Physiotherapists need to be able to analyse the results (Fig. 3.1.1). The procedure itself involves taking an arterial blood sample and is normally carried out only by medical or nursing staff and some extended scope physiotherapists with specialized training.

Fig 3.1.1 Example of a set of arterial blood gas results. As can be seen, a blood gas result may contain more information than blood gases alone.

Findings (Fig. 3.1.2, Table 3.1.1)

You should also consider haemoglobin (Hb) levels when interpreting ABG results (see 3.48 Pulse oximetry). Fig 3.1.2 summarizes the process of interpreting ABG’s in flowchart format.

Fig 3.1.2 Flowchart for arterial blood gas analysis.

Table 3.1.1 Blood gas measurements

pH	Measure of level of acidity or alkalinity of blood Normal range 7.35–7.45

P_aCO₂

Partial pressure of carbon dioxide in arterial blood (plasma)

Normal range 4.7–6 kPa (35–45 mmHg)

P_aO₂

Partial pressure of oxygen in arterial blood (plasma)

Normal range 10.7–13.3 kPa (80–100 mmHg)

S_aO₂

Saturation level of Hb in arterial blood (measures how fully saturated each unit of Hb is, given as a percentage)

Normal range 95–100%

Amount of bicarbonate (base) in the blood

Normal range 22–26 mmol l⁻¹

BE (base excess)

Base excess is a simpler way of expressing bicarbonate levels and gives the amount of above or below the average value of 24 mmol l⁻¹

Normal range −2 to +2

NB. Partial pressure refers to the pressure exerted by one specific gas (e.g. oxygen), which forms part of the total pressure exerted by the mixture of gases (e.g. oxygen, carbon dioxide and nitrogen) in the blood.

Process of Interpreting ABGs.

1. Check pH

a. Decide whether pH is within normal range or whether there is an acidosis (low pH below 7.35) or an alkalosis (high pH above 7.45).

b. Anything outside the normal range can interfere with metabolism and may become critical. Discuss any recent changes with medical or nursing staff.

2. Check P_aCO₂

If there is an acidosis or an alkalosis, you need to decide whether this is due to a respiratory or metabolic problem. Identify any hypercapnia (high P_aCO₂ above 6 kPa) or hypocapnia (low P_aCO₂ below 4.7 kPa) (Box 3.1.1).

i. Respiratory acidosis is when hypercapnia causes the blood to become more acidic (i.e. high P_aCO₂ and low pH).

Hypercapnia suggests that the patient is hypoventilating (underbreathing). This may be due to fatigue or neuromuscular weakness, so the patient may need support with ventilation, e.g. non-invasive ventilation (NIV). Hypercapnia may also be due to insensitivity to high P_aCO₂ levels, as seen in some patients with chronic obstructive pulmonary disease (COPD) (CO₂ retainers).

Hypocapnia suggests that the patient is hyperventilating (overbreathing). This may be due to pain or anxiety. The patient may need reassurance and might benefit from a pain review, or breathing control and relaxation techniques (see 3.55 Respiratory rate).

3. Check (or BE)

Top tip!

If there is a metabolic problem the pH and the move in the same direction as if in an elevator (e.g. if the pH is high the will also be high).

i. Metabolic acidosis is when lower levels of bicarbonate (or BE) cause the pH to become more acidic (both change in the same direction to become lower).

ii. Metabolic alkalosis is when higher levels of bicarbonate (or BE) cause the pH to become more alkaline (both change in the same direction to become higher).

4. Check for compensation

Compensation is the balancing of one system with the other (respiratory and metabolic) to make sure the pH stays within normal limits. This is very important for metabolism. Each system (respiratory or metabolic) can therefore adjust its levels of carbon dioxide or bicarbonates in response to changes in the other system. For example, if there is a respiratory acidosis, the kidneys can start to conserve bicarbonates in the blood (i.e. not pass as many out in the urine). This will raise

levels and make the blood more alkaline, thereby restoring the pH.

Top tip!

If the pH and the P_aCO₂ have moved in the same direction, this suggests that the respiratory system is compensating and the problem is metabolic.

If the pH and the have moved in the opposite direction, this suggests that the metabolic system is compensating and the problem is respiratory.

The respiratory system can react to change quickly (within a couple of hours) but the metabolic system may take approximately 2 days to respond. Any compensation may be full (complete) or partial (Box 3.1.3).

i. Full compensation is seen when both the P_aCO₂ and the

are outside the normal range and the pH is within the normal range.

ii. Partial compensation is when the P_aCO₂ and

are both out of range but the pH is not quite within normal limits.

Note that it may be impossible to distinguish between compensated respiratory acidosis and compensated metabolic alkalosis, or between compensated respiratory alkalosis and compensated metabolic acidosis without looking at other clinical findings or a series of ABGs.

The chart in Table 3.1.2 assumes that any compensation is complete not partial.

5. Check oxygenation

Hypoxaemia. P_aO₂ reflects the ability of the lungs to allow the transfer of oxygen from the environment to the circulating blood. A reduced P_aO₂, regardless of F_iO₂ (how much oxygen the patient is receiving), is called hypoxaemia. You should always check if a reading has been taken while the patient is receiving oxygen therapy, and, if so, how much they are receiving (see 3.43 Oxygen delivery). A P_aO₂ of 10.7 kPa is normal, but would not be considered normal if the patient is receiving 60% oxygen.

Identify any significant, deteriorating or potentially critical levels of hypoxaemia. In acute respiratory disease, a P_aO₂ <10.7 kPa may be significant and <7.3 kPa may be critical, but chronic respiratory patients may be able to tolerate lower oxygen levels, and hypoxaemia may not be considered significant until it drops below 7.3 kPa. Oxygen therapy should be considered for patients with significant (or worsening) hypoxaemia.

S_aO₂ levels may be used to determine the need for oxygen therapy. Give oxygen when S_aO₂ <90% (see 3.48 Pulse oximetry).

6. Check for respiratory failure

a. Identify whether the patient is in respiratory failure – is it type I or type II?

i. Type I respiratory failure occurs when P_aO₂ is low and P_aCO₂ is normal or slightly reduced.

ii. Type II respiratory failure occurs when P_aO₂ is low and P_aCO₂ is high.

b. Acute or chronic respiratory failure?

Table 3.1.2 Respiratory and metabolic acidosis and alkalosis

Top tip!

Type One failure is when One gas (i.e. Oxygen) is affected – remember they both begin with O!

Type Two is when Two gases (i.e. oxygen and carbon dioxide) are affected.

When respiratory failure is due to acute respiratory disease, there may be little or no compensation from raised

levels because it takes time (e.g. days) for adequate compensation to occur. Therefore, the pH is likely to be low (respiratory acidosis).

When respiratory failure is due to a chronic respiratory disease there may be compensation from raised

levels. Therefore, the pH may be normal, or only slightly lower than normal (compensated respiratory acidosis). Check any current ABG results against any previous or usual results as this will also help to confirm the diagnosis of acute or chronic failure.

It is important to identify the extent to which any respiratory failure is acute or chronic because patients with chronic respiratory disease can tolerate lower levels of hypoxaemia and may not need oxygen therapy until their levels become lower. Additionally, they may be reliant on a ‘hypoxic’ drive to breathe, and if they are given too much oxygen therapy their drive to breathe could be seriously reduced.

Documentation

Record each value together with time and date of test, and any oxygen therapy or ventilation support given at the time of measurement. Record the patient’s position if appropriate.

Clinical examples (answers follow)

Answers to clinical examples

Case 1

This man has a respiratory acidosis (uncompensated). It is an acute condition and may be due to pneumonia or a severe chest infection – note he has type II respiratory failure and may require additional ventilator support.

Case 2

This girl has respiratory alkalosis (uncompensated). This is an acute situation and has been caused by hyperventilation due to anxiety.

Case 3

This man has compensated respiratory acidosis. This is a chronic situation because there has been enough time for to increase and his pH is within the normal range, despite his high P_aCO₂ (remember he is an ex-miner; therefore, respiratory disease would not be uncommon).

Case 4

This man has partially compensated metabolic acidosis. His symptoms suggest diabetes, which can cause a fall in and therefore a fall in pH. There is some compensation because the P_aCO₂ has gone down, suggesting that he is breathing more in order to try and raise the pH. This is only partially successful because his pH is still below the normal range. Physiotherapy is not going to help his breathing at this point as he needs medical attention to stabilize his diabetes.

3.2 Attachments

Definition

These may be any piece of equipment that is attached to the patient, e.g. intravenous (i.v.) lines, central venous line, ECG lines, surgical drains, ventilator tubing, saturations monitor and catheter (Figs 3.2.1 and 3.2.2).

Fig 3.2.1 Example of patient attachments in an intensive therapy unit.

Fig 3.2.2 Example of patient attachments in the ward setting.

Purpose

The purpose of an attachment is specific to what is being monitored – many of these will be discussed throughout this chapter. However, the ultimate aim of attachments can be subdivided as:

• monitoring/assessment of the patient, e.g. saturations monitor, intracranial pressure (ICP) bolt

• provision or drainage of fluids, i.e. what is going in and out, such as drips and drains

• treatment/support of the patient, e.g. renal support, ventilator.

Procedure

Be aware of all attachments and take care not to displace any equipment during your assessment.

Findings

If you do not know what a piece of equipment or fluid running into the patient is, ask the nursing staff. It may be important information that will influence what you can/cannot do with the patient, e.g. changing position.

Documentation

As part of your assessment, all attachments should be noted within your documentation.

3.3 Auscultation

Definition

Auscultation is the process of using a stethoscope to listen to and interpret the lung/breath sounds generated by airflow through the airways.

Purpose

This assessment technique can help identify sputum retention in the airways, or areas of atelectasis. It may be used as an outcome measure before and after physiotherapy. It can also help identify deterioration or more serious pathology such as a pneumothorax that may need further medical investigation.

Procedure

• Equipment

– Good quality stethoscope (Fig. 3.3.1).

– Sterilizing wipes.

• Method

– Clean the diaphragm and earpieces with wipes.

– Place earpieces in your ears (earpieces should face forwards in order to fit into your auditory canals).

– Check that the stethoscope is tuned to the diaphragm (tap the diaphragm lightly – can you hear this clearly? If not twist the metal connector until you can hear the tapping sound most clearly).

– Ask the patient if they would be willing to remove any items of clothing in order to expose the chest area, providing this is appropriate and you can maintain their dignity and comfort.

– Position the patient so you can access anterior and posterior aspects of the chest, e.g. sitting up over the edge of the bed or sitting forwards in a chair. If they are confined to bed, you may need help to sit them forwards slightly when listening posteriorly or help them to roll into side lying. Note that you may have to access the posterior segments by moving your stethoscope under the patient if they are very unwell and unable to move.

– Warn the patient to inform you if they start to feel dizzy.

– Place the stethoscope firmly on the chest wall in the positions described in Fig. 3.3.2 and Table 3.3.1.

– Listen during both inspiration and expiration. Listen to each zone of the lungs on alternate sides of the chest to compare your findings.

– Make sure you listen to one or two full breaths in AND out at each point.

– Allow the patient a period of rest or normal breathing between zones or if they become dizzy.

– When you have finished, note your findings and clean your stethoscope.

Fig 3.3.1 Labelled diagram of a stethoscope.

Fig 3.3.2 Auscultation points.

H, horizontal fissure; LLL, left lower lobe; LUL, left upper lobe; RLL, right lower lobe; RUL, right upper lobe; RML, right middle lobe.

Reproduced and modified with kind permission from Pryor JA, Prasad SA. 2008 Physiotherapy for Respiratory and Cardiac Problems, 4th Edn. Edinburgh, UK: Churchill Livingstone.

Table 3.3.1 Auscultation zones

Mid-axillary Left and right Posterior

Findings

For each zone, record whether breath sounds are normal or bronchial, loud or quiet, and then identify any added sounds.

Breath sounds (Table 3.3.2) arise in the trachea and bronchi and are caused by the turbulence of the air as it flows in and out of these large airways. If you listen over the trachea (just below the cricoid cartilage or Adam’s apple) you will hear what they sound like at the source.You will notice that they are very loud here and also quite harsh sounding. Inspiration and expiration are heard clearly (both are loud) and there is a very slight pause between them. These sounds are known as bronchial breath sounds because they are generated in the bronchi (and trachea).

• Normal breath sounds. If you listen anywhere over the lung fields (including all of the zones shown in Fig. 3.3.2) the sounds are much quieter because you are over lung parenchyma and the air in the lungs has absorbed a lot of the sound. This attenuates the sound, making it smoother, gentler and more continuous, so it is harder to tell when inspiration changes to expiration. Since we expect to hear these sounds when auscultating over the lungs we call them ‘normal breath sounds’.

• Bronchial breathing (bronchial breath sounds heard over lung fields). If you are listening over the lungs and what you hear sounds loud, harsh and discontinuous (i.e. like bronchial breath sounds), it is not ‘normal’ and suggests that these sounds have not been dampened down by the air in the lungs – usually because in that area of lung the air has been replaced by something solid (consolidated). A solid area transmits sound very well because it vibrates more than air (ask the patient to say ‘99’ while auscultating and the sound will be very clear over consolidated lung tissue). These sounds may occur over an area of lobar pneumonia where the alveoli fill with clotted inflammatory exudate, or over collapsed lung tissue (occurring without a sputum plug), or at the lip of a pleural effusion.

• Breath sounds quieter than normal. If the breath sounds are very quiet it might be because the patient is very large and therefore the sounds have been dampened down by excess soft tissue. Make sure you press the stethoscope firmly to the chest wall and press through the adipose tissue to get the best sound transmission. It might, however, be because the breaths were quite small and not generating much turbulence. Perhaps the patient is not breathing very deeply? Does this fit with your observation and palpation? Is one side of the chest moving more than the other side?

Table 3.3.2 Breath sounds

Normal breath sounds

Soft, muffled, louder on inspiration, fade in expiration, ratio 1:2

Turbulence in the large airways

Bronchial breathing

Expiration louder and longer with pause between inspiration and expiration (sounds like Darth Vader)

Heard normally over trachea

If heard over lung fields, suggests:

• Consolidation

• Collapse without a plug

• May also be heard at the lip of a pleural effusion

Breath sounds quiet or absent?

May be due to:

• Collapse with complete obstruction of airway

• Sounds filtered by air (hyperinflation)

• Sounds filtered by pleura, chest wall (obese or muscular patients, pleural effusion, pneumothorax, haemothorax)

• Pneumothorax

Top tip!

Think! If a patient is not breathing very deeply – what possible implications might this have and what problems might this cause?

• Absent breath sounds. A pleural effusion, sputum plugging or pneumothorax could prevent sounds from being heard by absorbing the sound completely before it can be transmitted to the chest wall.

Top tip!

If you auscultate and hear a ‘silent’ chest, it may mean that the patient is in extremis and is unable to move air at all (check airway and stethoscope). This is a medical emergency and you need to seek expert medical assistance straight away!

• Breath sounds louder than normal. Loud breath sounds suggest more turbulence in the large airways. This is usually due to obstruction or narrowing of these airways, e.g. due to COPD. Narrower airways are harder to breathe through, so the patient may be working harder in order to breathe.

• Other added sounds.

– Crackles (Table 3.3.3)

– Fine crackles. Sound like rubbing a hair next to your ear. They may be due to pulmonary oedema or sputum but are often caused by the sudden opening of small airways when lung volumes are low, suggesting atelectasis. If it is the latter, they often resolve after some deep breathing exercises.

– Coarse crackles. Sound like rice crispies crackling as you add the milk. They may be caused by sputum, particularly if you notice that they reduce or change after coughing.

Table 3.3.3 Added sounds: crackles

Crackles	Short, non-musical, popping sounds, fine or coarse
*Fine crackles* Reopening of airways sounds like rubbing hair next to your ear	Atelectasis	• Short, explosive • Periphery lung • Reduce with deep breath
	Intra-alveolar oedema	• ‘Tissue paper’ • Do not resolve with deep breath or cough • Late inspiration (NB: interstitial fibrosis)
	Secretions small airways	• High pitched • Peripheral • Clear with cough
*Coarse crackles* Sounds like pouring milk on rice crispies	Obstruction more proximal and larger airways with sputum. May be inspiratory as well as expiratory	• Early expiratory: central airways • Late expiratory: more peripheral airways • Large deep sound • Changes/clears with coughing

Top tip!

Remember crackles are only heard if the velocity of airflow is adequate and breath sounds are audible. Coarse crackles move/disappear when the patient coughs, whereas fine crackles remain the same after coughing.

– Wheezes (Table 3.3.4). Whistling sounds due to narrowed airway walls vibrating against each other, indicating airway obstruction. High-pitched wheeze indicates bronchospasm or oedema in the walls of conducting airways. Low-pitched wheeze indicates sputum.

You should identify whether wheezes or crackles are heard during inspiration or expiration and whether they are heard early or late during the breath. Louder sounds heard early in the breath are more likely to be generated centrally (in the larger airways).

– Pleural rub (Table 3.3.5). A sound like boots crunching on snow suggests that the pleura are inflamed.

– Stridor (Table 3.3.5). This is a sound like a loud ‘barking’ noise. Occurs during both inspiration and expiration and is usually caused by significant upper airway obstruction, which could be a foreign body or tumour. If stridor is heard as a new/recent symptom, alert the medical staff immediately as the patient’s airway could be compromised.

Table 3.3.4 Added sounds: wheezes

*Wheezes*	Musical sounds due to vibration of wall of narrowed airway
*High pitched*	Bronchospasm	• Potential increased work of breathing
*Low pitched*	Sputum	• Disrupted turbulent flow • Change with coughing
*Localized*	TumourForeign body	• Limited to a local area on auscultation

Table 3.3.5 Other sounds

	Sounds like	Cause
*Pleural rub*	• Creaking/rubbing (like boots on snow) • Localized/generalized • Soft/loud • Equal inspiration to expiration	• Inflammation of pleura • Infection • Tumour
*Stridor*	• Constant pitch on inspiration and expiration • Produced in upper airways	• Croup • Laryngeal tumour • Upper airway obstruction ! Alert medical staff as the patient’s airway is at great risk of compromise

Top tip!

Auscultation is only a small part of respiratory assessment and its interpretation is subjective. Always consider your findings alongside other assessment information before drawing any firm conclusions.

Documentation

Record the patient’s position and your findings, e.g. ‘Normal breath sounds heard in all zones, quieter in right base. Coarse crackles in right base on mid-expiration, reduced after coughing’.

3.4 AVPU (see also 3.33 glasgow coma scale and 3.39 level of consciousness)

Definition

AVPU is a simple test to give an indication of the level of arousal of a patient. It is a quick neurological assessment and the acronym stands for Awake, Voice, Pain and Unresponsive.

Purpose

This was adapted from paediatric practice to acute adult care as a method of quickly identifying change in neurological arousal. While effective, it does not replace formal neurological assessment such as the Glasgow Coma Scale (see 3.33 Glasgow Coma Scale and 3.57 Sedation/agitation score).

Procedure

There are only four possible outcomes within this scale. Ask the patient a simple question such as ‘hello – can you hear me’. Look for the best response in the patient. If the patient is asleep, he or she should be woken first. It is not valid in patients who are sedated or having paralyzing drugs.

1. Alert. The patient is alert and responsive and answers clearly and coherently. The patient could be sitting up reading the paper or talking to visitors.

2. Voice. The patient is responding only to voice commands and may be drowsy, possibly keeping eyes closed and not speaking coherently. There is a response to your voice. Does the patient wake up when you call their name? This response may be only a grunt.

3. Pain. The patient responds only to pain. To elicit any response from the patient requires a painful stimulus (for procedure and appropriate painful stimuli, see 3.33 Glasgow Coma Scale).

4. Unresponsive. The patient is unresponsive. This patient is unresponsive or unconscious. They may be in a ‘coma’ with no eye opening or movement.

Findings

Note that you are looking for a change in status. If a patient who was previously alert is now only responding to voice, this is a significant change and should be notified to the team. Any patients who are only responding to pain or who are unresponsive warrant an urgent medical review.

Documentation

This should be documented in the neurological section of the assessment as the level of response according to the first letter of the acronym, e.g. ‘The patient was at “V” on the AVPU scale’. Some units write down the acronym AVPU and circle the appropriate letter e.g. AVP

3.5 Blood pressure (BP)

Definition

The force exerted by the blood against the walls of the arteries. Blood pressure (BP) can be measured in a large artery (e.g. brachial or femoral), and may be measured invasively through an arterial line or non-invasively through a cuff and sphygmomanometer (manually) or by using an automated BP machine (Figs 3.5.1 and 3.5.2).

Fig 3.5.1 Non-invasive blood pressure monitors. Manual sphygmomanometer (left) and automated blood pressure machine (right).

Fig 3.5.2 Invasive blood pressure measurement. Arterial blood pressure trace; the arterial trace is second from the top with a blood pressure of 101/49 and a mean arterial pressure of 66.

Purpose

The measurement of BP is very important when determining cardiovascular status and stability in the critically ill patient as well as monitoring patients at risk of deterioration that could lead to circulatory failure. The physiotherapist must also take BP status into account when standing and mobilizing patients and when prescribing exercise. BP may also be used as an outcome measure for physiotherapy treatment.

Procedure

Non-invasive BP monitoring: cuff and sphygmomanometer (Fig. 3.5.3)

• Choose an appropriate sized cuff for the patient (Table 3.5.1). The inflatable part of the cuff should go round at least 75% of the arm circumference, but it should not be any longer than the arm circumference.

• Observe the patient’s arm carefully throughout the procedure. If there is any pain or numbness or if the arm starts to change colour, becoming blue or purple, the cuff should be immediately deflated and removed from the arm.

1. The patient should be sitting still with their elbow extended and supported at approximately the level of the heart. Ideally, the patient should rest for 5 minutes before the measurement is taken.

2. Explain that the cuff will exert an uncomfortable pressure for a few seconds while inflated.

3. Ensure there is no residual air in the cuff (squeeze any air out), then wrap the cuff around the arm above the elbow joint so that the ‘arterial point’ on the cuff is over the brachial artery (medial to the biceps muscle on the anterior aspect).

4. Fasten the cuff firmly but not too tightly.

5. Inflate the cuff to a pressure higher than the ‘likely’ systolic pressure. For most people 150 mmHg will be sufficient; however, if a person is known to have a high BP, or if you are measuring following exercise, you will need to inflate to a higher pressure, up to a maximum of 260 mmHg.

6. Release the pressure in the cuff slowly while using a stethoscope over the brachial artery pulse at the anterior aspect of the elbow. Listen for the sounds generated by the blood flow in the artery. These are described as soft knocking or pounding sounds (Korotkoff sounds).

7. Record the pressure when you FIRST hear the knocking sounds. This is the systolic pressure.

8. Record the pressure when you STOP hearing the knocking sounds. This is the diastolic pressure.

9. Release the valve and allow the cuff to completely deflate before removing it from the patient’s arm.

10. Check the arm to ensure circulation (normal pink colour) is restored and no damage has been caused.

Fig 3.5.3 Blood pressure measurement using a sphygmomanometer.

Table 3.5.1 Blood pressure cuff sizes

Size of cuff	Upper arm circumference (measure at mid-point of humerus)
Child/small adult cuff	<23 cm
Standard/regular adult cuff	<33 cm
Large adult cuff	<50 cm
Adult thigh cuff	<53 cm

Cuff and automated BP machine (Fig. 3.5.4)

• Make sure you are familiar with the machine and any manufacturer’s instructions before commencing.

• Carry out steps 1–5 above; then press the start button on the automated BP machine.

• It is very important to observe the patient’s arm carefully. If there is any pain or numbness or if the arm starts to change colour, becoming blue or purple, the cuff should be immediately deflated and removed from the arm.

• If the machine stays inflated too long, or continually reinflates over and over again, stop the procedure and check the patient’s circulation.

• Check the arm to ensure circulation (normal pink colour) is restored and no damage has been caused.

Fig 3.5.4 Measuring blood pressure using an automated machine.

Findings

Average resting BP is 120/80 mmHg. The first figure (120 mmHg) represents the systolic pressure, achieved during ventricular contraction. The second figure (80 mmHg) is the diastolic pressure, achieved during ventricular diastole. Invasive measurements of BP will also calculate MAP (mean arterial pressure) (see 3.10 (Invasive) Cardiac monitoring).

Normal BP ranges between 95/60 and 140/90 mmHg, but does tend to increase with age. The significance of any ‘abnormal’ values (i.e. outside the range given) depends on what is usual for that patient. A one-off abnormal measurement may not be significant, because BP varies with many factors, including activity levels, emotion (including stress!) and temperature. It is more important to look at the ‘trend’ and identify any changes over time. However, if there is a sudden significant change in BP you should seek senior advice.

Hypotension is defined as BP <95/60 mmHg (adults). If BP is dropping over time, or is below the patient’s usual level, this could be significant because it could compromise blood flow to the brain, leading to fainting or, in more serious situations, circulatory failure and death. A patient whose pulse is higher than their systolic BP at rest is likely to be significantly compromised and may require urgent attention and circulatory support (e.g. intravenous fluids and possibly cardiopulmonary resuscitation (CPR)).

Postural hypotension may occur if the BP drops when the patient sits or stands up, leading to dizziness or fainting. Patients are most at risk when getting out of bed for the first time after a period of bed rest. If the patient’s BP is low, take extra care when getting them up and ensure that this is carried out slowly.

Hypertension is defined as BP >140/90 mmHg. The significance of high BP depends on the patient’s age and their usual values. A diastolic pressure of >95 mmHg warrants a degree of caution with any ‘active’ treatments or mobilization. Any unexplained increase in BP above the normal range and the patient’s usual values should be referred to the medical practitioner for investigation.

Top tip!

If the BP is much higher than the heart rate or much lower than the heart rate seek advice from a senior as this can indicate an acute problem.

Blood pressure should also be considered in conjunction with any medication the patient may be on that may affect the BP:

• Inotropes (e.g. adrenaline, noradrenaline, enoximone, milrinone) help to increase BP. Patients who need this support are less stable, and need extra caution with physiotherapy techniques.

• Anti-hypertensives (e.g. beta-blockers, angiotensin-converting enzyme inhibitors, diuretics) help to reduce BP and may affect the patient’s response to exercise (see 3.22 Drugs).

Documentation

Record measurement, e.g. resting BP on L arm in sitting using (name of) machine = 120/80 mmHg.

3.6 Blood results

Definition

There are a number of different types of blood tests; Table 3.6.1 summarizes those that are particularly relevant to physiotherapists. Other types of blood tests include those for immunology and virology.

Table 3.6.1 Types of blood tests relevant to physiotherapists

Purpose

Blood results reflect body systems and how they are functioning. They may give an indication of deterioration or improvement. Some results can be markers of specific problems. For example, they can be used to identify patients:

• developing a chest infection which might require chest physiotherapy

• at risk of bleeding and the need for caution with manual chest therapy techniques

• at risk of deep vein thrombosis (DVT) and caution with mobilization

• with anaemia who may be at risk of low oxygen levels.

Procedure

Blood tests in the main are carried out by medical and nursing staff. Some specialist physiotherapists may take some blood samples, e.g. ABGs.

Findings

Top tip!

There is much variation in the normal values referenced by different texts, online and in hospitals. Therefore, the ranges provided here are guides; when reviewing patient results the normal values used in your own facility should be used.

Full blood count

A common test that assesses the state of health of the patient (Table 3.6.2). For definitions, see the further reading suggested at the end of this section.

Table 3.6.2 Full blood count results

Test (normal range)	Too high	Too low
(WBC) (4–11 × 10⁹/l)	May be increased with infections, inflammation, cancer, leukaemia	Decreased with some medications (e.g. chemotherapy), when immune system is compromised, some severe infections, bone marrow failure
WBC differentials, i.e. neutrophils, lymphocytes, monocytes, eosinophils and basophils	Measures the percentage of each type of WBC in blood. A low level is generally due to immunocompromise. Neutropenia is a low neutrophil count and happens after chemotherapy; neutropenic sepsis is when the patient becomes very unwell and has no reserves to fight off infection
RBC (M = 4.5–6.5 × 10¹²/l) (F = 3.9–5.6 × 10¹²/l)

Increased when too many made and with fluid loss, e.g. diarrhoea, dehydration or burns Decreased with anaemia; may mean patients tire easily as reduced RBC and Hb reduce oxygen-carrying ability

Mirrors RBC results

Mirrors RBC results

Increased with B₁₂ and folate deficiency Decreased with iron deficiency and disorders of Hb

Platelets

(150–400 × 10⁹/l)

May be increased in people living at altitude. Myeloproliferative disorder may cause greater propensity for DVT and clotting problems. Oestrogen and the oral contraceptive pill can cause increased levels Decreased when greater numbers used, e.g. bleeding, some inherited disorders, leukaemia and chemotherapy. Caution with treatment as high risk of bleeding

DVT, deep vein thrombosis; F, female; Hb, haemoglobin; Hct, haematocrit; M, male; MCV, mean corpuscular volume; RBC, red blood cell; WBC, white blood cell.

Coagulation screen (Table 3.6.3)

This gives an indication of the body’s ability to form clots. Activated prothrombin time (APTT) and prothrombin time (PT) are often tested together to evaluate the function of all clotting factors. PT is often adjusted to the international normalized ratio (INR), especially in the assessment of anticoagulant therapy (blood thinners). Fibrinogen assesses the body’s ability to form and break down clots.

Table 3.6.3 Coagulation results

Test (normal range)	Too high	Too low
APTT (25–35 s)	Clotting deranged, bleeding time prolonged and interventions may have higher risk of bleeding; many treatments can be contraindicated. Check with senior!	Potential hypercoagulable state in which blood may clot too easily; this is unusual but could lead to, for example, DVT
PT (11–15 s)
INR (0.8–1.2)
Fibrinogen (2.0–4.0 g/l)	May rise sharply in any condition that causes inflammation or tissue damage. Rise will increase a person’s risk of developing a blood clot	Low levels impair the body’s ability to form a stable clot; may be an inherited disorder or can be the result of illness. Caution with treatment and discuss with senior!
Platelets	See Full blood count

APTT, activated prothrombin time; DVT, deep vein thrombosis; INR, international normalized ratio; PT, prothrombin time.

C-reactive protein (CRP)

CRP (Table 3.6.4) is an inflammatory marker (often used alongside the white blood count). It serves as a general marker of infection and inflammation.

Table 3.6.4 C-reactive protein and lactate results

Test	Too high	Very high
CRP Normally <6 mg/l

Acute infection or inflammation A CRP >100 mg l⁻¹ is suggestive of bacterial infection

Lactate

Normally 0.5–1.8 mmol/l

Gives an indication of anaerobic respiration Levels of 4–5 in presence of metabolic acidosis = lactic acidosis, i.e. your patient is very unwell!

CRP, C-reactive protein.

Lactate

Lactate (Table 3.6.4) is a by-product of anaerobic respiration and rises in patients with sepsis. It is also a marker of the severity of stress response. Hyperlactataemia is a mild-to-moderate persistent increase in blood lactate concentration (2–5 mmol l⁻¹) without metabolic acidosis. Lactic acidosis is a persistently increased blood lactate level (usually >4–5 mmol l⁻¹) in association with metabolic acidosis. It is not within the remit of this book to discuss lactic acidosis; see Further reading on this subject at the end of this section.

Urea and electrolytes (U&Es)

U&Es (Table 3.6.5) encompass renal function and electrolyte tests. Urea and creatinine are the main markers of renal function.

Table 3.6.5 Urea and creatinine results

Test	Measurement significance
Urea (2.1–8.0 mmol/l)	Urea is the final degradation product of proteins and amino acid metabolism and is the most important catabolic pathway for eliminating excess nitrogen in the body. Blood loss, fluid balance, renal failure and liver failure can also cause rises in urea
Creatinine (M = 80–115 μmol/l) (F = 70–100 μmol/l)	A waste product produced by muscles; related to muscle mass (women and children tend to have lower levels). Creatinine blood levels can also increase temporarily as a result of muscle injury and are generally slightly lower during pregnancy Creatinine clearance measures how well creatinine is removed from your blood by your kidneys. It is completed using a blood sample and 24 hour urine collection

Test

Measurement significance

Urea (2.1–8.0 mmol/l)

Urea is the final degradation product of proteins and amino acid metabolism and is the most important catabolic pathway for eliminating excess nitrogen in the body. Blood loss, fluid balance, renal failure and liver failure can also cause rises in urea

Creatinine (M = 80–115 μmol/l) (F = 70–100 μmol/l)

A waste product produced by muscles; related to muscle mass (women and children tend to have lower levels). Creatinine blood levels can also increase temporarily as a result of muscle injury and are generally slightly lower during pregnancy

Creatinine clearance measures how well creatinine is removed from your blood by your kidneys. It is completed using a blood sample and 24 hour urine collection

F, female; M, male.

Electrolytes are salts that conduct electricity and are found in the body fluid, tissue and blood (e.g. chloride, calcium, magnesium, phosphate, sodium and potassium). Sodium (Na⁺) is concentrated in the extracellular fluid (ECF) and potassium (K⁺) is concentrated in the intracellular fluid. Proper balance is essential for muscle coordination, heart function, fluid absorption and excretion, nerve function and concentration. Levels may be affected by diet, total body water and the amount of electrolytes excreted by the kidney.

Sodium (Na⁺)

Na⁺ (Table 3.6.6) plays a vital role in maintaining the concentration and volume of the ECF. It is the main cation of the ECF and a major determinant of ECF osmolality. Na⁺ is important in maintaining irritability and conduction of nerve and muscle tissue and assists with the regulation of acid–base balance.

Table 3.6.6 Sodium and potassium results

Test	Too high	Too low
Sodium (135–145 mmol/l)	Hypernatraemia >145 mmol l⁻¹ Caused by disruption in water balance: either too little going in or too much coming out, or by salt loading

Hyponatraemia <135 mmol l⁻¹ caused by water intoxication, altered ADH secretion and drugs, e.g. diuretics and MDMA (ecstasy). If seen in dehydrated patients, seek expert help Potassium (3.5–5.0 mmol/l)

Hyperkalaemia

>5.5 mmol l⁻¹ (severe is >7 mmol l⁻¹)

Decreased or impaired potassium excretion most common in renal failure but also potassium-sparing diuretics and specific inherited diseases

Hypokalaemia

<3.5 mmol l⁻¹

Caused by renal losses, GI losses and drug effects (commonly diuretics)

If potassium is out of range in either direction there is a high risk of cardiovascular instability, especially if the patient suffers from renal failure! If you are unsure if it is appropriate to treat, seek senior advice!

ADH, antidiuretic hormone; GI, gastrointestinal.

Potassium (K⁺)

K⁺ (Table 3.6.6) is the major ion of the body. Nearly 98% of potassium is intracellular, with the concentration gradient maintained by the sodium- and potassium-activated adenosine triphosphatase pump. The ratio of intracellular to extracellular potassium is important in determining the cellular membrane potential.

Small changes in the extracellular potassium level can have profound effects on the function of the cardiovascular and neuromuscular systems.

Other electrolytes have different functions but are not as commonly reviewed by physiotherapists and therefore will not be covered here.

Cardiac markers

These are substances released into the bloodstream when the heart is damaged. The two commonly used markers are troponin and creatinine kinase. These can be used to diagnose, evaluate and monitor heart problems.

Glucose

Blood sugar levels are important in maintaining acid–base balance in the body. It has previously been suggested that tight glycaemic control improved mortality, but this is currently under question. However, glucose levels (Table 3.6.7) are important because altered results may cause dramatic effects and yet can be easily treated.

Table 3.6.7 Glucose results

Test	Too high	Too low
Glucose Normal 3.6–6 mmol/l

Hyperglycaemia leads to fatigue and thirst. In the diabetic patient when high levels have been present for some time, diabetic ketoacidosis can develop – a medical emergency

Hypoglycaemia

Sympathetic responses: sweating, tremors and tachycardia

CNS symptoms of confusion convulsions, dizziness and syncope

CNS, central nervous system.

Microbiology

The pathology department can run specific tests for infections within the blood. If bacteria are identified, an appropriate antibiotic can be prescribed. Specific tests will not be discussed within this text.

Documentation

Blood results relevant to your assessment should be documented within the cardiovascular system (CVS) section of your assessment or under a heading of haematology. It is good practice to identify the trends of the results and note any cautions to treatment based upon these.

3.7 Breathing pattern (See under 3.54 respiratory pattern – page 148)

3.8 Breathlessness (dyspnoea) scales

Definition

Breathlessness (dyspnoea) is the subjective sensation of difficulty in breathing or the perception of an increased effort to breathe. There are several different tools that may be used to ‘measure’ this perception by attempting to quantify what is essentially a qualitative patient experience. Two scales that are commonly used by physiotherapists are:

• Borg breathlessness scale (CR10)

• Medical Research Council (MRC) scale.

Other breathlessness scales include visual analogue scales, the baseline dyspnoea index (BDI) and scales found within other quality of life measurement questionnaires such as the St Georges questionnaire and chronic respiratory questionnaire.

Purpose

Breathlessness scales have a number of uses:

• The Borg scale (CR10) can be used to rate exercise intensity during an exercise test and identify an appropriate level of intensity when prescribing exercise or activity. It may also be used to monitor progress during an exercise programme and as a guide when patients are learning to desensitize themselves to their breathlessness.

• The MRC scale can be used to classify patients according to the functional impact of their respiratory disease. This can be used to monitor progression or deterioration and in helping to select patients who are appropriate for pulmonary rehabilitation and medical interventions.

• Breathlessness scales can also be used as outcome measures for drug therapy and for physiotherapy interventions such as exercise programmes, breathing control or sputum clearance.

Procedure

Borg scale (Table 3.8.1)

Ensure that the patient understands the scale points and descriptors; then ask them to rate how strong their feeling of breathlessness is at that moment according to the criteria.

Table 3.8.1 The Borg CR10 scale

Number	Strength of perception of breathlessness
0 0.3 0.5 0.7 1 2 2.5 3 4 5 6 7 8 9 10 *	Nothing at all Extremely weak (just noticeable) Very weak Weak Moderate Strong (heavy) Very strong Extremely strong (almost maximal) Absolute maximum/highest possible

Number

Strength of perception of breathlessness

0
0.3
0.5
0.7
1
2
2.5
3
4
5
6
7
8
9
10
*

Nothing at all
Extremely weak (just noticeable)

Very weak
Weak

Moderate

Strong (heavy)

Very strong

Extremely strong (almost maximal)
Absolute maximum/highest possible

Note that some texts refer to the absolute maximum level of breathlessness as above 10; on some adapted scales, this may be marked with a symbol, e.g. ‘*’. There is also a Borg scale that uses 20 points (see 3.51 Rating of perceived exertion).

MRC scale (Table 3.8.2)

Ask the patient to pick the statement that is most applicable to them. If their breathlessness is variable, they should focus on the past 2 weeks when answering.

Table 3.8.2 Medical Research Council (MRC) scale

MRC score	Descriptor
1	I only get breathless with strenuous exercise
2	I get short of breath when hurrying on the level or walking up a slight hill
3	I walk slower than other people of the same age on the level because of breathlessness, or I have to stop for breath when walking at my own pace on the level
4	I stop for breath after walking about 100 yards or after a few minutes on the level
5	I am too breathless to leave the house or garden by myself (i.e. I can only leave the house if I am with others and/or need a car to get out)

Findings

Borg scale

As this is a subjective measure, patient ratings will vary considerably and we cannot compare patients with each other using this scale. Patients are generally encouraged to try and exercise at between 3 and 5 on the scale and to learn to pace themselves accordingly. Patients who get more breathless than ‘5’ during exercise or activity should be monitored carefully, but, providing their sensation of effort is back to resting levels within 5 minutes of stopping, they are generally considered safe to exercise at that intensity.

MRC scale

Some pulmonary rehabilitation programmes use MRC grade 3 and above as a criterion for inclusion in a pulmonary rehabilitation programme, as this indicates that the patient is limited by their breathlessness and may find benefit from such a programme.

Documentation

For the Borg scale, record the score and state whether at rest or during exercise. Record the intensity of any exercise undertaken and any additional (qualitative) comments the patient may make about their breathlessness.

For the MRC scale, record the score and note the status of the patient (i.e. whether or not the patient has had a recent exacerbation or whether he or she is in a stable condition).

3.9 Capillary refill test

Definition

A quick test performed on the nail beds to monitor dehydration and the amount of blood flow to tissue.

Purpose

This test is used to assess the amount of blood flow to the tissue and to determine the patient’s tissue perfusion. If capillary refill is slower than expected then reduced cardiac output or impaired digital perfusion is suspected and should be further investigated by medical staff.

Procedure

• This should be performed at the level of the heart.

• Pressure is applied to the nail bed until it turns white, indicating that the blood has been forced from the tissue (blanching).

• Once the tissue has blanched, pressure is removed.

• The time taken for the tissue to return to its normal colour is then recorded.

• The tissue should normally take less than 2 seconds to return to its normal colour.

Findings

A slow capillary refill time may indicate dehydration (hypovolaemia), hypothermia, peripheral vascular disease or sepsis. If the slow refill time is caused by dehydration the patient may potentially have dry tenacious secretions, which are difficult to expectorate.

A fast capillary refill time may indicate overhydration (hypervolaemia). This may have an impact on physiotherapy if the patient shows other signs of symptoms of fluid overload leading to pulmonary oedema. Capillary refill time can also be very fast if the patient is very hot and is vasodilated to lose heat.

Documentation

Capillary refill time should be recorded (especially if greater than 2 seconds) under the cardiovascular section of your assessment.

3.10 (Invasive) cardiac monitoring

Definition

Invasive cardiac monitoring comprises the calculation of cardiac activity and cardiac function through the insertion of invasive (intravascular) catheters.

Key terminology

• Stroke volume index : a calculation relating the stroke volume (the amount of blood pumped by the left ventricle in one contraction) to the body surface area (normal range = 33–47 ml/m²/beat).

• Cardiac index : a calculation that relates the cardiac output (stroke volume × heart rate) to body surface area (normal range = 2.5–4.0 l/min/m²).

• Global ejection fraction: the proportion of the volume of blood in the ventricles at the end of diastole that is ejected during systole; it is the stroke volume divided by the end-diastolic volume, often expressed as a percentage (normally range = 65 ± 8%).

• Mean arterial pressure: the average BP in an individual. It is not a true average as diastole counts twice as much as systole because two-thirds of the cardiac cycle is spent in diastole (normal range = 70–105 mmHg). It is calculated using the equation:

• Systemic vascular resistance: the resistance to flow that must be overcome to push blood through the circulatory system (normal range = 800–1200 dynes.sec/cm⁵).

Purpose

The purpose of invasive cardiac monitoring is to quickly ascertain how the heart is functioning, and to help assess the cardiovascular status of a patient. Information gained from these devices provides information on cardiac function and assists in the optimization of cardiac function as well as in the treatment of heart failure, kidney failure, pulmonary disease and complex fluid management. Such devices will be seen within the intensive therapy unit (ITU) and theatre environments.

For physiotherapists, cardiac monitoring will assist in the assessment of the cardiovascular system. This will aid in deciding whether physiotherapy treatment is required and whether the patient is likely to tolerate any intervention. If a patient has any form of invasive cardiac monitoring it should be observed throughout the treatment, and, if gross changes occur, treatment should be stopped immediately (e.g. sudden reductions in BP). In these circumstances, medical advice must be sought.

Procedure

The insertion of all invasive cardiac monitoring is completed by specifically trained doctors.

Arterial pressure

Intra-arterial pressure measurement is performed through the insertion of a line into an artery (this is called an arterial line). Arterial BP is then interpreted through a transducer and displayed on the monitor system.

Central venous pressure (CVP)

Reflects right ventricular filling and is usually monitored via a catheter which sits within the superior vena cava. The catheter is usually inserted via the subclavian vein within the thorax or the internal jugular vein. Less commonly, central venous catheters can be inserted via the femoral vein (see 3.11 Central venous pressure).

Pulmonary artery catheter (Swan–Ganz)

A pulmonary artery catheter is a catheter which is inserted into a pulmonary artery. This is done by a video-fluoroscopy-guided catheter that is passed via a major vein (e.g. internal jugular vein) through and into the right atrium and right ventricle. From here, the catheter can be forwarded into one of the pulmonary arteries. It is a diagnostic tool used to detect heart failure or sepsis.

Pulmonary artery occlusion pressure (previously known as wedge pressure) can also be recorded using a pulmonary artery catheter by passing a balloon-tipped catheter into a pulmonary capillary. The normal range for pulmonary artery occlusion pressure is 2–12 mmHg.

Continuous thermodilution (e.g. PiCCO®)

The PiCCO® system (Pulsion Medical Systems AG; Fig. 3.10.1) requires the insertion of a thermodilution catheter in the femoral or axillary artery and a central venous catheter (no catheter in right atrium required). By using a complex technique of transpulmonary thermodilution the monitor is able to provide specific parameters for arterial BP, heart rate, cardiac output, global end-diastolic blood pressure, intrathoracic blood volume index, cardiac function index, global ejection fraction, stroke volume, stroke volume variation and systemic vascular resistance.

Fig 3.10.1 PiCCO® system (Pulsion Medical Systems AG).

Reproduced with kind permission from Pryor JA, Prasad SA. 2008 Physiotherapy for Respiratory and Cardiac Problems, 4th Edn. Edinburgh, UK: Churchill Livingstone.

Findings

All of the above invasive cardiac monitoring systems indicate the function of the heart and can assist in the assessment of the whole cardiovascular system. Changes in the cardiac function will assist the medical and physiotherapy team in assessing the response to intervention and guide future treatment. For example, if a patient has a large change in cardiac output during manual hyperinflation, this will aid future decisions on whether to repeat treatment or choose an alternative modality.

For implications of arterial blood pressure, see 3.5 Blood pressure; for CVP, see 3.11 Central venous pressure.

Pulmonary artery pressure and PiCCO®. Pulmonary artery pressure will increase in poor left ventricular function, fluid overload (hypervolaemia) and mitral valve disease. However, low measurements will be seen in hypovolaemia. This information is important to physiotherapists as hypervolaemia may be seen in conjunction with pulmonary oedema, whereas hypovolaemia may cause drying of secretions making them harder for the patient to expectorate. Also, hyper- or hypovolaemic patients will react differently to rehabilitation because of the extra demands placed on the heart and vascular system.

Documentation

Arterial BP (where available) is recorded as part of the cardiovascular section of a system-based assessment. It may also be necessary to document non-invasive BP if grossly different as any reason for the difference (e.g. poor arterial BP trace). Any other forms of invasive cardiac monitoring may be recorded as required or as appropriate for the assessment being completed.

3.11 Central venous pressure (CVP)

Definition

CVP reflects the amount of blood returning to the heart (right ventricular filling or ‘preload’). It is usually monitored via a catheter situated within the superior vena cava.

Purpose

CVP measurement may be used to guide fluid therapy. It is useful for the physiotherapist as it can help us to identify patients who are:

• overloaded with fluid and at risk of developing pulmonary oedema

• dehydrated and may have dry tenacious secretions

• at risk of cardiovascular instability during treatment.

Procedure

The catheter can be inserted via the subclavian, the internal jugular or the femoral veins. The catheter is connected to a manometer that sits level with the right atrium of the heart (Fig. 3.11.1). A central line trace and value is seen on the patient’s monitor (this is often blue). Within critical care, continuous measurements are possible. Heart function is indirectly measured by CVP; therefore, in the critically unwell patient more specific invasive monitoring may be utilized (see 3.10 (Invasive) Cardiac monitoring).

Fig 3.11.1 Central venous pressure line set-up.

Reproduced with kind permission from Pryor JA, Prasad SA. 2008 Physiotherapy for Respiratory and Cardiac Problems, 4th Edn. Edinburgh, UK: Churchill Livingstone.

Findings

• Normal CVP = 3–15 cmH₂O

• A high CVP may be associated with conditions that cause a rise in right atrial pressure such as heart failure, reduced right atrial compliance, tension pneumothorax, fluid overload or pulmonary hypertension.

• A low CVP may suggest hypovolaemia (reduced fluid) and gross vasodilatation of blood vessels (e.g. as in sepsis).

• Changes in CVP can provide information to the medical team on current fluid balance and also response to fluid loading.

Documentation

CVP should be documented under the CVS section of your assessment.

3.12 Cerebral perfusion pressure (CPP)

Definition

Cerebral perfusion pressure (CPP) represents the pressure in the cerebral circulation that determines blood flow to the brain (perfusion). This value is calculated using the equation:

Purpose

Monitoring CPP allows the team to identify whether the patient’s brain has enough blood flow to prevent further damage and provide enough oxygen to the brain tissue. Physiotherapists must be aware of the CPP value as our treatment techniques may have an impact on both BP and ICP (intracerebral pressure) and therefore alter CPP – see 3.37 ICP.

Findings

The accepted value for CPP can be based on the individual, but commonly 50–90 mmHg is used. Persistently low pressures will cause brain ischaemia. High pressures may lead to bleeding and/or compression of brain tissue. Either situation could cause further brain damage.

If CPP is too high or too low, physiotherapy treatments (e.g. manual chest clearance, head-down positioning, suction or passive/active movements) may worsen the situation. They are likely to be contraindicated, or only used if considered essential to improve arterial oxygenation. If you do need to treat, determine whether the patient is stable enough and if there is any leeway if the BP should fall or the ICP should rise with treatment. Treatment decisions in this situation should be discussed with senior colleagues.

Documentation

The CPP value should be documented under the central nervous system (CNS) section of assessment and should be considered alongside MAP and ICP as well as the global clinical picture.

3.13 Chest drains

Definition

A chest (intercostal) drain is a tube inserted into the pleural space in order to drain air (pneumothorax) or fluid (pleural effusion, empyema, haemothorax or residual postoperative fluid) from the pleural space. The size of the tube can vary, from narrow bore (approximately 5 mm) to wide bore (approximately 1.5 cm). The tube leads away from the thorax to an underwater sealed unit which stops the drained fluid backtracking up the tube (Fig. 3.13.1). The drainage of fluid can be enhanced by the application of low-pressure suction. The tube will only be removed when it has stopped draining air or fluid.

Fig 3.13.1 Chest drain schematic. Underwater seal chest drainage. (A) single bottle system allowing use of one bottle via a ’Y’ connector to drain fluid and air. (B) Two separate bottles enabling drainage of air from the apical drain and fluid from the basal drain

Reproduced with kind permission from Pryor JA, Prasad SA. 2008 Physiotherapy for Respiratory and Cardiac Problems, 4th Edn. Edinburgh, UK: Churchill Livingstone.

Purpose

Chest drains can be placed as part of a surgical procedure or to treat medical symptoms. It is important to observe the location and drainage of the chest drain as part of physiotherapy assessment as its presence may affect the patient’s mobility and ability to expand the thorax. It is also important to notice whether the drain is blocked or not draining properly – this needs to be reported immediately.

Procedure

A simple look, listen and feel will tell you a lot:

• Look at where the drain enters the patient and the dressing around it. Do not take down the dressing, but look for oozing or leaks. Look at the tube and bottle forming the underwater seal and how the water level varies (Fig. 3.13.2).

• Listen to the patient – do they report any pain and how are they breathing?

• Feel the level of expansion of the chest.

Fig 3.13.2 Chest drain in situ post thoracotomy (A) and corresponding CXR (B). Note apical placement of drain (arrow).

Reproduced with kind permission from Harden B, Cross J, Broad M, et al. 2009 Respiratory Physiotherapy: An On-call Survival Guide, 2nd Edn. Edinburgh, UK: Churchill Livingstone.

Findings

The position of the chest drain will be assessed by the medical staff by chest radiograph.

Things to consider from a physiotherapy point of view:

• ‘Swinging’. The fluid in the tube should move during the respiratory cycle. If it is not swinging, check with the nursing staff. It could be that the tube is ready to come out, or that there is a problem with the tube. Check that the tube is not kinked or obviously blocked (by the patient sitting on it!). If not, discuss with the nursing or medical staff.

• ‘Bubbling’. Occurs if there is an air leak and air bubbles are seen in the drainage bottle. It is important to note whether bubbling happens in part of the respiratory cycle or just on coughing as this gives an indication of the severity of the leak. So what should you do if it is bubbling? Is this a new occurrence or not? If this has not happened previously, you will need to highlight this to the team.

• ‘Draining’. The volume of fluid drained needs to be measured. How is the volume measured? The volume is measured in millilitres (ml) by looking at the graduated lines on the side of the chest drain bottle. Remember that the bottle is filled with approximately 500 ml of water to create a negative suction pressure in the pleural space; therefore, 500 ml needs to be subtracted from the total amount of drainage in the bottle to determine how much fluid had drained from the pleural space – this is generally allowed for by our nursing colleagues when they chart drainage.

Pain can be an issue, and the level should be recorded in relation to the respiratory cycle (the patient reports pain on deep breathing) or in relation to coughing. There should be adequate analgesia to allow the patient to move. You should also monitor the patient’s arm movements, encouraging shoulder abduction (ordering a drink or waving movement), medial rotation (can they touch their back as if to do up a bra!) and lateral rotation (can the patient touch the back of the head to do their hair) and consider trunk movement, as this may be compromised.

Top tip!

A chest drain should always be below the level of the chest to prevent siphoning of the contents back into the chest cavity!

Patients can mobilize with a chest drain in place and should be encouraged to do so – make sure the drain is held below the level of the chest!

Documentation

Document how the wound site appears, whether the drain is swinging or bubbling, and the volume of fluid drained during a certain time period (often 24 hours). Document any limited range of movement of shoulder joint or trunk.

3.14 Chest imaging (including chest X-rays)

Definition

Images of the thorax used to aid diagnosis include chest X-rays (CXR), computer tomography (CT) scans, magnetic resonance imaging (MRI), ultrasound imaging and nuclear medicine. Physiotherapists may seek information regarding the outcomes of scans but are usually only involved in interpretation of CXR images, so these will be the focus of this section.

Purpose

Imaging is normally used by medical staff to aid diagnosis; however, physiotherapists often refer to this information to identify specific areas of loss of volume or collapse/consolidation that may respond to physiotherapy. Images may also be used as outcome measures for physiotherapy and may demonstrate improvements after sputum clearance or treatment to increase volume.

Chest X-rays

Uses X-rays to generate an image of the thoracic anatomy. These are the mainstay of imaging in acute care. CXRs are normally taken from behind the patient (posterior to anterior (or PA) film) to reduce the shadow of the heart. In a ward or critical care environment they are frequently taken from the front (anterior to posterior (or AP) film) because of limitations caused by the position of the patient. Occasionally, films are taken from the side (a lateral film).

In modern radiology, images are stored and viewed using a picture archiving and communication system (PACS). This stores and retrieves images digitally and has the added benefit of allowing you to view any reports on the film.

Computer tomography

This is an advanced form of X-ray scanning in which images are acquired from a 360° arc around the patient and reconstructed to give three-dimensional images of the study area. CT can be used to gain a much clearer picture of the structures within the chest. For example, prior to thoracic/lung surgery or to monitor disease progression as with cystic fibrosis (CF) or bronchiectasis. CT can also be used when pulmonary emboli are suspected (CTPA – CT pulmonary angiogram). CTs require a higher dose of ionizing radiation than a CXR.

Magnetic resonance imaging

This uses strong magnetic fields to give detailed three-dimensional images (i.e. no ionizing radiation is used). MRI is rarely used in respiratory investigations and is much better for body parts with higher water content (e.g. joints) as this technology relies on magnetic fields exciting water molecules to produce an image.

Ultrasound imaging

High-frequency sound waves are converted into an image using a probe over a localized area. This imaging process relies on a fluid medium to transmit the sound waves; therefore, it can be very useful to image the heart, effusions or other collections of fluid in the pleural space. Sometimes an ultrasound is used to identify where an effusion is and to mark a place on the skin to guide the doctors on where it should be drained.

Nuclear medicine

This field of medicine uses a variety of radioactive isotopes with short half-lives, whose movement through the body can be detected. This can give information about physiological processes, for example ventilation/perfusion (V/Q) scans, although CTPA scans are more commonly used in preference.

Procedure

The procedures are performed by trained specialists, either medical staff or radiographers. A few specialist physiotherapists are involved in these procedures in both image acquisition and ordering imaging.

Findings

The key to interpreting CXRs successfully is to take a systematic approach, otherwise you will miss something! Remember – do not view them in isolation. They are a useful diagnostic tool but do not give the whole story. Interpret the radiological evidence with the other clinical signs from your assessment and the patient’s history. Does the CXR match the clinical picture? Think about surface and the internal anatomy of the chest. Remember that this is a two-dimensional projection of a three-dimensional structure.

It is accepted practice that you view the image as if the patient were standing in front of you, so the right side of the image is the left side of the patient. To save confusion, the radiographers label the image with an ‘L’ or ‘R’ (see Fig. 3.14.1, which shows a PA film of a healthy 29 year old woman with some of the anatomical structures annotated). Note that the white areas represent densities (e.g. the heart) whereas the blacker areas represent less dense areas (air shows as black). Table 3.14.1 highlights some simple questions to consider when reviewing a CXR.

Fig 3.14.1 Posteroanterior film of a 29 year old woman.

Table 3.14.1 Questions to consider when reviewing a CXR

Who?	Who is the film of? A simple question but it is all too easy to look at the film of the wrong patient!
What?	What part of the body was radiographed? With PACS systems it is easy to bring up an image from another part of the body
When?	When was the film taken? You can look at an old film and wonder why the patient looks so well! It is also good to compare previous images with the most recent film to look for changes
Where?	Where was the film taken? A film taken on the ward will not be of the same quality as one taken in the department. Departmental films are taken with the shoulders protracted, thus keeping the scapula away from the lung fields
Why?	Why was the film taken in the first place? There is always a good clinical reason
How?	How was the film taken? AP vs PA. With an AP film the heart shadow is larger

AP, anteroposterior; PA, posteroanterior.

In Fig. 3.14.2, the same CXR of the 29 year old woman is shown. It has been marked for ease of interpretation using the system for interpretation of CXRs summarized in Table 3.14.2. Use the suggested points while looking at the radiograph in Fig. 3.14.2. This is just one system that can be used to go through CXRs – the key is to use the same system every time so that you do not miss anything out!

Fig 3.14.2 Posteroanterior film of a 29 year old woman with CXR analysis markers – see Table 3.14.2.

Table 3.14.2 A system for interpretation of CXR

A	Alignment and A quick look!	Is there anything obviously wrong? Is it a straight film or rotated? If the patient was not straight at the time of the radiograph, the positions of the structures will appear to have moved. To assess this, look at the proximal ends of the clavicles – they should be an equal distance from the spinous processes. If they are not, the side with the bigger gap is the side it is rotated towards
B	Bones	Are they all there or are there bits that should not be there at all? Look for fractures, and not just of the ribs. In trauma patients these are frequently not picked up until much later on and it may be that you are the first person to notice it. There are no fractures in Fig. 3.14.2
C	Cardiac	Look at the heart size and borders. The heart should be one-third of the diameter of the chest, with more on the left side than the right. The heart borders or lines around the heart should be smooth. There should also be a sharp angle seen between the heart borders and the diaphragm. These are known as cardiophrenic angles
D	Diaphragm	Can you see both of them clearly? The costophrenic angles between the ribs and the diaphragm should be clear and sharp. If not, there may be some fluid in the pleural space. Note that the right hemidiaphragm is always higher than the left hemidiaphragm owing to the position of the liver under the right lung
E	Expansion and Extrathoracic structures	Expansion is a reflection on the volume of air in the lungs. The normal level of expansion is to the 10th rib at the mid-clavicular point posteriorly or the 6th rib anteriorly. Underexpansion may mean poor lung volumes; overexpansion may be related to other pathologies, such as emphysema. Extrathoracic structures should be looked at for obvious changes or warning signs such as subcutaneous emphysema (air in the soft-tissue structures)

F Fields The lung fields are as a result of the vascular structures within the lung. As such, in an upright film there are more lung markings at the base than at the apex. These should extend to the edge of the chest wall. In pathological states, you should look for increased shadowing, decreased tissue density or absence of lung markings. You will need to be able to differentiate between collapse, consolidation, and air/fluid within the lung and outside the lung. In general, if there are areas of lung which have collapsed, the surrounding structures will shift towards that area; if there is consolidation, there will be an increase in the shadowing or ‘whiteness’ but with no shifting of structures G Gadgets There may be a variety of drips, drains, tubes, lines, wires, orthopaedic fixtures and fittings, prosthetic valves, pacemakers. There are none in Fig. 3.14.2

It is particularly important for the physiotherapist to be able to identify loss of volume and consolidation as these may suggest the need for intervention. It is also important to be aware of a pneumothorax as this may be a contraindication to treatment. Pulmonary oedema and emphysema are also important; for further details, see Further reading.

Documentation

Identify any obvious abnormality compared with the normal presentation, and describe it in terms of how it differs from normal (e.g. there is an area of increased density in the right upper lobe).

3.15 Chest X-ray (see under 3.14 chest imaging – page 68)

3.16 Chest wall shape

Definition

Identification of any variations of the skeletal structures of the thoracic cage, resulting in fixed or non-fixed changes that could affect respiration (e.g. the thoracic spine, ribs, sternum, clavicle and the associated joints).

Purpose

To identify patients:

• at an increased risk of respiratory complications due to a restrictive breathing pattern (e.g. after surgery)

• who might benefit from exercise or mobilization to improve chest wall mobility

• with severe airway obstruction where the effect on lung mechanics could limit their ability to breathe diaphragmatically or take part in exercise.

Procedure

(Any significant deformity may already be recorded in the patient’s notes.)

• Observe the patient with his or her top removed (if appropriate) from posterior, anterior and lateral aspects, and note any of the changes described in the findings below.

Findings

Variations in chest wall shape are shown in Fig. 3.16.1.

Fig 3.16.1 Chest wall shape.

Reproduced with kind permission from Lippincott, Williams and Wilkins 2004. Breath Sounds made Incredibly Easy. Springhouse Publishing Co.

Restrictive changes

• Pes excavatum (funnel chest): the sternum is indented.

• Pes carinatum (pigeon chest): the sternum projects forwards.

• Scoliosis: the thoracic spine is curved laterally and rotated.

• Kyphosis: the thoracic spine is curved anteroposteriorly.

• Stiff, immobile ribs due to osteoarthritis, osteoporosis or previous rib fractures.

• Thoracoplasty – rib resection.

This can result in a reduced inspiratory capacity (inspiratory reserve) and predispose to ‘low lung volumes’, causing a restrictive pattern. This may result in a reduction in maximum voluntary ventilation, which in turn will lower potential exercise tolerance. These deformities may also increase the work of breathing.

These factors predispose the patient to atelectasis and possibly respiratory failure and fatigue (particularly if the patient is facing additional respiratory compromise, such as pneumonia or because of abdominal or thoracic surgery).

Obstructive changes

Severe airway obstruction (e.g. severe COPD or CF) can lead to gas trapping and hyperinflated lungs that give rise to a barrel chest appearance. The chest appears deeper from front to back than normal and becomes more rounded. This is because the ribs are permanently elevated, even during expiration. Since the patient cannot lift the ribs very much further on inspiration (loss of bucket handle mechanism), they use their neck muscles to lift the clavicle and the whole thoracic cage in order to breathe in. They will have elevated clavicles and scapulae and a protracted shoulder girdle as a result of needing to use accessory muscles of inspiration.

Severe mechanical changes associated with obstruction will result in a flattened diaphragm that cannot descend much further. Therefore, teaching the patient diaphragmatic breathing would be inappropriate. Patients may need to fix their arms in front of the thorax in order to use their serratus anterior and pectoral muscles to help lift the thorax forwards in order to inspire, e.g. forward lean sitting.

Top tip!

These patients are working at a mechanical disadvantage. Therefore, when they are unwell, they have a limited respiratory reserve and so may deteriorate very quickly. They should be considered as at high risk of deterioration!

Documentation

State any observed variation in chest wall shape using above terminology under observation.

3.17 (Digital) clubbing

Definition

Digital clubbing might be a sign of underlying or chronic lung disease. It is a deformity of the nail bed of fingers and toes associated primarily with cardiac, gastrointestinal or respiratory disease.

Purpose

To identify patients with underlying respiratory or cardiac disease with significant hypoxia. The exact mechanism of developing clubbing is unclear; however, it is thought to be as a result of capillary proliferation. Digital clubbing usually occurs as a result of respiratory, cardiac or gut disease and occasionally can occur with no underlying pathology (Table 3.17.1).

Table 3.17.1 Some causes of digital clubbing

Procedure

An examination of the hands and nail beds will identify clubbing.

Findings

Figure 3.17.1 demonstrates digital clubbing of a 24 year old man with CF compared with the finger of the author. Note the bulbous end of the patient’s finger and loss of the acute angle in the nail bed.

Fig 3.17.1 Digital clubbing (top) as compared with normal.

Documentation

Note the presence of clubbing within the observations section of your assessment.

3.18 Consent

Definition

The provision of approval or assent, particularly and especially after thoughtful consideration (Oxford English Dictionary). Remember that, for an adult, it is only the person themselves or a designated person (advocate) in the absence of the individual’s capacity who can consent for treatment.

Purpose

To allow a patient to consider relevant information to decide whether they want to be assessed or treated. If we treat without consent we could be accused of battery/assault. Some of our patients will not be able to consent; this may be because they are unconscious, are not able to communicate or lack capacity. In this instance, we are able to treat in their best interests.

Documentation

All consent issues and how consent is obtained should be documented clearly at the start of any new intervention or treatment; some examples of how this may be done include:

• patient nodded/mouthed/verbally consented to assessment and treatment

• patient advocate consented to assessment and treatment

• patient unable to consent; therefore, assess and treat in best interests.

It is not appropriate to use abbreviations such as ‘VCG’ (verbal consent given) or ticks to document consent as this is inappropriate use of abbreviations and ticks do not give any indication as to how consent was obtained.

3.19 Cough assessment

Definition

Assessment of the factors affecting cough effectiveness and/or any problems associated with coughing (e.g. weakness, bronchospasm).

Purpose

• To determine whether cough is sufficient to maintain effective sputum clearance and identify factors adversely affecting cough effectiveness. Used to identify the most appropriate clearance intervention(s).

• To identify situations of excessive non-productive coughing that may respond to cough suppression (e.g. breathing control practice to reduce coughing).

• To identify problems associated with coughing that may be affecting the patient’s health or quality of life.

Procedure

Cough effectiveness

If your patient has signs/symptoms of sputum retention (e.g. crackles) you need to assess their ability to cough (directed cough):

• sit the patient up/forward and ask them to take a deep breath in first and then to cough as hard as they can.

Cough suppression

If the patient complains of frequent coughing but does not produce any sputum and there are no signs of sputum retention, assess their breathing pattern to determine whether there are any signs of hyperventilation, anxiety or excessive mouth breathing. The patient may benefit from breathing control or relaxation and practising cough suppression.

Chronic cough

Carry out subjective questioning to identify any problems associated with frequent coughing such as fatigue, anxiety, embarrassment, social situations in which coughing is a problem, lack of sleep, abdominal muscle strain, retching, fainting, or coughing fits which are difficult to control. Of note is that stress incontinence is common in chronic coughers.

• Use a questionnaire such as the Leicester cough questionnaire (LOC) in order to explore or quantify this further.

Findings

Potential factors affecting cough effectiveness:

• Can the patient take a deep breath in?

• Any inspiratory muscle weakness?

• Chest wall deformity or lack of mobility?

• Did you hear the glottis close, then open suddenly at the beginning of cough (the harsh sound that characterizes a cough) or did it sound more like a forced expiratory manoeuvre?

• Any pain that might be affecting cough? If so, consider pain control, or supported coughing if there is a wound or incision.

• Any wheezing? Patient may have airway obstruction affecting expiration – do they need bronchodilators?

• Does the patient have a condition which might cause weakness of the expiratory muscles? If so, could this respond to strengthening exercises or does the patient need some support such as manually assisted cough or the cough assist machine?

• Peak cough flow. The peak expiratory flow rate during cough gives an overall evaluation of cough efficiency; values below 160–270 l/min suggest poor airway clearance. A value of less than 160 l/min is not sufficient to clear secretions independently. It can be measured by coughing into a peak flow meter.

• Is the patient’s airway at risk? (Loss of bulbar function; see 3.60 Swallow assessment.)

• Is the patient unable to cough in response to direction? Are there any neurological reasons for inhibited cough reflex or lack of sensitivity in the airways? Has the patient lost other protective reflexes such as the gag reflex, swallow reflex or the expiratory reflex? These reflexes are controlled by the medulla oblongata and are referred to collectively as ‘bulbar function’.

Top tip!

A problem with bulbar function may need urgent attention such as the recovery position, airway insertion or suction, so highlight to senior immediately.

Documentation

Record observations and the patient’s response to any attempted intervention.

3.20 Cyanosis

Definition

A bluish discoloration of the skin and/or the mucous membranes that is caused by lack of oxygen in the blood and local tissues:

• Central cyanosis appears around the mouth, tongue and lips.

• Peripheral cyanosis: only the peripheries are affected (especially fingers, fingernails, toes and toenails).

Purpose

Central cyanosis may indicate significant respiratory or cardiac failure, which is potentially life-threatening, requiring immediate respiratory or circulatory support (see Findings below).

Procedure

Cyanosis can be observed directly through observation of the lips, tongue and fingers in good light.

Findings

• Cyanosis of recent onset should be immediately reported to the medical team.

• Cyanosis shows best on those with good levels of Hb. It is less visible in patients with anaemia.

• Cyanosis is usually only visible when 5 g Hb per 100 ml blood is deoxygenated. For most people in an acute situation, this would suggest a severe lack of oxygen and the need for immediate intervention (e.g. airway management, CPR, ventilation).

• People with severe chronic respiratory disease are more likely to show signs of cyanosis (at higher S_pO₂) because they may have more Hb (because of polycythaemia). Additionally, their oxygen content may actually be acceptable despite low S_pO₂; this is the result of increased Hb, which enables more oxygen to be carried, so it is important to find out whether this is ‘usual’ for them before responding.

• Note that cyanosis is more difficult to see in Afro-Caribbean and Asian patients because of darker skin tone.

Documentation

Record date and time, whether cyanosis is central and/or peripheral, on room air or oxygen therapy, the method of oxygen delivery and the percentage of any oxygen given.

3.21 Dermatomes

Definition

A dermatome is an area of skin with sensory innervation by one main spinal nerve root (Fig. 3.21.1).

Fig 3.21.1 Dermatome chart. n., nerve.

Reproduced with kind permission from Crossman AR, Neary D. 2002 Neuroanatomy: An Illustrated Colour Text, 2nd Edn. Edinburgh, UK: Churchill Livingstone.

Purpose

Knowing which nerve supplies an area of skin can be used to ascertain the level of injury or deficit. It should be noted that there is some overlap between dermatomes. Dermatome assessment is often carried out alongside assessment of myotomes and muscle charting (see 3.42 Myotomes and 3.41 Muscle charting).

Dermatomes can also be used to assess the level of analgesia, e.g. with an epidural.

Procedure

• Make sure any clothing that may restrict the assessment is removed (remember to maintain dignity of the patient).

• Using your hand, or a cotton wool ball, touch an area of skin that is unaffected to make sure the patient can feel this sensation.

• Ask the patient to close his or her eyes.

• Working from the top of the body down, stroke over different dermatomes and ask the patient to report changes in sensation. Make sure to compare left and right as deficits may be unilateral!

For the assessment of analgesia via epidural block, an ice pack rather than cotton wool is commonly used to assess the level at which the block is working.

Light touch and pinprick can also be assessed for differentiation between sensations (i.e. sharp and dull). This is commonly used in neurological assessment.

Findings

If an area is not innervated (e.g. no sensation) it may need to be protected from damage caused by lack of pain/temperature receptors.

It may be necessary to re-chart dermatomes on several occasions to assess improvement or deterioration in the level of sensation. This is particularly relevant in the management of early spinal injury in which ‘spinal shock’ (i.e. inflammatory response in the spinal cord) may cause a higher level of deficit than the original injury level. This needs to be closely monitored.

Documentation

Document at which level the patient can detect altered sensation (and which sensation you tested, e.g. sharp/dull/light touch) as per the dermatome chart (Fig. 3.21.1), e.g. ‘Sensation to light touch present above T6 level’.

3.22 Drugs

Definition

Physiotherapy assessment should include a list of the medications the patient is currently taking, how frequently they are taken and their drug history (DH) if appropriate.

Purpose

A clear understanding of the medication a patient is taking is invaluable, as this may highlight additional points from the patient’s past medical history that have not been identified. Sometimes, we need to ensure that patients have taken medications prior to physiotherapy treatment (e.g. pain relief or bronchodilators), whereas on other occasions certain medication may contraindicate physiotherapy treatments (e.g. patients on long-term steroids may not be able to tolerate chest wall percussion). Physiotherapists also need to be aware of possible side-effects of some medications in order to report any observations to the medical team. Remember that certain drugs can limit the interventions a therapist can use; therefore, a working knowledge of common drugs is important.

Procedure

There are a number of sources to obtain a DH. Most of this will come from the notes, drug charts, letters or a discussion with patients or family. Most physiotherapists are not involved in the prescription of drugs.

Findings

Tables 3.22.1–3.22.6 display some of the common classifications of medications patients may take. This is by no means comprehensive, and the reader is directed to other sources (such as a BNF (British National Formulary)) for more comprehensive information. Note that, if you come across a drug that is unfamiliar to you, you should ensure that you have an understanding of both what it is intended to treat and the implications for physiotherapy. The pharmacy team are an excellent resource if you cannot find what a drug is or why it is being used.

Table 3.22.1 Common respiratory medications

	Key drugs	Implication for physiotherapy
Oxygen	Oxygen should be viewed as a drug and as such be prescribed	High-dose oxygen in normal individuals over time can cause airway irritation (note that any patient who requires high-dose oxygen is very ill). There is a small population of patients with COPD who rely on hypoxic drive, and if given too much oxygen will stop breathing. However, treatment should not be denied to patients who will benefit from this vital treatment Physiotherapists should monitor saturation levels during treatment, particularly movement and exercise. It may be acceptable to increase or decrease oxygen flow in certain situations – check with your supervisor regarding your local policy

Bronchodilators (see examples below): may be delivered by inhaler or nebulizer

May need to be taken prior to chest clearance procedures or before exercise if the patient is ‘tight’ or ‘wheezy’

Can be used to relieve breathlessness in an emergency

Check inhaler technique

β₂-agonist

Salbutamol, terbutaline (short acting)

Salmeterol (Serevent), formoterol (Oxis) (long acting)

Can cause increased heart rate and tremors Anticholinergic

Ipratropium bromide (Atrovent) (short acting)

Tiotropium (long acting)

Can cause a dry mouth, which may make airway clearance more difficult Xanthines (bronchodilators with some anti-inflammatory effect)

Theophylline

Aminophylline

Phyllocontin

Can cause increased heart rate Steroids (inhaled); steroids may also be oral (see Table 3.22.6)

Beclometasone

Fluticasone

Budesonide

High-dose inhaled steroids have been associated with oral fungal infections. Encourage the patient to rinse their mouth after taking the drug Mucolytics

Carbocystine

Dornase Alfa (DNAse)

Hypertonic saline

Reduces viscosity of secretions and aids airway clearance

Carbocystine can cause GI bleeding

Hypertonic saline can increase bronchospasm

COPD, chronic obstructive pulmonary disease; GI, gastrointestinal.

Table 3.22.2 Common cardiac medications

While these have been placed in broad categories, these agents can affect several aspects of cardiovascular physiology
	Key drugs	Implication for physiotherapy
Inotropes (increase myocardial contractility)	Adrenaline (epinephrine) Noradrenaline (norepinephrine) Dopamine Dobutamine	Patients on inotropes are cardiovascularly unstable and need careful handling Monitor BP when treating
Anti-arrhythmia drugs (also known as anti-arrhythmics)	Digoxin Amiodarone Adenosine	Be aware of an abnormal cardiac rhythm and seek help of senior staff if you are unsure whether the patient’s clinical picture has changed
Beta (β)-blockers (reduce rate and strength of heart beat)	Atenolol Labetolol	Patients may not be able to respond to increased workload; thus, you may not be able to use HR as a guide to exercise prescription. Consider using RPE as well
Vasodilators (increase coronary blood flow and control angina)	GTN	Caution if mobilizing the patient for the first time; if the patient complains of chest pain or breathlessness, seek senior support immediately! Ensure patients have GTN handy when exercising if it is prescribed
Calcium channel blockers (reduce myocardial contractility and BP)	Diltiazem Lidoflaxine Nifedipine Verapamil	Caution if mobilizing for the first time as BP may drop – be aware of resting BP; you may need to repeat BP measurement during your intervention
Diuretics (increase urine production and can reduce BP)	Bendrofluazide Furosemide (Frusemide) Bumetanide Spironolactone	Increase the need to go to the toilet and can induce muscle cramps
Antihypertensive drugs	Captopril Enalapril Adalat	If a patient is on this medication, note that they have a history of increased blood pressure

BP, blood pressure; GTN, glyceryl trinitrate; HR, heart rate; RPE, rating of perceived exertion.

Table 3.22.3 Common antibiotics

	Key drugs	Implication for physiotherapy
Penicillins	Benzylpenicillin Flucloxacillin Amoxicillin	Any patient who is on antibiotics will have an infection and is likely to feel unwell. Side-effects of many of these antibiotics include nausea, vomiting and diarrhoea. It is important to adhere to infection control principles Note: some antibiotics (e.g. in CF/bronchiectasis) may be nebulized and should be taken after airway clearance techniques
Cephalosporins	Cefaclor Cefetaxime
Tetracyclines	Tetracycline Doxycycline
Aminoglycosides	Gentamicin

Table 3.22.4 Analgesic medications

The route of delivery is varied and can include inhaled, oral, intramuscular (i.m.) and intravenous (i.v.) routes and as a suppository. Care should be taken when mobilizing patients with epidurals in situ (in place) as they can become hypotensive (low BP) and may have altered motor control of their legs.
	Key drugs	Implication for physiotherapy
Paracetamol		Risk of liver toxicity, and is often contained in other preparations
NSAIDs	Ibuprofen Voltarol	Can cause irritation of the gut and cause GI bleeding. Some asthmatic patients are allergic to this group of drugs
Opiates	Morphine Diamorphine Codeine	Can depress the respiratory drive if the dose is too high. Pinpoint pupils may indicate that the patient has had a large dose of opiates

GI, gastrointestinal; NSAID, non-steroidal anti-inflammatory drug.

Table 3.22.5 Intensive therapy unit drugs

	Key drugs	Implication for physiotherapy
Sedation agents	Midazolam Propofol Fentanyl	The patient may vary from being awake and settled to not being able to respond to you
Paralysing agents	Vecuronium Pancuronium Atracurium	BE AWARE! The patient can make no muscular effort at all, so if removed from the ventilator the patient will stop breathing. As patients are paralysed, they will not be able to cough on suction

Table 3.22.6 Other common drugs

	Key drugs	Implication for physiotherapy
Anti coagulants (blood thinners)	Heparin Warfarin Aspirin Clexane	There is an increased risk of bleeding, so care needs to be taken and some procedures considered with extreme caution, e.g. nasopharyngeal suction. Check the patient’s clotting screen! (see 3.6 Blood results)
Insulins	Actrapid Humulin Mixtard Gliclazide	If your patient is on insulin, it is good practice to ensure that blood sugars are stable prior to mobilizing. If the patient’s blood sugars are poorly controlled they may become unresponsive
Immunosuppressant	Cyclosporin	As the immune system is suppressed, this leaves the patient more open to contracting infections
Steroids (oral/i.v.)	Prednisolone Dexamethasone Hydrocortisone	Long-term use can lead to diabetes, osteoporosis and a degree of immunosuppression Take care with manual clearance techniques if affected
Anti-epileptics	Carbamazepine Phenytoin Valproate	Be aware that the patient may have a history of fitting