Positioning Concerns

All patients spend some portion of the day in a horizontal position for rest or sleep. Some who are acutely ill or medically compromised spent extended time in bed, and major emphasis must be placed on the mobilization of patients early and often to prevent immobility from exerting its negative effects on all body systems (see Chapter 18). Studies have shown that patients who are medicated and spend extended time on ventilators in the ICU have developed critical illness neuromuscular syndrome or ICU-acquired weakness. Interventions shown to help prevent this problem are physical therapy/activity and daily interruptions of sedative medication.^1,2,3 These studies validate the need for intervention to prevent untoward effects of immobility and sedation.

Despite these problems, the time spent in a horizontal position can be used as an opportunity to assist patients in passive drainage and preventing the retention of lung secretions. It can be a natural beginning in the development of a patient’s long-term respiratory program (e.g., the prevention of respiratory complications in a patient with tetraplegia). Specific postural drainage positions are covered under airway clearance interventions (see Chapter 21). Using a combination of these positions and the patient’s position in bed, in the hospital or at home, can help to achieve multiple goals. First, various horizontal positions can assist patients in passively clearing secretions that they may have difficulty clearing actively. Pneumonia is still the leading cause of death in patients with spinal cord injury (SCI) who are tetraplegic.⁴ Second, these position changes provide for skin relief and better circulation. Finally, they assist in retarding the development of joint contractures or other musculoskeletal abnormalities. A four-position rotation (i.e., supine, prone, and side-to-side) or a modified six-position rotation (supine, three-quarter supine, side-lying, three-quarter prone on each side) is usually an effective and reasonable means of incorporating these goals into a long-term prophylactic program.

Simple adaptations may make ventilation easier in each of these postures. For example, when the patient is in the supine position, placing the patient’s arms up over his or her head facilitates greater anterior upper chest expansion.⁵ Likewise, positioning the pelvis in a slight posterior tilt facilitates more diaphragmatic excursion. (Detailed explanations of positioning are discussed in Chapter 42.) Observation of all precautions and contraindications to passive positioning is still warranted, and positions should be modified based on the individual need of each patient.

Just as passive positioning of the patient in bed helps to maintain airway clearance and improve ventilation potential, optimal passive positioning of the patient’s skeletal frame in an upright posture (sitting, standing) helps to maximize the mechanical advantages that facilitate breathing and improve cardiovascular fluid shifts. For example, patients with SCIs resulting in tetraplegia will be unable to support their intestinal contents properly under the diaphragm to allow for maximal expansion of the chest in all three planes of ventilation (see Chapter 39). The use of an abdominal support from the iliac crest to the base of the xiphoid process provides positive-pressure support to restore intestinal positioning to an upright position (Figure 23-1). Research has documented well the significant improvements in vital capacity (VC), inspiratory capacity, and tidal volume (TV) in sitting with the use of a strong abdominal support.⁶ These binders have also been used in nursing care to provide for better circulation and the prevention of hypotension.

The abdominal binder’s value in cosmesis may be underrated. Many patients with neurological issues were once healthy individuals with high self-esteem who took great pride in their appearance. Many now present with protruding bellies (the anterior and inferior shift of the intestines resulting from flaccid abdominal muscles), which may be psychologically disturbing to them. Thus the use of a binder may greatly aid in the restoration of these patients’ self-esteem, which should be a high-priority goal in any rehabilitation program.

A rigid type of abdominal support can be used when the vertebral column and the abdominal viscera need support. These are called body jackets or total contact thoracic lumbar sacral orthoses (TLSOs) (Figure 23-2). A TLSO is a rigid trunk support molded individually to the shape of the patient’s entire trunk from the axilla down to the pubis. It is composed of two separate pieces, a front and a back, ideally with an anterior cutout in the abdomen to allow for normal diaphragmatic displacement of the viscera. In addition to these jackets, an elastic binder is applied around the abdomen to allow for diaphragmatic motion but minimize excessive displacement of the abdominal contents. This is particularly appropriate for a growing child who needs more spinal stability and for the completely flaccid patient with tetraplegia, who may also require the same support. Because head and neck positioning are so dependent on trunk positioning, a body jacket may make the difference for these patients between being dependent or independent in an upright posture. It may result in significantly better head control and eye contact and improved phonation. However, because the TLSO limits trunk movement, its usefulness for each patient must be assessed carefully.

The next consideration in passive respiratory techniques is proper wheelchair positioning. Optimal performance in ventilatory functioning, as well as many other areas of rehabilitation, depends on good alignment of the body against the force of gravity. Symmetry must be strived for through the use of a body jacket, lateral trunk supports in the wheelchair, abdominal binders, or some other means (Figure 23-3). This is especially important for patients with hemiplegia in whom habitual asymmetrical posturing leads to musculoskeletal problems later. Symmetrical breathing patterns and uniform aeration of all lung segments are augmented by careful upright positioning. Therefore everything from the type of neck and trunk support to the height and width of the arm rests to the length and type of the foot supports must be carefully analyzed for each patient.

Ventilatory and Movement Strategies for Improving Functional Outcomes

Observing patient movement and ventilation is inherent in the physical therapist’s examination and evaluation of the patient. Patients often will hold their breath during activities. This will limit their ability to perform functional activities. When it is observed that breath holding is occurring or that the patient has dyspnea with activity, it is important to incorporate ventilatory strategies.

The patient is first positioned for successful ventilation. Then motor activities should be introduced. Interventions chosen will improve the patient’s ventilatory support, or the therapist should capitalize on the patient’s good ventilatory support to improve the motor activity. Using ventilatory strategies to improve motor performance or movement strategies to improve ventilation performance enables patients to achieve their functional goals sooner and have better health, including fewer respiratory complications. Generally, these simple concepts take no more than 1 to 2 additional minutes of therapy time, with no additional equipment costs other than a few extra pillows or towels. Therefore time and money are not mitigating factors. However, these ideas do require the practitioner to look carefully at the patient before beginning any treatment intervention and to ask, “Have I positioned my patient for ventilatory success?”; “Am I simply treating the patient in whatever position I found her or him in?”; and “Have I carefully chosen my verbal cues to include a ventilatory response and a functional response?” The practitioner must actively include ventilation in every activity to help the patient understand that breathing transcends all activities. Breathing is the bridge to function. A summary of the most important ventilation-movement strategies is listed in Box 23-2.

Considerations in Teaching Breathing Control to Patients with Primary Versus Secondary Pulmonary Dysfunction

Patients with primary lung disease, such as COPD, asthma, bronchitis, or cystic fibrosis, present a picture very different from that of patients with secondary pulmonary deficits, SCI, Parkinson disease, myasthenia gravis, or Guillain-Barré syndrome. In general, patients with primary lung disease tend to overuse their accessory muscles and greatly increase the work of breathing secondary to shortness of breath or coughing. They often complain that they have difficulty “getting the air out,” which demonstrates the decreased expiratory flow rates noted on pulmonary function tests. This can lead to dynamic hyperinflation, in which patients continue to gasp and increase the respiratory rate so more air is coming in, but there is not time for the air to be exhaled. Large volumes of air can get trapped in the lungs, which causes increased feelings of shortness of breath and panic. The goal with these patients is to teach them to relax the neck and chest accessory muscles and use more diaphragmatic breathing (abdominal and lateral costal breathing) to reduce the work of breathing in combination with relaxed pursed-lips breathing and prolonged exhalation. Their treatment programs focus on energy conservation, relaxation, and pacing activity with breath control. In pulmonary rehabilitation programs, exercise is a key component. Patients learn to coordinate their breathing with their activities and find that they have less dyspnea with exertion.16,17

There has been controversy in the literature about the effectiveness of diaphragmatic breathing. No standardized “norms” of how to perform diaphragmatic breathing exist. However, many skilled cardiovascular and pulmonary physical therapists would consider teaching the patient with COPD how to relax the accessory muscles and use the diaphragm as an important part of the patient’s pulmonary rehabilitation. Dechman reported that in a search of the literature, pursed-lips breathing was considered most effective by people with COPD and that the literature does not strongly support the use of diaphragmatic breathing in people with COPD.¹⁸ Cahalin found there are both positive and potentially detrimental effects to diaphragmatic breathing training.¹⁹ Each individual patient needs to be evaluated to consider whether diaphragmatic breathing may be beneficial. For example, patients with severe hyperinflation and flattened diaphragms secondarily will most likely not benefit from diaphragmatic breathing because the muscle length tension relationship is abnormal and will not result in an appropriate movement of the diaphragm. With patients who have mild to moderate COPD and are overusing the accessory muscles, diaphragmatic breathing may be very helpful; it may require less oxygen consumption, decrease the respiratory rate, and increase the tidal volume.

Patients with secondary pulmonary dysfunction, such as SCI, have a more restrictive component to inspiration. In these cases, accessory muscles may be intact, but they are not being used to facilitate deep breathing or coughing. Patients may have strong diaphragmatic breaths, but the upper chest collapses on inspiration (paradoxical breathing; see Chapter 39). The goal is to teach these patients to use the accessory muscles to balance the upper and lower chest. This facilitates an increase in vital capacity that prevents atelectasis and pneumonia by increasing the volume of ventilation and improving the cough mechanism.

The choice of appropriate ventilatory strategies is determined by the individual patient’s problem. The following questions should be considered when evaluating a patient:

Patients with primary pulmonary disease generally benefit from ventilatory strategies that relax the accessory muscles and facilitate relaxed diaphragmatic breathing. On the other hand, patients with secondary pulmonary dysfunction usually benefit from the balanced use of the diaphragm and accessory muscles to increase vital capacity and breath support for activities.

Pursed-Lips Breathing

Pursed-lips breathing is a strategy that is often spontaneously used by people with COPD during episodes of dyspnea. Many patients feel this breathing pattern helps to decrease their breathlessness. The effect of PLB is an increase in the time of exhalation, which results in a decrease in the end-expiratory volume and an increase in the total time of the respiratory cycle. This results in a decreased respiratory rate and increased TV. According to studies, a decrease in the Borg scale of perceived exertion also occurs when PLB is used.²⁰ This technique has been acknowledged by many patients with respiratory impairments as being very easy to learn and yet very effective, quick to use, and readily incorporated into their activities to reduce dyspnea.²¹

When instructing a patient in PLB, emphasis should be placed on a relaxed, slow, prolonged, controlled exhalation. Often when patients initiate PLB spontaneously, they use a forceful exhalation, which tightens the neck musculature and oral area. This builds a significant pressure that can counteract the effectiveness of the technique and the subsequent relief of dyspnea. A relaxed head, neck, and mouth are essential. If patients have difficulty relaxing the mouth, they may be encouraged to try making an sssss, or hissing, sound, which will still prolong exhalation and provide back pressure.

Relationship of the Diaphragm and Posture

The respiratory action of the diaphragm and other respiratory muscles is normally coordinated with the need to provide postural control of the trunk during movement of the extremities.⁸ The diaphragm acts both as a muscle of respiration and as a muscle that works in providing core stability to the trunk. However, when respiratory demand increases, the diaphragm may not be able to continue to provide both of these functions.^22–27 Because the diaphragm is the primary muscle of respiration, postural control may be impaired. A complete discussion of this concept is provided in Chapter 39.

Facilitating Diaphragmatic Breathing

In the initial phases of breathing retraining, patients are taught to use the easiest intervention that facilitates diaphragmatic breathing; if it is not successful, a progression of specific facilitation and inhibition techniques will be tried. A summary of methods of facilitating diaphragmatic ventilation patterns is given in Box 23-6.