VOL: 98, ISSUE: 12, PAGE NO: 58
Ruth Morley, BSc, is senior physiotherapist in acute medicine, St Thomas’ Hospital, London
Respiratory observations have long been a cornerstone of the regular assessment of patients on a medical ward.
But how easy is it to identify a problem, and how should health care professionals deal with an acutely unwell chest patient?
Nearly 85% of hospital inpatients who experience a cardiorespiratory arrest have documented observations of deterioration in the eight hours before the arrest (Bristow et al, 2000). Early identification of patients at risk of arrest can enable early intervention, which may prevent such physiological deterioration.
A variety of factors can cause a patient’s respiratory function to deteriorate; breathlessness may be the result of a ventilation defect (for example, pneumonia), a perfusion defect (pulmonary emboli) or even systemic illness (sepsis, sickle cell crisis, renal failure). It is therefore essential that the physiotherapist has a comprehensive working knowledge of how different organs interact. However, in every case early identification of problems provides a window of opportunity to manage them.
Assessment is one of the key skills of physiotherapists. Without a thorough assessment of not only the chest but also cardiac, renal and other systems the appropriate management strategies cannot be identified.
Recognising the signs
Respiratory observations are easy to undertake and provide an objective measure of a patient’s lung function. It is important not only to perform and analyse the observations but also to look for trends and changes over a period of time. What are the key parameters to look at?
Tachypnoea (high respiratory rate) has been found to be the most common abnormality in patients transferred to the intensive care unit (Goldhill et al, 1999). Resting respiratory rates will vary from person to person, depending on many factors, including their age, underlying chest disease and smoking history. However, when this rate increases it almost always signifies an increase in oxygen requirement for some purpose.
A drop in respiratory rate may be due to drug/opiate overdose, brain damage, diabetic coma or respiratory exhaustion. It can also sometimes result from giving patients too much oxygen if they have a history of chronic lung disease and an altered respiratory drive.
Although it is a vital observation, oxygen saturations are not more important than respiratory rate as a pre-determinant of admission to the ICU. Once the pulse oximeter is providing a steady reading a drop in oxygen saturations indicates a decrease in the amount of oxygen bonded with haemoglobin. It is important to consider saturations in relation to inspired oxygen. Also, it should be remembered that oxygen saturations may not read accurately if the patient has cool peripheries and poor circulation.
Increased temperature is one of the principal signs of infection, but it will also rise in a patient who has an increase in metabolic rate, secondary to a systemic problem.
Work of breathing
Rapid shallow breathing or other altered patterns of breathing indicate increased respiratory muscle effort - an increased work of breathing. Other signs include pursed-lip breathing, use of the accessory muscles of breathing (the neck and shoulder muscles, along with fixing the arms and raising the shoulders). Greater negative pressures generated within the chest in an effort to suck in air will cause recession of soft tissues and muscles in the intercostal and supraclavicular spaces. Forced expiration by contracting the abdominal muscles also indicates increased work of breathing.
Three key points should be borne in mind when auscultating a patient’s chest:
- Are there audible breath sounds in all areas of the lung?
- Are there any added sounds - for instance, crackles/wheeze/crepitations?
- Are the added sounds on inspiration, expiration or both?
Careful practice in auscultation skills enables physiotherapists to distinguish between different sounds, and the implications of these sounds may be suggestive of various different conditions. Auscultation in conjunction with an evaluation of the chest X-ray and other clinical signs will give the therapist an indication of which segments or lobes of the lung are affected.
It is important to visually analyse sputum, as colour and tenacity can give further clues to the patients’ condition. Indeed, pseudomonas has a distinctive smell in sputum.
More important is the assessment of a patient’s ability to clear sputum. If patients are independently and easily able to clear their own secretions they may not require physiotherapy. However, those who are becoming tired, overwhelmed by the volume of sputum or have an impaired cough for a variety of reasons will require physiotherapy to prevent deterioration into respiratory failure.
Patients who are becoming more unwell may look hot and flushed, pale and grey, or may become sweaty and clammy. They may have an altered level of consciousness or become agitated, confused, or aggressive. A rise in CO2 may result in a flapping tremor of the hands.
Ask the patient
Patients who may appear to be very short of breath and uncomfortable may, if asked, reveal that this is their normal state. Patients are often the first to inform health care professionals when they are becoming breathless or if they feel they are not getting enough oxygen.
Physiotherapists will also analyse blood gases, biochemistry, haematology and other relevant blood results, and evaluate peripheral circulation to ensure that they have a full picture of the patient’s presentation. Once all these areas have been assessed it is possible to consider the treatment options.
What is respiratory physiotherapy?
Respiratory physiotherapy involves a thorough assessment, identification of the problem and a variety of treatment and management techniques including education, exercises and controlled activity, and adjuncts such as intermittent positive pressure breathing (IPPB), continuous positive airway pressure (CPAP), non-invasive ventilation, suction, flutter device, and positive expiratory pressure mask.
In general, however, physiotherapists focus on three main areas - decreased lung volumes, increased work of breathing and retained secretions.
Lung volume may be reduced as a result of, for example, atelectasis (common in postoperative patients), consolidation, pleural effusions or pneumothorax. The latter two may respond simply to insertion of an intercostal chest drain.
Reduced lung volumes respond well to increasing patient mobility. This may consist of upper limb exercise in bed for the immobile patient, transferring patients to chairs, walking on the spot or climbing a flight of stairs. It is a simple yet effective treatment technique. For patients who are unable to sit out of bed, lower thoracic expansion/deep breathing exercises may be taught instead, in conjunction with good positioning.
Changing a patient’s position can increase lung volumes by choosing one that will allow better excursion (movement) of the diaphragm. Lying supine or slumped in bed will decrease lung volumes by pushing the abdominal contents up against the diaphragm, limiting movement.
For patients with a unilateral problem, such as a chest infection, consolidation should lie with the affected lung uppermost, as optimal ventilation and perfusion will occur in the dependent (lower area) lung.
If poor lung volumes begin to compromise the patient’s gas exchange, CPAP may be used to splint airways open and thus allow alveolar ventilation. This should be done in a closely monitored environment since there is a risk of haemodynamic instability with CPAP.
There should be recognition that the patient is acutely unwell and may need urgent intervention if CPAP does not improve the situation.
Clearance of sputum is commonly seen as a cornerstone of physiotherapy practice. Sputum may not be a problem if it is not compromising a patient’s oxygen saturations or respiratory rate and he or she is able to expectorate it independently - for example, some patients with COPD. However, if the cough is weak or ineffective or there is an overwhelming volume or tenacity of sputum ventilation may deteriorate, leading to respiratory failure.
Ensuring adequate oral fluid intake may maintain the effectiveness of the mucociliary escalator as well as prevent thickening of secretions. Humidifying oxygen may prevent drying of the mouth and nose and upper airways, heated humidification is far more effective (Williams et al, 1996).
Sputum may be easily cleared by mobilisation and breathing exercises. By increasing lung volumes (specifically tidal volumes) sputum can be loosened by air turbulence in bronchioles and moved to larger airways from where it can be coughed up. This can be facilitated by a series of breathing exercises known as the active cycle of breathing techniques which, when taught correctly, help clear secretions with minimal effort. Tidal volumes can be increased with the use of intermittent positive pressure breathing (IPPB) in patients who are unable, due to pathology or exhaustion, to take sufficiently deep breaths independently.
Additional manual techniques, such as shaking or percussion, may help, but only in specific circumstances assessed and suggested by a respiratory physiotherapist. They can have serious side-effects, including bronchospasm, when used or performed incorrectly.
Positioning to clear secretions can be used by identifying the lobe(s) affected and using a position where gravity will help to drain sputum towards the trachea, from where it can be coughed up. This is known as postural drainage. Such positions may also alter the ventilation-perfusion quotient ratio by changing the dependent area of the lung. It needs careful assessment in order to select the appropriate position and to modify it in the presence of various precautions.
If the above techniques are not successful in clearing secretions, the patient may need to be suctioned. This should only be performed if:
- The patient is compromised by sputum - for instance, increase in work of breathing, increase in respiratory rate or decrease in oxygen saturations;
- Secretions are audible in the upper respiratory tract. If they are in peripheral airways they will not be accessible with a suction catheter;
- The patient has been carefully assessed for evidence of precautions or contraindications;
- The practitioner is competent in suctioning techniques and aware of the effects and complications.
Management of breathlessness
Breathlessness is a subjective and frightening experience for patients, and they need to be given techniques to manage this. There is little relationship between blood gases and breathlessness (Hough, 1997), so patients can be profoundly hypoxic with minimal breathlessness or very short of breath with little change to their oxygen saturations. As a result, telling patients to ‘just relax’ or ‘just breathe slowly’ is rarely effective. Rather, they need to be shown positions that decrease breathlessness and advised on how to cope with breathlessness on exercise.
Changing the position of a patient can have a profound effect on respiratory rate and breathlessness. Most patients will automatically adopt a position that relieves their shortness of breath. If they cannot do so, sitting them upright in bed, or out in a chair, can increase their lung volumes considerably - this is related to the displacement of the diaphragm by the abdominal content. This is especially effective with obese patients or those with a large abdomen (for example, patients with ascites).
Supine or slumped lying in bed is the least helpful position for patients with respiratory distress (Hough, 1996). Some patients may benefit from leaning forward on to a table with their arms supported on pillows.
Pulmonary rehabilitation courses have proved invaluable in managing patients with breathlessness. Techniques used in pulmonary rehabilitation include educating patients in controlling their own breathing, improving their exercise tolerance, returning their confidence and managing their lung disease.
Respiratory physiotherapy is an exciting and challenging area in which to work, with frequent new ideas and developments. Rarely are two patients the same. It requires a good understanding of anatomy, physiology, and pathology to enable to the therapist to take an effective clinical reasoning approach to problem management and treatment.