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UNIVERSITY of MISSOURI - COLUMBIA
SCHOOL of HEALTH PROFESSIONS
Department of Physical Therapy
PT 7890 - Case Mgmt I - Acute & Chronic Medical / Surgical Conditions
Topic: Pulmonary Physical Therapy
Objectives: The learner will be able to:
1. Review the anatomy of the lung, including airways and pulmonary segments, and be able to describe
using a model or a sketch, and put in lay language for patients. Demonstrate landmark location for
auscultation of lung segments and approximate location of the diaphragm and organs (liver, kidney,
2. Draw a diagram depicting normal lung volumes and write equations for the composite volumes. Draw
comparison diagrams for restrictive and obstructive lung conditions and describe the differences.
3. Explain the meaning of various Pulmonary Function Tests (PFT) measures: FVC, FEV1, FEV1/FVC.
Compare the changes in these PFT that you would expect in COPD, and in RLD. Understand that results are
expressed as % of normal for gender, age, and height. (Hillegass p.434-436).
Explain how PFT can be used for prognosis and intervention planning
(Sharon Coffman’s syllabus p.15. Also see online Lab Tool Kit for values of severity of disease)
4. Review the etiology and clinical signs and symptoms of these Chronic Obstructive Pulmonary Diseases
(COPD). Compare the Lung Volumes and Pulmonary Function Test (PFT) results for COPD compared
to normal lungs. Distinguish between condition(s) associated with abnormal secretions, or with sepsis, or
with alveolar destruction or due to heredity, or that are reversible. Identify likely breath sounds
(adventitious and abnormal) for these conditions. Appreciate that disease signs and symptoms can
overlap or occur simultaneously.
Hint: to understand COPD pathology you must first have a working knowledge of Lung Volumes
(Hillegass p.55, O’Sullivan p.562) AND Pulmonary Function Tests – PFT (Hillegass p.434-436)
a. Chronic Bronchitis
e. Cystic Fibrosis
5. List the common S/S of Restrictive Lung Disease (RLD). Explain the categories of possible pathological
mechanisms of impairment for RLD (start with the table of contents in Hillegass on p.183-184, also p.185 Fig.5-
1). Compare the Lung Volumes and Pulmonary Function Test (PFT) results for RLD compared to normal lungs.
Recognize that for all of the many, varied etiologies of RLD, that the Lung Volumes and PFTs will be similar, but
that the RLD is driven by different impairments, and will therefore require different interventions.
Hint: to understand RLD pathology you must first have a working knowledge of Lung Volumes (Hillegass p.55,
O’Sullivan p.562) AND Pulmonary Function Tests – PFT (Hillegass p.434-436)
6. Identify factors in the development of:
d. cor pulmonale
e. pulmonary (artery) hypertension
f. pleural effusion
7. Recognize significance of the following Tests & Measures for persons with pulmonary disease,
particularly as they relate to physical therapy treatment:
a. Vital signs
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c. Pulse Oximetry (SpO2):
d. Chest radiograph
f. Arterial blood gases (ABG):
f. Pulmonary function tests
g. Graded exercise test
8 Recognize medications commonly used for persons with COPD, generic and trade names, and their
expected therapeutic effects (pharmacodynamic) as well as their common adverse side effects
(see document on course website: Cardiac and Pulmonary Medications)
a. bronchodilators (short and long acting)
b. anti-inflammatory agents
c. mucolytic and expectorants (Hillegass p.596)
9. Outline a physical therapy examination, and state the anticipated findings for a patient with COPD.
How might these findings vary for different types of COPD or compared to RLD findings?
a. vital signs
RLD will have to increase respiratory rate to increase minute ventilation (Ve) because TV x RR
COPD will often have a prolonged expiration relative to inspiration (normal is 1:2-3 for
b. breath sounds -- emphysema will have distant breath sounds. Secretions will cause
adventitious and abnormal breath sounds, and if consolidation is present, breath sounds will
c. dyspnea, dyspnea on exertion (DOE)
d. chest wall, posture, UE and trunk ROM
e. exposure to tobacco smoke (primary or secondary) is calculated in Pack-Years = # packs per day
multiplied by the number of years smoking. Exposure to environmental contaminants
f. cough --- with secretions will be productive. RLD has a dry, non-productive cough.
g. activity level
h. self-care, home and work assessment
10. Associate the following breath and voice sounds with possible causes
(Hillegass p.625-627, p.628 Table 16-5)
Adventitious breath sounds:
• Ronchi / wheezes:
• Rales / crackles:
Abnormal breath sounds:
• Distant or diminished:
Transmitted voice sounds:
11. Oxygen is a drug. Describe the PT’s role in the administration of oxygen. Appreciate the risk and
danger of oxygen toxicity from an excessively high flow rate. Describe an oxygen prescription that would allow
titration for exercise. Explain why PaO2 levels must be kept LOW for a patient who is a “CO2 Retainer”.
Given an E cylinder of oxygen, calculate the remaining minutes in the tank for a specified flow rate.
12. Explain and contrast the rationale and goals of Pulmonary Physical Therapy for patients with various
obstructive and restrictive lung diseases. Start with the techniques you have read about or reviewed in lab and
then categorize them with the applicable lung condition. Hint: Start with impairments.
Note: in cases of advanced COPD conditions, restrictive conditions may begin to present secondarily as well (e.g.
changes in the thoracic wall)
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13. State and explain indications, contraindications and precautions for postural drainage and percussion
(especially trendelenburg, head lowered position). Contrast manual and mechanical percussion. . Describe
alternative positions for postural drainage and adapt equipment and positioning for home use. Place a subject in
the correct traditional positions for postural drainage for a given lung segment.
Explain how positions will differ for a child or infant.
Frownfelter (HSL reserve) p.671-673 has good photos of children receiving postural drainage
Campbell p.1075-1077: Pulmonary Function in the Special Care Nursery
14. Instruct a patient in performance of Active Cycle of Breathing Technique (ACBT) (Hillegass p.653,
Instruct a patient in performance of Autogenic Drainage (see handout)
15. Recognize and interpret cardinal signs and symptoms of respiratory distress
See Hillegass p.268, p.655 for a collection of S&S
(Note: this question is not addressing Acute Respiratory Distress Syndrome (ARDS), a potentially fatal
condition which exhibits pulmonary infiltrates, and heart failure.)
16. Given a patient with a lung transplant, anticipate the preoperative needs, and postoperative and
long term rehabilitation requirements. Identify precautions. Recognize clinical findings unique to persons
following a lung transplant.
Describe the purpose of Lung Volume Reduction Surgery (LVRS).
Hint: Hillegass chapter 12 covers both heart and lung transplant. Since we will also be discussing heart
transplant during the cardiac unit, there are several phenomenon that are common to transplantation of
the heart and the lung: the implications of denervation; induced immunosuppesssion to prevent rejection;
steroid myopathy, etc.
17. Elucidate national stop smoking efforts. Participate in local stop smoking campaigns.
Discuss how you would approach this issue with a patient who smokes. Describe immediate and long
range benefits. Calculate a smoking patient’s “Pack-Year” = number of packs smoked per day –
multiplied by the number of years of smoking). In interviewing check for second hand exposure, from a
spouse, or work or social environment.
18. Demonstrate Breathing Techniques to decrease Work of Breathing (WOB), airway turbulence, V/Q
mismatch, and dyspnea. Appreciate that relaxed breathing in the normal lungs consumes 5% of total body
metabolic reserve, whereas in the diseased lung it can consume up to 25% of the metabolic reserve. Appreciate
why slowing the respiratory rate would not be an appropriate breath retraining technique for someone with RLD
(hint: Ve = TV x RR).
Kisner & Colby p.749-757)
• Pursed Lip Breathing (PLB)
• Paced breathing:
• Exhale with Effort:
• Diaphragmatic Breathing:
• Segmental Breathing:
• Sustained Maximal Inspiration(SMI) or Maximum Inspiratory Hold:
• Glossopharyngeal Breathing:
19. Explain how inspiratory muscles can be strengthened / trained using an an Inspiratory Muscle Training
(IMT) device. When would use of an IMT device not be appropriate? (Hillegass p.741-742: SCI and COPD)
20. Describe the purpose and function of an Incentive Spirometer. Explain why a volume-mode instrument is
more effective than a flow-mode instrument (Hillegass p.529-530).
21. Demonstrate steps in a clinical examination for chest pain; differentiate signs and symptoms of different
origin: musculoskeletal, pleural, myocardial ischemia / angina, dissecting aortic aneurysm.
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Hillegass: p.616, 632.
Goodman (recommended text & on reserve at HSL): Physician referral: p.356-358; Overview: Pulmonary Pain
Patterns: p.358-359; Key Points to Remember: p.360; Subjective Examination: p.361; Also p.805-813.
22. Demonstrate examination for tracheal deviation. Be careful not to over-massage the carotid bodies,
causing increased vagal tone (parasympathetic) and possible syncope. Describe the impairments that could cause
a tracheal deviation, and if the deviation would be ipsilateral or contralateral. (Hillegass p.242; Sharon
Coffman’s syllabus p.21)
23. List conditions that would cause orthopnea, and how to accommodate this. Also, what GI condition
decreases tolerance of supine?
24. Explain the principle of Positive Airway Pressure to “splint” open airways in obstructive conditions or for
the treatment of respiratory failure. This principle has application in various (passive) devices: Ventilators
(PEEP), CPAP, Intrapulmonary Percussive Ventilation (IPV). The same principal is also used in
bronchopulmonary hygiene active patient-use tools such as the Flutter Valve ® and the PEP (Positive Expiratory
Pressure) valve ®, as well as the Pursed Lip Breathing technique.
25. Briefly explain how the respiratory and metabolic systems maintain pH homeostasis and how this is
tracked by observing Arterial Blood Gasses (ABG).
Hillegass p.439-442 (but skip “Henderson-Hasselbalch Equation”)
Hillegass p.443: read the Clinical Note in the lower right hand corner. Very important! It describes typical ABG
for acute vs. chronic respiratory conditions
26. Explain the significance and possible causes of a right shift in the Oxyhemoglobin Dissociation Curve
(Hillegass p.64-65, and online posting)
27. Describe the 4 phases of an effective cough. List impairments that would decrease cough effectiveness /
airway protection. Instruct a patient in performance of an effective cough, and assited cough techniques. (Kisner
& Colby: p.758-760)
28. Relate SCI levels to the muscles available for respiration
29. List normal values for male and female adults for Hematocrit, Hemoglogin, RBC count. Explain the
etiology of Polycythemia and the consequences. (online Lab Tool Kit)