1. Cardiorespiratory assessment
CResp Wk 10_ Tut 2_10_11

2. Plan
Overview of respiratory and cardiovascular assessment to give you a framework on which to base your assessment process when out on clinical placement for the self ventilating adult patient
Handout on StudyNet
Please read around in the textbooks
CResp Wk 10_ Tut 2_10_11

3. Cardiorespiratory assessment
From lecture:
Why do we assess patients?
To identify physiotherapy problems for management
To ascertain the patient’s perceptions of their problems
To identify potential indications for treatment techniques/management strategies
To identify potential contra-indications for treatment techniques/management strategies
- Identify physiotherapy problems for management
- Ascertain patient’s perceptions of their problems
- Identify potential indications for treatment techniques/management strategies
- Identify potential contra-indications for treatment techniques/management strategies
CResp Wk 10_ Tut 2_10_11

4. Cardiorespiratory assessment
From lecture:
When do we assess patients?
First contact
Ongoing throughout treatment
Before and after every patient contact
Maybe use more formal outcome measures at certain times during management
Before discharge
First contact
Ongoing throughout treatment
Before and after every patient contact
Maybe use more formal outcome measures at certain times during management
Before discharge
CResp Wk 10_ Tut 2_10_11

5. How? Subjectively Objectively
Everything the patient/other staff tell us about the patient’s condition
Objectively
Everything we see/identify from charts/measure
(remember: points from other modules about writing up etc)
Everything the patient/other staff tell us about the patient’s condition
- Everything we see/identify from charts/measure
CResp Wk 10_ Tut 2_10_11

6. From patient or medical notes
Data Base – in groups What are the components and what does it tell us?
From patient or medical notes
HPC
(PC)
PMH SH
Including smoking, hobbies, accommodation FH
Occupational history DH
Including allergies
HPC : ongoing issues (Fever, Dyspnoea- relate to fnc, Chest pain, Cough/sputum, Exs tolerance, Patterns/24hr Function, Weight loss, Oedema,) & Norms,
PC: Onset sudden/insidious, Length time, Severity, Nature, Aggs/Easing, Pattern
PMH: prev episodes or other cardiovascresp diseases or neurological, musculoskeletal problems &/or Ops
CResp Wk 10_ Tut 2_10_11

7. From medical notes Medical test results Any reported ECG abnormalities
Sputum MC+S
CXR
current and any previous
Pulmonary/Lung Function Tests
Peak Expiratory Flow Rate (litres per minute)
Spirogram - expiration
Flow volume loops –expiration into inspiration
ABGs
Blood test results
Hb (14-18 g/100ml Men, g/100ml Women)
? Raised white cell count (N= 4-11x109 per litre)
Cardiac enzymes (Creatine Kinease, Troponin T)
Any reported ECG abnormalities
Microbial culture and sensitivity
Spirometery = lung volumes, forced expiratory rates. Flow loop = same as spirometry followed into Insp.
Hb usually transfuse <9/10
CK realised by damaged skeletal muscle, Trop. T more specific to cardiac
CResp Wk 10_ Tut 2_10_11

8. Spirometry The graph produced from a max. forced expiration following
a full inspiration is called a forced
expiratory spirogram.
Spirometer Measures:
-forced expiratory vol. in 1 second (FEV1)
-forced vital capacity (FVC)
-peak expiratory flow rate
-Normal ratio FEV1/FVC around 80% (75-85%)
Obstructive pattern:
↓ FEV1, ↔ FVC (ratio < 75%)
Restrictive pattern:
↓ FEV1, ↓ FVC (ratio usually above 90%)
Calculate your values against normative data at
Normal values based on age, height and gender.
Should always compare to predicted values i.e. taller men fit man very different to small elderly women and same ratio drop may be v. significant
>15% below predicted values is significant
VC=Vital Capacity FRC= Functional Residual Reserve TLC = Total Lung Capacity TV = Tidal Vol.
RV = Residual Volume
CResp Wk 10_ Tut 2_10_11

9. From medical notes Current drugs
?? Oxygen: route/duration and concentration
Bronchodilators: timings of doses to fit in with your treatment
Analgesia: timing to fit in with your treatment
Antibiotics
Inhaled steroids
Nebulisers
Nebulised: Steroids, Antibiotics, saline
CResp Wk 10_ Tut 2_10_11

10. Subjective Shortness of breath (SOB) - When? ? snoring
On Exertion (SOBOE)
At Rest (SOBAR), or at Night
Sleep with how many pillows?
Orthopnoea
Unable to lie flat without becoming dyspnoeic
Supposedly classic of pulmonary oedema but present in many respiratory diseases
Paroxysmal nocturnal dyspnoea (PND)
Sudden waking at night because of breathlessness.
Supposedly classic of pulmonary oedema but present in many respiratory diseases, especially morning dips of asthma
? Wake up coughing
? snoring
- Significant breathlessness indicated by rushed sentences or pausing between getting undressed.
- Orthopnoea: classically many resp. disease as increased pressure on diaphragm from abdo
OR: can be Cardiac as blood pools in lungs, cos of left ventricle insufficiency
- PND: SOBAR or nocturnal bronchospasm
- Snoring ?? Sleep Apnoea - symptom of tracheal insufficiency & airways collapsing followed by sudden
arousal from cortex stimulated by drop sats upto 75%. Can be Obstructive (obesity), Restrictive (AS) as Accessory MMs inhibited or Central (neurological)
CResp Wk 10_ Tut 2_10_11

11. Subjective contd Cough When Exacerbating factors
Type; dry or productive, +/- painful, ?pattern
Productive of phlegm/sputum?
Colour: consistency, smell, taste
Volume: teaspoon, egg cup, yoghurt
pot
Ease of expectoration
Pain- Muscular trauma, rib #s. Persistent cough May also lead to hernia & stress incontinence
Dry persistent - ? institial damage Loud Bark - ? Laryngeal/Tracheal disease
Chronic Productive – Chronic Bronchitis/Bronchiectasis
Nocturnal –?? Asthma sign in children/young. In older pts- ?? Cardiac failure /overload
Cough stimulated by Tracheal Rub prox to sternum or suctioning (Yanker & NP)
CResp Wk 10_ Tut 2_10_11

12. Subjective cont Chest Pain: Location Type Aggravating factors
How long does it last when aggravated?
Easing/relieving factors?
Aiming to ascertain
Is it pleuritic in nature
Localised/sharp, stabbing- worse on Inspiration
Is it cardiac in nature? (dull, central, gripping +/- radiates to jaw & arm)
Is pain relief adequate?
Is there a musculoskeletal component?
As lung parenchyma have no pain fibres, Pain generally: Musculoskeletal –Bony/Joints/Nerves
Pleuritic or could indicate PE, Tumors, MI/Angina
CResp Wk 10_ Tut 2_10_11

13. Sputum - Either in subjective or objective
Normal = mucoid
White/clear
Smokers
White with variable amounts of grey/black flecks/brownish
Infected = purulent
Yellow – some form of infection
Green (apple green classic of haemophilus influenza)
Dark green/brown - pseudomonas
Rusty brown – classic of pneumoccocal pneumonia
Red currant jelly - klebsiella
Consistency
Very thick ? Need humidification/increase in fluid intake
Very loose and frothy
Maybe pulmonary oedema especially if white tinged with pink
Bronchial casts – asthma, occasionally bronchiectasis
Normal to produce 100 ml tracheal-bronchial secretions/day
CResp Wk 10_ Tut 2_10_11

14. Sputum Blood stained = haemoptysis
Occasional flecks during acute infection – monitor
Excess over longer time period indicative of cancer
Other causes:
Pulmonary embolism/infarct TB
Ruptured blood vessel in bronchial mucosa (reasonably common with CF/bronchiectasis)
Old/new (dark/bright red)/frank haemoptysis
Smell!
Taste (to the patient!)
Strength of cough
? Effective (esp. relevant post-op i.e pain inhibition)
? Vocal cord paralysis/glottis closure
Frank haemoptysis? related to Tracheal or Bronchial trauma i.e suctioning or PE
Possibly life threatening involving rupture of Bronchial Artery. Isolated incidence ? sign of Bronchial CA
Common with Chronic Lung Dis.
Smell = Infection, Offensive = Anaerobic Infec
CResp Wk 10_ Tut 2_10_11

15. Subjective cont Exercise tolerance Depending on the circumstances
How far without getting SOB
? Hills/inclines
? Stairs
How long do you need to rest for?
Anything they can’t do because of their breathing
Depending on the circumstances
What the patient would like to be able to achieve as a result of physiotherapy intervention (can give good info re. goals/motivating factors)
CResp Wk 10_ Tut 2_10_11

16. Video
Using your handouts from StudyNet re Assessment when watching the video
Start to think about the order of questioning
The importance of listening to the answers
What is the usefulness of the answers – what do they mean?
CResp Wk 10_ Tut 2_10_11

17. On Examination Covert observation of patient: Observation of thorax:
Appearance, Posture, Alertness,
Respiratory rate/pattern (over 1min), Speech
Observation of thorax:
Tracheal position (mid line or shifted?)
Chest shape
Thoracic expansion
Degree
Where – upper/lower/ is expansion bilateral and equal
Use of accessory muscles/fixing upper limbs
General ease of ventilation/WOB
? Using pursed lip breathing
I:E ratio, ? Prolonged expiratory phase
Audible wheeze/harshness of respiration/stridor
- Posture suggest: Fatigue, Pain, Altered Conscious/Incohernet (Hypoxia), Restless, Bracing arms
- Obese: ?? Diaphragmatic fnc, Cachectic: ?? Nutrition/weakness
Unkept because of Limitations by SOB & self care or  esteem 2° Dis
Chronic lung Dis = Barrel shape Hyperinflated, Rigid chest,  AP diameter
Pigeon chest (pectus carinitum) Funnel chest (pectus excavatum), Kyphosis, Kyphoscolisis
Pursed Lip Breathing: Severe Airways Dis. provides own PEEP and stops airways collapsing.
Paradoxical breathing: Inward Abdo during Insp 2° fatigue
Apnoea: Absence breath Normal I:E is 1: Prolonged Expiration: Obstructive Lung Dis. & closure small airways > 15 secs Cheyne-Stokes: Irregular breathing (shallow or apnoeic breathing)
 WOB = Use: Sternomastoid & Scaleni MMs, Recession soft tissue (Supraclavicular Suprasternal, Intercostal 2°  -ve pressure in chest
Stridor = Monophnoic “strangled” Wheeze audible at mouth = Laryngeal or Tracheal narrowing / Upper Airways Obs
CResp Wk 10_ Tut 2_10_11

18. On Examination Observation of fingers/hands and toes/feet
Cyanosis
Peripheral
+/- Central
Clubbing
Respiratory disease (chronic)
Lung cancer
Liver disease
Congenital
CO2 flap
Observation of ankles/feet
Oedema
Perfusion
Observation of sputum
- Periph. Cyanosis = blue tinge 2°  stagnation of blood (gives of O2) from  Circ,  HB Saturation
- Central Cyanosis =  Gas exchange & Hypoxaemia.
Pulmonary Clubbing = Fibrosing Alveolititis, CF Recent onset ?? 1st sign Bronchial CA
C02 retention Flap = Periph. Vasodilation from Hypercapnia &  Warmth/Sweat
Oedema many reason but RESP PTs =  Kidney Perfusion from Chronic Hypoxaemia & Heart failure
CResp Wk 10_ Tut 2_10_11

19. Finger clubbing Loss of angle between nail bed and nail
Finger pad enlarges
Nail becomes spongy
CResp Wk 10_ Tut 2_10_11

20. On Examination Auscultation Vocal resonance & whispering pectoriloquy
Presence of breath sounds
Decreased/absent/bronchial
Presence of added sounds
Crackles/wheeze
Inspiratory/expiratory
Pleural rub
Vocal resonance & whispering pectoriloquy
Increased/decreased/normal
Percussion note?
Resonant/hyper-resonant/dull
CXR
You assess as well as reading any reports if available, +/- compare to previous films
SpO2
Crackles: air forced through narrowed airway – Oedema, Inflammation or Secs (Late Insp = Atelectasis, Early = Sputum retention
Wheezes; Vibration of airway wall as air rushes through ( Exp = Brochospasm, Insp/Exp = Obstruction)
 Voice = Consolidation, Atelectasis,  = Atelectasis with blockage, Pneumo, Pleural Effusion
PN (Middle finger-Distal IP struck) = Chest wall vibrating over underlying tissues. Resonant: Normal Hyperesonanace: Excess air (Pneumo) Stony Dull: Effusion/Fluid Dull : Atelectasis
Systematic X-ray interpretation: Orientation, View, Exposure, Inflation, Bones, Medistenum/trachea, Lung fields
CResp Wk 10_ Tut 2_10_11

21. CVS Temperature- HR BP Peripheral oedema Jugular Venous Pressure Core
Usually measure in the ear (rectally in ITU)
Axilla about C less than core
> C core temperature indicative of infection
Peripheral
About 2 0C less than core
Any more indicates CVS problems in unwell patient HR BP
Peripheral oedema
Indicates right sided heart failure
Jugular Venous Pressure
Normal JVP < 3-4 cm above sternal angle with the patient sitting up 45 degrees
CResp Wk 10_ Tut 2_10_11

22. Raised JVP
CResp Wk 10_ Tut 2_10_11

23. Other outcome measures
Exercise tests give an indication of progress
Borg scale
Perceived Exertion 6-20.
12-13 corresponds to 60% of VO2 max.
15 corresponds to 75% of VO2 max
Be consistent
MRC Dyspnoea Scale – for breathlessness
Visual Analogue Scale (VAS)
for breathlessness (specify which is used 0-10 or 0-5)
6MWT and modified shuttle walk test
Will do in Semester B – maybe mentioned in cardiac rehabilitation next week.
6MWT- walk as fast as reasonably possible along flat corridor, rest allowed but included in 6mins. Measure distance, Sats & HR = Endurance. 15% change is clinically significant. Need 3-4 practises
Shuttle or “Bleep” test = 10 m oval coned circuit, incremental  speed dictated by tape. ½hr between practice & test
MRC –
1. Not troubled by breathlessness except on strenuous exercise
2. Short of breath when hurrying or walking up a slight hill
3. Walks slower than contemporaries on the level because of breathlessness, or has to stop for breath when walking at own pace
4. Stops for breath after about 100 m or after a few minutes on the level
5. Too breathless to leave the house, or breathless when dressing or undressing
CResp Wk 10_ Tut 2_10_11

24. Shuttle Test & VAS 1 10 Visual Analogue Scale
No breathlessness Greatest Breathlessness
CResp Wk 10_ Tut 2_10_11

25. Variations on a theme Intubated and ventilated patient
Paediatrics and neonates
Always remembering clinical features of hypoxaemia and hypercapnia
CResp Wk 10_ Tut 2_10_11

26. Clinical Features of Hypoxaemia
Cyanosis
Tachypnoea
Tachycardia → arrhythmias/ bradycardia
Peripheral vasoconstriction
Respiratory muscle weakness
Restlessness → confusion → coma
CResp Wk 10_ Tut 2_10_11

27. Clinical Features of Hypercapnia
Flapping tremor of hands
Tachypnoea
Tachycardia → bradycardia
Peripheral vasodilatation leading to warm hands and headache
Respiratory muscle weakness
Drowsiness → hallucinations → coma
Sweating
CResp Wk 10_ Tut 2_10_11

28. Then … You should be able to:
Identify the patient’s physiotherapy problem list
Write a treatment plan related to the problem list
Identify short and long term goals
N.B. the degree of the patient’s contribution will vary
CResp Wk 10_ Tut 2_10_11

29. Physiotherapy problem Treatment plan (would need more details)
An example of one problem for a patient with newly diagnosed Bronchiectasis
Physiotherapy problem
Difficulty expectorating retained pulmonary secretions
Treatment plan (would need more details)
Teach the patient ACBT
Positioning to facilitate drainage of secretions
Added humidification
(Manual techniques)
Goals
Short term – to increase the patient’s ability to expectorate pulmonary secretions during physiotherapy treatment
Long term - to enable the patient to be independent in the management of their pulmonary secretions in a month
CResp Wk 10_ Tut 2_10_11

30. Goals Should be S.M.A.R.T Simple Measurable Achievable Realistic
Time scaled
CResp Wk 10_ Tut 2_10_11

31. In conclusion
A framework for all respiratory assessments (always includes CVS)
Detail will vary according to patient group
Practical this week
Some cardiovascular and respiratory tools of assessment in practice
CResp Wk 10_ Tut 2_10_11

32. Learning outcomes
identify the importance of the physiotherapist assessing a patient at the beginning during and at the end of every treatment
identify the differences and links between the subjective and objective assessment
describe the various components of a cardio respiratory assessment
discuss the implications of the results of the assessment on the composition of a physiotherapy problem list
discuss the implications of the results of the assessment on the composition of a physiotherapy treatment plan
relate the importance of the cardiovascular system assessment to the assessment of the respiratory system
identify the components of a cardiovascular assessment
begin to describe the implications of the results of a cardiovascular assessment
CResp Wk 10_ Tut 2_10_11

33. Bibliography
Bourke, S. J. (2003). Lecture notes on respiratory medicine. (6th ed.). Padstow UK: Blackwell Publishing.
Harden, B. (Ed). (2004). Emergency physiotherapy. Edinburgh: Churchill Livingstone.
Hough, A. (2001). Physiotherapy in respiratory care. (3rd ed.). Cheltenham: Nelson Thornes.
Pryor, J. A. & Prasad, S. A. (Eds). (2008). Physiotherapy for respiratory and cardiac problems - adults and paediatrics. (4th ed.). Edinburgh: Churchill Livingstone
Wilkins, R. L., Sheldon R. L. & Krider, S. J. (2005). Clinical assessment in respiratory care. (5th ed.). Missouri: Elsevier Mosby.
CResp Wk 10_ Tut 2_10_11