Definition and Purpose
• An ongoing process where the patient’s
status is continuously monitored and
reassessed through any interaction
(Smith and Ball, 1998, p.29).
• Enables therapist to determine
patient’s problem (Smith and Ball,
• Obtain a precise database which can be
use a base line for future reference
(Smith and Ball, 1998, p.29).
• Ensures understanding between the
therapist and patient which leads to an
accurate, prioritised problem list.
Areas of Assessment
Adapted from: Smith and Ball, 1998, p.29
• Medical notes and diagnostic test results
Information about current status, severity
and factors which may influence
• Record patient demographic data should be
recorded in physiotherapy treatment notes.
• Details and relevant information should be
noted (ie. History, examination,
investigation) should be noted.
• Special note should be taken on
Cardiovascular disorder since it may
influence patient’s overall condition and
• Musculoskeletal and neurological disorder
may have a bearing on management should
• Blood gas analysis and HCO₃⁻ or acid-base
balance Critical info about patient respiratory
status, enable therapist to determine severity and
urgency of intervention require.
• Partial pressure of oxygen (PaO₂) and arterial
oxygen saturation (SaO₃) Indicates level of
oxygen in blood. *Reduction of O₂ system
function may be impaired and nature of
intervention must be carefully considered (most
physiotherapeutic intervention ↑ O₂
• Present and past chest X-ray progression of
changes over a period of time.
Blood gas analysis and acid-base balance in respiratory disorders
Normal Values Early acute
may lead to
pH 7.35 – 7.45 → ↑ ↓ →
PaO₂ 12 – 14 kPa/
90 – 105 mmHg
↓ ↓ ↓ ↓
PaCO₂ 4.5 – 6.5 kPa/
33.8 – 48.8 mmHg
→ ↓ ↑ ↑
HCO₃⁻ 22 – 26 mmol/litre → → → ↑
Base excess -2 to +2 → → → ↑
Saturation 97 – 98% ↓ ↓ ↓ ↓
→ = Within normal Range
↑ = Increase above normal Range
↓ = Decrease below normal Range
Adapted from: Smith and Ball, 1998, p.30
• Obtain patient’s perspective of his/her disorder &
confirm & elaborate existing data (Smith and
Ball, 1998, p.30).
• Form of structured conversation and not formal
interview info is elicited in relaxed manner.
• Open question are encourage more effective in
gaining a fuller picture and additional relevant info.
• Close question can be used if specific yes/no is
• Initial questions Seek to gain background info, info
about patient and his/her lifestyle; Proceed to more
specific questions about patient’s symptoms. *eg:
begin with ‘What is the main problem?’
• Questions do not have to be asked in specific order (Try
to establish smooth, logical progression from one area
What are the initial questions??
How is it Conducted??
• Position of the Patient – In a position which
they find most comfortable.
• History of present complain, Drug
history, Past medical
history, Physiotherapy, Family
history, Occupational history, Allergies, Social
history, and Smoking history. *mnemonic:
How Do People Pay For Only A Small Smoke
• History of Present Complain Clarify the
sequence of events which have led to hospital
admission or treatment referral.
• Drug History Drug taken by patient (now & at
time of admission, dose, length of time, and
mode of delivery), does patient understand why
he or she is taking the medication and any side-
effects experienced and clarify the effectiveness
of drug taken.
• Medical History Encompass all relevant facts
regarding patient’s previous illness, surgery done
and previous hospitalization and management.
• Physiotherapy Any physiotherapy
treatment in the past? (If so when and for
what) What type of treatment and was it of
• Family History Any relatives suffer from
same disorder? Any diseases which have been
prevalent among immediate family members?
• Occupational History Relevant if patient
has occupation that could predispose to
respiratory or vascular condition.
• Allergies Aware of any allergies to food,
drugs or external agents such as pollen/house
dust mites? Can they be avoided??
• Social History Type of accomodation (ie. Is
it all a level or there is upstairs? Live alone or?
Any support from family, friends, neighbour or
outside agent?), ability of patient to maintain
an independent life (ie. Many patient with
chronic respiratory disease are malnourished
due to poor intake or hyper-metabolism) and
elicit an overall impression of the way which
the disorder affect patient lifestyle (ie. Ask
patient to describe a typical day from walking
in morning to going to bed at night. How does
the disorder affect social interactions?).
• Smoking History Does patient lives or works
with people who smoke, does patient have a
history of smoking [frequency, form (pipe,
cigar, un/filtered cigarettes), duration, tar
content of tobacco used, and has patient given
What are the More Specific Questions
Related to Respiratory Symptoms??
• Cough and sputum, Chest pain, Wheeze,
Breathless, and Other symptoms. *mnemonic:
Chronic Chest Will Behave Oddly.
Cough and Sputum
• Cough Questioning relates to nature &
productivity of cough (Does the patient have a
cough? If so, is it effective? Cough can also be
affected by pain, weakness or drug. How long has
the cough been present and when is it most
noticeable? Has it recently changed in nature or
become more persistent? Is cough productive? If
affirmative what colour is the sputum and how
much is expectorated each day?).
• Sputum Colour of suptum gives an insight into
the nature of the disorder.
Green Staphylococcus aureus
purulent (Contain pus)
Mucoid Airways Irritation
Flecked with Black Usually Smokers
– Rupture of small Blood Vessels
– Mucosal Ulceration
– Carcinoma of Bronchus (L)
– Pulmonary embolus (L)
– Lung Contusion (L)
White Frothy Sputum,
Thick Sputum Patient is dehydrated
• Vary in intensity and origin.
• Give psychological support alongside with
prescribed drug or physical management.
• Question Site and distribution + nature of
• Systems may precipitate pain
Cardiovascular system, pulmonary system,
digestive system, and musculoskeletal system.
Common Cause of Chest Pain
Region Example Elaboration on Example
Cardiac Angina Pectoris Constricting pain commonly radiating to
left arm and jaw.
Cause by cardiac ischemia.
Pericarditis Retrosternal pain often exacerbated by
Pulmonary Pleuritic Sharp stabbing pain aggravated by deep
breathing but not tender on palpation.
May associate with pulmonary infection,
pneumothorax or pulmonary embolism.
Tracheitis Raw central chest pain aggravated by
Digestive Oesophageal Reflux Retrosternal burning
Worst when lying down and leaning
Musculoskeletal Muscular Strain Dull ache around coastal margin
Can be due to excessive coughing
Rib Fracture Sharp localised pain worst on deep
breathing and extremely tender on
• Air flow through narrowed airways increase
work of breathing.
• Occur in presence of bronchospasm or with
stridor due to foreign body inhalation.
• Can be identify by both listening at the mouth and
• Noisy breathing associate with retained
secretions; True wheeze often musical.
• If wheezing present determine any
precipitating factors such as dust and pollen
• Presence of both inspiratory and expiratory
wheeze indicates severe airways narrowing such
as cause by copious tenacious secretions.
• Patient personal exp Dyspnoea *Must
differentiate Tachypnoea, Hyperpnoea,
• Question precipitating and easing factors, mode
of onset, and progression nature of
breathlessness *severity of breathlessness
functional and exercise limitations.
• Ask about nocturnal breathlessness (ie. How
many pillows do you sleep with) Orthopnoea
and paroxysmal nocturnal dyspnoea.
• Nocturnal breathlessness may occur in supine or
slumped positioned *reduction in functional
residual capacity (abdominal contents elevating
diaphragm and collapsing lung bases), Diaphragm
fatigue reduce gaseous exchange.
• Poor functioning of left ventricle resulted in
pooling of blood in pulmonary circuit.
• Lying ↑ venous return and redistribution of
stored blood within the pulmonary vascular
beds ↑ pulmonary hypertension
oedema which interferes with gaseous
Paroxysmal Nocturnal Dyspnoea
• Occur if patient with orthopnoea who usually
sleeps propped up (numbers of pillows, incline
sitting in ICUs & wards etc.) slides into a more
• Patients who experience only Orthopnoea or
Paroxysmal Nocturnal Dyspnoes caused by
cardiovascular disorder may also have
• Headaches, body weight, night sweats
• Headaches in morning *may indicate CO₂
retention (↑ PaCO₂ cerebral vasodilation
raises the pressure of the CSF Headaches)
• Rapid reduction in body weight *without
intention associated with advance carcinoma
• Night sweats typical for pulmonary TB *Check:
immunosuppressed? Advent new drug-resistant
strains of the TB bacillus?
• Physical examination of the patient.
• Determine the degree of respiratory disorder and/or
disorders of other systems affect normal functioning.
1. Note drips, drains & % of any supplemental O₂.
2. Review charts at bed side (Temperature, HR &
Rhythm, BP, peak flow & fluid balance) Record
current values and trend of parameters *Gives
valuable insight on progression.
• ↑ temperature = infection; Any instability of CV system
affects physiotherapeutic intervention; Assessment of
medication patient requires shows patient CV /
Haemodynamic status requires support.
Positioning of Patient
• Adequately undress & sitting at angle of 45⁰
However patient should be allowed to choose a
more comfortable position.
• Comprises observation, palpation & physical
• Begins with general observation detailed
examination commencing with lower extremities
(Allows patient to get used to being touched on
more acceptable areas before handling the more
• Observe facial expression before making contact
(behaviour alters once they aware of being
observe) level of alertness, psychological state
(degree of anxiety or distress).
• Signs of central cyanosis (lips, oral mucosa &
tongue) & pursed lip breathing. *If present
verified the PaO₂ & SaO₂ (Patient present with
anaemia may not appear cyanosed in reduce
O₂; Patient with polycythaemia appear
cyanosed with minimal reduction in O₂).
• Pursed lips breathing keep floppy airways from
closing but ↑ work of breathing.
Upper and Lower Extremities
• Focused on assessment of CV and MS systems
• CV Skin colour, texture, temperature, presence of
pulse and swelling.
• Peripheral cyanosis, cooler extremities & absent/poor
peripheral pulse Partial Obstruction or Low Blood
Pressure (atheroma/poor cardiac output).
• Look for clubbing of toes & fingers (increase curvature
& loss of angle of nail bed) [Sudden onset
associated with carcinoma; More insidious onset
associated with long term respiratory sepsis or cardiac
• Observation and palpation of muscle bulk and tone
should correlated with the level of activity.
• Airways obstruction: Abdominal muscles are actively
contracting during expiratory phase to force air out the
narrowed airways increase work of breathing and
doesn’t results in enhance respiratory flow *Palpate
abdomen confirms abdominal muscle activity.
• Diaphragmatic weakness: Paradoxical abdominal
movement. Accessory muscle ↑ thoracic size
(inspiration d/t ↓ intrathoracic pressure, ↓ pressure
diaphragm move upwards, abdominal walls fall
• Obese patient: enlarge abdomen offers resistance to
downward movement of diaphragm reducing basal
• * Violent changes in pressure associated with frequent
coughing may results in inguinal hernia.
Chest and Neck
• Begin: General observation of chest and neck
(overall shape, symmetry of thorax and
• Measurement of RR, depth and pattern should be
made without patient knowledge. *Awareness
may influence these 3 parameters
• Positioning: Sitting position of choice for
palpating tenderness, expansion, auscultation
• Palpate for tenderness and chest movt (upper
zone, middle (lingular) zones and Lower zones.
• Normal 12 - 18 breaths/min
• > 40 breaths/min = Tachypnoea
– Associate with ↑ work of breathing and may not
result in reduce PaCo₂
• Reduce rate = Hypopnoea
– Associate with ↑ PaCo₂
• Ratio of I:E = 1:2
• Deviation from the ratio is less efficient and leads
to ↑ work of breathing & altered blood gases
• Usually patients with airways obstruction is 1:3 or
• Also check for activity of accessory muscles of
respiration. *Although improvement in
ventilation at expense of ↑ breathing workload
which associated with ↑ O₂ consumption.
Jugular Venous Pressure (JVP)
• Estimated by looking at level of column of blood
in jugular veins.
• Bed end elevate 45⁰, patient’s neck veins may
only visible above clavicle. * Elevation of venous
pressure may distend these vessels up to the
level of the jaw.
• Measure in centimetres from the sternal angle.
• Normal JVP is 3-4 cm; any reading above this
measurement is abnormal
• A failing right ventricle *Right ventricle not
• Hypervolaemia (an increase in circulating fluid
• Generation of high pressure in the thorax on
expiration *when there is obstruction to
respiratory flow, high pressure generated on
expiration compress soft veins wall and
impede flow to the right ventricle, raising JVP.
Palpation of trachea
• Lightly place the thumb & fingers on either
side of trachea above suprasternal notch
Should be centrally positioned.
• Shift from midline indicate:
collapse, pneumothorax, lung tumour or a
large pleural effusion.
• Loss of lung volume causes a shift of trachea
towards the side of collapse.
• Pressure from pneumothorax, lung tumour etc
forces trachea towards opposite side.
Level of Hydration
• Place fingers in the axillae.
• Axillae should be warm and moist; if dry this
• Dehydration makes sputum clearance more
Hyperinflation of the Thorax
• Cause by certain chronic respiratory disease
(COPD or episodic respiratory disorder).
• Physical changes can be observe and plapated via
– Elevation of the upper thorax and shoulder girdle
making trachea length appear shorter.
– Loss of bucket handle movement and ↑ sternal lift
(Pump handle movement).
– Tracheal tug (Downward action of diaphragm pulling
on trachea via mediastinum). *Sharp downward
movement of thyroid cartilage & indrawing of coastal
margin on inspiration.
• Apical – Facing patient, place finger tips firmly around
base of the neck overlying the upper fibers of trapezius
& thumbs on sternal end of clavicle.
• Anterior Aspects of the Middle Zone – Facing
patient, place fingertips in axillae and applying tension
on the underlying skin, span thumbs towards midline.
• Posterior aspects of the Lower Zone – Standing
behind, place fingertips up towards axillae & apply
tension on underlying skin, span thumbs towards
* Once hands are in position, ask patient take a deep breath,
observe movement of thumbs away from midline to determine
degree, quality and symmetry of movement.
• Useful tools to measure outcomes of
• Listens in 1 position and compare with sounds
over the reciprocal position on opposite side.
• Breath sounds heard on auscultation are either
generated by turbulence in trachea and large
airways, air flow in smaller airways are usually
• Air is a poor conductor of sound which results
in attenuation or damping.
• Emphysema (greater number of air spaces)
difficult to hear anything at all
• Consolidation (no air) sounds are
transmitted over lung tissues.
Fluid or air in
Plug of sputum/bronchial
carcinoma prevents breath sounds
from being transmitted even over a
patch of consolidation
Large volume of air
reduce transmission of
sound waves whereas
fluid reflects fluid away
from chest wall.
(Pleural effusion /
Types of Sound
• Bronchial sounds = Sounds heard over the chest wall
are close to those heard over the trachea.
• Crackles = Short explosive sounds occur on pressure
equalisation across either narrowed airways or collapse
alveoli. (Heard during inspiration and expiration).
• Wheeze = Occur in both inspiration and expiration;
Present in bronchospasm, sputum, floppy airways &
oedema; Polyphonic wheeze = Widespread of airflow
obstruction; Monophonic wheeze = localised
• Pleural Rub = Sounds like boots crunching on snow,
stronger on inspiration than expiration and is
associated with pain.
• Vocal Resonance – Voice sounds may be heard
through a stethoscope
• Vocal Fremitus – Voice sounds may be felt by
placing hand over the chest wall.
• Helps to localise lung disease & is useful for
patient whose ventilatory effort is so poor that
use of stethoscope is negated.
• Place finger over intercostal space and tap it
sharply with middle finger.
• Similar areas of both sides are compared.
• Resonant note = normal lung; Hyperresonant
note = Large volume of air present over
pneumothorax; Dull percussion note =
Atelectatic, consolidated lung tissue or pleural
• To estimate exercise tolerance
• May be perform in chronic stage of disorder
• Ie: 6 minute walk test / shutter walk test.
• Results from testing gives accurate reference
point from which success of rehabilitation
programme & progression of the disease
process may be evaluated.
6 Minute Walk Test (6MWT)
• Measure the response to medical
interventions in patients with moderate to
severe heart or lung disease.
• Performed indoors, along a long, flat, straight,
enclosed corridor with a hard surface that is
seldom traveled. If the weather is
comfortable, the test may be performed
• Walking course length – 30m; Length of
corridor should be mark every 3m
Equipment for 6MWT
1. Countdown timer (or stopwatch)
2. Mechanical lap counter
3. Two small cones to mark the turnaround points
4. A chair that can be easily moved along the
5. Worksheets on a clipboard
6. A source of oxygen
9. Automated electronic defibrillator
6MWT Patient Preparation
1. Comfortable clothing should be worn.
2. Appropriate shoes for walking should be worn.
3. Patients should use their usual walking aids
during the test (cane, walker, etc.).
4. The patient’s usual medical regimen should be
5. A light meal is acceptable before early morning
or early afternoon tests.
6. Patients should not have exercised vigorously
within 2 hours of beginning the test.
Measurements of 6MWT
1. Repeat testing should be performed about the
same time of day to minimize intraday variability.
2. A “warm-up” period before the test should not
3. The patient should sit at rest in a chair, located
near the starting position, for at least 10 minutes
before the teststarts. During this time, check for
contraindications, measure pulse and blood
pressure, and make sure that clothing and shoes
Instruction for 6MWT
“The object of this test is to walk as far as possible for 6
minutes. You will walk back and forth in this hallway. Six
minutes is a long time to walk, so you will be exerting yourself.
You will probably get out of breath or become exhausted. You
are permitted to slow down, to stop, and to rest as necessary.
You may lean against the wall while resting, but resume
walking as soon as you are able. You will be walking back and
forth around the cones. You should pivot briskly around the
cones and continue back the other way without hesitation.
Now I’m going to show you. Please watch the way I turn
“Are you ready to do that? I am going to use this counter to
keep track of the number of laps you complete. I will click it
each time you turn around at this starting line. Remember that
the object is to walk AS FAR AS POSSIBLE for 6 minutes, but
don’t run or jog. Start now, or whenever you are ready.”
Interpretation of Assessment Findings
• Individual findings should not be consider in
isolation but view and evaluate in light all
• Construct a problem list and revised the order of
• Get agreement before objective setting to ensure
patient compliance with treatment.
• Realistic short and long term goal (Short term =
Current clinical features; Long term = Activities of
• Smith, M. and Ball, V. (1998) Cardiovascular
respiratory physiotherapy. Reprint, New Delhi:
Sanat Printers, 2005.
• American Thoracic Society (2002) ‘ATS Statement:
Guidelines for the Six-Minute Walk
Test’, AMERICAN JOURNAL OF RESPIRATORY AND
CRITICAL CARE MEDICINE, 166, pp. 111-117 APTA
[ONLINE] Available at:
fet/sixminute.pdf (Accessed: 5 January 2011).