physical therapist management of cardiopulmonary ... · –note the intensity, quality, and timing...

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Physical Therapist Management of

Cardiopulmonary Conditions in the Geriatric Client Melissa Bednarek, PT, DPT, PhD, CCS

Board Certified in Cardiovascular and Pulmonary Physical Therapy


• Explain appropriate technique to obtain a pulse, respiratory rate, and oxygen saturation

• Explain appropriate technique to obtain an accurate blood pressure

• Explain appropriate technique to auscultate heart sounds

• Explain appropriate technique to auscultate lung sounds

• Determine appropriateness for aerobic exercise, based on results of a cardiopulmonary exam

Learning Objectives


Chapter OneIntroduction


Reasons for Hospitalization

In 2010, in those 65 to 84 years of age and 85 and older, the most common causes of hospitalization were

– Congestive heart failure

– Pneumonia

– Cardiac dysrhythmias

Pfuntner, Wier, Stocks, 2013


Physical Therapy 2002– Survey to clinical instructors from two universities– Response rate of 64.8% (387 surveys)– Various practice settings with nearly half (43.4%) in outpatient – 59.5% agreed/strongly agreed that measuring vital signs should be included in a

physical therapy screening– 38% reported not taking heart rate (HR) as part of the exam of new patients the

week before the survey • 6% always measured HR in new patients

– 43% reported not taking blood pressure (BP) as part of the exam of new patients the week before the survey

• 4.4% always measured BP in new patients

– When given a list of reasons why HR and BP were not routinely measured, 52.3% responded it was not important for their patient population

– By setting, respondents in home health were more likely to take HR and BP than respondents in outpatient

Frese, Richter, Burlis, 2002

Measurement of Heart Rate and Blood Pressure by PTs


Cardiopulmonary Physical Therapy Journal 2016– Observational study of 74 PT sessions across 15 PTs in

six clinics

– 26% of patients had hypertension as a comorbidity

– Initial HR and BP were only taken during two sessions and post-activity HR and BP were taken during only one of those sessions

Millar, Village, King, McKenzie, Lee, Lopez, 2016

Measurement of Heart Rate and Blood Pressure by PTs (cont.)


Cardiopulmonary Physical Therapy Journal 2018– Outpatient PTs– Attitudes: 24.3% agreed/strongly agreed that they felt it

was important that a BP should be taken on every patient during an evaluation or re-evaluation

• Additional 24% were neutral

– Behavior: 15% measured a patient BP on evaluation or re-evaluation always/more than half the time

• 4.1% measured BP prior to treatment always/more than half the time

• 2.2% measured BP after treatment always/more than half the time

Arena, Reyes, Rolf, Schlagel, Peterson, 2018

Measurement of Heart Rate and Blood Pressure by PTs (cont.)


Journal of Clinical Hypertension 2017– American Medical Association meeting in 2015

– 159 students from medical schools in 37 states participated in the study

– Based on guidelines, participants assessed on 11 elements of a blood pressure measurement

• Focus on positioning with use of automated BP device

– 1 student completed all 11 elements

– 4.1 of 11 elements was average number performed properly

Rakotz et al. 2017

Blood Pressure Check Challenge


Chapter TwoVital Signs: Pulse, Respiratory Rate,

and Oxygen Saturation


• Pulse ≠ heart rate– Pulse is peripheral representation of cardiac contraction

• Values– First beat is 0– Normal: 60 to 100 bpm– Tachycardia: over 100 bpm– Bradycardia: under 60 bpm

• How long do you assess for?– Pulse is beats PER MINUTE, so anything less is an estimate– Increased likelihood to detect dysrhythmia, if present, with 60-second assessment

• Where can pulse be assessed?– Concerns with carotid artery pulses include slowing the pulse and plaques

• Important to assess– Rate– Rhythm: regular vs. irregular– Quality: strong vs. weak

Pulse


• Normal response– Increase with increasing workloads

• Consider effect of medications such as beta blockers

– Pulse recovery can be an indicator of fitness level

• Don’t start exercise if RESTING pulse over 120 bpm

ACSM Guidelines 10th Ed.Fletcher, Ades, Kligfield, Arena, Balady, 2013

Pulse and Exercise


Respiratory Rate• Values

– Normal: 12 to 20 breaths per minute

• How long do you assess for?– Respiratory rate (RR) is breaths PER

MINUTE, so anything less is an estimate

– Normal values are low to begin with, so likelihood of error is increased with estimates

• What is the best location to assess at?– Lateral view of patient, assessing

upper chest versus abdomen– Ask patient/family to remain quiet


• Normal response– Increase linearly and proportional to workload

• Don’t start exercise if RESTING respiratory rate over 30 breaths per minute– Consider educating the patient on a breathing strategy if

RR is elevated prior to exercise


Respiratory Rate and Exercise


Oxygen Saturation

• Arterial blood gases– Invasive means to measure hemoglobin bound

to oxygen

– SaO2

• Pulse oximeter– Noninvasive means to measure hemoglobin

bound to oxygen/carbon monoxide/metabolites

– SpO2


Pulse Oximeter

Requires pulsating blood to obtain measurement; thus, every pulse oximeter will come with a pulse rate and oxygen saturation

– Able to verify the accuracy of the pulse ox reading with comparison to manual pulse rate as obtained on opposite limb


• Lack of regular pulsating blood– Atrial fibrillation

– Peripheral vasoconstriction (i.e., cold fingers)

– Blood pressure in that arm

• Any barriers to the sensors– Fingernail polish

Concerns With Pulse Oximeter Accuracy


• SpO2

• Activity

– Rest

• Oxygen delivery system– For example, nasal cannula

• Oxygen level– For example, 2 lpm

• Accuracy of devices1

– Earlobe ≥ finger > forehead > toe

1. Seifi et al. 2018

Documentation of Readings


• Normal response– Stay within 5% of resting value

– May decrease with pulmonary issue (e.g., COPD, pneumonia)

• Don’t start exercise if RESTING SpO2 under 88%


Oxygen Saturation and Exercise


Chapter ThreeVital Signs: Blood Pressure


11 elements– Rest for 5 minutes prior to measurement– Legs uncrossed– Feet on the floor– Arm supported– Correct cuff size– Cuff placed over bare arm– No talking– No mobile phone use/reading– Measurement obtained in both arms– Correctly identifying blood pressure from the arm with the

higher reading as being clinically more important– Correctly identifying which arm to use for future readings

Rakotz et al. 2017

Elements in Obtaining a Blood Pressure


• Technique– Blood pressure cuff placed on arm per usual– Arm is relaxed at heart level– Slowly inflate the cuff while palpating the radial artery

– Note the pressure at which the pulse is lost• When completing a manual blood pressure, increase cuff

pressure to 20 to 30 mmHg above this value

– Unable to estimate diastolic blood pressure through this technique

• Uses of this technique– Initial estimation of SBP for patients unaware of their normal BP– Avoid pumping up the cuff to conventional 200 mmHg

Systolic Blood Pressure Through Palpation


Technique– Blood pressure cuff placed on arm per usual

– Arm supported at heart level and relaxed

– Increase cuff pressure to desired level

– Slowly deflate the cuff at a rate of 2 mmHg per heartbeat while listening for

• First faint tap (two consecutive taps): SBP

• Disappearance of sound: DBP

• Nearest 2 mmHg (no odd numbers)

Manual Blood Pressure


• In mmHg– Normal: under 120 and under 80

– Prehypertension: 120 to 139 or 80 to 89

– Stage 1 HTN: 140 to 159 or 90 to 99

– Stage 2 HTN: at least 160 or at least 100

• Recent work has attempted to connect home blood pressure readings to neuropsychological function in older adults

• Goal of treatment in those age 60 and older with HTN may not be 120/80

ACSM’s Guidelines 10th Ed.

ACSM Guidelines 10th Ed. Classification


• In mmHg– Normal: under 120 and under 80

– Elevated: 120 to 129 and under 80

– Stage 1 HTN: 130 to 139 or 80 to 89

– Stage 2 HTN: at least 140 or at least 90

• Key difference: diagnosis of HTN occurs at blood pressures starting at 130 mmHg or 80 mmHg– Implications for treatment

ACC/AHA Guidelines 2017

ACC/AHA 2017 Classification


• Normal response– SBP: increase with increasing workloads

– DBP: remain within 10 mmHg of resting value

• Don’t start exercise if RESTING– SBP over 200 mmHg or under 90 mmHg

– DBP over 110 mmHg or under 50 mmHg


Blood Pressure and Exercise


• Definition– At least 20 mmHg drop in SBP within three minutes of

supine to stand

– At least 10 mmHg drop in DBP within three minutes of supine to stand

– May be associated with symptoms of dizziness, light-headedness

• HR may increase with change in posture as a response to decrease in BP

American Academy of Neurology and American Autonomic Society

Orthostatic Hypotension


Defined as over 180 and/or over 120 and associated with new or worsening evidence of target organ damage

– Hospitalized if signs of organ damage

Hypertensive Crisis


Chapter FourCardiac Auscultation


Anatomy of the Heart


Anatomy of the Heart (cont.)

1

1

2 2

33 4 4

65 5

33 4 4

6


Cardiac Auscultation Sites

S2 heart sound– Aortic:

2nd ICS RSB

– Pulmonic: 2nd ICS LSB

S1 heart sound– Tricuspid:

4th/5th ICS LSB

– Mitral: 5th ICS L MCL


• Technique– Sitting or supine position

– Do not auscultate over clothing

– Slide stethoscope from aortic to pulmonic to tricuspid to mitral listening locations

– Note the intensity, quality, and timing of heart sounds

• Helpful hint: when listening to heart sounds, S2 is the sound you hear when you feel the radial pulse

Cardiac Auscultation


• Represents closing of the atrioventricular valves at the beginning of ventricular systole

• Produced by the sound of the tricuspid and mitral valves closing

– Loudest at the cardiac apex

• Sound is enhanced if the heart is brought closer the chest wall or after exercise

S1 Heart Sound


• Represents closing of the semilunar valves at the end of ventricular systole

• Produced by the sound of the aortic and pulmonic closing

– Loudest at the cardiac base

• Sound is enhanced if the heart is brought closer the chest wall or after exercise

S2 Heart Sound


Heart sounds with pulse rate of 60 bpm

What Are Normal Heart Sounds?


What About This?


S3– Softer sound after S2

– Normal in children and young adults

– Abnormal in those over age 40• Common cause is ventricular failure

– ‘Slosh-Ing-In’

What Are Abnormal Heart Sounds?


S4– Dull sound before S1

– Common cause is hypertension, MI, cardiomyopathy

– ‘A-Stiff-Wall’

What Are Abnormal Heart Sounds? (cont.)



Regurgitation– Valve closure is

incomplete, with resultant backward flow of blood



Stenosis– Valve opening is limited, with

resultant obstruction to forward flow of blood


BreakPlease Submit Questions to the Q&A Window


Chapter FivePulmonary Auscultation


Anatomy of the Lungs


Anterior Pulmonary Auscultation Sites


Posterior Pulmonary Auscultation Sites


Technique– Sitting position

– Do not auscultate over clothing

– Slide stethoscope from apex (#1) to base (#6/7) while comparing sides at each point

– Note the intensity, pitch, duration, and quality of lung sounds

– Instructions to patient: “take a little deeper breath than normal through your mouth whenever you feel the stethoscope on your skin”

Pulmonary Auscultation


Bronchial– Loud and high-pitched sound

– Normal sound over trachea and manubrium

– Heard on inspiration and expiration with a pause

What Are the Normal Lung Sounds?


Vesicular– Soft and low-pitched sound

– Normal sound in peripheral lung fields

– Heard on inspiration and first third of expiration

What Are the Normal Lung Sounds? (cont.)


Bronchovesicular– High-pitched sound

– Normal sound over 1st/2nd ICS anteriorly and between the scapula posteriorly

– Heard on inspiration and expiration without a pause

What Are the Normal Lung Sounds? (cont.)


Anatomic Locations of Sounds


Normal Abnormal Adventitious

Bronchial Bronchial (if in wrong location) Crackles

Bronchovesicular Decreased Wheezes

Vesicular Absent

Lung Sounds


• Bronchial breath sound heard in the periphery– Pneumonia

• Decreased– Hyperinflation with emphysema

• Absent– Atelectasis

Abnormal Lung Sounds


Crackles– Low pitched and discontinuous– Heard predominantly during inspiration– Air moving through fluid

– May be heard with HF

Adventitious Lung Sounds


Wheezes– High pitched and continuous– Heard predominantly during expiration– Bronchospasm

– May be heard with COPD

Adventitious Lung Sounds (cont.)


Chapter SixInterpretation and Appropriateness of Exercise


• Patient is a 75-year-old female who is being seen by home health physical therapy following admission for shortness of breath and weakness for five days

• PMH: CAD, MI, HTN, type 2 DM, OA

• Lives alone in a third-floor apartment with elevator access

• Uses a cane in the apartment and a wheeled walker when outside the apartment

Case One: Doris


Case One: Doris (cont.)• At rest

– Pulse: 88 bpm and regular– RR: 18 breaths per min– SpO2: 96% on room air– BP: 126 / 76 mmHg– Heart sounds: S1 and S2– Lung sounds: crackles in bilateral lung bases

• After ambulation in hallway with wheeled walker for five minutes– Pulse: 110 and regular– RR: 25 breaths per min– SpO2: 97% on room air– BP: 134 / 74 mmHg– Heart sounds: S1, S2, and S3– Lung sounds: crackles in bilateral lung bases


• Patient is a 82-year-old male who is being seen by home health physical therapy following three-day admission for COPD exacerbation

• PMH: COPD, (+) smoker and quit 22 years ago, PVD, type 2 DM

• Lives with daughter in one-floor home with three steps to enter

• Uses a wheeled walker for ambulation

Case Two: Melvin


Case Two: Melvin (cont.)

• Vital signs at rest– Pulse: 88 bpm and regular– RR: 22 breaths per min– SpO2: 93% on room air– BP: 122 / 70 mmHg– Heart sounds: S1 and S2– Lung sounds: crackles in bibasilar bases

• After ambulation in hallway with wheeled walker for five minutes– Pulse: 114 and regular– RR: 30 breaths per min– SpO2: 87% on room air– BP: 132 / 68 mmHg– Heart sounds: S1 and S2– Lung sounds: bronchial sounds in periphery


• Patient is a 67-year-old female who is being seen by outpatient physical therapy for knee pain. She was recently discharged from the hospital following brief admission for dehydration

• PMH: CAD, MI, HTN, A-fib, low back pain, R THR

• Lives with spouse in two-story home with two steps to enter and bed/bath on second floor

• Ambulates without an assistive device

• Works part-time as receptionist in doctor’s office

Case Three: Eileen


• Vital signs at rest– Pulse: 92 bpm and regular

– RR: 16 breaths per min

– SpO2: 98% on room air

– BP: 134 / 82 mmHg

– Heart sounds: S1, S2, and S4

– Lung sounds: normal

• After ten minutes of outdoor ambulation– Pulse: 120 and irregular

– RR: 23 breaths per min

– SpO2: 97% on room air

– BP: 142 / 78 mmHg

– Heart sounds: S1, S2, and S4

– Lung sounds: normal

Case Three: Eileen (cont.)


Case Three: Eileen (cont.)

• History?• Pulse

– Rest?

– Exercise?

• Respiratory– Rest?

– Exercise?

• Oxygen saturation– Rest?

– Exercise?

• Blood Pressure

– Rest?

– Exercise?

• Heart sounds

– Rest?

– Exercise?

• Lung sounds

– Rest?

– Exercise?


• Based on the most common causes of hospitalization in the older adult, a thorough cardiopulmonary exam is indicated for every patient

• Details matter

– Pulse rate vs. heart rate

– SpO2 vs. SaO2

– Blood pressure technique

• Become comfortable with normal heart and lung sounds so you can identify when something is not normal, even if you don’t feel comfortable naming it

Key Points


BreakPlease Submit Questions to the Q&A Window


Question and Answer Session


Thank You

Physical Therapist Management of Cardiopulmonary Conditions in the Geriatric Client

1

Bibliography

MedBridge Physical Therapist Management of Cardiopulmonary Conditions in the Geriatric Client

Melissa Bednarek, PT, DPT, PhD, CCS

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2. American College of Sports Medicine: ACSM’s Guidelines for Exercise Testing and Prescription. 10th ed., Lippincott, Williams and Wilkins, 2018.

3. Arena SK, Reyes A, Rolf M, Schlagel N, Peterson E. Blood Pressure Attitudes, Practice Behaviors, and Knowledge of Outpatient Physical Therapists. Cardiopulm Phys Ther J. 2018; 29:3–12.

4. Fletcher GF, Ades PA, Kligfield P, Arena R, Balady GJ, et al. Exercise standards for testing and training: a scientific statement from the American Heart Association. Circulation. 2013;128(8):873-934.

5. Frese EM, Richter RR, Burlis TV. Self-reported measurement of HR and blood pressure in patients by physical therapy clinical instructors. Phys Ther. 2002; 82: 1192-1200.

6. Frownfelter D and Dean E. Cardiovascular and Pulmonary Physical Therapy: Evidence to Practice, 5th ed., Mosby Elsevier, 2012.

7. Kaye KS et al. Utility of pulse oximetry in diagnosing pneumonia in nursing home residents. Am J Med Sci. 2002. 324(5): 237-242.

8. Millar AL, Village D, King T, McKenzie G, Lee J and Lopez C. Heart rate and blood pressure assessment by physical therapists in the outpatient setting – An observational study. Cardiopulm Phys Ther J. 2016; 27: 90-95.

9. Pfuntner, A (Truven Health Analytics), Wier, LM (Truven Health Analytics), Stocks, C (AHRQ). Most Frequent Conditions in U.S. Hospitals, 2010. HCUP Statistical Brief #148. January 2013. Agency for Healthcare Research and Quality, Rockville, MD. Available at http://www.hcup-us.ahrq.gov/reports/statbriefs/sb148.pdf. Accessed 8/18/19.

10. Rakotz MK, Townsend RR, Yang J, et al. Medical students and measuring blood pressure: Results from the American Medical Association Blood Pressure Check Challenge. J Clin Hypertens. 2017;19:614–619.

11. Seifi S, Khatony A, Moradi G, Abdi A, Najafi F. Accuracy of pulse oximetry in detection of oxygen saturation in patients admitted to the intensive care unit of heart surgery: comparison of finger, toe, forehead and earlobe probes. BMC Nursing. 2018;17:15.

12. Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison Himmelfarb C, DePalma SM, Gidding S, Jamerson KA, Jones DW, MacLaughlin EJ, Muntner P, Ovbiagele B, Smith SC Jr, Spencer CC, Stafford RS, Taler SJ, Thomas RJ, Williams KA Sr, Williamson JD, Wright JT Jr. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A

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physical therapist management of cardiopulmonary ... · –note the intensity, quality, and timing...

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