir. ]., 12, 799-804.
Suzuki, S. and Sato, M. ( 1 995) Expiratory muscle Tariq, M. ( 1999) A foreign body in the bronchus still
training and sensation of respiratory effort during presents problems. Int. ]. Clin. Pract., 5 3 ( 1), 8 1-
exercise in normal subjects. Thorax, 5 0, 366-370. 82.
Swann, P. ( 1 989) Stress management for pain control. Tasaka, S., Kanazawa, M. and Mori, M. ( 1 995) Long
Physiotherapy, 75, 295-298. term course of bronchiectais and bronchiolitis
Swanston, M. ( 1 993) Pain assessment with interactive obliterans as late complication of smoke
computer animation. Pain, 5 3 , 347-3 5 1 . inhalation. Respiration, 62, 40-42.
Swartz, K . ( 1 996) A national survey o f endotracheal Tashkin, D. P., Simmons, M. S., Chang, P. ( 1 993)
suctioning techniques in the pediatric population. Effects of smoked substance abuse on nonspecific
Heart Lung, 25, 52-60. airway hyperresponsiveness. Am. Rev. Respir. Dis. ,
Swerts, P. M. J. ( 1 990) Exercise reconditioning in the 147, 97-103.
rehabilitation of patients with COPD. Arch. Phys. Tattersall, R., Ledson, M. J. and Convery, R. P.
Med. Rehabil. , 7 1 , 570-573. ( 1997) The effect of posture and physiotherapy on
Swingle, H. M., Eggert, 1. D. and Bucciarelli, R. 1. reflux in adult CF patients. Thorax, 52(suppl. 6),
( 1 984) New approach to management of unilateral A43.
tension pulmonary interstitial emphysema in Taylor, D. R. (2000) Interactions between
premature infants. Pediatrics, 74, 354-357. corticosteroids and �2 agonists. Thorax, 55, 595-
Sykes, K., Young, J. D. ( 1 999) Respiratory Support, 602.
BMJ Publishing, London. Taylor, K. M. ( 1 998) Brain damage during
Szasz, T. S. ( 1 968) The psychology of persistent pain, cardiopulmonary bypass. Ann. Thorac. Surg. , 65,
in Pain, (ed. A. Soulairac), Academic Press, S20-S26.
London. Teague, W. G. ( 1 997) Pediatric application of
Taggert, J. A. ( 1 9 94) Evaluating unplanned noninvasive ventilation. Respir. Care, 42, 4 1 4-422.
endotracheal extubations. Dimens. Crit. Care Teasdale, K. ( 1 995) Theoretical and practical
Nurs. , 1 3 , 1 14-1 2 1 . considerations on the use of reassurance in the
Takeda, S . ( 1 997) The effect o f nasal CPAP o n plasma nursing management of anxious patients. J. Adv.
endothelin- 1 concentrations in patients with Nurs. , 22, 79-8 6.
532
REFERENCES
Tector, A. J., Kress, D. C. and Downey, F. X. ( 1 998) Tiep, B. L. ( 1 9 9 1 ) Reversing disability of irreversible
Transition from cardiopulmonary bypass to the lung disease. W. ]. Med. , 154, 5 9 1 -597.
HeartMate LVAD. Ann. Thorac. Surg. , 65, 643- Tierney, A. J. ( 1 995) Undernutrition and elderly
646. hospital patients. J. Adv. Nurs. , 23, 228-236.
Ten Hove, R. (200 1), quoting Pearson, On-Call Tillett, J. M. ( 1 993) Effect of continuous rotational
Conference, Nottingham. therapy on ICP in the severely brain-injured
Thistlethwaite, J. E. ( 1 998) Respiratory tract patient. Crit. Care Med. , 2 1 , 1 005-1 0 1 1 .
infections. Update, 5 6, 1 08-1 1 2 . Timmons, B . H . and Ley, R . ( 1994) Behavioral and
Thomas, E. A . ( 1 987) Pre-operative fasting - a Psychological Approaches to Breathing Disorders,
question of routine ? Nurs. Times, 8 3 (49), 46- Plenum Press, New York.
47. Tirimanna, P. R. S. ( 1 996) Evaluation of the
Thomas, V. ( 1 995) Psychological characteristics and suitability of weekly peak expiratory flow rate
the effectiveness of patient-controlled analgesia. measurements. Br. ]. Gen. Pract., 46, 1 5- 1 8 .
Br. J. Anaesth. , 74, 271-276. Tobias, J. D. ( 1 994) Pain management and sedation in
Thomas, H. M. ( 1 996b) Pulmonary rehabilitation. the pediatric ICU. Pediatr. Clin. North Am., 4 1 ,
Chest, 1 09, 299-300. 1 269- 1 280.
Thomas, G. A. O. ( 1 996a) Nicotine and Tobias, J. D. ( 1 997) Noninvasive monitoring of CO2
gastrointestinal disease. Q. ]. Med. , 89, 485-488. during respiratory failure in toddlers and infants.
Thomas, G. ( 1 997) Use of the prone position. Care Anesth. Ana/g. , 85, 55-5 8 .
Crit. Ill, 13, 96-100. Tobin, M. J. ( 1 988) Respiratory muscles i n disease.
Thomas, G. A. O. (2000) Role of smoking in Clin. Chest Med. , 9, 263-286.
inflammatory bowel disease. Postgrad. Med. J., 76, Tobin, M. J. ( 1 990) Dyspnea. Arch. Intern. Med. , 1 5 0,
273-279. 1 6 04-1 6 1 1 .
Thomas, E. O. and Manara, A. R. ( 1 998) A review of Tobin, M. J. ( 1 9 9 1 ) Respiratory Monitoring, Churchill
percutaneous tracheostomy. Br. ]. Intensive Care, Livingstone, Edinburgh.
8, 122-129. Tobin, M. J. and Yang, J. ( 1 990) Weaning from
Thomas, J., Cook, D. J. and Brooks, D. ( 1 995) Chest mechanical ventilation. Crit. Care Clin. , 6, 725-
physical therapy management of patients with 746.
CF. Am. ]' Respir. Crit. Care Med. , 1 5 1 , 646- Todd, D. B. ( 1 996) Prescription of exercise. Update,
650. 52, 408-4 1 1 .
Thomas, S., Andrews, A. M. and Hay, N. P. ( 1 999) Todisco, T . ( 1 995) Effect o f bamiphylline on
The anti-microbial activity of maggot secretions. ]. tracheobronchial mucus clearance. Respiration, 62,
Tissue Viability, 9, 1 27-1 3 1 . 1 6-20.
Thomsen, O . O . ( 1 993) What do gastroenterologists Todisco, T. ( 1 996) NDYAG laser therapy using a
in Europe tell cancer patients? Lancet, 341, 473- fiberoptic bronchoscope. Eur. Respir. ]. , 9 (suppl.
476. 23), 3 75S.
Thomson, A. ( 1 997) The role of negative pressure Tolep, K. ( 1 996) Swallowing dysfunction in patients
ventilation. Arch. Dis. Child. , 77, 454-458. receiving prolonged mechanical ventilation. Chest,
Thomson, D., Hassenkamp, A.-M. and Mansbridge, 1 09, 1 6 7-1 72.
C. ( 1 997) The measurement of empathy in a Torres, A. ( 1 992) Pulmonary aspiration of gastric
clinical and a non-clinical setting. Physiotherapy, contents in patients receiving mechanical
83, 1 73-180. ventilation. Ann. Intern. Med. , 1 16, 540-543.
Thomson, L. R. ( 1 973 ) Sensory deprivation: a Torrington, K., Sorenson, D. and Sherwood, L.
personal experience. Am. ]. Nurs., 73, 266-268. ( 1 984) Postoperative chest percussion with
Thorax ( 1 997) Asthma in adults and schoolchildren. postural drainage in obese patients following
Thorax, 52(suppl. 1) S2-S8. gastric stapling. Chest, 86, 89 1-895.
Thoresen, M. ( 1999) Protecting the brain. Semin. Tougaard, L., Krone, T. and Sorknaes, A. ( 1 992)
NeonatoL., 5, 1-2. Economic benefits of teaching patients with
Tidwell, S. L. ( 1 990) Effects of position changes on COPD about their illness. Lancet, 339, 1 5 1 7-
mixed venous oxygen saturation in patients after 1 520.
coronary revascularization. Heart Lung, 19, 574- Touw van de, T., Mudaliar, Y. and Nayyar, V. ( 1 998)
578. Cardiorespiratory effects of manually compressing
533
REFERENCES
the rib cage during tidal expiration in acute severe surgery. Arch. Phys. Med. Rehabil. , 67, 463-
asthma. Crit. Care Med. , 26, 1 3 6 1 - 13 67. 466.
Tonnesen, P. ( 1 999) Higher dosage nicotine patches Urbaitis, J. c. ( 1 999) Psychiatric treatment helps
increase one-year smoking cessation rates. Eur. survivors of suicide attempts. Crit. Care Med. , 27,
Respir. J., 13, 238-246. 458-459.
Tovar, E. A., Roethe, R. A. and Weissig, M. D. ( 1 998) Valacio, R. and Lie, M. ( 1 994) Diuretics and ACE
One-day admission for lung lobectomy. Ann. inhibitors. Care Elderly, 6, 294-296.
Thorac. Surg. , 65, 803-806. Valenzuela, R. C. and Rosen, D . A. ( 1 999) Topical
Trochtenberg, S. ( 1 994) Nebulized lidocaine in lidocaine-prilocaine cream (EMLA) for
refractory cough. Chest, 105, 1 5 92-1593. thoracostomy tube removal. Anesth. Analg. , 88,
Trooster, T. ( 1 997) Peripheral muscle weakness and 1 1 07-1 1 08 .
deconditioning commonly occur in patients with Valji, A . M . ( 1 998) Postpneumonectomy syndrome.
HVS. Eur. Respir. ]. , 1 0, 72s. Chest, 1 14, 1 766- 1 769.
Trudel, G., Uhthoff, H. K. and Brown, M. ( 1 999) Valladares, P. ( 1 996) Comparing clinical management
Extent and direction of joint motion limitation of overdoses. Emerg. Nurse, 4, 6-8.
after prolonged immobility. Arch. Phys. Med. Van der Woning, M. ( 1 997) Should relatives be
Rehabil. , 80, 1542-1547. invited to witness a resuscitation attempt?
Tsang, K. W. T., Ho, P. I. and Chan, K. N. ( 1 999) A Accident Emerg. Nurs., 5, 2 15-1 8 .
pilot study of low-dose erythromycin in Van Dixhoorn, J. ( 1 986) Behavioral characteristics
bronchiectasis. Eur. Respir. J. , 1 3 , 36 1-364. predisposing to hyperventilation complaints.
Tschopp, J. M. (2000) Treatment of spontaneous Gedrag Gezondh., 14, 1 69-174.
pneumothorax. Respiration, 67, 1 08-1 1 1 . Van Dixhoorn, J., Duivenvoordent, H. J. and Staal, J.
Tsubota, N., Yanagawa, M. and Yoshimura, M. A. ( 1 987) Cardiac events after myocardial
( 1 994) The superiority of exercise testing over infarction: possible effect of relaxation therapy.
spirometry in the evaluation of postoperative lung Eur. Heart ]. , 8 , 1 2 1 0-1214.
function for patients with pulmonary disease. Surg. Van Doorn, P. ( 1 982) Control of the end-tidal PC02
Today, 24, 1 03-1 05 . in the hyperventilation syndrome. Bull. Eur.
Tucker, E. Z. ( 1 9 9 1 ) Tracheostomy speaking valve i n Physiopathol. Res., 1 8 , 829-836.
pediatric ventilator-assisted patients. Respir. Care, Vansteenkiste, J., Rochette, F. and Demedts, ? (1991)
36, 1 2 7 1 . Diagnostic tests of hyperventilation syndrome.
Turner, R . E. ( 1 997) NPPV: Face versus interface. Eur. Respir. ]., 4, 393-399.
Respir. Care, 42, 3 8 9-394. Varoli, F. ( 1 998) Endoscopic treatment of
Turnock, C. ( 1 997) ICU syndrome. Br. ]' Intensive bronchopleural fistulas. Ann. Thorac. Surg. , 65,
Care, 7 , 1 44-147. 807-809.
Tweeddale, P. M., Rowbottom, I. and McHardy, G. J. Vaughan, R. S., Menke, J. A. and Giacoia, G. P.
R. ( 1 994) Breathing retraining. ]' Psychosom. Res. , ( 1 978) Pneumothorax : a complication of
3 8 , 1 1-2 1 . endotracheal tube suctioning. ]' Pediatr. , 92, 633-
Twigley, A. J . and Hillman, K . M. ( 1 985) The end of 634.
the crystalloid era? Anaesthesia, 40, 8 60-8 7 1 . Veall, G. R. Q. ( 1 995) Prolonged starvation in
Twycross, A . ( 1 998) Perceptions about children's pain paediatric surgery. Anaesthesia, 50, 458-460.
experience. Prof. Nurse, 1 3 , 822-826. Venables, T. ( 1 994) Helping patients who want to
Twycross, R. and Lack, S. ( 1 984) Therapeutics in quit smoking. Respir. Dis. Pract., 1 1 (2), 6-8.
Terminal Cancer, Pitman, Bath. Verboon, J. M. L., Bakker, W. and Sterk, P. J. ( 1 986)
Twycross, R. and Lack, S. ( 1 990) Oral Morphine in The value of the forced expiration technique with
Advanced Cancer, Beaconsfield Ltd, Beaconsfield. and without postural drainage. Eur. J. Respir. Dis. ,
Ulbricht, G. F. ( 1 986) Laryngectomy rehabilitation: a 69, 1 69-1 74.
woman's viewpoint. Women Health, 1 1, 1 3 1-136. Verbrugge, S. J. c. ( 1 998) Lung overinflation without
Ulrich, R. S. ( 1 984) View through a window may PEEP promotes bacteremia. Intensive Care Med. ,
influence recovery from surgery. Science, 224, 24, 1 72-177.
420-42 1 . Verklan, M. T. ( 1 997) Bronchopulmonary dysplasia.
Ungeman-deMent, P., Bemis, A . and Siebens, A. Neonat. Netw. , 16(8), 5-1 1 .
( 1 986) Exercise program for patients after cardiac Verra, F. ( 1 995) Ciliary abnormalities i n bronchial
534
REFERENCES
epithelium of smokers. Am. J. Respir. Crit. Care Watkins, C. A. ( 1999) Mechanical and
Med. , 1 5 1 , 630-634. neurophysiological changes in spastic muscles.
Vilar, F. J. ( 1 998) Management of Pneumocystis Physiotherapy, 8 5 , 603-609.
carinii pneumonia in intensive care. Br. J. Intensive Watson, J. M. ( 1 997) Does influenza immunisation
Care, 8, 53-60. cause exacerbations of chronic airflow obstruction
Villaire, M. ( 1 995) ICU from the patient's point of or asthma? Thorax, 52, 1 90-1 94.
view. Crit. Care Nurse, 1 5 , 80-87. Watson, M. ]., Horn, S. A. and Wilson, B. A. ( 1 999)
Vitacca, M. ( 1 998) Acute effects of deep Assessing a minimally responsive brain injured
diaphragmatic breathing in COPD patients. Eur. person. Br. J. Ther. Rehabil. , 6, 436-44 1 .
Respir. J., 1 1, 408-4 1 5 . Webb, A . K and Govan, ]. R . W . ( 1 998) Burkholderia
Vos, H. R . ( 1 993) Making headway with intracranial cepacia: another twist and a further threat.
hypertension. Am. J. Nurs., 93, 28-36. Thorax, 5 3 , 333-334.
Vos, P. J. E., Folgering, H. Th. M. and van Webb, R. K, Ralston, A. C. and Runciman, W. B.
Herwaarden, C. L. A. ( 1 995) Predictors for ( 1 9 9 1 ) Potential errors in pulse oximetry.
nocturnal hypoxaemia in normoxic and mildly Anaesthesia, 46, 207-2 12.
hypoxic patients with COPD. Eur. Respir. J., 8 , Weber, ? ( 1 999) Effect of continuously nebulized
74-77. ipratropium bromide plus albuterol on emergency
Wagner, P. D. ( 1 992) Ventilation-perfusion matching department length of stay. Chest, 1 15 , 93 7-944.
during exercise. Chest, 1 0 1 , 1 925-1 98S. Weber, D. J., Paasch, R. and Rutala, W. A. ( 1 999)
Wahba, R. W. M. ( 1 9 9 1 ) Perioperative functional Nosocomial infections in the ICU. Chest, 1 1 5 ,
residual capacity. Can. J. Anaesth., 38, 384-400. 34s-4 1s.
Wainright, S. P. and Gould, D. ( 1 996) Endotracheal Wedzicha, J. A. ( 1 986) Polycythaemia in hypoxic lung
suction. J. Clin. Nurs. , 5, 3 8 9-3 98. disease. Respir. Dis. Pract. , 3, 26-30.
Wald, S. L. ( 1 993) The effect of secondary insults on Wehberg, E. K. ( 1 996) Nitric oxide mediates fluid
mortality and disability after severe head injury. J. accumulation during cardiopulmonary bypass. J.
Trauma, 34, 3 77-3 8 1 . Thorac. Cardiovasc. Surg. , 1 12, 1 68-174.
Waldmann, C . S. ( 1 998) Management o f head injury Weill, D., Mack, M. J. and Tennison, D. ( 1 998)
in a district general hospital. Care Crit. Ill, 14, 65- Adverse effects of medications commonly
69. administered to thoracic surgical patients. Chest
Waldmann, C. and Gaine, M. ( 1 996) The intensive Surg. Clin. North Am. , 8, 6 8 1 -702.
care follow-up clinic. Care Crit. Ill, 12, 1 1 8- 1 2 1 . Weiner, H . ( 1 9 9 1 ) Stressful experience and
Walker, A. ( 1 995) Patient compliance and the placebo cardiorespiratory disorders. Circulation, 8 3 (suppl.
effect. Physiotherapy, 8 1 , 1 20-1 26. II), 11-2-11-8.
Walker, P. ( 1 998a) Baclofen, a treatment for chronic Weiner, P. ( 1 995) Inspiratory muscle training during
hiccup. J. Pain Symptom Manage. , 1 6, 1 25-132. treatment with corticosteroids. Chest, 1 07, 1 04 1-
Walker, M. ( 1 998b) Protection of the cervical spine in 1 044.
the unconscious patient. Care Crit. Ill, 14, 4-7. Weiner, P., Azgad, Y. and Ganam, R. ( 1 9 92)
Waller, D. A. ( 1 999) A physiological comparison of Inspiratory muscle training in patients with
flutter valve drainage bags and underwater seal bronchial asthma. Chest, 1 02, 1 3 5 7- 13 6 1 .
systems for postoperative air leaks. Thorax, 54, Weiner, P., Berar, N . and Davidovich, A . (2000) The
442-443. perception of dyspnoea in patients with asthma,
Walsh, J. M., Vanderwarf, C. and Hoscheit, D. ( 1 989) before and after inhaled glucocorticosteroids.
Unsuspected hemodynamic alterations during Respir. Med. , 94, 1 6 1-165.
endotracheal suctioning. Chest, 95, 1 62-165. Weinstein, R. A. ( 1 9 9 1 ) Epidemiology and control of
Wang, B., Tang, J. and White, P. F. ( 1997) Effect of nosocomial infections. Am. J. Med. , 91, 1 79s-184s.
the intensity of transcutaneous acupoint electrical Weisberg, S. C. (2000) Pharmacotherapy of asthma in
stimulation. Anesth. Analg. , 85, 406-4 1 3 . children. Pediatr. Pulmonol. , 29, 46-6 1 .
Warren, C. P . W . ( 1 980) Pulmonary disorders and Weissleder, A. ( 1976) Physical therapeutic approach
physiotherapy in patients who undergo to the control of an acute asthmatic attack. Phys.
cholecystectomy. Can. J. Surg. , 23, 384-3 86. Ther. , 56, 68 1-683 .
Watcha, M. F. (1 996) Nausea and vomiting. Curro Weissman, C . ( 1 993) Stressing the critically ill patient.
Opin. Anaesthesiol. , 9, 300-305. J. Crit. Care, 8, 100-1 08.
535
REFERENCES
Weissman, c., Kemper, M. and Damask, M. C. Whittaker, J. A . ( 1990) The effects o f refeeding on
( 1984) Effect of routine intensive care interactions peripheral and respiratory muscle function. Am.
on metabolic rate. Chest, 86, 8 15-8 1 8 . Rev. Respir. Dis., 142, 283-288.
Welsby, I . and Mythen, M . G . ( 1997) Gut perfusion WHO ( 1 996) The Global Burden of Disease, Harvard
during cardiac surgery. Curro Opin. Anaesth. , 1 0, School of Public Health, Cambridge, MA.
34-39. Wichmann, M. W., Ayala, A. and Chaudry, I. H.
Wencker, M., Banik, N. and Buhl, R. ( 1 998) Long ( 1 998) Severe depression of host immune
term treatment of alpha I -antitrypsin deficiency functions following closed-bone fracture, soft
related pulmonary emphysema with human tissue trauma and hemorrhagic shock. Crit. Care
alpha I -antitrypsin. Eur. Respir. ]. , 1 1, 428-433. Med. , 26, 1 3 72-1378.
Wenger, N. K. ( 1 9 82) Early ambulation. Adv. Widmer, S., Conway, A., Cohen, S. and Davies, P.
Cardio!. , 3 1 , 1 3 8-1 4 l . ( 1 997) Hyperventilation: a correlate and
Werebe, E . C . ( 1999) Systemic distribution o f talc predictor of debilitating performance anxiety in
after intrapleural administration in rats. Chest, musicians. Med. Prob!. Performing Artists, 12, 97-
1 15 , 1 90-1 9 3 . 1 06.
Wessel, D. L. ( 1 9 9 3 ) Hemodynamic responses to Wiener, C. M., McKenna, W. J. and Myers, M. J.
peri operative pain and stress in infants. Crit. Care ( 1 990) Left lower lobe ventilation is reduced in
Med. , 2 1 , S3 6 1-S362. patients with cardiomegaly in the supine but not
West, J. B. ( 1 995) Respiratory Physiology, 5th edn, the prone position. Am. Rev. Respir. Dis. , 1 4 1 ,
Williams & Wilkins, Baltimore, MD. 1 5 0-155.
Westbrook, J. L. and Sykes, M. K. ( 1 992) Wiener, J. P. ( 1 992) Postoperative pleural and
Peroperative arterial hypoxaemia. The interaction pulmonary abnormalities in patients undergoing
between intrapulmonary shunt and cardiac output. CABG. Chest, 1 02, 1 3 1 3-13 14.
Anaesthesia, 47, 307-3 1 0. Wiener, M. D., Garay, S. M. and Leitman, B. S.
Westgren, N. ( 1998) Quality of life and traumatic ( 1 99 1 ) Imaging the ICU patient. Clin. Chest Med.,
spinal cord injury. Arch. Phys. Med. Rehabil. , 79, 12, 1 69-198.
1433-1439. Wiest, G. H., Lehnert, G. and Bruck, W. M. ( 1 999) A
Wetter, D. W. ( 1 9 94) Smoking as a risk factor for heated humidifier reduces upper airway dryness
sleep-disordered breathing. Arch. Intern. Med. , during CPAP. Respir. Med. , 93, 2 1-26.
1 54, 2219-2224. Wietasch, G. J. K., Mielck, F. and Scholz, M. (2000)
Wheatley, J. R. ( 1 990) The effect of hyperinflation on Bedside assessment of cerebral blood flow by
respiratory muscle work in acute induced asthma. double-indicator dilution technique.
Eur. Respir. j., 3, 625-632. Anesthesiology, 92, 367-375.
White, D., Stiller, K. and Roney, F. ( 1 999) The Wiggins, J. ( 1 99 1) Steroid trials in the assessment of
incidence and severity of symptoms of air flow limitation. Respir. Med. , 85, 295-
incontinence in adult CF patients. wcn 299.
Proceedings, p. 3 5 . Wijkstra, P. J. ( 1994) Relation of lung function,
White, K . L . ( 1 988) Foreword, i n Medicine and maximal inspiratory pressure, dyspnoea and
Culture, (ed. L. Payer), Henry Holt, New York. quality of life with exercise capacity in patients
White, R. J. ( 1992) The diagnosis and initial with COPD. Thorax, 49, 468-472.
management of head injury. N. Eng!. ]. Med. , 327, Wildhaber, J. H. ( 1 996) Effect of electrostatic
1 5 07-1 5 1 l . charge, flow, delay and multiple actuations on
White, K. M., Winslow, E . H . and Clark, A. P . ( 1 990) the in vitro delivery of salbutamol. Thorax, 5 1,
The physiologic basis for continuous mixed 985-988.
venous oxygen saturation monitoring. Heart Lung, Wiles, F. W. and Hnizdo, E. (1991) Relevance of
1 9, 548-5 5 l . airflow obstruction and mucus hypersecretion to
Whitehead, B . F . and Leval, M. R. ( 1 994) Paediatric mortality. Respir. Med., 85, 27-35.
lung transplantation: the agony and the ecstasy. Wilkes, L. ( 1983) Nightmare, in The Oxford Book of
Thorax, 49, 437-439. Death, Oxford University Press, Oxford.
Whitney, J. D. ( 1 989) Physiologic effects of tissue Wilkie, P. ( 1 997) Teaching medical students in
oxygenation on wound healing. Heart Lung, 1 8 , general practice. Student Br. Med. ]., 5 , 445.
466-476. Wilkins, R. L., Krider, S. J. and Sheldon, R. L. ( 1 995)
536
REFERENCES
Clinical Assessment in Respiratory Care, Mosby, Winslow, E. H. ( 1 995) Dangling: a review of relevant
Toronto. physiology, research and practice. Heart Lung, 24,
Wilkinson, S. ( 1 996) Get the massage. Nurs. Times, 263-272.
92(34), 6 1-64. Wiselka, M. ( 1994) Influenza. Br. Med. J. , 308, 1 3 4 1-
Williams, J. (2000) Audit of hyperventilation 1 345.
syndrome. ACPRC Conference, poster. Wissing, D. R. ( 1 9 8 8 ) Use of respiratory care
Williams, S. J. ( 1 993) Chronic Respiratory Illness, procedures in the management of hospitalized
Routledge, London. asthmatics. Ann. AI/erg. , 6 1 , 407-420.
Williams, M. T. ( 1 995) Chest physiotherapy and Wolf, J., Holcombe, E. and Grier, M. D. (2000)
cystic fibrosis. Chest, 1 06, 1 8 72-1 882. Symptoms and suffering at the end of life in
Williams, S. J. ( 1 993) Chronic Respiratory Illness, children with cancer. N. Eng/. J. Med. , 342, 326-
Routledge, London. 333.
Williams, G. C. and Deci, E. L. ( 1 998) The Wolf, S. L., Coogler, C. and X u , T. ( 1 997) Exploring
importance of supporting autonomy in medical the basis for Tai Chi Chuan as a therapeutic
education. Ann. Intern. Med. , 129, 303-308. exercise approach. Arch. Phys. Med. Rehabil. , 78,
Williams, A. R., Hind, M. and Sweeney, B. P. ( 1 994) 8 8 6-892.
The incidence and severity of postoperative Wollam, P. J. ( 1 994) Prediction and assessment of
nausea and vomiting in patients exposed to bronchodilator response in mechanically ventilated
positive intra-operative suggestions. Anaesthesia, patients. Respir. Care, 39, 730-735 .
49, 340-342. Wollmer, P . , Ursing, K . and Midgren, B. ( 1985)
Williamson, I. J. ( 1 993) Role of oxygen during Inefficiency of chest percussion in the physical
recovery from exercise in patients with COPD. therapy of chronic bronchitis. Eur. J. Respir. Dis. ,
Thorax, 48, 1 056. 66, 233-239.
Willis, J. ( 1 996) Flotation beds. Nurs. Times, 92, 45- Wolter, J. M. ( 1 997) Home intravenous therapy in
48. CF. Eur. Respir. J. , 1 0, 896-900.
Wills, P. J. and Cole, P. J. ( 1 996) Mucolytic and Wong, F. C. ( 1 9 94) Transcranial doppler monitoring.
mucokinetic therapy. Pulm. Pharmacol. , 9, 1 9 7- Intens. Care Britain, Greycoat, Harley St, London,
204. 66-69.
Wills, P. J., Hall, R. L. and Chan, W. ( 1997) Sodium Wong, W. P. ( 1 998) Acute respiratory distress
chloride increases the ciliary transportability of CF syndrome. Physiotherapy, 84, 439-450.
and bronchiectasis sputum. J. Clin. Invest., 99, 9- Wong, W. P. ( 1999) Use of body positioning in the
13. mechanically ventilated patient with acute
Willson, D. F . ( 1 998) Surfactant i n pediatric respiratory failure. Physiother. Theor. Pract., 15,
respiratory failure. Respir. Care, 43, 1 070-1085. 25-4 1 .
Wilson, A. E. ( 1996) Effect of backrest position on Wong, W . P. (2000) Physical therapy for a patient in
hemodynamic and right ventricular measurements. acute respiratory failure. Phys. Ther. , 80, 662-
Am. J. Crit. Care, 5, 264-270. 670.
Wilson, D. C. ( 1 992) Respiratory problems in the Wong, D. H. and Shier, M. E. F. ( 1 997) Chronic
newborn. Br. J. Intensive Care., 2, 287-294. obstructive pulmonary disease and postoperative
Wilson, R. ( 1 988) Secondary ciliary dysfunction. Clin. pulmonary complications. Curro Opin. Anaesth.
Sci. , 75, 1 13-120. 1 0, 254-25 8.
Wilson, R. ( 1 999) Bacterial infection and COPD. Eur. Wong, C. A., Cole, A. A. and Watson, L. ( 1 996)
Respir. J. , 13, 233-235. Pulmonary function before and after anterior
Wilson, R. C. and Jones, P. W. ( 1 989) A comparison spinal surgery in adult idiopathic scoliosis. Thorax,
of the visual analogue scale and modified Borg 5 1 , 534-536.
scale for the measurement of dyspnoea during Wood, A. M. ( 1 993) A review of literature relating to
exercise. Clin. Sci., 76, 277-282. sleep in hospital. Intens. Crit. Care Nurs. , 9, 1 29-
Wilson-Davis, S. L. ( 1 997) Air entry in infant 136.
resuscitation: oral or nasal routes? J. Appl. Wood, M. K. and Spiro, S. G. (2000) Pulmonary
Physiol., 82, 152-155. embolism. Hosp. Med. , 6 1 , 46-50.
Winer, J. B. ( 1 994) Diagnosis and treatment of Woodward, S. ( 1996) Nutritional support for head
Guillain-Barre syndrome. Care Crit. Ill, 1 0, 23-25. injured patients. Prof. Nurse, 1 1 , 290-292.
------ 537
REFERENCES
Worcester, M. c., Hare, D. L. and Oliver, R. G. Young, I . H . ( 1 989) Effect o f low dose nebulized
( 1 993) Early programmes of high and low morphine on exercise endurance. Thorax, 44,
intensity exercise and quality of life after acute 3 8 7-390.
myocardial infarction. Br. Med. J., 307, 1 244- Young, J. ( 1 998) Rehabilitation for older people. Br.
1 247. Med. J., 3 16, 1 108- 1 1 09.
Wren, W. S. ( 1 989) Anaesthetic technique in the Young, S., Bitsakou, H. and Caric, D. ( 1 991)
newborn. Intensive Care Med. , 1 5 , S46-S49. Coughing can relieve or exacerbate symptoms in
Wright, A. L. ( 1 989) Breast feeding and lower asthmatic patients. Respir. Med. , 85 (suppl. A), 7-
respiratory tract illness. Br. Med. J., 299, 946- 12.
949. Yuksel, B. ( 1 994) Comparison of the effects on lung
Wright, E. C. ( 1 993) Non-compliance - or how many function of two methods of bronchodilator
aunts has Matilda? Lancet, 342, 909-9 1 3 . administration. Respir. Med. , 88, 229-233.
Wu, C. L . , Jani, N . D. and Perkins, F. M . ( 1 999) Yule, W. ( 1 999) Post-traumatic stress disorder. Arch.
Thoracic epidural analgesia versus intravenous Dis. Child. , 80, 1 07-1 09.
patient-controlled analgesia for the treatment of Yung, B. ( 1 996) Totally implantable venous access
rib fracture after motor vehicle crash. J. Trauma, devices in CF. Respir. Med. , 90, 353-356.
47, 564-5 67. Zadai, C. ( 1 9 9 1 ) Cardiopulmonary ageing and
Wuyam, B., Payen, J. F. and Levy, P. ( 1 992) exercise, in Respiratory Care, (ed. J. A. Pryor),
Metabolism and aerobic capacity of skeletal Churchill Livingstone, Edinburgh, pp. 1 99-
muscle in chronic respiratory failure related to 226.
COPD. Eur. Respir. J., 5, 1 5 7- 1 62. Zalacain, R., Sobradillo, V. and Amilibia, J. ( 1 999)
Wyncoll, D. L. A. and Evans, T. W. ( 1 999) Acute Predisposing factors to bacterial colonization in
respiratory distress syndrome. Lancet, 354, 497- COPD. Eur. Respir. J., 13, 343-348.
SOL Zapletal, A., Stefanova, J. and Horak, J. ( 1 983) Chest
Wysocki, M . ( 1 999) Noninvasive ventilation i n acute physiotherapy and airway obstruction in patients
cardiogenic pulmonary edema: better than CPAP? with CF - a negative report. Eur. J. Respir. Dis. ,
Intensive Care Med. , 25, 1-2. 64, 426-433 .
Yamamoto, H. (2000) Long-term effects of nasal Zar, H. J . , Brown, G. and Donson, H . ( 1 999) Home
CPAP on daytime sleepiness, mood and traffic made spacers for bronchodilator therapy in
accidents in patients with OSA. Respir. Med. , 94, children with acute asthma. Lancet, 354, 979-982.
87-90. Zenz, M. ( 1 997) Pain therapy. Curro Opin. Anaesth. ,
Yang, Q.-H. ( 1 9 9 1 ) Effect of lung inflation on 10, 367-368.
regional lung expansion in supine and prone Zhuang, J., Schmoker, J. D. and Shackford, S. R.
rabbits. J. Appl. Physiol., 71, 76-82. ( 1 992) Focal brain injury results in severe cerebral
Yaster, M. ( 1 995) Pain relief. Pediatrics, 95, 427- ischemia despite maintenance of cerebral perfusion
428. pressure. J. Trauma, 33, 83-88.
Yaster, M., Tobin, J. R. and Billett, C. ( 1 994) Zideman, D. A. ( 1 994) Guidelines for paediatric life
Epidural analgesia for severe vaso-occlusive sickle support. Br. Med. J., 308, 1349-1 355.
cell crisis. Pediatrics, 93, 3 1 0-3 1 5 . Zidulka, A., Braidy, T. F. and Rizzi, M. C. ( 1 982)
Yellon, R . F., Coticchia, J. and Dixit, S. (2000) Position may stop pneumothorax progression in
Esophageal biopsy for the diagnosis of GOR in dogs. Am. Rev. Resp. Dis. , 126, 5 1-53.
children. Am. J. Med. , 108(4A), 1 3 1 S-138S. Ziegler, D. W. ( 1 994) The morbidity and mortality
Yellowlees, P. M. ( 1 989) Psychological defences and of rib fractures. J. Trauma, 37, 975-979.
coping styles in patients following a Iife Zimmerman, M. D., Appadurai, K. and Scott, J. G.
threatening attack of asthma. Chest, 95, 1 298- ( 1 997) Survival. Ann. Intern. Med. , 127, 405-
1 3 03 . 408
Yildiz, F . (2000) Inhaled corticosteroids may reduce Zimmet, P. (2000) Globalization, coca-colonization
neutrophilic inflammation in patients with stable and the chronic disease epidemic. J. Int. Med. ,
COPD. Respiration, 67, 7 1-76. 247, 3 0 1-3 1 0.
538
INDEX
If it is not here, see the Glossary
Numbers in bold are for Figures and Boxes, numbers in italic are for Tables.
Abdomen 3 9 Aerosol 139, 140 Anaphylactic shock 4 1 0

Abdominal Afterload 326 Angina 3 1
breathing 154, 173 Ageing 1 8 Angioplasty 27 1
for asthma 82 Agonist 133 Angiotensin antagonists 335
for CF 90 Agoraphobia 293 Ankylosing spondylitis, 103
contenrs 4 AJDS 104, 1 07 Antagonist 1 3 3
distension' 148 Air enrry 42 Antibiotics 1 37
paradox 37, 6 1 Air leak 267, 269 in asthma
Abscess 1 0 8 Air trapping 68 in bronchiectasis 86
postural drainage for 1 92 Airflow/airways obstruction 65, 66 in CF 89
on x-ray 46, 5 1 measuremenr 58 nebulized 89
Absorption atelectasis 1 20, 249, 348 Airway closure 1 8 Anticholinergics 1 34, 136
Accessory muscles 36 with ACB 1 95 Antimuscarinic drugs 1 3 6
in emphysema 69 in children 427 Antioxidants
Accuhaler 140 in older people 1 8 and asthma 74
ACE-inhibitor drugs 32, 335 Airway pressure 3 64 and smoking 20
Acetylcysteine 137 Airway pressure release venrilation and surfactant 6
Acid-base balance 1 5- 1 7 35 1-2 Aneurysm, aortic 248, 264
Acidosis 1 5-16 Airways 5 and coughing 203
Acquired immune deficiency syndrome floppy 65, 67 Anxiety 225, 3 3 6
107 Guedel 207 and surgery 252
see also AJDS for IPPV 343-5 Aorta, coarctation of 276
Active cycle of breathing 194 nasopharyngeal 207, 208 Aortofemoral graft 264
for CF 90 resistance 5 Apnoea 3 7
see also ACB Alarms 3 8 6 in babies 445
Activities of daily living 33, 242 Albumin 2 9 Arnold's nerve response 203
see also ADL in inrensive care 3 3 3 , 362 Aromatherapy 244
Acu pressure in liver disease 1 14 Arrest
for asthma 84 in pulmonary oedema 45 cardiac 3 8 1
for cough assistance 203 Alcohol 132 respiratory 382
for hiccups 251 Alexander technique 244 Arrhythmias 1 4
for nausea 250 Alfenranil 3 3 7 atrial 3 3 1
for pain 258 Alkalosis 15-16 manual techniques and 1 94
for urine retenrion 25 1 Allergens 74-5 monitoring of 3 3 1
Acupuncture 83, 244 Allergic bronchopulmonary nodal 33 1
Acute lung injury 4 1 2 aspergillosis 92 postural drainage and 193
Acute respiratory distress syndrome Alphal -anritrypsin 3, 89 supravenrricular 3 3 1
4 1 1-18 deficiency 93 Arterial blood gases 1 1- 1 7
clinical features 4 1 3 Alternative therapy in asthma 77
medical treatment 4 1 4 see complementary therapy in intensive care 324
mortality 4 1 8 Alveolar-capillary membrane 1 0, 60, 96 Arterial line disconnection 386
pathophysiology 4 1 2 Alveoli 1, 1 0, 1 4 Arterialised capillary blood 1 26
physiotherapy 4 1 5 Alveolitis 9 7 Arteriography 53
ADH 29 Aminophylline 1 34, 1 3 6 Asbestos 3
ADL 307 Amiodarone 96, 1 1 6, 3 3 6 Asbestosis 97
see also activities of daily living Anaemia 29 Ascites 1 14
Adrenaline 335 Anaerobic threshold 23 Aspergillus 92
Adrenergic drugs 135 Analgesia 256 Aspiration 1 02
Advance directive 3 2 1 in inrensive care 3 3 7 case study 340-1
Aegophony 44, 9 8 patient-controlled 257 pneumonia 1 05-7
Aerochamber 140 pre-emptive 253 and tracheostomy 28 1
539
INDEX
Assessment 28-64 Bacteria 1 1 6 Breathing 8

for babies 439 Bacteriology 3 0 deep 7, 9
for children 426 Bagging see manual hyperinflation paradoxical 37, 395, 406
in intensive care 3 6 1 , 367 Bag-mask ventilation 383 pattern 3 6, 426
for rehabilitation 2 13-24 Balloon pump, intra-aortic 3 3 8-9 rapid 7
Assist-control 350 Balloon-tipped catheter 329 Breathing control
Assist mode 350 Bambuterol 134 see abdominal breathing
Asterix 34, 1 14 Bamiphylline 137 Breathing exercises
Asthma 67, 73-84, 75 Barrel chest 34, 68 basal costal 153
acute 76, 77 Barotrauma 346, 366 localised 153
blood gases 15, 1 6 Base excess 15-17 for secretion clearance 194, 199
breathing techniques for 8 1 Becloforte 134 after surgery 260
and breathlessness 1 67 Beclomethasone 134 for loss of volume 152
brittle 76 Becotide 134 see also deep breathing, breathing re
cardiac 1 1 2 Bed rest 24 education
causes of 74 Beds 371-2 Breathing re-education 17 1-3
in children 429 Benchmark 449 for hyperventilation syndrome 301
clinical features 76 Beta-blockers 30, 3 3 6 Breathlessness 3 1, 166-9
drug management 8 1 and asthma 75 assessment for 215, 237
education 78 and exercise 233, 288 in children 426
exercise for 8 3 Bicarbonate 15-16 drugs for 1 3 6
exercise-induced 77 standard 1 5- 1 6 i n dying people 3 12
extrinsic 76 Bigeminy 3 3 2 in hyperventilation syndrome 295
in intensive care 393 Bilevel positive airway pressure 1 7 9 mechanism of 166
intrinsic 76 and IPPV 3 5 2 in older people 308
nocturnal 78 see also BiPAP and oxygen 1 1 9
occupational 78 Biofeedback 244 physiotherapy for 169, 173, 230,
oxygen for 1 26 in CF 90 390
and pregnancy 23 Biopsy 143, 265 in pulmonary oedema 1 12
Asystole 3 3 3 BiPAP Bricanyl 134, 135
Atelectasis 1 47-8 for sleep apnoea 1 12 Bronchial breathing 42
assessment of 40, 44 for rib fracture 407 Bronchiectasis 44, 84-7
positioning for 1 50, 1 5 1 see also bilevel positive airway postural drainage for 1 92
following surgery 249, 250, 254, pressure Bronchiolitis 430
271 , 277 Bird 1 60 Bronchitis
and VAIQ 1 4 see also IPPB acute 1 1 6
o n x-ray 4 8 , 5 1, 5 4 , 420 Bird fancier's lung 96 chronic 44, 66-7
Atenolol 3 3 6 Bleeding 383 Bronchoconstriction 2
Atopy 74, 429 Blood lactate 24 Bronchodilators 134, 135-6
Atracurium 337 Blood pressure 30, 326 in asthma 8 1
Atrial fibrillation 332 see also BP combination therapy 72
Atrial flutter 333 Blood, pulmonary 8, 10 in COPD 72
Atrophy 24 Blue bloater 7 1 , 1 72 in intensive care 337
Atrovent 134, 1 3 6 Borg 237, 288-9 Bronchogram 8 6
Audit 455-7 Botulism 405 see also bronchography
Auscultation 41-4 Bowel resection 263 Bronchography 53
in babies 439 BP 30 see also bronchogram
cervical 1 02 in children 426 Bronchophony 43
Autogenic drainage 1 9 6-8 with exercise 23 Bronchopleural fistula 267
for CF 90 with exercise training 233, 288 postural drainage and 193
Autohaler 1 3 9, 140 after heart surgery 272 Bronchopulmonary dysplasia 444
see also blood pressure Bronchoscopy 143
Ih-adrenergics 135 Bradycardia 30 Bronchospasm 2
Ilz-agonists 1 34, 135 sinus 3 3 1 in asthma 74
liz-stimulants 1 35-6 ventricular 3 3 1 in chronic bronchitis 67
Babies 434-46 Breath-holding 1 73 drugs for 135
physiotherapy for 438 Breath sounds 4 1 , 44 in obstructive disease 65, 66
Baclofen 138, 397 in intensive care 363 suction and 208
Bacteraemia 409 see also auscultation Bubble-through humidifier 1 8 8
540
INDEX
Bucket handle action 69 Central line 327 Clickhaler 140

Budesonide 134 Central venous pressure 327-9 Clinical governance 449
Buffer 15-16, 29 Cerebral oedema 3 99, 400 Closing volume 1 8
Bulbar weakness 101, 1 8 1 Cerebral perfusion pressure 399-404 and smoking 21
Bulla Cerebrospinal fluid 3 9 9 Clotting problems 3 62, 408
with emphysema 72, 73 Chemistry 29-30 manual techniques and 1 94
on x-ray 5 1 , 63 Chemoreceptors 4, 1 67 suction and 208
Bullectomy 265 Chest drains 268-70 Clotting studies 29
Bundle branch block 333 clamping 269 Clubbing 34, 98
Bupivacaine 257 disconnection 270 CO 1 8
Burns 1 8 , 4 1 9 for pneumonectomy 265 C02 1 7- 1 8
Buteyko 8 2 for pneumothorax 100 with exercise 23
positioning for 1 5 1 output 24
Cache tic 3 3 Chest infection 1 1 6-7 retention 77
Calcium channel blockers 3 3 5 in children 430 production 62
Cancer after surgery 250 Cocaine 1 1 6
laryngeal 278 Chest shape 34 Collagen vascular disease 96, 408
lung 108 Chest wall 4 Collapse 52, 9 3
oesophageal 1 15, 276 Cheyne-Stokes breathing 37, 3 9 8 i n ARDS 4 1 2
positioning for 152 Children 425-34 o n x-ray 9 3 , 261
see also palliative care assessment of 426 see also atelectasis
Cannabis 1 1 6, 3 1 2 and bereavement 3 1 1 Collateral ventilation 71
Capillaries, pulmonary 1 0, 1 4 and consent 427 Colloid 3 3 3
Capillary blood 1 2 diseases of 429-3 1 Colour 33
Capillary refill 4 1 dying 433 Combivent 1 3 6
Capnography 325 physiotherapy for 427-9 Commando 278
in hyperventilation syndrome 297, surgery for 43 1 Communication
299 Chinese herbal medicine 1 37, 43 1 with breathless people
Capnometry see capnography Chloride 29 with dying people 3 1 1-12
Captopril 335 Chlormethiazol 337 in intensive care 318, 3 69
Carbon dioxide Choking 93 in neurological disease
partial pressure 12, see also PaC02 Cholecystectomy 263 between staff 322
see also CO2 Cholinergic receptors 1 3 5 see also speech-language therapy
Carbonic acid 15 Chromones 133, 134, 429 Compensation 1 6
Carbon monoxide 3 Chronic airflow limitation 65 Competence 450
poisoning 130, 4 1 9 Chronic fatigue syndrome 24, 293 children 427
and smoking 22 in children 43 1 patients 320
Carcinoma 1 08 Chronic lung disease of prematurity staff 458
see also cancer 444 Complementary therapy 82, 243-4
Cardiac arrest 3 8 1 Chronic obstructive pulmonary disease Compliance 5-6, 6
i n babies 445 65-73 static 6
Cardiac ourput 34 causes 66 dynamic 6
and IPPV 346 clinical features 70 effect of positioning 149
low 363 drugs for 72-3 Computed tomography 53-4
monitoring 330 end stage 73 Condenser humidifier 1 9 0
Cardiac rehabilitation 287-9 1 exacerbation 72 Confusion 306
benefits 287 in intensive care 393 Congestive cardiac failure 1 1 3
safety for 288 oxygen for 72 Contusion 407
Cardiac surgery physiotherapy for 73 manual techniques and 1 94
atelectasis 148 and smoking 67 Corticosteroids 134
see also heart surgery work of breathing in 7 see also steroids
Cardiac tamponade 384 see also COPD Consent 320
Cardiogenic shock 410 Cilia 2 Consolidation 14
Cardiopulmonary bypass 270 Circuit exercises 235, 236, 238 in ARDS 4 1 2
Cardiopulmonary resuscitation 3 8 1 Circulation in aspiration pneumonia 1 06
Cardiovascular disease 1 12 bronchial 1 0 assessment for 42, 40, 44
Catecholamines 26, 4 1 1 pulmonary 1 0 and physiotherapy 148
Catheters 205 Cirrhosis 409 on x-ray 48, 1 17, 261
for children 428 Clapping see percussion Constipation 308
541
INDEX
Continuous positive airway pressure Crystalloid 334 Desensitization to breathlessness 1 74,

156-60 CT scan 94 232
and [PPY 352 of ARDS 414 Dexamethasone 402
to reduce work of breathjng 1 79 of emphysema 94 Dextran 333
see also CPAP Cuff Dextrocardia 92
Contractu res 24 tracheal tube 344 Dextrose 334
in Guillain-Barre syndrome 395 tracheostomy 279, 280 Diabetes 16, 1 15-1 16
Control of breathing 3-4 Cuirass 180 rehabilitation for 214
Controlled mandatory ventilation 350 Cupping 1 93 Diaphragm 4
COPD 74, 86 Cyanosis 33 endurance 15
and FEY] 2 1 5 in chjldren 427 fatigue 7 1 , 3 5 6
and malnutrition 1 3 1-3 Cyclosporin 275 and malnutrition 1 32
and manual hyperinflation 375 Cystic fibrosis 85, 87-92 paral ysis 61
oxygen for 127 case study 209 rupture 406, 422
see also chronic obstructive clinical features 88 on x-ray 48, 49
pulmonary disease education for 89 Diaphragmatic breathing
Coronary heart disease 1 13 exacerbation of 8 8 see abdominal breathing
Cornet 202 gene therapy for 89 Diary
Cor pulmonale 70 inspiratory muscle training for 240 for asthma 8 0
Costophrenic angles 49 medjcation for 8 9 i n pulmonary rehabilitation 225
Cough 3, 3 1-2, 202-4 pathophysiology o f 8 7 smoking 227
in CF 92 physiotherapy for 9 0 Diazepam 337
in children 428 precautions for 9 1 DIC 4 1 1
drugs for 13 8 screening for 88-9 see also disseminated intravascular
in dying people 3 13 surgery for 90 coagulation
facilitation 202 x-ray of 209 Diffusion 10
and head injury 401 Cytokines 74 measurement 60
nocturnal 204 Digoxin 336
paroxysmal 204 Dairy foods 1 3 2 Disability 214
postoperative 26 1 , 262 Dead space 8 Discomfort
precautions 203 with exercise 23 in dying people 3 14
in quadriplegia 396 and IPPY 347 in intensive care 3 1 8
suppression 204 Death see dying Disconnection of equjpment 385
with pneumothorax 1 00 Death rattle 3 14 Diskhaler 140
Cough belt 272-3 Decortication 268 Disseminated intravascular coagulation
Cough mixture 1 3 8 Deep breathing 1 5 2-3 408
Cough syncope 204 positioning for 1 5 1 see also DIC
CPAP 3 5 1 after surgery 2 6 1 Diuretics 1 6, 138, 335
for CF 92 on a ventilator 372 Dizziness 32
in children 427 Deep vein thrombosis 1 13 rhDNase 89, 92
for heart failure 1 13 prevention 26 1 D02 1 7- 1 8
after heart surgery 272 after surgery 25 1 Dobutamine 336
for pneumonia 1 04, 105, 106 see also DVT Do-not-resuscitate 3 2 1
for rib fracture 407 Defence 1 Dopamine 3 3 6
for sleep apnoea 1 1 1 Dehiscence Dopexamine 336
and weaning 358 sternal 271 Dopram 138
to reduce work of breathing 180 wound 25 1 Doxapram 1 3 8
see also continuous positive airway Dehydration 29, 3 0, 40 Drowning 420 .
pressure definition 333 Drug-induced lung disease 1 1 6
Crackles 41, 43 in dying people 3 1 3 Drugs 133-43
Cranial surgery and coughing 203 Dementia 306 for breathlessness 136
Crash 3 8 1 and bereavement 3 10 for bronchospasm 135
Creatinine 29 and smoking 2 1 cardiovascular 335
Crepitations 43 Denial 3 1 0 for coughing 1 3 8
Criteria 450, 456 Depression 3 2 , 70, 225 delivery devices 138
Critical illness neuropathy 405, 4 1 2 in dying people 3 1 4 for dying people 3 12
Croup 430 i n intensive care 3 1 8, 370 illicit 1 1 6
Cryoanalgesia 258 in older people 306 for infection 13 7
Cryotherapy 109 after surgery 25 1 for inflammation 133-5
542
INDEX
for oedema 1 3 8 and IPPV 349 in hypervenrilation syndrome

i n older people 306 Endotoxin 409, 4 1 1 293-5
for pain 258 Endotracheal tube 344 Falls 32
side effects 134 in babies 437 Farmer's lung 96
for smoking cessation 228 displaced 363, 364 Fatigue 32
for venrilation 138 End-tidal COz monitoring 402 inspiratory muscle 7, 8, 24, 37
see also medication Endurance 62, 240 after surgery 250
Dry-powder inhalers 139, 140 Energy conservation 24 1 Feeding
DVT Enronox 258, 337, 402 in babies 437
and epidurals 257 Eosinophils 29, 3 8 , 74 carbohydrate 335
prevenrion 262 Epidural 257 enreral 334
and trauma 396, 404 in babies 436 inrravenous 335
see also deep vein thrombosis Epiglottis 2 nasogastric 264
Dying people 309-14 Epiglottitis 430 see also nutrition
communication with 3 1 1-2 Epilepsy 383 FEF zs_7s 59
management of symptoms 3 1 2 Epistaxis, postural drainage and 193 FEFs o 59
Dynamic compression o f airways 3 , Equal pressure point 1 94, 195 Feldenkrais 244
194 ERV 56 FEV, 56, 58, 5 9
Dysphagia 102 see also expiratory reserve volume to measure secretion clearance 1 84
Dyspnoea 166 Evaluation 449 FEV,/FVC 56, 5 9
see also breathlessness Evidence-based practice 450 Fever 3 0
Exercise see also temperature
Easi-breathe 139, 140 arm 236 Fibrillation
ECG 33 1-3 anaerobic 289 atrial 332
Eclampsia 23 capacity 6 1 ventricular 332, 333
Ecstasy 1 1 6, 408 i n cardiac rehabilitation 288 Fibrosing alveolitis 96
Ectopics 33 1-2 in CF 91, 92 Fibrosis 66, 96
Education effects 23-4 on x-ray 46, 50
for asthma 78 flexibility 230 Fissure
in cardiac rehabilitation 287 in hypervenrilation syndrome 301 horizonral 49, 52, 54
for CF 89 in inrensive care 379 oblique 52, 54
conrinuing 457 in older people 307-9 Fitting 383
for hypervenrilation syndrome 299 isometric 234, 289 Flail chest 406-7
in pulmonary rehabilitation 221 isotonic 234, 289 CPAP for 1 60
Eformoterol 134 and oxygen 120 Flixotide 134
Elastic recoil 66-7 prescription 234, 288 Flow-volume loop 59, 60, 323, 325,
Elderly people 306-9 in pulmonary rehabilitation 232 364
Electrocardiography 33 1-3 for secretions 1 92 Flu see influenza
Electrolarynx 282 testing 44, 217, 221 Fluid chart 3 0
Embolectomy 1 14 tolerance 44, 307 Fluids
Embolism training 232, 288 in babies 437
air 3 85 for loss of volume 148 in inrensive care 3 3 3 , 347, 362, 4 1 2
fat 407 and work of breathing 7 monitoring 326
pulmonary 14, 1 1 3-14 Exhalation and surgery 25 1 , 253
postoperative 261 forced 36 Fluoroscopy 52
on x-ray 53 see also expiration Fluticasone 134
Emergencies 38 1-7 Expansion 3 9 Flutter device 201
in babies 445 Expectoration 185 Flutter valve 268
EMLA 258 Expiration 4-5 Foradil 134
Emphysema 44, 65, 66, 67-9 see also exhalation Forced expiratory volume in 1 sec 55
on CT 94 Expiratory reserve volume 57 see also FEV ,
and elastic recoi I 5 see also ERV Forced vital capacity 55
primary 93 Extracorporeal membrane oxygenation see also FVC
pulmonary inrerstitial 346, 438 340 Foreign body 93
senile 1 8 Extracorporeal support 3, 340, 415 Fracture see rib fracture
see also COPD Extubation 358 FRC 56
Empyema 99, 268, 277 Exudate 99 see also functional residual capacity
after surgery 267 Frusemide 1 3 8
End-inspiratory-hold 153 Fainting 32 Full blood counr 29
543
INDEX
Functional residual capacity 5, 1 8 , 57 Hayek 1 8 1 Hyperinflation 68-70

see also FRC HC03- 1 6 , in asthma 76
FVC 56, 59 Head box 124 dynamic 68
measurement 58 Head injury 3 9 8-405 in emphysema 68
Head and neck surgery 277 on x-ray 47
Gag 3 posrural drainage and 193 Hyperkalaemia 29
Gas dilution 5 9 Heart block 332, 333 Hypermetabolism 334
Gas transfer 60-1 Heartburn 1 15 Hypernatraemia 29
Gas trapping 68 Heart failure 70, 1 13 Hyperpnoea 166
see also PEEP, intrinsic Heart rate 3 0 Hyperreactivity 74, 75
Gastric tonometry 330 in children 426 Hypertension 30
Gastro-oesophageal reflux 32, 1 15 maximum 236, 288, 2 9 1 in COPD 70
in asthma 75 Heat-moisture exchange 190 posrural drainage and 1 93
in CF 88, 9 1 for IPPV 345 pulmonary 1 1, 70, 412
in children 428 Heimlich valve 100 Hypertrophic pulmonary
Gastrostomy 264 Heliox 1 3 0-1 osteoarthropathy 109
Glasgow coma scale 401-2 Heparin, suction and 208 Hyperventilation 1 6, 166
Glaucoma Hepatomegaly 1 14 in head injury 398-9, 402
and atrovent 1 3 6 Heroin 1 1 6 in liver disease 1 14
a n d cannabis 1 1 6 Hiarus hernia Hyperventilation syndrome 291
Glossopharyngeal breathing 1 8 0 postural drainage and 193 and ACB 196
Glottis 3 Hiccups 251 assessment 295-8
Glue ear 92 High-side-Iying 168 case study 3 14
Glue sniffing 1 1 6 Hila 48 causes 292
Ground glass o n x-ray 49, 97 Histamine 74 in children 43 1
Grunting 426-7 HIV 1 07 effects 294
Goals 147 Homan's sign 25 1 treatment 299-305
Goblet cells 67 Home Hypnosis 250
Goggles 208 management 244, 304 Hypnotherapy 83, 244, 305
Goodpasture's syndrome 408 ventilation 1 76, 445 Hypocapnia 12
Guedel airway 207 visits 244 Hypocarbia 1 2
Guideline 450 Homeopathy 83, 92 Hypoglycaemia 1 1 6
Guillain-Barre syndrome 393 Honeycombing on x-ray 49, 97, 1 02 Hypokalaemia 29
Gut Hoover's sign 69, 1 72 Hyponatraemia 29
and IPPV 348 Hot water bath see humidification, hot Hypotension 30
ischaemia 4 1 1 water postural 32, 306
lining 14, 335 Huffing 1 94-6 Hypothermia 420
Humidification 1 85-92 Hypoventilation 13, 14, 1 6
Haematemesis 38 for babies 437 i n COPD 7 1
Haematocrit 29, 70 cold water 1 8 8 nocturnal 1 1 1
Haematology 29 heat-moisture exchange 1 9 0 Hypovolaemia 333, 362
Haemodialysis 409 hot water 1 8 7 and surgery 253
Haemofiltration 409, 4 1 1 for IPPV 345 Hypovolaemic shock 410
Haemoglobin 1 2-13 , 29 room 1 9 1 Hypoxaemia 12-15, 14
saruration with oxygen 1 1-12, 324 nebulized 1 8 8 after surgery 250
Haemopneumothorax 406 and oxygen 1 2 1 Hypoxia 1 1-13
Haemoptysis 37, 383 for tracheostomies 282
in CF 92 Humidity 1 85-6 I : E ratio 71
and coughing 203 Hydralazine 335 and IPPV 349
in bronchiectasis 85 Hydration 40, 1 8 6-7 19A 3
manual techniques and 1 94 Hydrocortisone 1 34 IgE 74, 75
postural drainage and 1 93 Hyoscine 1 0 1 Ileus, paralytic 264
suction and 208 Hypercapnia 1 2-15, 1 4 IMA 270-1, 272
Haemorrhage 25 1 , 3 8 3 in COPD 71 Imagery 244
intraventricular 4 4 1 , 444 in neuromuscular/skeletal disorders Imaging 45
Haemothorax 99, 406 1 03 radionuclide 52
Half-life 1 3 3 permissive 352, 414 Immobility, effects of 24-5
Handicap 2 14 Hypercarbia 12 Immune system 29
Hands 34, 3 63 see also hypercapnia Immunoglobulin 3
5 44
INDEX
Immunosuppression 1 07 Intracranial pressure 3 99-405 in emphysema 69

after transplant 275 monitoring 401-2 in CF 88
Impairment 2 1 4 Intrathecal 258 in older people 308
Incentive spirometry 1 5 6 Interstitial lung disease 44, 50, 96-8 postoperative 264
for quadriplegia 3 9 7 Inverse ratio ventilation 352, see also nutrition
for sickle cell disease 1 15 Iodinated glycerol 1 3 8 Mannitol 137, 1 3 8 , 402
Incisions 263 IPPB Manometer 374, 441
for heart surgery 270 to reduce work of breathing 1 8 0 Manual hyperinflation 372-6
for lung surgery 264 see also intermittent positive pressure in babies 440
for oesophagectomy 277 breathing and blood pressure 3 62
Incontinence 3, 27, 306 Ipratropium 134 complications of 375
Indomethacine 137 Iron lung 1 8 0 effects of 373
Indrawing of soft tissues 36 IVOX 339 after heart surgery 272
Infants 434-46 Isoflurane 337 precautions 375
Infection 409 pressures 374
chest 1 16-7, 430 Jejunostomy 264 technique of 373
control of 322 Jet nebulizer 1 4 1 , 1 8 8 Manual techniques
drugs for 13 7 Jet ventilation 354 in babies 441
fungal 92 Jugular venous oximetry 402 in intensive care 376
Inflammation 66 Jugular venous pressure 34 for secretion clearance 1 93
in asthma 76 Mandatory minute ventilation 352
in ARDS 412 Kaposi's sarcoma 1 09 Mapleson's C 373
in bronchiectasis 85 Ketoacidosis 1 6 Mask
in CF 85 Keyhole surgery 248 for noninvasive ventilation 1 78
in COPD 67 Kidney disease 1 14 for suction 208
drugs for 133-5 Kidney failure 1 4, 408 Massage 244
in obstructive disease 65 Kyphoscoliosis 34, 1 03 for pain 3 1 3
Influenza 1 16 Mastectomy 277, 278
Infusion pumps 335 Lactic acidosis 23 Maximum expiratory pressure 6 1
Inhalers 1 3 9 , 143 Laerdal mask 383 Maximum inspiratory pressure 6 1
in children 429 Laparoscopy 248, 263 Maximum mid-expiratory flow 5 9
Inotropes 335 Laparotomy 263 Maximum oxygen consumption 62
Inspiration 4 Laryngectomy 278-83 Maximum static mouth pressures 6 1
Inspiratory:expiratory ratio Laryngospasm 207 Maximum voluntary ventilation 5 8
see I : E ratio Laryngotracheobronchitis 430 Mean arterial pressure 3 26
Inspiratory muscle strength 6 1 Larynx 4, 5 in head injury 3 99, 400
see also fatigue Laser via bronchoscopy 143 Mechanical aids
Inspiratory muscle training 239-41 Lateral x-ray 52, 53 to clear secretions 1 9 8
in asthma 83, 240 Lavage 143 t o increase volume 1 5 5
in CF 9 1 , 240 Left atrial pressure 329 t o reduce work of breathing 1 75
in COPD 240 Left ventricular failure 1 13 Mechanical ventilation 343-59
in quadriplegia 397 Liver disease 1 14, 409 in babies 437
and weaning 358 in CF 92 benefits 345
Inspiratory reserve volume 57 Living will 3 2 1 complications 346
see also IRV Lobectomy 265, 282 disconnection 3 8 6
Intal 133 Lung function test see respiratory indications 343
Intensive care 3 1 7-422 function test modes 350
admission to 3 1 7 Lung volume patient distress on 386-7
diseases 393 measurement 5 9 principles of 345
environment 3 17 methods t o increase 147-65, 372 settings 349
rehabilitation in 3 1 7 in babies 439 Mechanics of breathing 4-8
Interleukins 74 in children 427 Meconium aspiration 443
Intermittent mandatory ventilation 350 reduction surgery 266 Mediastinum 47
Intermittent positive pressure breathing Medication
1 60-3 Maggot therapy 13 7 in intensive care 335
for secretion clearance 202 Magnetic resonance imaging 54 see also drugs
see also IPPB Magnetic nerve stimulation 62 Meditation 83, 244
Internal mammary artery 270 Malaena 3 8 for pain 3 1 3
see also lMA Malnutrition 1 3 1 Medulla 4
545
INDEX
MEFso 59 Myasthenia gravis 405 Noradrenaline 335

Mesothelioma 1 09 Myocardial infarction 287, 332 Nose 2
METs 236 Nosocomial infection
Metastases 1 09 Naloxone 1 1 6 NSAIDs 256
manual techniques and 1 94 Narcotics 1 1 6 Nutrition 1 3 1 -3
Metered dose inhaler 1 3 9 Nasal cannula 1 2 1 , 1 23 , 126, 1 29 in CF 90
Methicillin-resistant staphylococcus and humidification 1 9 1 and exercise 234
aureus 322 Nasal catheter 1 23 in head injury 402
Microatelectasis 148 Nasal mask ventilation 1 75 in intensive care 334, 41 1
Microbiology 30 see also noninvasive ventilation and pressure sores 371
Midazolam 3 3 7 Nasal passages 5 supplementary 132
Miner's lung 9 7 Nasogastric tube 52 and weaning 357
Minimal access surgery 248 Nasopharyngeal airway 207, 208 see also malnutrition, feeding
Minitracheostomy 208 Nasopharyngeal aspirate 429
and jet ventilation 355 Nausea Obliterative bronchiolitis 275
and weaning 358 and cannabis 1 1 6, 250 Obesity 1 8, 1 9-20, 1 1 0
Minute ventilation/volume 8, 58 in palliative care 3 1 2-3 Obesity-hypoventilation syndrome 1 1 1
and IPPY 349 after surgery 250 Observation 33
Mite, house dust 74 Nebuhaler 140, 1 4 1 Obstetrics 23
Mixed venous blood 329 Nebulizers Obstructive disease 60, 60, 65-95
Mixed venous oxygenation 329 in children 430 Oedema 34
Mixed venous saturation 330 for drugs 1 4 1 , 338 in COPD 72
Mobility 32 for humidification 188 -90 drugs for 13 8
chart 307, 309, 452, ultrasonic 1 8 8 , 1 9 1 Oesophageal speech 282
controlled 148-9 Nedocromil sodium 134 Oesophageal varices 92
in intensive care 380 Negative pressure ventilation 180 Oesophagectomy 276-7
safety 148 Neonatal unit 434, 436 CPAP for 1 5 9
after surgery 260, 272 Neonates 435 O n calls 387-9, 454
for loss of volume 148 see also babies Ondine's curse 359
Monitoring 322, 363 Neurogenic shock 4 1 0 Opioids
of arterial oxygen 324, 326 Neurophysiological facilitation of for dying people 3 13
of cardiac output 3 3 0-1 respiration 154-5 see also morphine
of CO2 325 Neuromuscular blockade 3 3 7 Orthopnoea 3 1 , 1 1 2
of fluids 326 Neuromuscular disorders 101 Oscillator 1 8 1, 202
haemodynamic 326 atelectasis in 148 high frequency 354
of heart rhythm 3 3 1 cough assistance for 202 Osteoporosis
o f tissue oxygen 329 inspiratory muscle training for 240 in CF 92
of ventilator interactions 322 in intensive care 393 in dying people 3 1 4
Morphine Neutropenia 362 manual techniques and 1 94
for breathlessness 1 3 6 Neutrophils 29, 3 8 Outcomes 450, 452
for pain 256 Nicotine 2 1 in asthma 83
Motivation 224 replacement 2 1 , 228 in CF 91
Motor neurone disease 1 0 1 Nijmegen questionnaire 297 in hyperventilation syndrome 305
MRI 54 Nitrates 335 for loss of lung volume 1 63
MRSA 322 Nitric oxide 336, 4 1 4 for secretion clearance 209
Mucociliary clearance 1 85 Nitrogen loss 3 3 4 for rehabilitation 245
see also secretions Nitrogen washout 5 9 for excess work of breathing 1 8 1
Mucociliary transport 3 Nitrous oxide see Entonox Overdose
Mucus membrane 2 Nodal rhythm 3 3 1 paracetamol 408
Mucus trap 3 8 Noise 3 1 8, 434 see also poisoning
Multiple sclerosis 1 0 1 Noninvasive ventilation 1 75 Oximeters 2 1 7, 220
and cannabis 1 1 6 in ARDS 4 1 4 Oximetry 125, 325
Multisystem failure 409-12 in asthma 8 4 Oxitropium 134, 1 3 7
Muscle relaxants 337 in CF 9 2 Oxivent 1 3 4
Muscles in COPD 73 Oxygen 1 1 9-30
respiratory 4-5 complications 1 77 acute 125
accessory 4 modes 1 79 ambulatory see portable
inspiratory 7 in neuromuscular disorders 1 0 1 , 397 in babies 437
intercostal 4 in sleep apnoea 1 1 2 and breathlessness 1 1 9
546
INDEX
complications of 120 Palpation 39-41 Plethoric 33, 7 1

concentrator 1 28-9 Pancoast's tumour 1 10 Pleura 6
controlled 125, 126, 127 Pancreatitis 389, 408 Pleural drains 268
cost of breathing 63 Pancuronium 337 Pleural effusion 44, 98-9, 366
cylinder 128-30 Panic attacks 304 and lung compression 148
dissociation curve 12-13, 12, 126 PaOZ 15 x-ray of 46, 47, 49, 52
domiciliary 1 26-9 Paralysing agents 337 Pleural rub 43
and exercise 1 20, 129 Paralytic ileus 264 Pleurectomy 268
hyperbaric 130 Parenchymal lung disorders 1 6 6 Pleurisy 107
indications 1 1 9 Paroxysmal nocturnal dyspnoea 3 1, Pleurodesis 268
intermittent 126, 127 1 12 Pneumobelt 1 8 1
liquid 129, 130 Peak airway pressure 323, 345, 3 64 Pneumoconiosis 97
long-term 72, 126-9 Peak cough flow Pneumomediastinum 347, 3 66
masks 121-3 Peak expiratory flow 55 Pneumonia 1 03-7, 1 1 7
nocturnal 128 see also peak flow aspiration 105-7, 446
partial pr� ssure of 11, see also PaOz Peak flow 5 8 broncho- 1 04
portable 1 29-130 in asthma 74, 7 6 , 7 9 in children 43 1
prescription 120, 1 24, 217 Pectus carinatum 34 LegionelJa 1 05
after surgery 250 Pectus excavatum 34 lobar 1 04
tension 1 1-13 PEEP nosocomial 105
tent 124 in ARDS 4 14 oxygen for 126
toxicity 120, 348 in babies 438 positioning for 1 5 1
Oxygen consumption 7, 1 7 intrinsic 68, 349 Pneumocystis carinii 1 04-5
wi th exercise 23 and manual hyperinflation 375 on x-ray 50, 63
to minimize 366 physiological 352, 357 Pneumonectomy 265-6
wi th sleep 25 see also positive end-expiratory coughing and 203
Oxygen content 1 1-12, 1 7 pressure radical 268
Oxygen delivery 1 3 , 1 7, 7 0 PEG 264 suction and 208
Oxygen extraction 1 8 Pelvic floor exercise 1 9 9 Pneumonitis 1 06, 1 1 6
Oxygen transport 17 Pentamidine 1 05 Pneumopericardium 347, 366
Oxygen uptake 1 7, 24 Percussion 1 93 Pneumotachograph 58
maximum 24 see also manual techniques Pneumothorax 5, 44, 99-100, 406
Percussion note 39-40, 44 in babies 445
Pso 12 Percussors 202 in CF 88, 90
Pacemaker Perfusion 10-1 1 and IPPV 347
artificial 338 distribution of 1 1 postural drainage and 193
natural 3 3 1 gradient 9, 1 0 suction and 208
Pacing 1 74 and IPPV 347, 348 tension 384
in hyperventilation syndrome 3 04 wasted 13, 14 on x-ray 49
phrenic nerve 397 Peritoneal dialysis 409 Poisoning 4 1 8
wires 338 Pertussis 43 1 Pollutants
Packed cell volume 29 pH 15 with asthma 74
PaCOZ 15 Pharyngeal muscles 4 wi th exercise 23
Paediatrics 425 Pharynx 2 Polyarteritis nodosa 408
see also children Phrenic nerve Polychondritis 1 44
Pain 3 1, 253-9 injury 267, 271 Polycythaemia 70
assessment 254-5 stimulation 62 Pons 4
in babies 436 Pickwickian syndrome 1 1 1 Positioning
in children 432 Pink puffer 71, 1 72 for ARDS 415
in dying people 3 1 3 Pigeon chest 34 in babies 439
effects o f 254 Pigeon fancier's lung see bird
- for breathlessness 168, 230
handling patients in 255 fancier's lung in children 427
medication for 256 Plasma 333 for head injury 402, 404
in older people 308 exchange 338 for haemopnewnothorax 406
phantom 253 expanders 333 in intensive care 3 7 1 , 372
pleuritic 3 1 Plasmapheresis 338 for neuromuscular disorders 1 0 1
postoperative 253 Plateau 349 for pleural effusion 9 9
Palliative care 3 1 0 Platelet count 29 for pneumothorax 1 00
Pallor 33 Plethysmography 5 9 for secretion clearance 1 92
547
INDEX
after surgery 260, 272, 277 Pulmonary oedema 44, 45, 50, 1 12-13 Respiratory failure 1 17
for loss of volume 149 and fluid chart 3 0 Respiratory function tests 54-63
for VAlQ 151 non-cardiogenic 1 1 6 in COPD 72
Positive end-expiratory pressure 353-4 neurogenic 3 9 9 for rehabilitation 215
see also PEEP positioning for 170 Respiratory insufficiency 1 17
Positive expiratory pressure 1 98-201 postural drainage and 193 Respiratoty muscle function 6 1-2
see also PEP suction and 208 Respiratory physiotherapy 147
Postnasal drip 32 after transplant 275 Respiratory rate 34-6
Postoperative physiotherapy 258 Pulmonary rehabilitation 21 1-47 in children 426
in children 433 assessment for 2 1 3 Respiratory stimulant 1 3 8
Postpolio syndrome 1 0 1-2 benefits of 2 1 1-12, 2 13 , 245 Resting positions 169
Posture criteria for 2 1 2 Restrictive disease 60, 60, 96-103
assessment of 33 safety for 214-5, 233 breathing for 172
and breathlessness 1 73, 230, 243 Pulse pressure 3 62 inspiratory muscle training for 240
Postural drainage 1 92 Pursed lip breathing 36, 7 1 , 173 rehabilitation for 2 1 3
in babies 44 1 P.02 1 7 Resuscitation
for bronchiectasis 8 6 Pyrexia 3 0 cardiopulmonary 29, 445
for CF 9 1 fluid 334
in children 428 Quadriplegia 3 95 Reticular pattern on x-ray 49, 97
in intensive care 3 76, 396, 40 1 see also spinal cord injury Retinopathy of prematurity 437
Postural hypotension 1 8 , 19, 24 Quality of life scales 3 3 , 2 1 5-7, 2 1 8 Retraction of soft tissues 36
Potassium 29, 3 62 Questionnaire 33 Retrolental fibroplasia
Prader-Willi syndrome 1 1 1 see retinopathy of prematurity
Prednisolone 134 Radial traction 67 Rheumatoid djsease 97
Prednisone 134 Radiolabelling 1 85 and smoking 20
Pregnancy 22-3 Rebreathing bag 373 Rhinosinusitis 86
and smoking 22 Recession of soft tissues 36, 71 Rib fracture 406, 420
Preload 3 26 Recoil 4, 5 manual techniques and 194
Preoperative management 252 Recurrent laryngeal nerve 1 09, 267 on x-ray 5 1 , 421
in chjldren 43 1 Refeeding syndrome 335 Rib springing 155
Pressure Referrals 455-6 Right atrial pressure 327
alveolar 5 Reflexology 92 Right heart failure 1 13
intrathoracic 5 Rehabilitation Ring shadows 48, 5 1 , 86
pleural 5 in intensive care 3 17, 379, 3 93 Road accidents 406
transmural 5, 1 94 for older people 306-9 in children 433
transpulmonary 5 after surgery 2 1 3 Rocking bed 1 8 1
Pressure control 345, 437 see also cardiac/pulmonary Rolling see turning
Pressure sores 3 7 1 rehabilitation RV 56, 5 9
Pressure support 350-1 Relatives see also residual volume
Pressure-time curve 3 23 , 3 5 1 of dying people 3 10
Pressure-volume loop 323, 324 in intensive care 3 1 9, 4 1 8 Sail sign 47
Preterm 435 physiotherapy and 147, 369 Salbutamol 134
Primary ciliary dyskinesia 92 and suicide 4 1 8 Saline 334
P.r.n. 256 Relaxation 1 70-1 hypertonic 38, 191
Prone 4 1 5-8 in cardiac rehabilitation 29 1 instillation of 379, 442
in babies 439 in hyperventilation syndrome 302 nebulizer 1 8 8
Propanolol 233, 336 in pulmonary rehabilitation 243 Salmeterol 134
Propofol 3 3 7 Research 450 Sa02 1 1-12
Prostacydin 3 3 6 Reservoir mask 122-3 Sarcoidosis 97
Prothrombin tjme 2 9 Residual volume 57, 59 Saturation 1 1-12, 324
Protocol 450 see also RV Scalenes 4
Pulmicort 134 Resistance Scleroderma 97
Pulmonary artery 1 8 of airways 5 Secretions, bronchial 45
occlusion pressure 329 of parenchyma 5 drugs for 13 7
pressure 3 29 Respiration 8 physiotherapy for 184, 376
wedge pressure 3 29 Respiratory arrest 382 in babies 44 1
Pulmonary capillary wedge pressure 329 with tracheostomy 283 in children 427
Pulmonary function tests see Respiratory centres 4 postoperative 261
respiratory function tests Respiratoty distress syndrome 444 Sedatives 336, 361
548
INDEX
Segmentectomy 265 Special care baby unit abdominal 263-4

Seizures 383 see neonatal unit breast 277
postural drainage and 193 Specific airways conductance 1 85 cardiac 270-3
Self-percussion 1 94 Speech-language therapy 1 02 in children 43 1
Sengstaken tube 408 after laryngectomy 28 1 complications 249-50, 266, 271
Sensory deprivation/overload 3 1 8-9 Spinal cord injury 3 95 head and neck 277
Sepsis 1 8 , 409 atelectasis 148 heart 270-3, 274
Sepsis syndrome 4 1 0 see also quadriplegia lung 264-8
Septicaemia 409 Spinal headache 258 pleural 268
Septic shock 4 1 0 Spirogram 59 video-assisted 248
Serevent 134, 135, 1 3 7 Spirometry 58 virtual 248
Sexuality 226 Sputum 32, 3 7-9, 184-5 Surgical emphysema 3 9, 267, 347
Shadows on x-ray 49, 50, 52 culture 3 8 and coughing 203
Shaking 193 induction 3 8 and IPPY 347
Shock 410 specimen 3 8 , 429 manual techniques and 194
spinal 397 Stab wound 406 postural drainage and 1 9 3
Shunt 1 1 Stairs 307 Sustained maximal inspiration
and atelectasis 25 1 after heart surgery 272 see end-inspiratory-hold
and oxygen 1 20 safety 149 S,,02 330
Shuttle 217, 220 Standards 452-4 Swallowing problems 1 02, 277
Sick building syndrome 1 9 1 Status asthmaticus 77 in dying people 3 1 3
Sick role 425 Steam inhalation 1 8 7 Swan-Ganz 329
Sickle cell disease 1 14 Stenting 1 10 Swedish nose 1 9 0
Side-lying 10, 150 Step test 9 1 Sympathomimetic drugs 1 3 5
Sigh 9 Sternal click 272 Symptoms 3 1
on IPPY 349 Sternomastoid 36 Synchronized intermittent mandatory
Silent chest 77 Steroids 1 34-5 1 ventilation 350-1
Silhouette sign 47 Stethoscope 4 1 and pressure support 3 5 1 -2
Sinus rhythm 3 3 1 Strength 240 Systemic inflammatory response
Sitting Stress syndrome 4 1 0
for breathlessness 1 69 in babies 436 Systemic lupus erythematosis 97, 408·
in intensive care 3 8 0 effects of 25 Systems failure 408
postoperatively 260 in intensive care 3 1 8, 3 69
and pressure sores 3 7 1 reduction of 243 Tachycardia 30
for loss o f volume 1 5 1 relocation 3 8 0 sinus 3 3 1
Six-minute distance 217 and surgery 252 supraventricular 3 3 1
Skeletal disorders 1 03 Stridor 4 1 Tachypnoea 3 6, 1 66
Sleep 1 69 heliox for 1 3 1 Tactile vocal fremitus 4 1 , 43, 44
in babies 436 i n children 427 Tamponade 384
effects of 25 in motor neurone disease 1 0 1 after surgery 2 7 1
in intensive care 3 1 8, 369 Subcutaneous emphysema Tank ventilator 1 80
rapid-eye-movement 25 see surgical emphysema TB 1 07-8
Sleep apnoea 1 1 0-1 1 , 71 Suction 205 Teamwork 3 2 1
in children 43 1 in babies 44 1-3 TED stockings 262
Sleeve resection 265 in children 428 Teenagers 425
Slumped position 150, 1 5 1 closed-circuit 377 Temperature 30, 3 62
Smoke inhalation 4 1 8 for dying people 3 14 in babies 437
Smoking 1 8 and head injury 402 peripheral 3 62
cessation 126, 226-9 for intubated people 376 TENS 258, 407
effects of 20-2 oral 207 Tension pneumothorax 3 84, 385
passive 22 pharyngeal 205 Terbutaline 134
Sniff pressures for 206 Tetanus 405
to test the diaphragm 6 1 Suicide 4 1 8 Tetraplegia 3 95
for loss o f volume 154 Superior vena caval obstruction 1 10 Thalassaemia 1 1 4-5
Snoring 1 1 1 Supine 1 8 Theophylline 72, 1 34, 1 3 6, 1 3 8
Sodium 29 Surface tension 6 Thermodilution 3 3 0
Sodium chromoglycate 134 Surfactant 6, 13 7 Thoracic expansion exercises 153
Spacer 140-1 replacement 4 14, 444 Thoracic mobility 230-1
Speaking valve 280 Surgery 248-86 Thoracoplasty 266
549
INDEX
Thoracoscopy 248, 265 Tumour Vibrators 202

Thoracotomy 265 cough assistance for 202 Videofluoroscopy 102
positioning for 1 5 1 �ee also cancer Viruses 74, 1 1 6
Thrombolytic therapy 1 14 . Tlirbd haler 139, 1 40 Visor 208
suction and 208 Turbulance 5 . Visual analogue scale
Tidal volume 9, 57 Tu.rni,ng �70 for breathlessness 215, 216
in intensive care 326 and head'inju ry 4 0 1 for pain 255
see also VT Type I respiratory failure 1 17 Vital capacity 55, 61
Tilade 1 3 3 Type II respiratory failure 1 1 7 measurement 58
TLC 5 6 , 5 9 for neuromuscular disorders 101
Ulcerative colitis
Tobacco see smoking Vital signs 3 0
and smoking 2 1
Tonsils 2 i n children 426
Unconsciousness 3 7 1
Total lung capacity 56-7 Vitalograph 58
Underwater seal drains 268
see also TLC Vitamin C 1 3 7
Uppe� lobe diversion 1 1 , 49, 50
Total lung capacity for carbon and smoking 20
in COPD 72
monoxide 60 Vocal resonance 43, 44
Urea 29
T-piece 1 24, 357 Voice sounds 43
Urine retention 25 1
Trachea 5 Volumatic 140, 141
Uvulopalatopharyngoplasty 1 1 2
deviation of 4 1 , 46 Volume control 345
on x-ray 46 Vapour 1 8 7 Vomiting 250
Tracheal stimulation 203 Varices 408 VOz 1 7-18
Tracheal tube 344 Vascath 408 VO zmax 236
Tracheostomy 278-83 disconnection 386 VT 5 6
cuff 279, 280 Vascular catheter VAiQ 15
complications of 28 1 see vascath with exercise 23
decannulation 359 Vascular markings 49 measurement 60
fenestrated 279-80 Vasoconstriction 14, 363 scan 52, 54
humidification for 282 hypoxic 1 1 , 70
and incentive spirometry- 156 V�sodilation 1 1, 14 Washings 143
obstruction 283 Vasodilators Water's bag 373
percutaneous 278, 344 pulmonary 3 3 6 Water trap 187
silver 279 systemic 3 3 5 Weakness 32, 1 0 1
speaking 280 Venesection 7 0 o f diaphragm 6 1
ventilation 1 8 1 Venous admixture 1 1 inspiratory muscle 8, 37
Transcutaneous electrical nerve Ventilation 8-9 Weaning 8, 355-9
stimulation 258 alveolar 8 for COPD 393
Transcutaneous monitoring 326 dead space 8 terminal 321
Transdiaphragmatic pressure 61 wi th exercise 23 Wedge pressure 329
Transfer factor 60 gradient 8-9, 9, 1 0, 1 9 Wedge resection 265
Transplantation 273-6 high frequency 354, 414 Wegener's granulomatosis 408
in CF 90 on lPPV 347, 348 Wheeze 3 1 , 4 1 , 43
in fibrosing alveoLitis 98 liquid 3 3 9 Whispering pectoriloquy 44
heart 273 wasted 13, 14 White blood cells 29
heart-lung 274 see also mechanical ventilation Whooping cough 43 1
inspiratory muscle training for 240 Ventilation/perfusion mismatch 1 3 Work of breathing 6-7, 166
kidney 1 14 Ventilation/perfusion ratio 1 1 in asthma 76
liver 408 see also VAIQ in emphysema 68
lung 273 Ventilator 364 with exercise 23
rejection after 275 graphics 322-4 on [PPV 350
Transtracheal catheter 1 2 1 , 1 24 see also mechanical ventilation
Xanthines 134
Transudate 99 Ventolin 134, 135
X-rays 45-54
Trauma 18, 406 Ventricular
in babies 439, 440
Tremor 34 assist device 339
portable 46, 364
flapping 14, 34 fibrillation 332, 333
Trigeminy 332 Venturi mask 1 21-2, 124, 126 Yoga 83, 172, 243
Trigger Verapamil 335
for lPPV 345, 349 Vertigo 32 Zolpidem 73
for noninvasive ventilation 1 77 Vibrations 193 Zones, blood flow 10
Tuberculosis 107-8 see also manual techniques silent 59
550

Physiotherapy in Respiratory Care 3rd Ed - A. Hough (Nelson Thornes, 2001) WW PDF

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Physiotherapy in Respiratory Care 3rd Ed - A. Hough (Nelson Thornes, 2001) WW PDF

Uploaded by

Copyright:

Available Formats

VI

An evidence-based approach to respiratory

Physiotherapy RespiratOry Specialist

First published in 1991 by:

Third edition published in 2001 by:

Page make up by Acorn Bookwork, Salisbury, Wiltshire

Printed and bound in Italy by Canale

1 PHYSIOLOGICAL BASIS OF CLINICAL PRACTICE 1

Chronic obstructive pulmonary disease 65

4 RESTRICTIVE AND OTHER DISORDERS 96

5 GENERAL MANAGEMENT 119

6 PHYSIOTHERAPY TO INCREASE LUNG VOLUME 1 47

Breathing exercises 152

7 PHYSIOTHERAPY TO REDUCE THE WORK OF BREATHING 166

8 PHYSIOTHERAPY TO CLEAR SECRETIONS 184

9 PULMONARY REHABILITATION 211

Inspiratory muscle training 239

10 PHYSIOTHERAPY FOR PEOPLE UNDERGOING SURGERY 248

11 PHYSIOTHERAPY FOR SPECIFIC GROUPS OF PEOPLE 287

12 INTENSIVE CARE, MONITORING AND SUPPORT 317

13 MECHANICAL VENTILATION 343

14 PHYSIOTHERAPY FOR PATIENTS IN INTENSIVE CARE 361

15 DISORDERS IN INTENSIVE CARE PATIENTS 393

16 PHYSIOTHERAPY FOR CHILDREN AND INFANTS 425

Modifications for specific neonatal disorders 443

17 EVALUATION OF RESPIRATORY PHYSIOTHERAPY 449

G LOSSARY OF ABBREVIATIONS, DEFINITIONS, SYMBOLS AND VALUES 461

A pPENDIX A: TRANSATLANTIC DICTIONARY 470

ApPENDIX B: POSTURAL DRAINAGE POSITIONS 471

A pPENDIX C: RESOURCES 472

A pPENDIX D: ARTICLES ON PATIENTS' EXPERIENCES 476

A pPENDIX E: OUTCOMES FOR PULMONARY REHABILITATION 477

A pPENDIX F: CONVERSIONS 479

ANNOTATED BIBLIOGRAPHY 480

Respiratory care is an immensely satisfying There are patient handouts, tables of

Introduction • Oxygen dissociation curve

• Pharynx The oxygen cascade

• The respiratory muscles Effect of pregnancy

• Resistance Effect of exercise

• Work of breathing Effect of immobility

• Inspiratory muscle weakness Effect of sleep

Ventilation/perfusion relationships Mini case study

INTRODUCTION against the elements. This chapter will place less

onslaught. Indeed, so effective is the pulmonary �G""Y"

people with obstructive airways disease because

_______ ��_c�i ______ { ______ ��� _____

Pressure Bronchioles Slow

wall is unopposed and the lung hyperin­

evolved in the same way as elephants, which Inspiratory

disease (COPD) at rest (Pilbeam, 1 998, p. 1 1 1 ).

shocked state (Pilbeam, 1998, p. 141).

Inspiratory muscle weakness

Weakness is failure to generate sufficient force in Anatomical dead

an otherwise fresh muscle. It is not reversible by Alveolar ventilation

appropriate, encouraging activity. Causes of 3000 ml

respiratory muscle weakness are: Pulmonary capillary

• lung volume: vessels are stretched in the Shunt (%) Implications

F102 = fraction of inspired oxygen

It is no good having a well-ventilated alveolus if

mechanism called hypoxic vasoconstriction helps Oxygen content

PaC02 nation at tissue level, and resting Pa02 does not

0.6 60% inspired oxygen.

Upper flat portion of the curve

_______ ��_c�i { �� _

wall is unopposed and the lung hyperin

or an attempt to avoid fatigue by reducing venti base required to restore pH to normal. It

• Normal pH + change in PaC02 and bicarbo

nervous systems, and other organs and physiolo