Physiotherapy management of chest in stroke patients

1. D r . H i n a V a i s h ( P T )
B P T , M P T ( C a r d i o p u l m o n a r y )
A s s i s t a n t P r o f e s s o r , M M I P R ,
M a h a r i s h i M a r k h a n d e s h w a r ( D e e m e d t o b e
U n i v e r s i t y ) , M u l l a n a , A m b a l a
PHYSIOTHERAPY
MANAGEMENT OF CHEST
IN STROKE PATIENTS

2. STROKE
 Stroke is the sudden loss of neurological function
caused by an interruption of the blood flow to the
brain. Neurological deficit must persist for 24 hours
 Stroke is the leading cause of death and disability
among adults.
 Ischemic stroke is the most common type, affecting
about 80% of individuals with stroke

3. CLASSFICATION
Strokes are classified by
 Etiological categories (thrombus, embolus,
hemorrhagic)
 Specific vascular categories(anterior cerebral artery
syndrome, middle cerebral artery syndrome & so
forth)
 Management categories (TIA, minor stroke, major
stroke, deteriorating stroke, young stroke)

4. CARDIOPULMONARY
MANIFESTATIONS AFTER
STROKE

5. BREATHING AFTER STROKE
Stroke may disrupt breathing either by
(A)causing a disturbance of central rhythm generation
(B) interrupting the descending respiratory pathways
leading to a reduced respiratory drive
(C) causing bulbar weakness leading to aspiration.

6. PATTERNS OF RESPIRATORY IMPAIRMENT
DUE TO STROKE
CORTEX
 Hemispheric ischaemic strokes influence
respiratory function to a modest degree.
 Reductions of both chest wall and diaphragm
excursion contralateral to the stroke have been
reported.
 Patients with bilateral hemispheric cerebro-
vascular disease show an increased respiratory
responsiveness to carbon dioxide and are liable
to develop Cheyne-Stokes respiration suggest-
ing disinhibition of lower respiratory centres

7. Cheyne-Stokes respiration

8. Contd…..
 Diffuse cortical vascular disease may also lead to a
selective inability of voluntary breathing
 Intermittent upper airway obstruction and apnoea
due to periodic fluctuations in the position of the
vocal cords is associated with cortical supranuclear
palsy due to bilateral lesions of the operculum.

9. BRAINSTEM
 Unilateral or bilateral lateral tegmental infarcts in
the pons may lead to apneustic breathing and
impairment of carbon dioxide responsiveness, while
similar lesions in the medulla may result in acute
failure of the automatic respiration.

10. Cntd…..
 Acute vascular lesions in the lower brainstem
compromise respiratory control, particularly during
sleep, leading to irregularities of rate and rhythm of
breathing which lead to Cheyne-Stokes respiration,
hypopnoea, and obstructive apnoea.

11. CERVICAL CORD
 Infarction of the spinal cord at high cervical
levels may selectively affect respiratory control.
 Lesions of the anterior pathways, particularly
descending reticulospinal, lead to loss of
automatic control and sudden nocturnal death
from apnoea while involvement of the
dorsolateral corticospinal tracts may lead to
automatic respiration .

12. CHEST WALL KINEMATICS
 Optoelectronic plethysmography was used to
document the asymmetry of respiratory movements
of the chest wall during hemiplegia.
 In particular, the paretic side showed reduced
expansion during VH (when the drive is under
cortical control) and increased expansion during
chemical stimulation (when the drive is under brain
stem control).

13. Cntd….
 Altered respiratory mechanics & efficiency reflect
impaired chest wall movement & asymmetry resulting
in decreases lung volume, decreases pulmonary
perfusion and vital capacity
 Function of the intercostal muscles is affected
specifically during voluntary hyperventilation on the
affected side
 Reduced diaphragmatic movement is present on the
paralysed side during volitional inspiration when
compared with automatic inspiration. The
hemidiaphragm may be involved on the affected side in
patients with hemiplegia

14. SPASTICITY
 Hemiplegic patients may lean towards their involved
side in sitting because of weakness or spasticity
causing lateral flexion resulting in asymmetrical
breathing pattern and decreased ventilation
 Spasticity increases metabolical and oxygen demand

15. ARTERIAL OXYGEN SATURATION
 Patients with acute stroke are at risk of hypoxaemia
and the degree of oxygen desaturation may depend
on posture1
 Patients with an early dense hemiplegia due to
cerebrovascular accidents were shown to have a
greater degree of hypoxia 2

16. Cntd…..
 Facial and pharyngeal weakness contributes to an
inability to control oral secretions, swallowing
effectively and protect the upper airway.
 Muscle disuse and restricted mobility secondary to
hemiplegia leads to cardiopulmonary deconditioning
and inefficient oxygen transport

17. Cntd….
 Hemiparesis results in gait deviations, which reduce
movement efficiency and economy resulting in an
increased energy cost associated with ambulation
which may reduce exercise tolerance because of
fatigue
 Ambulating with a walking aid is associated with a
significantly increased energy cost which further
reduces exercise tolerance

18. COMPLICATION
 Dysphagia : lead to dehydration and compromised
nutrition
 Pulmonary aspiration more common during the
acute phase of recovery and can occur during any
phase of swallowing
 The patients have a weak and ineffective cough
resulting in retention of secretions and later
development of Pneumonia

19. PRINCIPLES OF PT MANAGEMENT
Goals of the management of the patient with
hemiplega includes :
Short term
 Optimise alveolar ventilation
 Optimise lung volume & capacities and flow rates
 Optimise V/Q matching and gas exchange
 Reduce the work of breathing
 Protect the airways from aspiration

20. Cntd….
 Facilitate mucociliary transport
 Optimise secretion clearance
Long term
 Maximise aerobic capacity & efficiency of oxygen
transport
 Optimise physical endurance and exercise capacity
 Optimise general muscle strength
 Maximise the patient quality of life, general health &
well being

21. ACUTE CARE
 In the acute stage, the patient may be unconscious
and so require assistance to maintain normal
respiratory function and removal of secretion from
the upper airways
 Acute ischemic stroke patients may benefit from
lower head-of-the-bed positions to promote residual
blood flow to ischemic brain tissue if the ICP is
normal.

22. Cntd….
 Stroke patients are at a risk of hypoxia so
supplemental oxygen should be given to the patients
with saturation below 95%
 Dysphagia management : upright positioning of
head, varying food consistensy

23. MONITORING
Patient monitoring includes
 Dyspnea
 Respiratory distress
 Breathing pattern (depth, symmetry, frequency)
 Arterial saturation
 Cyanosis
 Heart rate
 Blood pressure

24. INTERVENTIONS TO MAXIMISE
CARDIOVASCULAR FUNCTION

25. Body Positioning
 Improving chest wall alignment may alleviate
ventilatory deficit on the involved side
 Upright position
 Greater chest wall excursion can be achieved by
inhibiting the chest wall movement on the
uninvolved side
 Sidelying is the best posture to achieve this
inhibition. Start with ¾- supine and progress to full
sidelying posture

26. Breathing control
Techniques to reduce respiratory rate
 Controlled breathing(diaphragmatic breathing,
sniffing)
 Counter rotation
 Pursed lip breathing
 Incorporating simple therapy task
 Ventilatory movement strategy

27. Coughing Maneuver
 Cough reflex is suppressed or weak resulting in
difficulties in removal of secretions
 Costophrenic assist
 Abdominal thrust assist
 Anterior chest compression assist

28. Strategy to manage spasticity
 A reduction in truncal tone can be promoted using
technique of rhythmic initiation combined with axial
trunk rotation
 Side sitting on the hemiparetic side provides
sustained stretch to the spastic side flexors

29. Airway clearance techniques
 Postural drainage accompanied with
vibration and percussion to increase the
effectiveness
 Modified PD positions should be used if the
ICP is raised i.e. the head of the bed should
remain flat instead of being tipped into head
down position
 Suctioning should be done to remove the
secretions in case of ineffective cough

30. Cntd….
 Chest wall mobility exercises includes movement in
all planes
 Range of motion exercises: exercise are conducted in
upright position to minimise the work of heart and
breathing
 Patient education
 Efficient locomotion or wheelchair ambulation to
reduce early onset of fatigue

31. AEROBIC EXERCISES
 Physical deconditioning
following prolonged
period of immobilization
 Start with functional
activities like overground
walking
 Treadmill walking/
stationary cycling

32. THANK YOU