5 facts about cardiorespiratory physiotherapy
George Ntoumenopoulos, Danni Dunlop, Ianthe Boden, Marie Williams, Kylie Johnston and Lara Edbrooke discuss five lesser known facts about cardiorespiratory physiotherapy and what you can implement in your current practice.
1. Lung ultrasound can improve decision making
The limited diagnostic accuracy of lung auscultation and the portable chest radiograph in critical care is a challenge physiotherapists must address. The reduced diagnostic accuracy of the portable chest radiograph compared to lung ultrasound (LUS) for the detection of common lung pathology, such as lung collapse, pulmonary oedema, consolidation, pleural effusion or pneumothorax (Xirouchaki et al 2011), questions the findings of previous landmark trials and critical care physiotherapy recommendations (Stiller et al 2013, Stiller 2013). LUS is a diagnostic tool that should be adopted by critical care physiotherapists, with the increasing evidence-base for its excellent diagnostic accuracy and real-time monitoring capabilities (Via et al 2012, Volpicelli et al 2012, Hew & Tay 2016). Physiotherapists can acquire the preliminary knowledge and skills in LUS (Ntoumenopoulos et al 2017) but there may be potential barriers such as time, mentors, perceived scope of practice issues to the uptake and use of LUS in clinical practice (Ntoumenopoulos & Hough 2014) that need to be addressed.
Beyond the potential for LUS to better discern whether chest physiotherapy is indicated (Leech et al 2015), it may also be of use to non-invasively assess the effect of the intervention, such as manual or ventilator hyperinflation to recruit collapsed lung (Cavaliere et al 2011). With issues around physiotherapy in critical care (eg, 24/7 access, respiratory vs rehabilitation focus, limited physiotherapy staffing-to-patient ratios, skill mix), it will be a challenge to feasibly incorporate another diagnostic tool with busy caseloads. LUS should enable us to determine the prevalence of acute pulmonary conditions amenable to physiotherapy and allow clinicians to use their time more appropriately.
1. Xirouchaki N, Magkanas E, Vaporidi K, Kondili E, Plataki M, Patrianakos A, et al. Lung ultrasound in critically ill patients: comparison with bedside chest radiography. Intensive care medicine 2011;37(9):1488-1493.
2. Stiller K JS, Grant R, Geale T, Taylor J, Hall B. Acute lobar atelectasis: a comparison of five physiotherapy regimens. Physio Theory and Practice 1996;12:197-209.
3. Stiller K. Physiotherapy in intensive care: an updated systematic review. Chest 2013;144(3):825-847.
4. Via G, Storti E, Gulati G, Neri L, Mojoli F, Braschi A. Lung ultrasound in the ICU: from diagnostic instrument to respiratory monitoring tool. Minerva anestesiologica 2012;78(11):1282-1296.
5. Volpicelli G, Elbarbary M, Blaivas M, Lichtenstein DA, Mathis G, Kirkpatrick AW, et al. International evidence-based recommendations for point-of-care lung ultrasound. Intensive care medicine 2012;38(4):577-591.
6. Hew M, Tay TR. The efficacy of bedside chest ultrasound: from accuracy to outcomes. Eur Respir Rev 2016;25(141):230-246.
7. Ntoumenopoulos G, Ong HK, Toh HC, Saclolo RP, Sewa WD. Evaluation of a pilot programme on diagnostic thoracic ultrasound curriculum for acute care physiotherapists. Australasian Journal of Ultrasound in Medicine 2017;20(4):147-154.
8. Ntoumenopoulos G, Hough J. Diagnostic thoracic ultrasound within critical care. Journal of physiotherapy 2014;60(2):112.
9. Leech M, Bissett B, Kot M, Ntoumenopoulos G. Lung ultrasound for critical care physiotherapists: a narrative review. Physiotherapy research international : the journal for researchers and clinicians in physical therapy 2015;20(2):69-76.
10. Cavaliere F, Biasucci D, Costa R, Soave M, Addabbo G, Proietti R. Chest ultrasounds to guide manual reexpansion of a postoperative pulmonary atelectasis: a case report. Minerva anestesiologica 2011;77(7):750-753.
2. Cardiorespiratory physiotherapists work in advanced practice roles
With additional training programs, cardiorespiratory physiotherapists now have opportunities to work in innovative advanced scope roles. In 2015, the Austin Health physiotherapy department in Victoria received a grant to develop an individualised, integrated model of care led by a critical care-trained physiotherapist for high-risk surgical patients in the detection, surveillance and treatment of postoperative pulmonary complications (PPC).
High-risk surgical patients experienced a high rate of PPC at Austin Health (Story 2011, Austin Health POST Investigators 2010), two-thirds of which occurred in the first two postoperative days. This represents a threefold increase compared to low-risk patients undergoing upper abdominal surgery (Haines et al 2013). PPCs were related to increased hospital stay and costs, and patients were also more likely to have a medical emergency team review and utilise critical care outreach resources (Story 2011, Haines et al 2013). Most of these patients had a delay to mobilisation (Haines et al 2013).
A physiotherapy-led model of care was implemented in 2016 to increase the detection of deterioration and promote early mobility in this patient cohort. A senior critical care physiotherapist monitors high- risk surgical patients, identifies barriers to mobility, and remediates them to ensure mobilisation occurs. The advanced practice physiotherapist coordinates postoperative care alongside an intensive care fellow and an acute pain service team, which assist with fluid boluses and pain medication titration. PPC incidence has decreased to 19.2 per cent in the high-risk surgical cohort, with a concurrent decrease in mean length of hospital stay by five days (Dunlop & Berney 2016).
Story, D. (2011). Postoperative Mortality and Complications. Best Practice and Research in Clinical Anaesthesiology, 25(3), 319-27
The Austin Health Post-Operative Surveillance Team (POST) Investigators (2010). Methodology of structured co-management of high-risk postoperative patients in a teaching hospital. Critical Care and Resuscitation, 12(4), 277-86
Haines, K., Skinner, E., Berney, S. & The Austin Health POST Study Investigators (2013). Association of postoperative pulmonary complications with delayed mobilisation following major abdominal surgery: an observational cohort study. Physiotherapy, 99(2), 119-25
Dunlop, D & Berney, S. (2016). Managing post-operative complications that delay mobilisation in high risk surgical patients: An Advanced Scope of Practice Physiotherapy Role. Advanced Practice in Allied Health Progress Report: Allied Health Workforce Grant Program 2014-2015. Department of Health &Human Services.
3. Pre-operative physiotherapy prevents postoperative pneumonia
More than 150,000 major abdominal surgery procedures are performed every year in Australia (Australian Institute of Health & Welfare). An upper abdominal incision has negative effects on respiratory mechanics, with 90 per cent of patients having significant atelectasis within 24 hours of surgery (Strandberg et al 1986). If not ameliorated, a postoperative pulmonary complication can occur in up to 50 per cent of patients.
Over the past 70 years, physiotherapy has focused on coaching patients in deep breathing and coughing exercises to reverse atelectasis and prevent airway bacterial stagnation (Reeve & Boden 2016).
Until 20 years ago, patients were admitted to hospital the day before surgery when ward-based physiotherapists prepared patients to start breathing exercises immediately after surgery. With a change to hospitals admitting patients on the morning of surgery, pre-operative assessments switched to outpatient-based clinics within a month of surgery. At this time, physiotherapy services remained primarily ward-based and pre-operative preparation by physiotherapists effectively ceased.
Research challenges the paradigm of a postoperative-alone physiotherapy service. A recent international double-blinded, placebo-controlled, multi-centre trial involving 441 patients (PEDro 9/10) found that a single pre-operative physiotherapy session reduced postoperative pneumonia rates by half, within the context of standardised early ambulation and no postoperative chest physiotherapy (Boden et al 2018). This confirms three previous trials (Castillo & Has 1985, Fagevik Olsen et al 1997, Samnani et al 2014), and may support preliminary findings that postoperative chest physiotherapy in some cohorts is unnecessary as long as pre-operative physiotherapy is provided (Denehy 2001, Condie et al 1993). Consistent evidence supporting the benefit pre-operative physiotherapy suggests that hospitals may need to reconsider the timing of physiotherapy to best prevent the onset of serious postoperative complications.
Procedures and healthcare interventions (ACHI 9th edition), Australia, 2015−16 to 2016−17. Australian Institute of Health and Welfare. https://www.aihw.gov.au/reports/hospitals/procedures-data-cubes/contents.... Accessed on 18/12/2018
Strandberg A, Tokics L, Brismar B, et al. Atelectasis during anaesthesia and in the postoperative period. Acta Anaesthesiol Scand 1986; 30(2):154-8.
Reeve JC, Boden I. The physiotherapy management of patients undergoing abdominal surgery. N Z J Physiother 2016;44(1):33-49
Boden I, Skinner EH, Browning L, et al. Preoperative physiotherapy for the prevention of respiratory complications after upper abdominal surgery: pragmatic, double blinded, multicentre randomised controlled trial. BMJ 2018; 360:j5916.
Castillo R, Haas A. Chest physical therapy: comparative efficacy of preoperative and postoperative in the elderly. Arch Phys Med Rehabil 1985; 66(6):376-9.
Fagevik Olsen M, Hahn I, Nordgren S, et al. Randomized controlled trial of prophylactic chest physiotherapy in major abdominal surgery. Br J Surg 1997; 84(11):1535-8.
Samnani SS, Umer MF, Mehdi SH, et al. Impact of Preoperative Counselling on Early Postoperative Mobilization and Its Role in Smooth Recovery. Int Sch Res Notices 2014; 2014:250536.
Denehy L. PhD thesis: The physiotherapy management of patients following upper abdominal surgery. School of Physiotherapy, Faculty of Medicine, Dentistry, and Health Sciences. Melbourne. University of Melbourne, 2001.
Condie E, Hack K, Ross A. An investigation of the value of routine provision of postoperative chest physiotherapy in non-smoking patients undergoing elective abdominal surgery. Physiotherapy. 1993;79:547-52.
4. Breathlessness is not a single generic sensation
Distress with breathing is not a normal part of ageing or an inevitable consequence of having a chronic cardiorespiratory, musculoskeletal or neurological condition. Breathlessness includes distress/discomfort and distinct sensory qualities (eg, air hunger, tightness, work/effort) reflecting different mechanisms which vary in intensity and emotional and behavioural consequences. Chronic breathlessness is distressing, disabling and persists despite optimal management.
Chronic breathlessness is not just a result of underlying disease and does not have a direct 1:1 relationship with severity of pathology. This perception is generated through complex interplay of sensory information from multiple systems, affective state and expectations or beliefs. Fear, anxiety and pain makes the experience of breathlessness worse. While most chronic breathlessness has a pathological origin, this sensation is maintained and increased by cognitive, emotional and behavioural adaptations.
Chronic breathlessness is under- recognised, assessed and managed. Things you can implement in clinical practice include asking about breathlessness and assess using multidimensional instruments, using evidence-based therapies that target multiple domains of breathlessness (eg, pulmonary rehabilitation improves exercise capacity and reduces anxiety related to breathlessness-related activities; hand-held fans reduces breathlessness recovery time and support exercise), and challenging unhelpful breathlessness beliefs.
Booth S, Johnson MJ. Improving the quality of life of people with advanced respiratory disease and severe breathlessness. Breathe 2019; 15: 198–215
Williams MT, Johnston KN. Multidimensional measurement of breathlessness: recent advances. Curr Opin Support Palliat Care. 2019 ;13(3):184-192.
Herigstad M, Faull OK, Hayen A et al. Treating breathlessness via the brain: changes in brain activity over a course of pulmonary rehabilitation. Eur Respir J 2017;50(3):
5. Rehabilitation in inoperable lung cancer improves patient outcomes
Advances in diagnostic procedures and treatments have resulted in increasing management options for people with inoperable lung cancer and have led to improvements in survival for this population (National Comprehensive Cancer Network 2018). People with inoperable lung cancer continue to experience high levels of symptom burden, including dyspnoea, cancer-related fatigue, weight loss and pain (Sung 2017). Routine symptom monitoring has been found to improve outcomes for people with advanced cancer (Basch 2016).
Exercise is safe for people with lung cancer. Several international hospital-based exercise trials are being conducted. Mixed setting approaches may be feasible; largely home-based but also including supervised sessions to ensure correct exercise technique and adherence to training principles, including intensity.
A recent randomised controlled trial of home-based rehabilitation demonstrated improvements in health-related quality of life and symptom severity, but not physical function, six months after commencing medical treatment. The program included aerobic and resistance exercises, behaviour change techniques and symptom support (Edbrooke 2019a). Importantly, the program was reported by participants to be highly acceptable (Edbrooke 2019b). Physiotherapists should individually prescribe and modify exercise programs based on assessment findings (including physical function and symptoms) and patient preferences.
Basch E, Deal AM, Kris MG, et al. Symptom monitoring with patient-reported outcomes during routine cancer treatment: a randomized controlled trial. Journal of Clinical Oncology 2016;34(6):557-65. doi: 10.1200/jco.2015.63.0830
Edbrooke, L.; Aranda, S.; Granger, C. L., et al. Multidisciplinary home-based
rehabilitation in inoperable lung cancer: a randomised controlled trial, Thorax. 2019a, DOI
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rehabilitation in inoperable non-small cell lung cancer-the patient experience, Support Care
Cancer. 2019b, DOI 10.1007/s00520-019-04783-4.
Sung, M. R.; Patel, M. V.; Djalalov, S., et al. Evolution of symptom burden of
advanced lung cancer over a decade. Clin Lung Cancer. 2017, 18, 274-280.
National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology. Version 3. 2018. https://www.nccn.org/professionals/physician_gls/default.aspx
Dr George Ntoumenopoulos, APAM, is a consultant physiotherapist in the intensive care unit at St Vincent’s Hospital, Sydney. His main areas of research include the investigation of novel outcome measures for secretion retention and lung aeration using ultrasound in the intubated and ventilated patient.
Danni Dunlop has worked at Austin Health since 2011. She currently holds an advanced scope of practice role in high-risk surgical patient management, as well as working in the Austin intensive care unit.
APA Cardiorespiratory Physiotherapist Ianthe Boden is the cardiorespiratory clinical supervisor at the Launceston General Hospital. Ianthe is completing her PhD at the University of Melbourne on preventing respiratory complications after major abdominal surgery.
Associate Professor Marie Williams, APAM, is Associate Head, Research, School of Health Sciences at the University of South Australia. Marie has interests in education, research training, management chronic respiratory disease and mechanisms underpinning the perceptual experience of breathlessness and how or whether this sensation can be altered.
Dr Kylie Johnston, APAM, is a senior lecturer in the School of Health Sciences at the University of South Australia. With a clinical background in cardiorespiratory physiotherapy, Kylie’s research focuses on implementation of care for people with chronic lung conditions and consumer perspectives.
Dr Lara Edbrooke, APAM, completed her PhD this year on rehabilitation in inoperable lung cancer. She is a lecturer at the University of Melbourne and the Grade 4 of Allied Health Research at Peter MacCallum Cancer Centre.
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