Critical Evaluation of Physical Therapy Assessment and Management of HOSPITAL ACQUIRED PNEUMONIA(HLA) In CCU In A Particular Patient

MUHAMMAD ASIM ISHAQUE SID 2345251

OUTLINE
Case Scenario Some basics Mechanisms Assessment Management CW 2 question However the medical management of Pulmonary oedema, LVF and pneumonia is beyond the scope of this presentation.

Overview of Case Scenario

60 years old MD of building company, diagnosed with acute MI 3 days ago. Under the management of LVF Since 24 hr suffering from pyrexia and increased RR

Chest x-ray also depicts LVF and Pneumonia Right lower lobe
CPAP with PEEP 7.5 cmHO with saturations of 92-94% Clinically Obese and heavy smoker Married with wife and two children

Some Basics
Myocardial Infarction
Myocardial necrosis due to cession or interruption of blood supply (Chales and Marshall 1989).

Left Ventricular Failure When left ventricular is unable to pump the blood rety returned to it (Hough 2001).

Contin...
PNEUMONIA Is inflammation of lung parenchyma associated with Alveolar filling by exudates. (West 1992) Types (clinical ) Community acquired Hospital acquired (HLA) Pneumonia confined to a lobe is called LOBAR and which is patchy and diffuse is called Bronchopneumonia (Poter 2003).

Contin...
Hospital acquired pneumonia
is respiratory infection develop more than 48hrs after hospital admission (Masterton et al. 2008). Risk factors reduced mucocilary activity and age and inactivity

Obesity Body weight greater than 20% more than ideal body weight. Can lead to reduced lung compliance Ventilation-perfusion mismatch can occur due to preferential ventilation of lung apices( Reid and Chung 2004).

What is actually happening?

Myocardial Infarction Less effective pumping Backing up of blood in Lt. Ventricular

Increased Atrium Pressure and pulmonary capillary bed Fluid is forced from capillaries into interstitial spaces and then into alveoli Pulmonary Oedema

Dyspnoea (Brannon et al. 1998:109)

What is actually happening?

HLA PNEUMONIA Pneumatic region is not ventilated OBESITY Alteration of regional ventilation

PaO2 Falls
Increased Breathing Effort (Hough 2001)

Ventilation-perfusion mismatch
Hypoxemia (Reid and Chunk 2004, 127)

Objective Assessment (Pryor et al. 2008:1)

Obesity Difficulty in breathing Use of accessory muscles CPAP Pyrexia Reduced expansion of chest (rt. )

ASSESSEMNT

Percussion Dull on Rt. Lower lobe Auscultation , Bronchial Breathing on consolidated area , Crackles (Hough 2001:103)
)

ECG (Charles and Marshall 1989:184) Reduced R wave and pathological Q wave reflects loss of viable myocardium ST elevation diminishes and T wave inversion Chest X-Ray Cardiac shadow is enlarged , Increased interstitial lung marking, Homogenous opacity right lower lobe (Porter 2003:267) Haematology White Blood cell count will be raised Biochemistry Arterial Blood gases SaO2 will be measured for assessment of arterial Oxygen saturation (Porter 2003:268)

ASSESSMENT

ASSESSMENT
Problems
Poor cardiovascular function Decreased cardiac output Poor gaseous exchange in affected region Retained secretion

Outcome Measures
Hemodynamic measure like BP, HR, and Cardiac output Pulse, Temperature SpO2 , ABGs, Auscultations, Chest wall movement , chest x-ray Sputum weight, auscultations, temperature, chest X-ray

ASSESSMENT
Problem Dyspnoea , increased work of breathing and increased use of accessory muscles Decreased mobility/Poor exercise tolerance Decreased ROM of shoulder and other joint Poor understanding of condition, and self management Outcome Measure RR, Chest Wall movement and Borg Scale of perceived Breathlessness Bed mobility, Ability to self transfer Observation , ROM Interview and discussion and

Management
Positioning
Side-Lying the rt. Lung uppermost To maximize V/Q ratio on Rt. Lower lobe and hence oxygenation (Dean 1985) Crowe et al. (2003) in their qualitative systematic review have also recommended this position for Unilateral however it was based on only on study . Ibanez, Raurich and Abizanda (1981)have documented increase in the PaO2/ FiO2 ratio when patients were positioned with affected lung uppermost.

Management
As FRC will be decreased because of Pneumonia, smoking and Obesity , postural modification can help to manipulate this. According to Tucker and Jenkin (1996), side lying can improve ventilation in non-dependent lung combined with Lower thoracic expansion exercises which could be due to improved chest wall expansion a greater negative Intra pleural pressure Side-lying can be helpful in reducing the Breathless by changing the length tension relationship of diaphragm , hence better contraction during inspiration (Dean, 1985,ONeil and McCarthy , 1983).

Management
Upright sitting for pulmonary oedema Breathing Exercises Diaphragmatic breathing Decreasing work of (Kigin, 1990) breathing, improve gaseous exchange & Oxygenation Segmental Breathing lateral costal expansion and posterior basal expansion though controversial probably can help in expansion of specific chest lung zone. Tydeman (1989) found no difference in outcome between control and the group which receive chest physio mainly chest expansion and Breathing exercises.
Copious secretions afte48 hrs , postral drainge with ACYCLE OF CAN BE INITAITED HOWVERE HEAD DOWN IS AVOIDED

Management
Postural drainage
In case of copious amount of secretion , PD with Modified position will be used with ACTIVE CYCLE OF BREATHING TECHNIQUES will be used , to avoid head down position. Percussion and vibrations will be avoided due to well documented hemodynamic and metabolic detrimental effects lasting at least 30 min(Hammon, Connors, and McCaffree 1992 and Harding, Kemper, and Weissman 1994). Hemodynamic status of the patient will be monitored during the treatment as recommended by Stiller(2000).

Management
Continuous Positive Airways Pressure is the maintenance of Positive airway pressure throughout the respiratory cycle. Continuous use is expected to help this patient by (Denehy and Berney, 2001) Increasing FRC reducing shunt fraction improving lung compliance reducing work of breathing Underlying mechanism (Peuzzi , 1996 and Katz et al. 1981 )
CPAP increased lung volume decreased collateral flow res. Improved collateral flow to obstructed lung region Increased FRC

Management
Evidence supports the use of Positive end expiratory pressure with CPAP (Falk et al. 1984) however it can be assumed that successful use of positioning in this patient can lead to reduction of PEEP. Cardiac Rehabilitation is usually started on first day . As patient will be stable by now passive ROM and ankle pumping exercise with breathing exercise can be started(Davidson and Maloney 1985). Assisted bed mobility will be started and sitting at the edge of the bed with assistance with monitoring of vitals gradually progression is made (Stiller and Phillips 2003).

Management
Patient education Effects of intervention will be explained and patient will be explained that his participation and motivation will be core to a successful management plan.

Course work 2 question

Patient with recurrent MI uncontrolled by medical treatment are candidates for Coronary Artery Bypass Grafting (CABG). Keeping in view the risk factors (Obesity, Smoking and Age) associated, patient under consideration can be a candidate for CABG if measures to risk factor modification would be followed hence my CW2 question is Whether Pre-operative cardiopulmonary physiotherapy reduces the postoperative complication after CABG.

References
Brannon, F., Foley, M., Starr, J. A., and Saul, L. M. (1998) 3rd edn. Cardiopulmonary rehabilitation: Basic theory and application. Philadelphia: F. A Davis Company Charles, R. G., and Marshall, A.J. (1989) Cardiology. Oxford: Heinemann Medical Books Crowe, J., Brooks, D., Kelsey, C., and Lacy, J.B. (2003) Cardio respiratory physical therapy for patients with acute medical conditions: Qualitative systematic review. Physiotherapy Canada 55, 203-215 Davidson, D. M., and Maloney, C.A. (1985) Recovery after cardiac events. Physical Therapy 65 (12) 1820-1827 Dean, E. (1985) Effect of position on pulmonary function. Physical Therapy 65 (5) 613-618 Denehy, L., and Berney, S. (2001) The use of positive pressure devices by physiotherapist. European Respiratory Journal 17, 821-829 Falk, M., Kelstrup, M., Anderson, J., Falk, P., and Stoving, S. (1984) Improving the ketchup bottle method with PEEP, in cystic fibrosis. European Journal of Respiratory Disease 65, 423-432

References
Hammon, W. E., Connors, A. F., and McCaffree, D.R. (1992) Cadiac arrthythemias during the postural drainage and chest percussion of critically ill patient. Chest 102, 1836-1841 Harding, J., Kemper, M., and Weissman, C. (1994) Midazolam attenuates the metabolic and cardiopulmonary response in acute increase in oxygen demand. Chest 106, 194-200 Hough, A. (2001) 3rd edn. Physiotherapy in respiratory care. Cheltenham: Nelson Thomes Ltd. Ibanez, J., Raurich, J. M., and Abizanda, R. (1981) The effect of lateral position on gas exchange in patients with unilateral lung disease during mechanical ventilation. Intensive care Medicine 7, 231-234 Katz, J., Ozanne, G., Zinn, S., and Fairly, B. (1981) Time course and mechanism of lung volume

References
Kigin, C.M. (1990) Breathing exercises for the medical patient: The art and science. Physical Therapy 70, 700-704 Masterton, R., Galloway, A., French, G., Street, M., Armstrong, J., Brown, E., and Cleverley, J. (2008) Guidelines for the management of hospital acquired pneumonia in the UK: Report of the working party on hospital acquired pneumonia of the british society for antimicrobial chemotherapy. Journal of Antimicrobial Chemotherapy doi: 10.1093/jac/dkn162 ONeil, S.O., and McCarthy, D.S. (1983) Postural relief of dyspnoea in severe chronic airflow limitation: relationship to respiratory muscle strength. Thorax 38, 595-600 Peruzzi, W. (1996) The current status of PEEP. Respiratory care 41, 273-279 Porter, S. (ed.) 4TH ed. (2003) Tidys Physiotherapy. United-KingdomButterworth-Heinemann

References
Reid,W., and Chung, F. (2004) Clinical management notes and case histories in cardiopulmonary physical therapy. NJ: SLACK Incorporated Stiller, K. (2000) Physiotherapy in intensive care: Towards evidence based practice. Chest 118, 1801-1813 Stiller, K., and Phillips, A. (2003) Safety aspects of mobilising acutely ill in patients Physiotherapy Theory and Practice 19, 239-257 Tucker, B., and Jenkin, S. (1996) The effect of breathing exercises with body positioning in regional ventilation. Australian Journal of Physiotherapy 42 (3) 219-217 Tydeman, D. (1989) An investigation into the effectiveness of physiotherapy in treatment of patients with community acquired pneumonia. Physiotherapy Review 5, 75-81 West, J.B. (1992) 5th edn. Pulmonary Pathophysiology. Canada: Williams & Wilkins