1.1 The scope of respiratory physiotherapy

Patients with respiratory problems are encountered in many different settings, from long-term care in the community to critically ill patients on an intensive therapy unit (ITU) (also known as critical care) (Figs 1.1–1.3). Respiratory care may be an integral part of the patient’s management in secondary care (hospital) settings, such as respiratory, medical, and surgical and orthopaedic wards as well as burns, care of the elderly, paediatric, neurological, neurosurgical and oncology units. It may also be required for patients with mental health problems or learning disabilities. Physiotherapists work in many of these settings and also within primary care (in the community) for the longer-term rehabilitation of these patients. They may be employed in multiprofessional ‘rapid response’ or ‘early discharge’ teams, in which they share the responsibility for assessing and managing acutely ill patients in their own home.

Fig 1.1 Patient with chronic obstructive pulmonary disease at home with oxygen.

Fig 1.2 Pulmonary rehabilitation.

Fig 1.3 The intensive therapy unit (critical care) setting.

This book will cover physiotherapy assessment in any of the above settings. It is recognized that our role with many respiratory patients may be directed more towards function and rehabilitation than towards specific respiratory problems. Although the focus of this book will be on the assessment of the cardiovascular and respiratory systems, the checklists and tools also include reference to some generic assessment procedures (e.g. functional assessment) and aspects of musculoskeletal and neurological assessment (e.g. pain assessment and muscle testing); however, these have not been considered in detail and the reader is directed to other books in the toolkit series for further information.

The case history in Box 1.1 illustrates the scope of respiratory physiotherapy.

1.2 Why do we assess?

When assessing a patient you should have a clear idea of the purpose of the assessment before you start. There may be several aims of a ‘respiratory’ assessment (see 1.3 Aims of respiratory assessment); although all or most of these issues may need to be addressed at some point, it is necessary to prioritize which are the most significant at the time of assessment. Be aware that priorities may change, and you need to be flexible and responsive to changes in the patient’s condition and situation.

1.3 Aims of respiratory assessment

Assessment may be carried out in order to:

The assessment procedures that you use and the significance of the assessment findings will vary according to the patient’s situation and the stage in the patient’s pathway of care.

1.4 Assessment approaches

Physiotherapy assessment of the respiratory patient may be classified into three main approaches:

Goal-oriented assessment

This type of assessment combines aspects of systems-based and functional assessment but with a particular focus on goal setting in order to provide a patient-centred approach. This requires a flexible, tailored assessment that is likely to differ for each patient and does not fit into a prescribed protocol.

These three approaches represent the three domains of ‘body structure and function’, ‘activity’ and ‘participation’ that have been identified in the International Classification of Functioning, Disability and Health, produced by the World Health Organization (see Further reading) (Fig. 1.4).

Fig 1.4 Physiotherapy assessment follows a biopsychosocial approach. All three components of assessment are used at some stage, but the degree of contribution may change from patient to patient.

1.5 Assessment in the community

When visiting patients in their own home, assessment priorities may vary depending on whether you are working with acutely ill patients (e.g. in a ‘hospital at home’ or ‘early discharge’ team) or whether you are visiting patients who are medically stable for rehabilitation purposes.

With an acutely ill patient, your role may involve making a decision about whether the patient needs admission to hospital or whether he or she requires urgent medical care in order to remain at home (Fig. 1.5). With more stable patients, your priority may be towards optimizing their mobility, function and quality of life to help them to achieve their personal goals and optimum potential. Assessment of an acute respiratory patient in the community setting requires analysis of medical, functional, environmental and social situations, which may be liable to change.

Fig 1.5 Acute patient in the community decision-making flowchart. CPR, cardiopulmonary resuscitation; NICE, National Institute for Health and Clinical Excellence.

Clinical reasoning therefore requires ongoing re-evaluation of the risk of managing the patient at home, and any decision to admit the patient to hospital is made in accordance with national guidelines (e.g. those produced by the National Institute for Health and Clinical Excellence 2010; see Further reading) and also taking into account the local health and social provision. Some criteria are clear (e.g. unconscious or acutely confused patient), but many are dependent on local services and skills of staff. Patients have the right to choose where treatment is delivered. Discuss all treatment options and risks with patients so that a joint decision can be made, and liaise with other members of the multidisciplinary team.

1.6 Clinical reasoning in respiratory care

Cardiorespiratory assessment is not just about being able to perform the assessment techniques. The implications of the results must be considered and links to other findings and the clinical picture must be made.

At the end of your assessment you should ask yourself:

Problems related to respiration are frequently classified as one or more of the following:

The patient’s problems may be more generic, such as pain, anxiety, reduced exercise tolerance, functional and mobility limitations, or social problems. Once these problems have been identified, the clinical reasoning process proceeds to treatment planning and implementation, which are not in the remit of this book. Readers may find Respiratory Physiotherapy: An On-call Survival Guide (Harden et al 2009; see Further reading) helpful with regard to managing the respiratory problems listed above.