Diaphragmatic Breathing

Let’s talk about this super simple technique that can change everything. Diaphragmatic breathing is really just how we are all supposed to be breathing most of the time. The purpose of the diaphragm is to facilitate breathing. Diaphragmatic breathing improves gas exchange and increases lung volumes. These are all really good things if we need to get more air in, such as in restrictive lung diseases like pneumonia, post-lung resection, or pulmonary fibrosis. It can also be a useful technique to mobilize secretions or other obstructions in the airway for people who have obstructive lung conditions like congestive heart failure or COPD.

Source

It can be a bit difficult to grasp the actions and movements of the diaphragm unless you understand its purpose. The diaphragm has a central tendon and attaches to the costal margins, spine, and xyphoid process to create a barrier between the thoracic cavity and abdominal cavity. There are openings in the diaphragm muscle (hiatus) for the passage of the major blood vessels (the descending aorta and inferior vena cava), the trachea, the esophagus, and a few other small circulatory structures.

As you can see in the picture, when this muscle is relaxed, all of its length is up inside the chest cavity. Per the standard skeletal muscle, when it contracts and the fibers shorten. This brings the insertion (the central tendon) to the origin (the costal margins, spine, xyphoid). The central tendon lowering down into the abdomen, increasing the volume of the thoracic space to allow for lung expansion and decreasing the volume of the abdominal space. There are other accommodations that happen to make up for this volumetric change, but we will talk about those in a different post.

Because of the negative pressure system within our pleural space, this increase in thoracic volume draws air into the lungs, allowing for increased ventilation and diffusion (aka gas exchange) to take place, specifically in the lower segments of the lungs. This allows for greater oxygen intake and great CO2 removal, or more efficient breathing, than if the diaphragm were not engaged during this task. Breathing that does not engage the diaphragm utilizes the upper intercostals and accessory muscles to open the upper portions of the lungs only for gas exchange. This is less efficient and is typically seen in patients who have chronic heart and lung diseases or spinal cord injuries.

Why do we stop breathing the way we should?

Well, there are many reasons. Skinny jeans, corsets, getting our picture taken, learned habits, sitting without a back support, spinal deformations, pain avoidance, central nervous system damage, gastrointestinal disturbances, space-occupying lesions, change in muscle strength or length (disuse atrophy or trigger points can come in to play here), changes in abdominal content volume (pregnancy or obesity), change in lung volume (resections), lung function changes (disease states)… the list is endless. The major factor is whether or not it becomes a persistent problem. The body is a smart system and it can compensate for pretty much anything, but, similar to other musculoskeletal impairments, long term compensations are what lead to problems.

Photo by freestocks.org on Pexels.com

What can we do about it?

Bring it back! The diaphragm may shut down for a number of reasons, but it can bounce back with pretty minimal input. The reason for that is because it is such an essential muscle! It utilizes three spinal levels to ensure its function (C-3, 4, 5, Stay Alive!) because redundancies ensure we can breathe, at least in part, even if there is some damage.

The reason we had to talk about all that old information about origins, insertions, and actions is because these things are going to be important when attempting to facilitate diaphragm function. We used to teach people to have patients lying in hooklying with an object of interest (TV remote, cell phone) on their abdomen. We would ask them to breath inward and use their air to raise the item on their abdomen. When the diaphragm contracts to compress the diaphragm, the contents have to go somewhere and that is usually outward, so the object rises. BUT HERE’S THE PROBLEM WITH THAT: The diaphragm doesn’t move that way! These techniques typically result in the patient performing a Valsalva maneuver.

The diaphragm doesn’t move up and down when in the hooklying position! It moved cranial/caudal, which is completely different. The diaphragm attaches all the way around our body (nearly 360 degrees), so we need to be facilitating it’s expansion all the way around, also! We can’t do that if someone is lying on their back for many reasons:

  • This applies resistance to the posterior segments of the diaphragm muscle, making it harder to activate all portions of the muscle.
  • The diaphragm needs to work in 360 functional space including all positions of the body! So diaphragm exercises need to be performed in sitting, standing, squatting, quadruped, laying, and whatever yoga pose you come up with next.

There is a small case for initially instructing diaphragm exercise in hooklying, because this allows for gravity neutral activation, but you better move on pretty quick if your patient is ambulatory and doesn’t have a high spinal cord injury, or you won’t be doing them any good.

Photo by Chevanon Photography on Pexels.com

What does diaphragm facilitation look like?

There are many ways to facilitate diaphragm activation but here are some I like to use:

  • Visual Feedback: Place the patient in a chair in front of a mirror and have them breathe in and out using their diaphragm. Do this with them so they can see what you look like as well.
  • Verbal cues:
    • “Breathe in deeply, bringing the air all the way down to the bottom of your lungs”
    • The “Triple Sniff”: Ask your patient to sniff quickly three times. The first two sniffs need to be short and the third one needs to be long.
  • Manual Facilitation: Place hands all the way around the patient! We cannot cue diaphragm breathing in one plane because that’s not how it happens so here are some options:
    • Basic: one hand on chest, one hand on abdomen – abdomen should raise equal to or more than chest with inhalation (not my favorite as it results in Valsalvas more times than not).
    • Better: Place C-shaped hands around the inferior costal margin bilaterally. Ask the the patient to breathe in to your hands.
    • Best: With your C-shaped hands, follow that inferior costal margin inward on the exhale and provide a deep quick stretch just before the inhale to cue diaphragm and lower intercostal muscle activation.

When utilizing manual facilitation, you will want to make sure you feel all margins of the insertion expanding and contracting so you may have to facilitate from several different points on the costal margin over several repetitions.

Any other tips, Doctor B?

The diaphragm works in concert with the pelvic floor. Make sure your patient doesn’t have to use the bathroom and isn’t tightening their pelvic floor again exhalation. This results in over-compression of the abdominal contents and result in prolapse or incontinence. This is especially a concern for female athletes, new mothers, and women who have chronic breathing problems. 55% of women without a chronic lung disease reported incontinence, whereas 71% of women with a chronic lung disease reported incontinence.

Female athletes (I’m looking at you, gymnasts!) can also use many other muscle systems to facilitate breathing and compensate for their diaphragm. Be sure to check out breathing with the scapulae and even the glutes! This can have serious implications for the pelvic floor, also.

Patients who have spinal cord injuries, or some degenerative neurological conditions such as MS, GBS, or ALS may have partially impaired diaphragm function and will require several different types of facilitation. Just like airway clearance techniques, these interventions are always best performed in addition to each other, not in isolation.


Patients who have chronic diseases that results in poor lung function, like we mentioned above, typically need to get more air OUT of their lungs before putting more air INTO their lungs with diaphragmatic breathing. Check out this post on dynamic hyperinflation to learn more about that. You may also find that facilitating diaphragmatic breathing results in expectoration of secretions for patients who have obstructive lung conditions. This is because they are finally getting some ventilation to these no-often-used parts of their lungs! Alternating techniques that remedy dynamic hyperinflation with diaphragmatic breathing, as well as providing some positive expiratory pressure can make fore a really useful set of exercises for someone who has impaired lung function, but make sure you get the order of operations correct!


Do you have any funny verbal cues you like to use for diaphragm retraining? Tell me about them in the comments!

Blow Out the Candles…

If there is any treatment that I feel like gets used in a cookie-cutter fashion, it’s pursed-lip breathing. As much as I hate seeing this technique used for every single patient that has shortness of breath, it does have clinical usefulness. So let’s talk about how to implement pursed-lip breathing properly based on patient presentationContinue reading “Blow Out the Candles…”

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References:

Button, B. M., Holland, A. E., Sherburn, M. S., Chase, J., Wilson, J. W., & Burge, A. T. (2019). Prevalence, impact and specialised treatment of urinary incontinence in women with chronic lung disease. Physiotherapy105(1), 114–119. https://doi.org/10.1016/j.physio.2018.07.006

Lee, D. (2019). Butt-grippers, Back-grippers and Chest Grippers. Retrieved from https://dianeleephysio.com/education/butt-grippers-back-grippers-and-chest-grippers/

Follow @DoctorBthePT on Twitter for regular updates!

Postural Drainage

We’ve all seen that dreaded picture in our textbooks… All the human figures laying in so many different positions with pillows and tables tilted all over… and I very clearly remember thinking, “How on earth am I supposed to remember all of those?” Well, good news. You really don’t have to. It’s great if you do, don’t get me wrong, but for the purpose of general patient care, you can take a less specific approach and still have good results. Many of those positions cannot be achieved without a hospital bed unless you have a young, strong, and flexible patient, and if your patients is that young, strong, and flexible, they probably don’t need postural drainage.

Chest Physiotherapy (CPT) and Postural Drainage Positions | Respiratory  therapy student, Physical therapy assistant, Physiotherapy
Source

Yea, let’s be honest. Some of those are just not going to happen in any setting other than a hospital. So, if you don’t work in a hospital, how can you hope to achieve postural drainage? Good news, it’s no where near as difficult as it may seem. There is one solid rule to follow: Put the bad sound on top.


Step 1: Auscultate

As with so many cardiovascular and pulmonary interventions I’ve discussed, you have to know what you are listening for before you can ever hope to position someone properly. You can read all about lung auscultation in this post to get the details on that. But, basically, you have to auscultate to identify a segment that requires drainage.

Step 2: Identify the Segment

If you auscultated properly, you can compare the points you auscultated to an image for the underlying lung anatomy and figure out which segment is giving you adventitious sounds. If you you can’t google the picture really quick on your phone or computer, at least identify the lung side (right or left) and general lobe (superior, middle, lower). Remember, the left lung doesn’t have a middle lobe. Please don’t ever say you are assessing or treating the left middle lobe. It doesn’t exist.

Step 3: Put the Bad Sound on Top

Position the patient in a comfortable way so that the portion of the lung that produced the adventitious sound on auscultation is at the highest point of the body. Many of these can be achieved laying down in some way, but it will usually mean positioning the patient in sidelying at the very least. As you can see above, 6 of the 12 positions have some component of sidelying. So, if you are getting your patient in sidelying with the lung making bad sounds on top, you’ll make something better. Use as many pillows as it takes.


That’s it! Not so bad, right??? But you can’t stop there. Postural drainage positions are great and all, but, as with most other pulmonary interventions, they should not be used in isolation. While you have your patient in the drainage position, apply some other interventions to improve secretion mobility and clearance. Postural drainage positions should continue after your chosen interventions to facilitate further secretion clearance, about 10 minutes or so after you are done. Here is a list of ideas:

And, if you think about it, some of those positions probably won’t be needed by the majority of our patients. Sure, there are people with hypersecretion diseases, like cystic fibrosis, that may require drainage from all segments of their lungs on a regular basis. But your typical patient with COPD may only need a segment or two at a time, and may only be able to tolerate a segment or two at a time. And you can always refer back to your favorite diagram if you need specifics!

If we put it in the scope of the bigger picture, most of our patients are upright and sitting or standing during the day. Some are supine. If your patient is spending the majority of the day in standing or sitting already, they will likely not require that position for drainage, as the apical and anterior segments being drained all day long. If they are supine all day, they won’t likely need the anterior segments drained because they have been draining all day. You’ll be much more likely to need to opposite postures to address the bases, as secretions get trapped in them more easily due to their dependent position. Smaller segments such as the lingular segment may need more attention than others due to the position and somewhat closed off nature of the anatomy.


You’ll also need to remember that, although these may seem like simple positional changes, they are not for everyone. There is a reason this is part of skilled rehab intervention. Positioning is far more important than many give it credit for. Here’s some examples:

ICP Concerns – Patients who have concerns regarding intracranial pressure monitoring, such as those with recent neurosurgery, brain injury, or placement of an ICP bolt for any reason should not be inverted for postural drainage.

Shortness Of Breath (Dyspnea)
Source

Orthopnea – patients with cardiac conditions in addition to pulmonary may have difficulty breathing when laying supine. This is typical for patients in advanced heart failure and some patients who have COPD. This will definitely interfere with your positioning, but you can compensate using pillows or power bed controls to give them a little elevation to their comfort.

Prone Positioning – patients with respiratory conditions may initially be very hesitant to lie in prone as they feel it will restrict their breathing, especially if pillows are used around their face or head. However, we know that prone positioning actually increases ventilation, so physiologically, this is not a concern. Patients may still not tolerate this positioning due to fear or anxiety. Note that patients who are proned (such as when inpatient ICU status while ventilated) are typically sedated because this is a taxing posture for people who have difficulty breathing. Don’t expect a high tolerance in the begining.


All in all, I’ve had even the most severe end-stage COPD patients in prone over the edge of their beds with their hands on the floor to facilitate secretion mobilization while on supplemental oxygen with their spouse performing vibration. It can be done. And you can do it, too!


I feel like that superior lingular segment is the culprit 75% of the time. Do you find yourself regularly treating a specific lung segment? Tell me which one in the comments!

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More form the Pulmonary Rehab Toolbox…

Spilling the Box of Pearls: All the Tips on Supplemental Oxygen Management

In my recent post on COPD management, I mentioned that there are some really important parts of supplemental oxygen management that you need to be aware of and consider in your practice. If you are assisting patients who utilize supplemental oxygen regularly, you need to keep these things in mind. You also may be workingContinue reading “Spilling the Box of Pearls: All the Tips on Supplemental Oxygen Management”

Chronic Disease Part 2: Chronic Obstructive Pulmonary Disease (COPD)

This is part 2 in a multi-part series on the role of Rehab Providers in the management of chronic disease. Don’t forget to check out Part 1: Heart Failure! Chronic Obstructive Pulmonary Disease is a widely diagnosed disease of the lungs that includes the diagnoses of emphysema and chronic bronchitis. COPD can be caused byContinue reading “Chronic Disease Part 2: Chronic Obstructive Pulmonary Disease (COPD)”

Aerosol Generating Procedures

The long awaited clarification on aerosol generating procedures for physical therapists and physical therapist assistants has finally dropped! The APTA just released its professional guidelines for what portions of physical therapist and physical therapist assistant care equates to an aerosol generating procedures, therefore requiring increased PPE for procedure performance to ensure clinician safety. On AprilContinue reading “Aerosol Generating Procedures”

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References:

Fink J. B. (2002). Positioning versus postural drainage. Respiratory care47(7), 769–777.

Hewitt, N., Bucknall, T., & Faraone, N. M. (2016). Lateral positioning for critically ill adult patients. The Cochrane database of systematic reviews2016(5), CD007205. https://doi.org/10.1002/14651858.CD007205.pub2

Follow @DoctorBthePT on Twitter for regular updates!

I’ll Huff and I’ll Puff… But the Huff Will Be More Effective

What is a huff? Huffing is one of the more difficulty techniques to learn for airway clearance. I find that most of my patients have trouble mustering the strength to perform a good solid huff. It’s not just that it is unfamiliar, but also that it takes diaphragm strength that they just don’t have. But when they nail it, it is so effective! So I keep teaching it even though it’s hard.

Huffing is part of the Forced Expiratory Techniques (FET). The name pretty much describes itself. You force an exhalation to mobilize secretions. Like many other airway clearance techniques, they are better when used in conjunction with other techniques, not independently.

So, along that line, when used as an FET, huff tend to be followed by diaphragmatic breathing or deep breathing cycles, or huffs may be incorporated in to the active cycle of breathing to achieve a similar outcome. There are several variations of the ACBT that can be implemented, but you can read about the standard one here. FET is also a great technique to place in between bouts of vibration or percussion, as evidence shows that this combination is significantly more effective when performed together, especially when used for long term management.

I’ve found the best way to teach it is to just show them. It’s kind of a silly sound and people tend to be a bit shy about performing it alone. I show them first so I’m the one to look silly, and then we do it together. When I teach a patient to huff as part of their FET home program, there are a few cues I like to use:

  1. The Ho, Ho, Ho
    • I ask the patient, “What does Santa Claus say?” Now I will admit that some people (it’s rare) do actually get this wrong and say “Merry Christmas”. So, I’ll give them the answer. Then they say, “Ho, Ho, Ho”.
    • Then I ask them to say it again but pretend Santa has smoked for 40 years.
    • This pretty much always works and is easy for a patient or caregiver to remember.
  2. The Culturally Sensitive Approach
    • I ask the patient to force a wheeze using their belly muscles to push air forcefully.
    • As long as I’m also demonstrating at the same time, this also almost always works. It does tend to require cues for increased force production.
Huff

Here’s what a decent huff sounds like:


What’s the difference between a huff and a cough?

That’s a really simple answer (not really my style, right?). The difference between a huff and a cough is an open glottis. Holding the glottis open lets air flow freely through the trachea, producing the airy huff sound.


Why not just cough?

Well, coughing is exhausting. My patients cough all day as it is and they really don’t want to cough more than they have to. They typically already have irritated airways from coughing or supplemental oxygen. Of course I also teach them energy conservation when it comes to coughing, but sometimes we need something a little less aggressive that can be performed more frequently for airway clearance. Huffing is equally effective at clearing secretions when compared to coughing, but is less strenuous when performed properly.

In some patients, too much huffing can result in collapse of lung tissue due to the back pressure against the glottis. Huffing doesn’t generate such high pressure, so the risk of collapse is less.


Making it personal…

Another variation you can play with is huffing at different lung volumes. Huffing at high lung volumes (when your lungs are mostly full of air already) helps to mobilize secretions in the peripheral regions of your lungs because the air has filled up those spaces and you utilize the huff the vibrate that air. Huffing at low lung volumes (when there isn’t much air in your lungs) helps to focus secretion mobilization to the larger more central airways to move those gathered secretions out.

You would typically want to huff at higher volumes first to mobilize peripheral secretions inward and then huff at lower volumes to mobilize what you’ve collected so it can be expelled. However, that depends on what the patient needs. If you are hearing ronchi on your auscultation, you’d probably want to huff at low volumes to clear the larger central airways before anything else.

Take a listen to the different between the two. When huffing at high lung volumes, you have your patient take a deep breath in and then huff it out. But, when huffing at low lung volumes, you have the patient breathe in and then most of the way out before the huff.

Huff at High Lung Volume
Huff at Low Lung Volume

Remember, FETs are aerosol-generating procedures, so be sure you and your patient are masked and in proper PPE. Like I said, these techniques are effective, so you’ll probably need some tissues handy also, or a cup if you are needing to collect a sample. And, as always, don’t forget to auscultate afterwards to assess progress!


Very useful and very effective, the best kind of tool to have in your toolbox! What is your favorite Pulmonary Rehab Tool we have discussed so far? Tell me in the comments!

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Postural Drainage

We’ve all seen that dreaded picture in our textbooks… All the human figures laying in so many different positions with pillows and tables tilted all over… and I very clearly remember thinking, “How on earth am I supposed to remember all of those?” Well, good news. You really don’t have to. It’s great if youContinue reading “Postural Drainage”

The Duet Device

Have you seen an Acapella Duet before? This is another one of those things I wish I could hand out to maybe half of my patients. A Duet device is a special kind of Positive Expiratory Pressure (PEP) that provides resistive oscillatory pressure to exhalation which promotes increased lung volumes due to re-inflation of collapsedContinue reading “The Duet Device”

FEV1

I spent some really great times as an educator in a heart and lung transplant program at a large hospital system. Specifically, I was a therapy educator. I taught PTs, PTAs, OTs, COTAs, and SLPs what they needed to know to safely provide rehab to patient after heart and lung transplants. I saw so manyContinue reading “FEV1”

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References:

D’Abrosca F, Garabelli B, Savio G. (2017). Comparing airways clearance techniques in chronic obstructive pulmonary disease and bronchiectasis: positive expiratory pressure or temporary positive expiratory pressure? A retrospective study. Brazilian Journal of Physical Therapy. 21(1):15-23. DOI: 10.1016/j.bjpt.2016.12.001.

Fink J. B. (2007). Forced expiratory technique, directed cough, and autogenic drainage. Respiratory care52(9), 1210–1223. Retrieved from http://rc.rcjournal.com/content/52/9/1210/tab-pdf

McIlwaine, M., Bradley, J., Elborn, J. S., & Moran, F. (2017). Personalising airway clearance in chronic lung disease. European respiratory review : an official journal of the European Respiratory Society26(143), 160086. https://doi.org/10.1183/16000617.0086-2016

Torres-Sánchez, I., Cruz-Ramírez, R., Cabrera-Martos, I., Díaz-Pelegrina, A., & Valenza, M. C. (2017). Results of Physiotherapy Treatments in Exacerbations of Chronic Obstructive Pulmonary Disease: A Systematic Review. Physiotherapy Canada. Physiotherapie Canada69(2), 122–132. https://doi.org/10.3138/ptc.2015-78

Follow @DoctorBthePT on Twitter for regular updates!

Spilling the Box of Pearls: All the Tips on Supplemental Oxygen Management

In my recent post on COPD management, I mentioned that there are some really important parts of supplemental oxygen management that you need to be aware of and consider in your practice. If you are assisting patients who utilize supplemental oxygen regularly, you need to keep these things in mind. You also may be working with patients who are new to supplemental oxygen. This may be the case if you are working with someone who has had COVID-19 and is transitioning settings, or if you work with people who may be new to COPD or other lung diseases.

The first exacerbation of a chronic lung disease is always the scariest because the patient doesn’t know what to expect. They come home with all this new equipment and medicines, and they have no idea what to do with themselves. Usually, rehab and nursing can get them straightened out pretty quick, but sometimes you catch this on the fly and have to completely adapt your process.

Remember, for those who are new to oxygen, they may be pretty overwhelmed as it is. Taking in all this safety info and attempting to coordinate any changes to what they came home with will be very difficult for them as their cognitive load is already very high. Many of these things will fall to you to manage for the initial time frame. You’ll be lucky if they remember even half of what they were told as part of their discharge instructions.

Photo by Andrea Piacquadio on Pexels.com

So, on to the list of things we mentioned in the previous post on COPD management. I was going to go in to detail on these items in that post but decided it would just be too much and wasn’t necessarily specific to COPD management. These things can really be applied to all cases where supplemental O2 is required. This post is going to be specific to rehab considerations, but if you are looking for information on supplemental O2 delivery systems and devices, you can check out this post. These tips are all my own, and just what I’ve come to find works best in the long run.

  1. Supplemental oxygen is typically delivered by a static concentrator that utilizes lengths of tubing that deliver oxygen to the patient wherever they are, which means tubing laying on the floor.
    • Tubing on the floor is a tripping hazard for the patient as well as any other people living in the home. This tripping hazard increases when the patient also uses an assistive device as this is one more (at least) point of contact with the floor that must be cleared with each step. The risks and benefits of utilizing this standard delivery method must be weighed and compensated for each patient individually. Here are some considerations:
      • How active is your patient?
      • Is your patient already a significant fall risk?
      • Are there others in the home that are a significant fall risk, for example, a spouse with dementia?
      • Does the patient utilize a wheelchair? Tubing on the floor creates a barrier and could be considered a restraint if the patient cannot wheel over the tubing in their chair.
      • Is there another option for oxygen delivery that would successfully meet he patient’s needs?
      • Is there another option for oxygen delivery that is within the payer scope?
    • And, yes, supplemental oxygen NEEDS to be worn in the shower. Showering takes a lot of energy and time which requires lots of oxygen. Without it, this particular ADL (and pretty much all ADL, if I’m being honest) are not safe.
    • Oxygen is flammable. Keep it away from gas stoves, lighters, cigarettes, and any other source of flame or high heat.
    • Don’t forget that, as a disease progresses, so too will the patient’s oxygen needs. They may require more or less depending on their disease.
      • If they have something chronic and long term like COPD, they will probably require an increase over time. This is important to monitor closely as they could transition to being a CO2 retainer which would indicate some further work on your part, like reviewing ABGs and contacting the physician for a change in orders.
      • If they have an acute condition like pneumonia, they may be able to wean off of their oxygen over time. I’ve had this happen in patients, also. It’s a really great day when they get to send all that equipment back! But you’ll need to coordinate an overnight oxygen saturation study with the DME provider and perform a functional capacity test (like a 6-minute walk test) to be sure the patient is safe.
  2. Oxygen needs to be mobile to go with the patient when they go, and where a large static concentrator cannot follow. Therapists need to facilitate equipment setup to achieve this via mobile concentrators or other portable devices. This equipment must also be coordinated with their assistive device if they have one.
    • Mobile oxygen options vary by DME provider. You can have portable oxygen concentrators (or POCs), oxygen conservers, or cryogenic liquid oxygen delivery systems (Helio). All have their advantages and disadvantages and patients may have more than one delivery method depending on their needs.
    • Insurance will typically only cover one type of delivery system, and it is typically the standard concentrator with tubing if the patient is on standard flow orders. High flow orders can necessitate different delivery systems (such as liquid oxygen).
    • When used in conjunction with an assistive device, portable oxygen delivery systems can be attached in many ways.
      • Portable concentrators can go in a walker basket, on the walker seat, in a backpack, or over the shoulder in the carry bag.
      • Liquid oxygen has to be stored in an insulated bag (usually provided to the patient) and requires more equipment. The liquid has to be transformed in to a gas, which requires several steps, before it can be delivered to the patient. These tanks may require mounting brackets to the sides of wheelchairs, walkers, or the inside of the car to keep them safe. There are some that can be carried in carrying bags, but they are heavy (about 10 pounds) and require increased energy expenditure.
      • Small portable tanks with or without conservers (also known as “on demand” regulators) can be placed in a walker basket, carried in the carrying bag over the shoulder or on the walker handle, or can be mounted to a walker using a standard tank mounting bracket.
      • Mobile units will be limited in ability to provide adequate flow as most do not exceed 4 L/min, and will be limited in battery life based on flow needs. They will need to be charged whenever not in use.
    • When a patient is not regularly ambulatory, you may consider changing up their delivery system based on their functional status.
      • If they are in a recliner or bed most of the day with the exception of when you or another caregiver is present, you may consider have a spare small tank and canula to use for activity only, and have them use the concentrator at all other times.
      • If they are more mobile, you may switch them to smaller tanks to be used throughout the day and have them only use the concentrator at night for sleeping. This is a very successful approach in my practice. Patients love that they can be more mobile without tubing on the floor. Some concentrators come with an attachment that allows the concentrator to fill smaller oxygen tanks for exactly this purpose.
      • To make these changes, a physician order is not typically required as long as the flow rate isn’t changing. You can simply call the DME company, explain the safety concerns and ask for what you want.
  3. Backup oxygen supply is essential should there be an interruption in the power supply or the concentrator malfunctions.
    • All patients on supplemental oxygen should have a kilo tank, helio reservoir, or other backup supply available (maybe a charged portable concentrator) and know how to access it. Having the tank is great, but if their bedroom is upstairs and the tank is in the garage, that isn’t going to be helpful for them.
    • Kilo tanks have large regulators and can be used to fill smaller tanks or can be tapped directly via canula, but there needs to be at least 24 hours of spare oxygen in the home and the patient needs to know how to contact the DME company to let them know of a power supply failure so the DME can get more supply to them before their kilo runs out.
    • This is a step that is frequently missed in long term oxygen management, so remember to ask about it or check for a back up supply. If there isn’t one, call the DME company and get one delivered.
  4. Patients need to be educated on how to properly store tanks and swap regulators, as well as how to utilize their oxygen through any other delivery device such as their CPAP, a Duet, or a nebulizer.
    • Oxygen is still a drug that requires a physician order for proper use. It should not be used in any way other than how it is prescribed. However, it still remains our job to ensure it is used properly. Just like other drugs, patients can “ration” their supply if they are going to have to pay out of pocket for refills. This leads to hypoxia, cognitive impairments, and serious medical issues.
    • Spare tanks should be stored upright in some type of device that secures them from a fall. I have seen tanks chained to walls or inside of cars, I’ve seen velcro straps used, I’ve seen 2 liter pop bottle holder trays (they hold small tanks perfectly!). The DME company should have a solution for safe storage as part of their service to the patient. Backup supply tanks also need to be secured at they are tall and tipsy. Spare tanks should not be stored with regulators on them to prevent leaking.
    • Swapping regulators is an easy process, don’t be afraid that you are going to make the tank explode. There will be a loud puff of air but nothing more. Teach your patient to do this also.
    • If your patient is dependent upon supplemental oxygen, they also need to be utilizing this oxygen during other respiratory treatments. This includes CPAPs, BiPAPs, Nebulizers, Duets, and Acapellas.
      • CPAPs, BiPAPs, and nebulizers have a special attachment for supplemental oxygen to flow in. The DME providers should be setting this up, but sometimes it gets missed.
      • And if you are implementing a PEP device such as the Acapella or Duet, you need to make sure your patient is still getting their supplemental oxygen during use. Duets can run the oxygen directly through the bottom attachment. Acapellas allow the patient to still run oxygen via a nasal canula, but if that isn’t working, you can place the oxygen at the end of the Acapella so their are still breathing it in.
  5. Patients need to be educated on when to clean or replace canulas, tubing, masks, connectors, and any other parts of their oxygen delivery system to prevent pneumonia.
    • Canulas and masks should be replaced weekly, tubing biweekly or monthly (depending on the type of tubing). Connectors should be replaced with the parts they are attached to. So, connectors between lengths of tubing should be thrown out with the tubing. Tubing lengths should not exceed 50ft to maintain the proper flow rate.
    • Masks can be cleaned (just like CPAP masks) using vinegar and water, air dry. Tubing shouldn’t be cleaned as it retains too much moisture and can actually increase the risk of pneumonia. If you see moisture in the tubing, run the oxygen through it without having it attached to the patient until it is dry. (Put the patient on another source of oxygen while you do this.)
    • Dirty parts can lead to pneumonia and other respiratory infections. I’ve found that patients tend to have a drawer or box somewhere with all their “spare” tubing and canulas, not realizing that they are supposed to replace this stuff regularly.
    • If tubing or canula pieces become stiff (like from age or body oils), they should be replaced.
  6. Adaptations are available to make supplemental oxygen delivery more comfortable for the patient.
    • The most common one is a humidifier. It looks like a small cup of water attached to the concentrator. The oxygen creates bubbles in the cup if it is working properly. These typically require distilled water which leads patients to not refill them when they should, and then they don’t get used. They really do make that oxygen much more comfortable and humidifiers also prevent bloody noses and sore throats.
    • Ear padding is available for people who need to wear canulas and glasses or for people who have discomfort on their ears from the canula. I’ve even seen pressure ulcers on ears due to canulas so this is a big concern. The padding is easy to place on the canula, you just have to ask for it.
    • Canula face padding is also available for noses and cheeks to make the canula as comfortable as possible.

And the final tip I have for you about management of supplemental oxygen is this: Watch your patient change from mobile oxygen to concentrator oxygen and back.

I do this with literally every patient I evaluate that uses oxygen, new or not. I will tell you that in seven years of doing home health care, I’ve only ever had two patients do this properly. I actually time them. No joke. I time how long it takes them to do it. I once timed a patient as they went three and a half minutes without oxygen while they were trying to figure out how to change from static to mobile oxygen sources. They were exhausted, short of breath (go figure), and desaturated to 84%. I intentionally let them go all the way until they were done, under my close supervision.

The most common mistake patients make is they don’t set up their mobile before taking off the canula from the concentrator. It usually goes down like this:

  1. I ask them to show me how they switch from concentrator to mobile tank
  2. They take off the canula for their concentrator
  3. They hunt around the house for their mobile tank
  4. They hunt around for a canula
  5. They get everything put together
  6. They try to figure out how to turn the regulator on (if there is even a regulator on the tank at all)
  7. They can’t see the numbers on the regulator so they have to get glasses…

Do you see where I’m going? They spend way to much time without oxygen trying to figure this out. That is why I always ask them to show me how they do it. By moving step 2 in the above process to the last step, they maintain their safety. One simple change, that’s all it takes. Most of the time, when I show people this, they are in awe. It’s like I waved my magic wand.

Now that I’ve rambled on and on about this, I need you all to go out and wave your magic wands. Go make those patients so much safer. Take the reigns of their oxygen management for a time to make sure they are safe and then teach them how to do the same.


Try out a few of these clinical pearls and let me know how it goes in the comments!

More from the Pulmonary Rehab Toolbox…

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References:

Hardavella, G., Karampinis, I., Frille, A., Sreter, K., & Rousalova, I. (2019). Oxygen devices and delivery systems. Breathe (Sheffield, England)15(3), e108–e116. https://doi.org/10.1183/20734735.0204-2019

Hillegass, E. (2020). Vital Signs, oxygen, & exercise prescription: How are these impacted by COVID-19? PACER Project. Cardiovascular and Pulmonary sections of the APTA. Retrieved from https://www.youtube.com/watch?v=lj716KWNcig

Follow @DoctorBthePT on Twitter for regular updates!

Vibration & Percussion

If you read my post on airway clearance techniques, you probably saw vibration and percussion down at the bottom of the force progression. Although I have covered several other pieces of the force progression (Active Cycle of Breathing, PEP Devices, etc) in subsequent posts, I haven’t touched on these topics yet because they haven’t been necessary in patients with COVID-19, and that is where the focus has been. But, to bring things back around, now that we are inching forward, I want to make sure I touch on all the topics I’ve been neglecting intentionally to make sure you all have what you need to effectively treat patient with COVID-19. That means we will get to postural drainage and diaphragmatic breathing, also.

So, about that force progression. That post was a long time ago, so here is the force progression I created a few years ago. My mentor and several colleagues are MDT therapists, so we were all big on force progressions. Because I saw a different kind of patient, I decided to make my own.

Brockway, K. (2017)

During this time of pandemic, it is important to keep in mind that, while these procedures are important for the patients who require them, they are definitely aerosol generating procedures and caution must be taken when performing them. That means wearing your your full PPE. This also means that (per the notes on the bottom of the force progression) you need to know the relative precautions and absolute contraindications for use of vibration and percussion techniques. Notice from the progression that they require the most amount of external force. If you’ve performed these procedures, you know that you can’t effectively mobilize secretions with white glove force. You’ve got to get your elbows in to it (you’ll see what I mean).

Vibration and/or percussion should also not be utilized in isolation of other interventions. These interventions need to be incorporated in to a pulmonary hygiene program that includes several other aspects of care such as postural drainage, pharmaceutical secretion management (such as with inhaled respiratory medications), and exercise-based interventions to promote the highest level of effectiveness and patient outcomes. Typically, these more forceful interventions should only be utilized for patients who have difficulty clearing large amounts of secretions, such as those with COPD or cystic fibrosis.

You can learn a whole lot more about COPD HERE, but let’s talk about why you may need to utilize this intervention. COPD is symptomatically comprised of chronic cough and hypersecretion. These symptoms are present because of bronchiectasis, or the destruction of the linings of the smaller airways. These two items are independent risk factors for reduced exercise capacity in patients with chronic bronchitis (a component of COPD), as well as being associated with increased risk of infection, hospitalization, and exacerbation. Bronchiectasis can also be present without COPD, but is a typical funding in obstructive lung conditions. Hypersecretion is where vibration and percussion work their magic. When secretions thicken (based on several factors we discuss here), they become more difficult to mobilize and an increase in force is required.


Contraindications

There are going to be some great reasons to perform this intervention, but there are also some great reasons not to. Performing percussion over the following would be contraindicated:

  • Recent or Unhealed Fractures
  • Active or Unhealed Thoracotomy Sites
  • Unexplained Chest Wall Pain (Could be occult rib fracture)
  • Areas of Atelectasis or Pneumothorax (no sound or significantly diminished sound when auscultating, typically after a trauma or surgical intervention to the chest wall – like open heart procedures)

There are also some medical considerations that may indicate percussion should not be performed on a given patient:

  • Long term anticoagulation therapy/Hemophilic – this could result in diffuse bruising and pain or deeper bleeding.
  • Long term use of corticosteroids as they weaken bone tissue and increase the risk of fractures, even with minimal force. This may not be an absolute contraindication depending on the degree of cortical bone loss. Weigh the risks clinically. If you have no other option and your patient is immobile… keep in mind the medical conditions that require long term use of corticosteroids.
  • A patient with unstable chest pain – percussion would be very uncomfortable and increase chest pain. If chest pain is unstable angina, you have bigger things to worry about.
  • Hyper-Reactive Airway Disease/Related airway conditions – this is a relative contraindication, not an absolute. These patients may be the ones who really need this type of intervention, so use with caution and use your clinical judgement. You’ll need to decrease your force and utilize less FET force also to prevent bronchospasm.
  • If you suspect in any way that there may be a pulmonary embolism present – This is a much bigger concern than consolidation and needs to be addressed medically before any further intervention as it is a life-threatening condition.

Starting off…

You need to know where on your patient you are planning to do these interventions. Percussion and vibration are not to be used globally except in certain situations. Children and adults with cystic fibrosis that require long term secretion management can utilize global vibration and/or percussion by way of a HFCWO (High-Frequency Chest Wall Oscillation) machine. (Yes, adults can get cystic fibrosis. I had a lung transplant patient who was 31 and wasn’t diagnosed with cystic fibrosis until the age of 16. One of my friend’s husbands was recently diagnosed with cystic fibrosis in his 50s.) Some patients with COPD or other obstructive lung diseases may also require this extra help, but they are the exception, not the rule. So, back on point, how do you know where to apply your intervention?

You have to auscultate. Take a listen to your patient. Do it systematically and listen to where you hear the largest amount of secretions peripherally. Ronchi are a good indication of large amounts of secretions in large airways (also bad), and crackles are good indications of secretions in smaller airways. The overall goal of airway clearance is to move secretions from the periphery to the central, larger airways so they can be expelled. Listen for the peripheral crackles and perform your airway clearance interventions over those areas. THEN LISTEN AGAIN! That’s how you know if your interventions were successful and will indicate whether or not you need to move across and/or down in the force progression (above). You can also consider your intervention successful if it triggers a productive cough! That’s the whole point, isn’t it? You can read more about successful lung auscultation HERE.

Talk to your patient. Let them know what you need to do, why you need to do it, and what that will entail. Give them the power to control the interventions, in that they can stop you at any time if they become uncomfortable. Talk to them during performance (this will come up again later) so they feel comfortable communicating with you. Many patients feel like they must hold still, be quiet, and just endure interventions because a medical person is telling them to do so. Don’t be that person. Make your patient part of the intervention.

It is recommended in several articles I’ve read, however, most of them do not provide a source, to ensure you are monitoring your patient’s oxygen saturation via pulse oximeter while you are performing manual interventions for secretion mobilization. I can see the logic because if you have a large amount of secretions gather in the large airways, they could potentially block the airway. However, I’d also say that’s the point and you need to finish up your intervention with an FET to produce expectoration to remove the blockage. We will talk about that at the end.

AAANNNDDD FINALLY… Put your patient in the appropriate postural drainage position, as best as they can tolerate, prior to providing either or both of these interventions. They won’t be nearly as effective if the patient is not in the correct position, or at least, in a position that partially supports the gravity-assisted flow of the secretions.


Vibration

Vibration is a great tool to use for patients who cannot tolerate percussion, as the forces are different and less ballistic. Vibration is exactly what it sounds like. You place your hands on the patient and apply a deep vibratory force into the segment you are intending to treat. I actually find this to be more fatiguing for me than percussion. I also feel like it isn’t as effective as percussion, but that’s personal bias only.


Percussion

Percussion is different from vibration in that it requires repeated ballistic force being applied to the affected segment of the lung. This takes special positioning of the hands on the part of the clinician, as well as intentional movement to prevent fatigue. You’ll also want to regularly assess your patient’s tolerance as well as your own technique which can be done simultaneously! Check out the video to see what I mean.


Finish it up right!

Like I said above, none of these are great on their own. They need to be utilized in combination with other airway clearance techniques. FETs (short for forced expiratory techniques) are great and have a strong evidence base. Examples of FETs are, positive pressure, huffing, deep coughing, directed coughing, or the active cycle of breathing. My personal preference is to alternate percussion with FETs to improve patient tolerance to the more forceful treatments. It gives them a break in between to recover. I have no evidence for this other than anecdotal, but patients seem to appreciate the rest break. And don’t forget: LISTEN AGAIN!

Remember that percussion and vibration are utilized to mobilize secretions from small peripheral airways to the larger central airways. So you need to keep the secretions moving from that point all the way out of the airway. Follow up your manual interventions with some huffing, the active cycle of breathing, some intentional coughing, a PEP device, or just some deep breathing. These techniques will move those secretions from the larger airways to the trachea and then out.


What does the evidence say about all this?

So, for transparency, I’ll tell you that there isn’t much evidence on these interventions. You’ll find some, but not nearly as much as interventions like exercise. And much of the evidence is a bit older. It seems like the research done on these topics kind of stopped in 2010. There are a few newer ones but you have to dig pretty deep.

And as far as safety goes, even though we see a long list of absolute and relative contraindications, these are relatively safe interventions as long as you follow the proper clinical guidelines, force progression, and patient tolerance. Even in the most effected level of COPD (GOLD 3-4), invasive pulmonary oscillation and percussion is utilized safely (Those machines we talked about above). That’s mechanical force! That isn’t graded the way humans grade force. A machine will apply as much force as you tell it to regardless of patient tolerance, clinician comfort, or effectiveness. Yet, still, it has been found to be completely safe when administered by skilled professionals.

The evidence we have available, and I’ve had to go global here, tells us that manual interventions for acute exacerbations do not prevent future exacerbations. However, manual interventions for acute exacerbations do improve patient perception of dyspnea which is the number one complaint they will have. So, address their number one complaint and you may be their favorite person! Not every person who has an obstructive condition will be able to clear their secretions on their own, even with all the marvelous instruction you have provided, so you have to have manual interventions in your back pocket.


Do you perform manual interventions for airway clearance? What is your favorite combination for moving large secretions? Tell me in the comments!

More from the Pulmonary Rehab Toolbox…

HFNO

HFNO stands for High Flow Nasal Oxygen. This is something that was used frequently in patients who were desaturating quickly with symptoms of COVID-19. It has the ability, through the use of several different devices or setups, to deliver very high concentrations of supplemental oxygen to patients with advanced pulmonary diseases or conditions. In theContinue reading “HFNO”

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References:

Chakravorty, I., Chahal, K., & Austin, G. (2011). A pilot study of the impact of high-frequency chest wall oscillation in chronic obstructive pulmonary disease patients with mucus hypersecretion. International journal of chronic obstructive pulmonary disease6, 693–699. https://doi.org/10.2147/COPD.S22896

Fink J. B. (2002). Positioning versus postural drainage. Respiratory care47(7), 769–777. Retrieved from https://pubmed.ncbi.nlm.nih.gov/12088547/

Fink J. B. (2007). Forced expiratory technique, directed cough, and autogenic drainage. Respiratory care52(9), 1210–1223. Retrieved from http://rc.rcjournal.com/content/52/9/1210/tab-pdf

McIlwaine, M., Bradley, J., Elborn, J. S., & Moran, F. (2017). Personalising airway clearance in chronic lung disease. European respiratory review : an official journal of the European Respiratory Society26(143), 160086. https://doi.org/10.1183/16000617.0086-2016

Nicolini, A., Grecchi, B., Ferrari-Bravo, M., & Barlascini, C. (2018). Safety and effectiveness of the high-frequency chest wall oscillation vs intrapulmonary percussive ventilation in patients with severe COPD. International journal of chronic obstructive pulmonary disease13, 617–625. https://doi.org/10.2147/COPD.S145440

Shen, Y., Huang, S., Kang, J., Lin, J., Lai, K., Sun, Y., Xiao, W., Yang, L., Yao, W., Cai, S., Huang, K., & Wen, F. (2018). Management of airway mucus hypersecretion in chronic airway inflammatory disease: Chinese expert consensus (English edition). International journal of chronic obstructive pulmonary disease13, 399–407. https://doi.org/10.2147/COPD.S144312

Torres-Sánchez, I., Cruz-Ramírez, R., Cabrera-Martos, I., Díaz-Pelegrina, A., & Valenza, M. C. (2017). Results of Physiotherapy Treatments in Exacerbations of Chronic Obstructive Pulmonary Disease: A Systematic Review. Physiotherapy Canada. Physiotherapie Canada69(2), 122–132. https://doi.org/10.3138/ptc.2015-78

Westerdahl, E., Osadnik, C., & Emtner, M. (2019). Airway clearance techniques for patients with acute exacerbations of chronic obstructive pulmonary disease: Physical therapy practice in Sweden. Chronic respiratory disease16, 1479973119855868. https://doi.org/10.1177/1479973119855868

Chronic Disease Part 2: Chronic Obstructive Pulmonary Disease (COPD)

This is part 2 in a multi-part series on the role of Rehab Providers in the management of chronic disease. Don’t forget to check out Part 1: Heart Failure!

Chronic Obstructive Pulmonary Disease is a widely diagnosed disease of the lungs that includes the diagnoses of emphysema and chronic bronchitis. COPD can be caused by several things such as genetic diseases (alpha-1-antitrypsin deficiency, for example, which causes emphysema in children and adults), lifestyle choices (such as smoking), work environments with poor engineering controls and toxic output (asbestos, coal, and steel production), or community/home environments that require regular burning of substances with toxic output for a heat source or for food preparation.

Like the name suggests, it is an obstructive lung condition, meaning that stuff gets in the airway making it hard for air to get OUT of the lungs. Air trapping, mucus hypersecretion, physiological and physical changes to the body, chronic cough, and decreased overall activity level are all signature components of COPD. COPD used to be ranked based on severity for GOLD levels which are based on FEV1. This system is not part of a clinical picture of symptoms assessment instead of the sole descriptor:

GOLD, 2020

COPD is often accompanied by (or even caused by) other chronic diseases such as left heart failure. It can exist in isolation, but even then, the treatments tend to induce other chronic conditions. Long term COPD management with corticosteroids has a host of side effects including osteoporosis, diabetes, vision impairments, and increased risk of infection (among others). Long term use of bronchodilators (inhalant medications, typically) have been linked to myocardial infarctions, hypokalemia, and bronchospasm. These side effects lead to some interventions being contraindicated (such as percussion) that would otherwise be helpful in COPD symptom management.

If you treat patients with COPD regularly, you tend to get a feeling for what COPD looks like. That’s because it comes with physiologic changes that eventually result in physical changes (similar to most chronic diseases!) that can be spotted across the room: barrel chests, blue-ish lips, digital clubbing, sunken eyes, coughing regularly, accessory musculature popping out of the collar of a shirt… And those are just the things we can see. The thinks we can’t see are worse. Chronic cough is also associated with urinary incontinence and chronic back pain, and diseases of breathing are associated with depression and anxiety.

Our goal with patients who have COPD is two-fold:
Reduce the risk of rehospitalization and improve quality of life.
These two goals include all the medical management and functional interventions we would apply. But first…

We have to quantify it

Just because someone has COPD doesn’t mean they necessarily need a PT or any other rehab provider involved in their care, so we need to make it clear when and why we are necessary. We need to express what deficits they are facing because of their COPD (or any other comorbidity). You’ll need some tools for this. There are many that are somewhat generic, but there are some disease specific tools, too. These tools are great because they can really help direct your interventions to give the patient the most BANG for their BUCK! We will talk about a few of them here, but there are many.

The COPD Assessment TEST (CAT) – highly recommended and free, this is the test recommended by the Global Initiative for Chronic Obstructive Lung Disease (GOLD)

Leicester Cough Questionnaire (LCQ) – Used frequently in research specific to COPD

Chronic Respiratory Questionnaire (CRQ) – proprietary assessment owned by McMaster University

SF-36 – More generic but a wealth of evidence to support its applicability (developed at RAND as part of the Medical Outcomes Study)

The Cough and Sputum Assessment Questionnaire (CASA-Q) – also proprietary, but validated with the SF-36 and disease specific

The Patient Reported Outcomes Measure Information System (PROMIS) Global Rating Scale – a free NIH funded HRQoL Questionnaire

Many physical function and exercise capacity tests can also be utilized, such as the 6-minute walk test, the 2-minute step test, the 400 meter walk test, and many others. For more information on standardized tests and measures that are valid for patients with COPD, check out SRALab (formerly rehabmeasures.com). I like to use a combination of different measures to better capture the “whole-patient” picture, one physical, one subjective report, and maybe one or two others based on the reported deficits.

Then we have to treat it

You may find several areas of impairment based on your chosen outcomes measures, so you may have several areas of physical, mental, and emotional function to address, either by yourself or in conjunction with your team. Chronic diseases like COPD, which deplete oxygen supply to the brain and weigh a heavy burden on patients and their caregivers, tend to have long lasting emotional and mental effects, so don’t forget to refer to your colleagues across disciplines.

For people with COPD, secretion management is also going to be a large part of their long term plan, but it is also something they face acutely in the hospital or subacute setting that rehab therapists can very easily improve. We know that, independent of any other factors, mucus hypersecretion is a risk factor for hospitalization and death. So what do we have in our toolbox? Oh, so many great things! Click the links for more details of each tool or technique.

AcapellaTM Oscillatory PEP Devices

Oscillatory PEP therapy is effective at increasing secretion transport, decreasing breathlessness, reduced hyperinflation, and is as effective as other airway clearance techniques at improving disease-specific quality of life. However, flutter valves have ben found to be more fatiguing for patients than other types of airway clearance such as the active cycle of breathing (ACBT). Patients with COPD do not experience greater discomfort when performing one airway clearance technique over the other, even when utilizing gravity-assisted positions (or postural drainage). ACBT and oscillatory PEP have near equal outcomes for patients with COPD when performed with or without postural drainage positions when it comes to dyspnea, cough frequency, and overall weakness. Although, ACBT was found to be more efficient as moving secretions from the smaller focal airways than oscillatory PEP interventions. There were also no differences in the effects on lung function as both tools improved FEV1 and FVC. In my mind, that’s great news!

That means we can utilize either one, depending on our goals with the patient, and still achieve similar outcomes! If our patient fatigues easily, we may stick to the ACBT, but if we are targetting dynamic hyperinflation or need to significantly improve overall quality of life we may chose a PEP. In my regular practice, I give both and here’s why:

  • PEP devices are easier to use, remember to use, and take less time to perform than the ACBT.
  • Having a PEP around provides a visual reminder that the patient needs to do airway clearance techniques
  • I want the effects of both when I treat patients with COPD, as many patients need to improve their disease-specific quality of life and their dynamic hyperinflation, but also fatigue quickly, and I want them to have options. Having options for long term management that can all be performed independently with or without devices increases the chance they will actually be used.

No technique for airway clearance is as effective on its own as it is when combined with something else. Postural drainage can be combined with most techniques to target specific segments.

Then we have to manage it

In addition to secretion management, patients with COPD tend to need supplemental oxygen. There is a high degree of training that is required for the effective use of this drug including how to manage the equipment, how to therapeutically manage the drug from a rehabilitation perspective, and how to incorporate the equipment and the drug in to everyday life. There are many safety concerns that accompany supplemental oxygen delivery, which are usually the reasons rehabilitation providers are brought in. However, if we can prevent the safety events from happening at all by seeing the patient earlier, rather than later, that’s all the better. You can click the links for more information on each piece of this, but I’ll address some of the safety concerns in brief:

  • Supplemental oxygen is typically delivered by a static concentrator that utilizes lengths of tubing the deliver oxygen to the patient wherever they are, which means tubing laying on the floor.
  • Oxygen needs to be mobile to go with the patient when they go where a large static concentrator cannot follow. Therapists need to facilitate equipment setup to achieve this via mobile concentrators or other portable devices. This equipment must also be coordinated with their assistive device if they have one.
  • Backup oxygen supply is essential should there be an interruption in the power supply or the concentrator malfunctions. All patients on supplemental oxygen should have a kilo tank or other backup supply available and know how to access it.
  • Patients need to be educated on how to properly store tanks and swap regulators, as well as how to utilize their oxygen through any other delivery device such as their CPAP, a Duet, or a nebulizer.
  • Patients need to be educated on when to clean or replace canulas, tubing, masks, connectors, and any other parts of their oxygen delivery system to prevent pneumonia.

I could really just keep going on this forever… I’ve spent a large amount of time teaching patients how to properly use, manage, and maintain their supplemental oxygen. Maybe I’ll just do a whole other post on factors to consider when managing supplemental oxygen. Keep your eyes peeled for that!

Also, keep in mind the long term changes that happen over time with COPD. We need to be keeping our eyes on those ABGs and looking for an elevated PaCO2 which might tell us that our patient has become a CO2 retainer. This is critical in the management of our patients with COPD and will inform how you manage and monitor their oxygen. Click the link to read more. We may also need to strongly promote fall prevention strategies as these patients have a high risk of falls and a high risk of injury with falls. We will talk a little bit more about this later.

Speaking of long term changes, even though we’ve talked this whole time about getting all that trapped air out, we need to briefly talk about getting air in. Specifically, long term diaphragm weakness is to be expected with physical changes like becoming barrel chested. Diaphragm strengthening using an IMT is crucial, but to be used with caution.

Finally, we need to exercise them!

Finally, right? I bet you thought this part would never come. There is currently no Clinical Practice Guideline for Physical Therapists in the Management of COPD (I checked, twice, and emailed people), but the evidence for high-intensity interval training (HIIT) is pretty clear.

High-intensity interval training produces significant increases in maximal exercise capacity based on outcomes of the 6 minute walk test, as well as a reduction in lower extremity discomfort during exercise, which may be due to peripheral muscle changes in response to exercise. Patients with COPD who perform high-intensity interval training respond with an improvement in VO2max that is two to three times greater than with typical moderate intensity training. High-intensity interval training is also known to produce physiological changes including left ventricular remodeling that improves the overall patient response to exercise with increased oxygenated blood traveling to the muscles and other tissues. HIIT also produces improvement in functional activity and exercise capacity (measured via the 6 minute walk test), improvement in lung function (such as FVC), and in work efficiency.

The overall consensus on HIIT for patients with COPD is that, in the end, the outcomes are the same as when using moderate intensity continuous exercise, however, the results are achieved much faster and patient compliance is higher. So High-Intensity Interval Training is how you give your patients more BANG for their BUCK.

If you are not a provider in a pulmonary rehab setting, do NOT forget about pulmonary rehab! Evidence has shown that pulmonary rehab programs result in 52% fewer hospital readmissions, 4.27 less days in the hospital, and 19% fewer deaths in the same time frame in comparison to patients with COPD who did not have pulmonary rehab!

Photo by Burak K on Pexels.com

Of course, HIIT, if designed properly, can be performed by almost any patient at any level. I can absolutely make a HIIT program out of breathing exercises. I’ve done it. So if you have no arms and legs, I can give you a HIIT program. But this cannot be done alone. Address those functional deficits, retrain breathing patterns, improve ADL performance efficiency, and ensure oxygen safety. Manage the medications and their side effects, monitor the oxygen and exertion levels, and instill confidence that COPD may be life-altering, but it doesn’t have to be life-ending.

With chronic disease, it’s a package deal.


What specialty referrals do you make for your patients with COPD? Tell me about them in the comments!

More from the Pulmonary Rehab Toolbox…

The Counting Talk Test

Time to give you guys another tool. This one is especially important for patients with COVID-19, and it’s not terribly often that we get an objective measure for exertion. I’ve found the counting talk test to be critical in quantifying exertion in my patients with respiratory diagnoses. This measure is phenomenal for taking breathlessness inContinue reading “The Counting Talk Test”

Orthostasis

“Whoops! Down I go! I thought I was going up, but apparently not!” I have heard this many times. Sometimes I hear it from the people around me just generally throughout the day. They black out or see stars or feel “whoozy” or report being lightheaded when they stand up from the couch or getContinue reading “Orthostasis”

The Beta Blockade

Ugh, medications… I know, I know. I will try to make this as painless as possible. This one matters. It REALLY matters. For patients who have COVID-19 and for patients who don’t. Please take a quick read. Let’s start off by asking some questions. What does a β-blocker do? Blocks norepinephrine and epinephrine from bindingContinue reading “The Beta Blockade”

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References:

Adolfo, J. R., Dhein, W., & Sbruzzi, G. (2019). Intensity of physical exercise and its effect on functional capacity in COPD: systematic review and meta-analysis. Jornal Brasileiro de Pneumologia45(6), e20180011. Epub September 26, 2019.https://doi.org/10.1590/1806-3713/e20180011

Birring SS, Prudon B, Carr AJ, et alDevelopment of a symptom specific health status measure for patients with chronic cough: Leicester Cough Questionnaire (LCQ)Thorax 2003;58:339-343.

Chakravorty, I., Chahal, K., & Austin, G. (2011). A pilot study of the impact of high-frequency chest wall oscillation in chronic obstructive pulmonary disease patients with mucus hypersecretion. International journal of chronic obstructive pulmonary disease6, 693–699. https://doi.org/10.2147/COPD.S22896

D’Abrosca, F., Garabelli, B., Savio, G., Barison, A., Appendini, L., Oliveira, L., Baiardi, P., & Balbi, B. (2017). Comparing airways clearance techniques in chronic obstructive pulmonary disease and bronchiectasis: positive expiratory pressure or temporary positive expiratory pressure? A retrospective study. Brazilian journal of physical therapy21(1), 15–23. https://doi.org/10.1016/j.bjpt.2016.12.001

Global Initiative for Chronic Obstructive Lung Disease (GOLD) (2020). Global Strategy for the Diagnosis, Management, and Prevention of COPD – 2018 Report. [Adobe Acrobat document]. Available from: https://goldcopd.org/wp-content/uploads/2017/11/GOLD-2018-v6.0-FINAL-revised-20-Nov_WMS.pdf

Katajisto, M., & Laitinen, T. (2017). Estimating the effectiveness of pulmonary rehabilitation for COPD exacerbations: reduction of hospital inpatient days during the following year. International journal of chronic obstructive pulmonary disease12, 2763–2769. https://doi.org/10.2147/COPD.S144571

Lee, A. L., Burge, A. T., & Holland, A. E. (2017). Positive expiratory pressure therapy versus other airway clearance techniques for bronchiectasis. The Cochrane database of systematic reviews9(9), CD011699. https://doi.org/10.1002/14651858.CD011699.pub2

O’Donnell A. E. (2018). Medical management of bronchiectasis. Journal of thoracic disease10(Suppl 28), S3428–S3435. https://doi.org/10.21037/jtd.2018.09.39

Rand Healthcare. (2020). The 36-Item Short Form Survey. Retrieved from https://www.rand.org/health-care/surveys_tools/mos/36-item-short-form.html

Ries, A. L., Bauldoff, G. S., Carlin, B. W., Casaburi, R., Emery, C. F., Mahler, D. A., Make, B., Rochester, C. L., Zuwallack, R., & Herrerias, C. (2007). Pulmonary Rehabilitation: Joint ACCP/AACVPR Evidence-Based Clinical Practice Guidelines. Chest131(5 Suppl), 4S–42S. https://doi.org/10.1378/chest.06-2418

Ross, L. M., Porter, R. R., & Durstine, J. L. (2016). High-intensity interval training (HIIT) for patients with chronic diseases. Journal of Sport and Health Science. 5(2):139-144. Retrieved from https://www.sciencedirect.com/science/article/pii/S2095254616300102

Ryrsø, C.K., Godtfredsen, N.S., Kofod, L.M. et al. (2018). Lower mortality after early supervised pulmonary rehabilitation following COPD-exacerbations: a systematic review and meta-analysis. BMC Pulm Med18,154. https://doi.org/10.1186/s12890-018-0718-1

Shen, Y., Huang, S., Kang, J., Lin, J., Lai, K., Sun, Y., Xiao, W., Yang, L., Yao, W., Cai, S., Huang, K., & Wen, F. (2018). Management of airway mucus hypersecretion in chronic airway inflammatory disease: Chinese expert consensus (English edition). International journal of chronic obstructive pulmonary disease13, 399–407. https://doi.org/10.2147/COPD.S144312

image credit

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More Than Just A Respiratory Disease: The Tools You Need to Rehab COVID-19

Isn’t COVID-19 just a respiratory disease? If only that was true. We are good at treating respiratory infections. We have lots of drugs for viral, bacterial, parasitic, and fungal infections of the lungs. Most of them work really well! We also have several back-up treatments, inhaled medications, and adjuvant therapies (like rehab!) that make primary treatments even more effective. We are pretty darn good at treating respiratory infections. So, if COVID-19 was a respiratory disease only, we would have been all over that. We’ve been battling influenza in varying forms for over a century. We’ve stopped pneumonia in its tracks in even the most fragile patients. So, why haven’t we been able to put a cork in COVID-19? The answer is NO, it isn’t just a respiratory disease.

Yes, influenza can give you muscle aches. Yes, pneumonia, if left untreated, can lead to sepsis. But, COVID-19 causes severe physical damage to multiple organs and systems in your body. Particularly susceptible are the kidneys, heart, and brain. It is thought that their susceptibility is due to their expression of ACE-2 receptors, something this coronavirus is eager to find. Even the blood-brain barrier can’t keep it out, because this coronavirus destroys the barrier. The pancreas, skin, and blood vessels are also at particular risk.

We’ve talked about these topics quite a bit in the several previous posts. What do I have to offer that is new? I’m going to start treating COVID-19 like a multi-system disease. Just like we treat diabetes, just like we treat heart failure, just like we treat most other chronic diseases. Notice how I mention “chronic” disease? That’s intentional. That’s because we really don’t know what the long term effects of COVID-19 are going to be. Many people who didn’t require any medical intervention are several months out now on their infections and are still experiencing symptoms such as shortness of breath with little to no activity, and other symptoms that just keep lingering. Many experts feel that the damage this coronavirus causes to the endothelium (the lining of the vessels) will cause a long term increased risk for blood clots and strokes. As rehab providers, we need to know if someone has had COVID-19 because we will want to keep this in the back of our minds when performing our differential diagnosis.

Researchers are finding elevated inflammatory markers in people who have had COVID-19 including C-reative protein and interleukin-6. These are the same inflammatory markers we blame for so many long term inflammatory conditions in people who have end-stage renal disease (ESRD). Down to the cellular level, this disease changes our physiological function, interfering with the renin-angiotensin-aldosterone system (RAAS). This hormone based system also helps regulate inflammation, fluid levels, and blood pressures. People who have heart failure depend on regulated fluid levels in their body, so upsetting this already debilitated system would cause them serious harm.

Photo by Anna Shvets on Pexels.com

Sure, we can treat the inflammation with dexamethosone. We can pump you full of antibiotics to prevent opportunistic infections. We can give you antivirals to slow the damage. We can thin your blood down to water and hope it still carries oxygen. We can treat the breathing problems with budesonide. Heck, we just can breathe for you. We can put you out so you don’t feel a thing. We can filter your blood for you. We can circulate your blood for you. We can flip you over so you breathe better. We can even wake you up just a little bit and walk you around the room attached to 30 different machines with a team of 8 or more highly skilled medical providers… But my goodness, we’ve never really had to do all of that at one time for one single person… And now we are doing it for thousands of people at hundreds of facilities all over the world.

Not a single one of those treatments is the answer. Every treatment that is hailed as the next “magic” answer to COVID-19 doesn’t address the whole disease. It may address part of it, like the early phase with minimal symptoms, or the asymptomatic phase, or the late acute phase, but nothing addresses all of it. We can definitely cut the mortality rate, which is a huge step, but no single treatment has been enough to prevent it all together. People who otherwise take these “hailed” medications for pre-existing medical conditions still contract COVID-19. The burden of this disease is huge and we have only seen a few months worth of damage.

Don’t get me wrong. I WANT there to be a cure or treatment or something that is effective at just wiping this thing out. We’ve done it with other viruses and bacteria through vaccines (like with Polio and Pertussis) or engineering controls like water sanitization (for Cholera). I’m also not saying a vaccine is the answer. What I’m saying is, I’m not ready to jump to conclusions about a single drug or treatment. Evidence, research, and time are important. We could find the greatest thing ever that treats everything perfectly, but then down the road we find it has side effects even worse than what we otherwise would have experienced. This has happened before (remember thalidomide?), and I don’t want it to happen again. Even if we come up with the perfect treatment or preventative tomorrow (fingers crossed!) we still have the people currently experiencing COVID-19 and its sequelae that need quality treatment.

All of this doesn’t mean we know nothing. Quite the opposite! We can actually predict with greater than 90% accuracy what someone’s clinical disease course will be, what levels of care they will need, and what treatments will be the best for them at each phase. We know that COVID-19 isn’t overall that deadly, but we do know that it is very damaging, and either one isn’t good. Polio was pretty damaging, too. We have three new studies confirming airborne transmission is possible and likely, especially in close confines and indoor environments. This research is what informs re-openings, mask wear, and other protective measures. I’d say we actually know quite a bit which is why we now know that this is a multi-system disease that needs to be treated like one.


Treating a Multi-System Disease

If we have a patient with diabetes, we don’t just treat their blood sugar. Even as rehab providers, we look at their circulation, their peripheral sensation, their central and peripheral balance, their cardiac function, their vision, and so many other aspects because we know that diabetes causes impairments in all of these domains. If we have a patient with heart failure, we never just look at their heart, do we? We know they have changes in their kidneys, their lungs, their vasculature, and their muscles… So we use test and measures to address all of these components. This is exactly How we need to be looking at survivors of COVID-19.

In the rehab world, what can we do to address COVID-19 as a multi-system disease? How does this change the way we screen, evaluate, and treat? You will need to look at the whole patient. Even in the outpatient setting, they are not just knee pain who had COVID-19 two months ago. If you are seeing patients in any setting who have had COVID-19, even tested positive but remained asymptomatic, you need to be looking at a number of things and the APTA has summed it up in 5 easy measures:

  1. Physical Function. Can we start out with, “Duh?”. The best way to do that is to use the Short Physical Performance Battery (otherwise known as the SPPB). This is a combination of three already standardized tests (timed chair rise, gait speed, and static balance) that give you raw scores and a sum score that is highly predictive of function. This is a great tool across functional levels and gives you a good amount of functional information to inform and direct your treatments. You can get all the deets here:

2. Strength. COVID-19 is known for causing weakness in the small muscle groups and the core. You may have a patient who can stand, but they can’t write their name. They may do a squat, but can’t walk 10 feet. Anyone who you meet that has had an ICU stay for COVID-19 is at risk for ICU acquired weakness (ICUAW). In that case, the Medical Research Council Sum Score (MRC-SS) is recommend for assessing strength. There are several articles listen in the references for the MRC-SS, but generally it is a combination of manual muscle tests of certain muscle groups.
Here is the source for this file: ResearchGate.

You can also learn more about scoring this was from this video:

3. Endurance. You’ve probably heard by now of someone who had COVID-19 and needed months of rehab. Or who didn’t go to the hospital but still gets short of breath walking short distances. Whether it’s due to long term immobility in the hospital or actual parenchymal damage to the lung tissue (or other body systems), endurance becomes significantly affected. The recommended test for endurance in people who have had COVID-19 is the 2 minute step test. This is a favorite of mine for people of all ages! I’ve used this for my ESRD patients, VAD patients, young athletes, and middle-aged adults. You can download the one-page here:

4. Cognition. We have talked several times about the effects COVID-19 can have on the brain. In this case, you should probably have a tool in your pocket to assess cognition. There are some specific cases of COVID-19 that are associated with delirium lasting longer than 72 hours. In the absence of other serious symptoms, you may find this patient in your clinic for any number of reasons or you may find that one of your current patients starts to develop some strange symptoms. The SLUMs (the Saint Louis University Mental Status Exam) is the recommended assessment to use in this case. You can access it for free here:

5. Quality of Life. Isn’t this what we should always be focused on? What can we do as rehab providers to improve someone’s quality of life? Unfortunately, we so often do not assess or quantify it, so it can be difficult to demonstrate improvement other than subjective report. The ED-5Q-5L is a simple questionnaire that can reliably quantify the quality of life for patients who have had COVID-19. Unfortunately, I can’t give you this one. However, you may be able to get it for free when you register with the company who created it. You can do that here: https://euroqol.org/support/how-to-obtain-eq-5d/ You can also view a sample of the document in English.

There is your tool box! You’ve got something for every major system. Obviously you can insert other objective measures you may need specific to your patient. For the time being, this is what we’ve got, and I think it’s a pretty strong set of tools. Hopefully, soon, we won’t need to worry so much about all of this, but until that day comes, we will continue to be the frontline against community spread, and the treatment for those with longterm medical complications regardless of their setting.


Have you used any of these tools for assessing patients after a run with COVID-19? Did you run in to any ceiling effects? Tell me about how they did and how they progressed in the comments!

More Reads…

It’s Getting Hot in Here: Body Temperature

How many times have you had your temperature taken lately? I think I’ve had my temperature taken thousands of times in the last few months. We are seeing the increased use of forehead scanning thermometers and temporal scanners, all the non-contact forms of temperature assessment, to screen folks for COVID-19 symptoms upon entry to anyContinue reading “It’s Getting Hot in Here: Body Temperature”

References:

American Physical Therapy Association. (2020). APTA Academies and Sections Consensus Statement: COVID-19 Core Outcome Measures. Retrieved from https://www.apta.org/contentassets/1a6e0ee7cd25403888d2959c1c8476cd/covid-19-core-outcome-consensus-statement-june-2020.pdf

Arshad, S., Kilgore, P., Chaudhry, Z. S., Jacobsen, G., Wang, D. D., Huitsing, K., Brar, I., Alangaden, G. J., Ramesh, M. S., McKinnon, J. E., O’Neill, W., Zervos, M., & Henry Ford COVID-19 Task Force (2020). Treatment with hydroxychloroquine, azithromycin, and combination in patients hospitalized with COVID-19. International journal of infectious diseases : IJID : official publication of the International Society for Infectious Diseases97, 396–403. https://doi.org/10.1016/j.ijid.2020.06.099

Azimi, P., Keshavarz, Z., Laurent, J. G. C., Stephens, B. R., Allen, J. G. (2020). Mechanistic Transmission Modeling of COVID-19 on the Diamond Princess Cruise Ship Demonstrates the Importance of Aerosol Transmission. medRxiv 2020.07.13.20153049. Retrieved from doi: https://doi.org/10.1101/2020.07.13.20153049

Bonn, D., Smith, S. H., Somsen, A., van Rijn, C., Kooij, S., van der Hoek, L., Bem, R A. (2020). Probability of aerosol transmission of SARS-CoV-2. medRxiv 2020.07.16.20155572. Retrieved from doi: https://doi.org/10.1101/2020.07.16.20155572

Connolly, B., Thompson, A., Moxham, J., Hart, N. (2020). Relationship Of Medical Research Council Sum-Score With Physical Function In Patients Post Critical Illness. American Journal of Respiratory and Critical Care Medicine. 201:A3075. Retrieved from https://doi.org/10.1164/ajrccm-conference.2012.185.1_MeetingAbstracts.A3075

Connolly, B. A., Jones, G. D., Curtis, A. A., Murphy, P. B., Douiri, A., Hopkinson, N. S., Polkey, M. I., Moxham, J., & Hart, N. (2013). Clinical predictive value of manual muscle strength testing during critical illness: an observational cohort study. Critical care (London, England)17(5), R229. https://doi.org/10.1186/cc13052

Kingsland, J. & Sanfins, A. (2020). COVID-19: Doctors round up evidence of damage outside the lungs. Medical News Today. Retrieved from https://www.medicalnewstoday.com/articles/covid-19-doctors-round-up-evidence-of-damage-outside-the-lungs

Rikli, R.E., Jones, C.J. (1999). Functional fitness normative scores for community residing older adults ages 60-94. Journal of Aging and Physical Activity. 7:160-179. https://geriatrictoolkit.missouri.edu/cv/2min-step-rikli-jones.doc

Santarpia, J. L., Herrera, V. L., Rivera, D. N., Ratnesar-Shumate, S., Reid, S., Denton, P. W., Martens, J. W. S., Fang, Y., Conoan, N., Callahan, M. V., Lawler, J. V., Brett-Major, D M., Lowe, J. J. (2020). The Infectious Nature of Patient-Generated SARS-CoV-2 Aerosol. medRxiv 2020.07.13.20041632. Retrieved from doi: https://doi.org/10.1101/2020.07.13.20041632

Tsui, E. L. H., Lui, C., Woo, P. P. S., Cheung, A. T. L., Lam, K. W., Tang, T. W. , Yiu, C. F., Wan. C. H., Lee, L. H. Y. (2020). Development of a data-driven COVID-19 prognostication tool to inform triage and step-down care for hospitalised patients in Hong Kong: A population based cohort study. medRxiv. 2020.07.13.20152348 Retrieved from doi: https://doi.org/10.1101/2020.07.13.20152348

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Chronic Disease Part 1: Heart Failure

Ya’ll know how much I love freeing the yoke! Chronic disease is a huge burden to the general population. This post is the first in a series of posts addressing some of the major chronic diseases placing a yoke around the necks of our patients. We will discuss what these diseases are, what causes them, and what we can do about it! I’ll help you with what you need to know before you go. Let’s talk about one of the major culprits: Heart Failure.

In 2012-2013, new terminology was adopted for the description of heart failure types. Even though it is not widely used, the new language has increased awareness of and research on diastolic dysfunction and opened our eyes to the two major types of heart failure. We used to just think “left” or “right” or “both”, and that wasn’t exactly wrong, but heart failure is more complicated than that, so the terminology needed to be a better descriptor of what was actually going on.

Heart Failure reduced Ejection Fraction (HFrEF)

Also classically known as systolic heart failure, Heart Failure with Reduced Ejection Fraction indicated that the patient has an Ejection Fraction of <40%. In patients with this diagnosis, EKG abnormalities are more common, indicating that heart rhythm issues are present. HFrEF is clearly associated with coronary heart disease (CHD). HFrEF is typically caused by:

  • Myocardial Infarction
  • Viral myocarditis
  • Physical damage to the heart tissue

Damage to the actual cardiac muscle, electrical, valvular, or vascular tissue is what reduces the ejection fraction in these patients. Either the pump can’t pump as hard (left ventricle), the electrical function is interrupted which results in incoordination and decreased strength of contraction (left ventricle), the valve can’t close and open properly so blood slips out when it isn’t supposed to, or the coronary vasculature can’t supply the oxygen and nutrients to the musculature that it requires. In some of the more long-term causes, blood pools up in the left ventricle, stretching the muscle beyond it’s optimal length and reduces the strength of contraction.

This heart failure is typically more of sudden onset which can result in patients having increased difficulty coping and managing the symptoms. Thankfully, because it typically has a sudden onset, the heart musculature doesn’t have enough time to atrophy before rehab professionals are able to intervene. So, although the patients with this type of heart failure may struggle emotionally or mentally with their new diagnosis, their physical function is less limited after initial diagnosis. This is, of course, dependent on the degree of infarction or physical damage.

Photo by Karolina Grabowska on Pexels.com

There are some in the category who do have significant physical damage or require longer term treatment, such as with viral infections. They may be significantly debilitated due to PICS. Sometimes, this condition is caused by long term disease which results in a larger level of damage, especially if the diseases are left uncontrolled for a longer period of time. Causes of this kind of damage can include:

  • Hypertension
  • Coronary Artery Disease (CAD)
  • Mitral Regurgitation
  • Aortic Stenosis

This is a great population for us to jump in with. These are the folks that are still feeling pretty ok. They know they are going to be facing difficulties, but they typically are ready to go on the rehab to prevent HFrEF from affecting them for as long as possible. They can also undergo procedures to correct for some of these issues (like TAVR procedures for valve repairs). But for hypertension and CAD, prevention is key. One of my patients with HFrEF diagnosis had to be discharged early from home care services because he had reached his only self-selected goal which was to go kayaking with his grandsons. All the warm and fuzzies. We still transitioned him to outpatient cardiac rehab for long term management, though.

Heart Failure preserved Ejection Fraction (HFpEF)

In Heart Failure with preserved Ejection Fraction, the left ventricle of the heart cannot properly fill with blood. Overall, less blood than “normal” still leaves the heart, but 55% or more of the blood in the left ventricle still leaves the chamber. Therefore, the ejection fraction is maintained, but the cardiac output is still less. The ventricle can still pump well but the ventricle walls may be very stiff, so cannot relax enough to fill properly during diastole. This can also happen is the heart wall muscle becomes too thick and the chamber no longer holds as much blood. HFpEF can be diagnosed if the ejection fraction is anything greater than 40%. HFpEF is more likely in females and renal failure a more common comorbidity. Causes include:

  • Long term hypertension
  • Complication of uncontrolled diabetes or long term diabetes (severely stiffened arteries systemically including coronary arteries)
  • Failure/Sarcopenia due to debility and/or obesity
  • Hypertrophic Cardiomyopathy
  • Aortic Stenosis
  • Pericardial Disease (abnormalities of the sac surrounding the heart)

As you can see, many of the causes are the same as HFrEF. That is because the development of these conditions depends on the systemic condition of the person, comorbidities, overall physical level, and many other factors. However, the difference here is that HFpEF is typically caused by long term chronic diseases, which means that I’ve seen a lot of these patients.

The difficulty with treating HFpEF is that these patients ride the long slow train down the very slight decline. There can definitely be a triggering event that starts the train ride, but it is all down hill. The burden of chronic disease takes its toll on their body and the recovery process involves riding that long slow train back up the hill. This takes a lot of time and a lot of effort on the part of the patient and the therapist. The other hard piece to the puzzle is that we don’t usually get to intervene here until much later in the disease process which means there has been systemic muscle atrophy, multiple system failure, and ongoing difficulty with chronic disease management. These patients require a good deal of monitoring at all times when participating in activity because they tend to have a very low overall tolerance.

Photo by Anna Shvets on Pexels.com

The medication burden to the patient with HFpEF is also much higher and more difficult to sustain. They are typically treated with mineralocorticoid receptor antagonists (spironolactone or eplerenone) which cause hyperkalemia, as well as other medications that elevate potassium, so potassium level and intake must be monitored regularly. Have you ever heard of Milrinone? Nasty business… And then add in that they may also require hemodialysis three days per week and the toll that takes on a person physically, mentally, and emotionally… I have tons of research on that but we will address ESRD in another post.

This all means that, as the physical therapist, exercise may not be the best or only intervention you are providing. This also means that you have some serious considerations for whole-patient management that go far beyond your assessments and interventions. Let’s talk about some of those things…

The treatment is still exercise!

Regardless of the type of heart failure, the treatment is the same: MOVE! Where you start is definitely going to differ based on acuity and type. More acute HFrEF may need phase 1 cardiac rehab interventions, but may progress to stage 3 quickly and be on their merry way. However, patient with HFpEF will be in phase 2 for a very long time and may meander across stages and settings of care. They typically endure a relapsing/remitting disease course that places a large burden on themselves and their caregivers. Baseline functional assessments and outcome measures are critical for patients with HFpEF because progress is long and labored so maintaining skilled care can be more difficult.

Straight from the Clinical Practice Guideline, here is the exercise prescription patients with heart failure need. Please observe those RPE levels… that’s right… 90-95% peak workload is your target.

Physical therapists must prescribe aerobic exercise training for patients with stable, NYHA Class II-III HFrEF using the following parameters: Time: 20–60 min; Intensity: 50%–90% of peak VO2 or peak work; Frequency: 3–5/wk; Duration: at least 8–12 wks; Mode: treadmill or cycle ergometer or dancing (Evidence Quality I; Recommendation Strength: A—Strong) 
Physical therapists should prescribe high-intensity interval exercise training in selected patients for patients with stable, NYHA Class II-III HFrEF using the following parameters: Time: >35 min; Intensity: >90%–95% of peak VO2 or peak work; Frequency: 2–3/wk; Duration: at least 8–12 wks; Mode: treadmill or cycle ergometer. HIIT total weekly exercise doses should be at least 460 kcal, 114 mins, or 5.4 MET-hrs. (Evidence Quality I; Recommendation Strength: A—Strong) 
Shoemaker, M. J., et al. (2020)

There is also plenty of information on strengthening of the muscles of respiration using IMT training and proper prescription of resistance training. Dr. Shoemaker and his crew even provide the guidance for combining all the different types of training so you can get it all in. We will get in to more details of High-Intensity Interval Training in another post. I’m super excited for that!

Other than exercise…

Keep in mind all the things we talked about in the post about the Rule of 2s! all of these things still come in to play for every one of these patients. Many patients with HFrEF don’t receive the education on how to manage their heart failure using the Rule of 2 because they tend to be quickly in and out of treatment, but that doesn’t mean they don’t need it! If they want to get back to their normal life and live it the best they can for as long as possible, they need to manage themselves properly to prevent decompensation and be healthy enough to participate in exercise or activity-based interventions.

Yes, that means you need to take your patient’s weight. You need to check their weight log. You need to listen to their lungs at every visit and know what you are listening for. You need to check their heart rate (manually, because they have rhythm issues, remember?), blood pressure, and pulse oximetry before, during, and after activity. And if you are in the outpatient setting, you definitely need to do this. Just because someone walked in to your clinic today doesn’t mean they are healthy. That 72 year old man here for a basic knee evaluation may have knee pain from joint effusion resulting from lower extremity edema secondary to fluid overload. I’ve seen it. This is chronic disease management. Within our scope, within our ability = our responsibility.

For more specifics to treating patients with heart failure, please take a read on the BRAND SPANKING NEW Clinical Practice Guideline for Physical Therapists Managing Heart Failure!


What baseline functional outcome measure is your “go-to” for patients with heart failure? Tell me in the comments!

Sternal Precautions

“Patients exchanging habits of activity for complete rest are likely to become rapidly worse.” This quote fuels my everyday. These words have informed nonsurgical and surgical rehabilitation and its evolution from handing out bed rest like Oprah hands out cars to getting people moving early and keeping them moving often. Here’s the crazy thing: ThisContinue reading “Sternal Precautions”

Dehydration

Gosh, this is a fine line… Especially in the patients I regularly see. A colleague and I often say, “If you have any more water, you’ll die. If you don’t have any more water, you’ll die.” This is actually a frequent education topic that I cover with patients. Scary? Yes, but true. So, why isContinue reading “Dehydration”

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References:

Black, H. R. & Pitt, B. (2015). HFpEF: The ‘New’ Heart Failure. Commentary for MedScape. Retrieved from http://www.medscape.com/viewarticle /838790#vp_3

Ho, J. E., Gona, P., Pencina, M. J., Tu, J. V., Austin, P. C., Vasan, R. S., Kannel, W. B., D’Agostino, R. B., Lee, D. S., Levy, D. (2012). Discriminating clinical features of heart failure with preserved vs. reduced ejection fraction in the community. European Heart Journal. 33(14):1734–1741. https://doi.org/10.1093/eurheartj/ehs070

Oktay, A. A., Rich, J. D., & Shah, S. J. (2013). The emerging epidemic of heart failure with preserved ejection fraction. Current heart failure reports10(4), 401–410. https://doi.org/10.1007/s11897-013-0155-7

Pai, R. K., Thompson, E. G., Gabica, M. J., Husney, A. (2019). Heart Failure With Reduced Ejection Fraction (Systolic Heart Failure). HealthWise. Retrieved from https://www.uwhealth.org/health/topic/special/heart-failure-withreduced-ejection-fraction-systolic-heartfailure/tx4090abc.html#:~:text=Heart%20failure%20with%20reduced%20ejection%20fraction%20happens%20when%20the%20muscle,less%20than%20the%20body%20needs.

Pai, R. K., Thompson, E. G., Gabica, M. J., Husney, A. (2019). Heart Failure With Reduced Ejection Fraction (Systolic Heart Failure). HealthWise. Retrieved from https://www.uofmhealth.org/health-library/tx4091abc

Shoemaker, M. J., Dias, K. J., Lefebvre, K. M., Heick, J. D., & Collins, S. M. (2020). Physical Therapist Clinical Practice Guideline for the Management of Individuals With Heart Failure. Physical therapy100(1), 14–43. https://doi.org/10.1093/ptj/pzz127

Follow @DoctorBthePT on Twitter for regular updates!

Exercise-Induced Hypertension

Have you ever had patient exercising during your treatment session and taken their blood pressure only to find that is has shot up pretty high? They didn’t have symptoms of high blood pressure so you rested them and it came right back down. But, then you find that it keeps happening… What does this mean? Are they just intolerant to exercise due to deconditioning? Not necessarily. Exercise-induced hypertension can happen even in healthy individuals. There have been questions for several years about what exercise-induced hypertension means, and the answers are becoming clear.

So what is a normal blood pressure response to exercise?

We expect systolic blood pressure to rise about 20-60 mmHg during exercise, but this varies from patient to patient and is based on symptomology. It is fairly standard to see a rise of 8-10mmHg per MET of exercise, which eventually plateaus at peak activity level. A better cut off number is 180mmHg. Diastolic blood pressure, however, we need to keep an eye on. We do not want diastolic blood pressure to rise greater than 10 mmHg with activity.

Blood pressure can also drop with exercise, which is actually the long term goal of using exercise to manage hypertension. However, too much of a drop and this does indicate activity intolerance, especially when it drops in conjunction with a drop in heart rate. When blood pressure significantly drops in response to exercise, it can also be an indicator of future cardiovascular events. If systolic blood pressure drops are 10mmHg or more, it is an absolute red flag and any exercise or activity must stop. More of a drop than that can indicate severe active pathology like an active infarction or significant reduction in cardiac output. However, dehydration must also be considered, especially when the patient has diuretic medications on board. We talk about this more in this post.


What is Exercise-Induced Hypertension?

Also known as Exercise HTN, Exaggerated Blood Pressure Response to Exercise (EBPRE), or Hypertensive Response to Exercise (HRE). Exercise-Induced hypertension is an apparently ‘normal’ resting BP (<140/90 mm Hg) but excessively high exercise BP. Specifically, a systolic BP of ≥210 mm Hg for males and ≥190 mm Hg for females and, although less common, a diastolic BP ≥110 mm Hg for both males and females at any exercise workload. It is found in 18% of normotensive people, as much as 40% of hypertensive people, and in more than 50% of people with Type 2 Diabetes Mellitus.

Exercise-induced hypertension can also be defined as a blood pressure greater than the 90th percentile or normal during moderate intensity workload. You can view a table of what is considered 90th percentile of normal blood pressure during exercise here:

Exercise-induced hypertension may be indicative of an early phase of essential hypertension or pre-hypertension, indicates poor left ventricular adaptations and function, and may also be an indicator of poor hypertension control. Exercise-induced hypertension is associated with a significantly higher risk of cardiovascular events and mortality due to these events, even when present in otherwise healthy people without other risk factors.

Photo by Andrea Piacquadio on Pexels.com
What causes exercise-induced hypertension?

So many things…

  1. Metabolic conditions such as diabetes, metabolic syndrome, or high cholesterol, and any other conditions that lead to insulin resistance, vascular stiffness, or atherosclerosis.
  2. Conditions that impair systemic vasculature such as systemic inflammation. Several lab values have been associated with abnormal blood pressure responses to exercise, most of which are markers for inflammation:
    1. C-reactive protein
    2. Albumin-creatinine ratio (kidney function marker)
    3. Interleukin-6
  3. Large artery wall stiffness, such as in the aorta, femoral, or brachial arteries. Stiffness in the large arteries does not allow for proper compliance adjustments when volumes of cardiac output increase to accommodate exercise.
  4. Neurohormonal Vascular Control impairments, such as with traumatic brain injuries or neurodegenerative processes (even just aging). The neurovascular dynamics in response to exercise come primarily from a memory mechanism, not from peripheral changes due to exercise. This is because exercise is an active choice. Peripheral changes due to exercise (from chemoreceptors and mechanoreceptors) will inform these memory responses and further adjust the vasculature as needed. But the initial response is central. If those parts of the brain that hold these memories for how to respond to an increase in activity are damaged, blood pressure could rise unchecked until peripheral responses can catch up. (My inner nerd really came out in this one… I was completely entranced in learning about this!)
  5. Impaired hemodynamics. We will elaborate a little more on this later in the post but, generally, if your are not hemodynamically stable, your blood pressure response to anything is going to abnormal.

What else does the research say?

Although the risk for Exercise-Induced Hypertension is greater in males, it seems to indicate a higher risk of future medical problems for women. An article written in 1985 regarding hypertensive response to exercise in women was recently updated with new information regarding the effects of this phenomenon on women. The authors found that women are at increased risk for heart failure with preserved ejection fraction (HFpEF) largely due to higher prevalence of arterial and cardiac stiffening. The authors also found several pre-clinical indicators of pathology based solely on the exercise blood pressure response.

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In a large longitudinal study, a 36% increase was found in the rate of cardiovascular events and mortality in individuals with an HRE at moderate exercise intensity. In addition, for every 10mmHg rise in systolic blood pressure with moderate intensity exercise, a 4% increase in the risk for cardiovascular events was present. Moderate intensity exercise was defined as stage 1 or stage 2 of an exercise test, OR the intensity of normal daily activities. So, these authors found that just the activity of a normal day was enough to illicit hypertensive responses in healthy people who experienced exercise-induced hypertension.

And here is where things REALLY get weird…

If you are working with patients who have known underlying cardiovascular pathology (NOT hypertension), it is actually PROTECTIVE for them to have an exaggerated blood pressure response to activity! Studies have shown that this is actually an adaptive response of the cardiovascular system to maintain myocardial function (Remember that Frank-Starling Principle we talked about?). When I was researching all of this I kept thinking, “what is this magic?” But as I thought about it, it makes sense because higher pressure helps maintain patency of the coronary arteries to promote improved perfusion for increased workload.


As Physical Therapists, we are the frontline.

The first step? Screening. Dr. Severin and his crew stated, “It is our ethical duty to screen.” We have the tools and the knowledge to screen people for hypertension and should do so every chance we get. To be honest, we typically can tell who is at really high risk for hypertension with a glance at their chart, and we can typically tell who really isn’t at risk for hypertension in the same way. But, what about all those people in between? And what about those completely healthy people who demonstrate exercise-induced hypertension? We have to screen.

“Exercise BP response may be an inexpensive screening tool to identify women at highest risk for developing future HFpEF.”

Sarma, et al. (2020)

Another study found that, in people at risk for hypertension who had normal resting blood pressures and no exercise-induced hypertension, lifestyle modification was enough to significantly reduce the development of hypertension at 1 year post-intervention. However, if exercise-induced hypertension was already present, lifestyle modifications were not enough, and long term exercise had to be part of the intervention to reduce the risk.

“it seems mandatory to mutually promote early diagnosis/treatment of exaggerated blood pressure response to exercise in healthy subjects without hypertension and encourage physical activity in prevention, treatment, and control of all stages of hypertension.”

Calderone, et al. (2017)

A randomized controlled trial showed that 12 weeks of treadmill-based exercise training could improve both ambulatory and exercise BP measures in individuals with resistant hypertension (defined as uncontrolled BP despite the use of ≥3 antihypertensive medications, including a diuretic). Can you imagine? Being on 3 or more blood pressure medications at the same time and STILL having hypertension? I can see the orthostasis from here! I’ve actually had several patients in exactly this situation. Hopefully, people are able to attempt treatment of their hypertension with exercise and/or lifestyle modifications first, but let’s be honest, this rarely happens. Patients are almost immediately placed on ACE inhibitors and then eventually beta-blockers when they have hypertension in isolation. But, when the pharmaceutical route fails, it’s up to us.

“In fact, there is an the ample evidence in the literature that physical activity could positively affect endothelial function, arterial stiffness, neurohormonal response and finally blood pressure levels both in healthy men and in hypertensive patients and so should be considered a very important element in the prevention and management of cardiovascular disease.”

Calderone, et al. (2017)

Prescribing the appropriate intensity and time of exercise to be therapeutic for managing hypertension is essential. According to ACSM, people with hypertension should exercise at a moderate intensity (3-5/10 or 12-14/20 on the Borg Scales or 3-6 METs) aerobic exercise 5-7 days per week. In addition, they should also perform dynamic resistance exercise 2-3 days per week and flexibility exercise 2-3 days per week. A minimum of 30 minutes and maximum of 60 minutes per bout is sufficient, OR, if utilizing HIIT exercise, 10 minutes bouts. This is because regular aerobic exercise results in reductions in blood pressure of 5-7 mmHg among individuals with hypertension and these reductions translate to a reduced risk of CVD of 20-30%. You may need to start small and progress gradually to achieve this with your patients if they are more debilitated OR at a higher risk of cardiovascular event. BUT, the effects are dose-dependent, so if you don’t reach the therapeutic threshold, you won’t see results.

Exercise blood pressure should be measured at every patient treatment. The reality is, you are going to be the only person who even has the opportunity to measure someone’s blood pressure during exercise BEFORE they experience a cardiovascular event. You will be the only one who had the opportunity to detect exercise-induced hypertension before it manifests as something more treacherous. Take the opportunity because it could very literally save the life of the person in front of you.


How many people have you encountered that have exercise-induced hypertension? What were their clinical characteristics? Tell me in the comments!

More Reads…

Diaphragmatic Breathing

Let’s talk about this super simple technique that can change everything. Diaphragmatic breathing is really just how we are all supposed to be breathing most of the time. The purpose of the diaphragm is to facilitate breathing. Diaphragmatic breathing improves gas exchange and increases lung volumes. These are all really good things if we need toContinue reading “Diaphragmatic Breathing”

I’ll Huff and I’ll Puff… But the Huff Will Be More Effective

What is a huff? Huffing is one of the more difficulty techniques to learn for airway clearance. I find that most of my patients have trouble mustering the strength to perform a good solid huff. It’s not just that it is unfamiliar, but also that it takes diaphragm strength that they just don’t have. ButContinue reading “I’ll Huff and I’ll Puff… But the Huff Will Be More Effective”

Vibration & Percussion

If you read my post on airway clearance techniques, you probably saw vibration and percussion down at the bottom of the force progression. Although I have covered several other pieces of the force progression (Active Cycle of Breathing, PEP Devices, etc) in subsequent posts, I haven’t touched on these topics yet because they haven’t beenContinue reading “Vibration & Percussion”

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References:

Caldarone, E., Severi, P., Lombardi, M., D’Emidio, S., Mazza, A., Bendini, M. G., & Leggio, M. (2017). Hypertensive response to exercise and exercise training in hypertension: odd couple no more. Clinical hypertension23, 11. https://doi.org/10.1186/s40885-017-0067-z

Dimeo F, Pagonas N, Seibert F, Arndt R, Zidek W, Westhoff TH. Aerobic exercise reduces blood pressure in resistant hypertension. Hypertension. 2012;60:653–658. Retrieved from https://pubmed.ncbi.nlm.nih.gov/22802220/

Kim, D., & Ha, J. W. (2016). Hypertensive response to exercise: mechanisms and clinical implication. Clinical hypertension22, 17. https://doi.org/10.1186/s40885-016-0052-y

Le, V., Mikitu, T., Sungar, G., Myers, J., Froelicher, V. (2008). The Blood Pressure Response to Dynamic Exercise Testing: A Systematic Review. Progress in Cardiovascular Diseases. 51(2):135-160. https://doi.org/10.1016/j.pcad.2008.07.001

Mayo Clinic. (2019). Exercise: A drug-free approach to lowering high blood pressure. Retrieved from https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/in-depth/high-blood-pressure/art-20045206

Sabbahi, A., Arena, R., Kaminsky, L. A., Myers, J., & Phillips, S. A. (2018). Peak Blood Pressure Responses During Maximum Cardiopulmonary Exercise Testing: Reference Standards From FRIEND (Fitness Registry and the Importance of Exercise: A National Database). Hypertension (Dallas, Tex. : 1979)71(2), 229–236. https://doi.org/10.1161/HYPERTENSIONAHA.117.10116

Sarma, S., Howden, E., Carrick-Ranson, G., Lawley, J., Hearon, C., Samels, M., Everding, B., Livingston, S., Adams-Huet, B., Palmer, M. D., & Levine, B. D. (2020). Elevated exercise blood pressure in middle-aged women is associated with altered left ventricular and vascular stiffness. Journal of applied physiology (Bethesda, Md. : 1985)128(5), 1123–1129. https://doi.org/10.1152/japplphysiol.00458.2019

Schultz MG, Hordern MD, Leano R, Coombes JS, Marwick TH, Sharman JE. (2011). Lifestyle change diminishes a hypertensive response to exercise in type 2 diabetes. Med Sci Sports Exerc. 43(5):764-9. Retrieved from https://pubmed.ncbi.nlm.nih.gov/20881877/

Schultz, M. G., & Sharman, J. E. (2014). Exercise Hypertension. Pulse (Basel, Switzerland)1(3-4), 161–176. https://doi.org/10.1159/000360975

Severin, R., Sabbahi, R., Albarrati, A., Phillips, S. A., Arena, S. (2020). Blood Pressure Screening by Outpatient Physical Therapists: A Call to Action and Clinical Recommendations. Physical Therapy. 100(6):1008–1019. Retrieved from https://doi.org/10.1093/ptj/pzaa034

Weiss, S. A., Blumenthal, R. S., Sharrett, A. R., Redberg, R. F., & Mora, S. (2010). Exercise blood pressure and future cardiovascular death in asymptomatic individuals. Circulation121(19), 2109–2116. https://doi.org/10.1161/CIRCULATIONAHA.109.895292

WHO. (2020). What is Moderate-intensity and Vigorous-intensity Physical Activity?https://www.who.int/dietphysicalactivity/physical_activity_intensity/en/

Zaleski, A. (2019). Exercise for the Prevention and Treatment of Hypertension – Implications and Application. American College of Sports Medicine. Retrieved from https://www.acsm.org/blog-detail/acsm-certified-blog/2019/02/27/exercise-hypertension-prevention-treatment

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A Public Service Announcement: The Chain of Infection (and How YOU Can Break It!)

This post is written for one and all. If you are not a rehabilitation or medical professional, please read this post. Even if you are, please read this post. I’m going to address some things that need clarification. You can have all the opinions you would like, but there are some things that are just facts. Not opinions, not choices, not beliefs. Facts will continue to exist whether or not you believe in them. Facts can and do change contextually and over time, but not based on someone’s opinion of them. They change in response to a change in evidence, science, and environment.

Today I’m going to provide you with some old evidence and old science. The reason for that is two-fold. First, it’s because masks are OLD! We’ve been using them for a long time. The second is because I didn’t want to use any single bit of research that was influenced by the environment of COVID-19. The world view of science has become terribly distorted in the last year so I’ve only used research from before the time of “alternative facts” and just used facts. Keeping it simple.


The other day, I met a young woman who described herself as, “someone other people don’t like,” because she doesn’t wear a mask. She then said that even when she worked in the hospital, she just “didn’t like” wearing them. She then attempted to get me to agree with her that, “well, you work in healthcare, you know they don’t work. They stop droplets but they don’t stop the virus.” She then told me that 30 of her friends have COVID-19 from a large camping trip and are very sick and that she wouldn’t wish it on anyone.

Let me make this perfectly plain:

MASKS WORK.

  • They work best when used in conjunction with other methods of infection control.
  • Different types of masks work to different levels and nothing is perfect. Not all masks, and not even all surgical masks, are created equally.
  • Masks that are not worn properly work less.

This person I met who “worked in a hospital” is spreading fallacies and doesn’t understanding virology, infection control, or public health concepts. She is also terribly confused based on her story of her friends’ illnesses. I’ve heard so many arguments against masks by people from all walks, medical or not, science or not, government or not. But here are the facts:

How and Why do Masks Work?

To answer that, we have to discuss the Chain of Infection. There are 6 links, which are pictured below. At any point, we as humans can insert ourselves or our interventions in to the chain to reduce or stop the infection risk.

Step 1: You can’t get sick if there isn’t a microbe around to get you sick. This is where engineering controls can really make a difference. Proper ventilation, cleaning, and other engineering controls remove infectious agents and, therefore, remove the risk of infection.

Step 2: You have to have an infectious source. This would be the person who is infected. This person, if they were aware that they were sick or contagious, could stay home and away from others, not sharing what they have and then the infection dies without being passed to another person. Antibiotics, antivirals, antifungals, and antiparasitics can also intervene here. Kill the infectious agent in the host so it can’t spread.

Step 3: The microbe has to exit the person who is sick. Some viruses have very specific ways they can leave the body, such as only through certain bodily fluids. HIV is one of these viruses. Many body fluids do not serve as a means of exit for HIV, only certain ones (blood, etc.). In conditions like tuberculosis, the microbes are spread in the air by the infected person breathing (respiratory droplet nuclei). The infected person would likely have a hard time keeping a respiratory microbe inside their body and they symptoms typically produce coughs or sneezes, so engineering controls can be helpful here again, OR the person can block the exits of their body by using a mask to prevent the spread of microbes to others. Some microbes that don’t require respiratory transmission, like sexually transmitted viruses, are blocked by other barrier devices.

Step 4. The microbe has to have a means of contact to another person. It can’t just be any contact, it has to be the specific type of contact that the microbe requires. The microbes on your hands have to get to your eyes, nose, mouth, or whatever they can infect. If you utilize interventions such as washing your hands, that may never happen. Some microbes linger in the air (like we discussed above with tuberculosis) and have to be breathed in. This is also where barrier devices are useful. You can wear a barrier device to protect yourself.

Step 5. Once the microbe has made contact, it must access the type of tissue in your body it is able to infect. So, just because you became that person in step 4 who had contact with droplets on your hands, doesn’t mean you’ll contract an illness, unless your then put your hands in your mouth or rub your nose. Once this happens, the microbes have entered your body. There are a few things that can prevent this from happening including PPE. Healthcare workers know we are going to make it through step 4 on a daily basis, so we wear gloves, gowns, shields, and other pieces of equipment to ensure that the droplets that do land on us can’t cause infections. We throw all that stuff away so the droplets don’t contact any part of us.

Step 6: Once the microbe has entered the body, the immune system goes to work. But if the immune system isn’t strong enough for any reason, it will become easily overwhelmed. This doesn’t necessarily have to be a weakened immune system, either. Sometimes, microbes are able to overwhelm even healthy immune systems. That’s why even healthy people get sick sometimes. Some microbes are just really good at what they do. People who do have weakened immune systems sometimes take antibiotics every day to help fight off infections that find a way in.

Specific to COVID-19…

In the specific case of COVID-19, the virus can’t magically travel from person to person on its own. As a respiratory pathogen, it has to be carried on droplets or droplet nuclei that are breathed out, coughed out, sneezed out or spit out in one way or another (these are called “aerosol generating procedures“). The spread of both droplets and droplet nuclei are significantly reduced by a mask. Because people may not know they are infected, we automatically skip to step 3 in the chain of infection. Once the virus exits the body of the carrier by one of these methods, it is transmitted to those around them. Masks then reduce the ability of someone else’s droplets to land in your nose or mouth because they are covered. This is why protection is a 2-way Street. If your mouth and nose are uncovered, my droplets have a higher chance of landing in your mouth and nose and your droplets have a higher probability of making it to me. Like I said, nothing is perfect, but the mask helps reduce the risk.

Something I see brought up often is that healthcare providers are wearing masks, but they still get sick. This is where we need to consider is viral load. The more people you come in contact with who have any viral illness, the higher your viral load. And remember, with COVID-19, the majority of people are asymptomatic carriers. But, we also know that with COVID-19, the more exposure to the virus, the more severe the disease presents. Wearing a mask significantly decreases your viral load, allowing your body to fight a smaller amount of virus so can remain healthy. It allows your immune system to do its job without being overwhelmed by the infection. So, yes, medical providers wear masks and still get sick. That is because we take on a much higher viral load, especially in the emergency care and ICU settings, because so many of the people medical providers come in contact with have COVID-19. You are in lesser contact in the community because those people aren’t showing that they are sick. Only patients showing symptoms, who are much more likely to carry disease, seek medical care.

Here is another example:
In the world of wound care, we have patients wash wounds with soap and water, or sometimes specific agents, to reduce the bacterial load on their wounds. If the wound is already infected, washing it reduces the work the body has to do to fight off the infection. In other words, it supports immune function. If the wound isn’t infected yet, reducing the bacterial load helps the wound not get infected because the immune system doesn’t get overwhelmed and can continue to do its job.

For more information about viral load, engineering controls, and different levels of infection control, please check out this post! PPE is the WORST!


But I can’t breathe in a mask!

If you know me, you probably know that I spent years working with people pre- and post-lung transplant who were at the end stage of lung disease. They were literally days away from suffocating to death. After transplant, they were on immunosuppressant drugs for the rest of their lives. All of these people wore masks whenever they went out to protect themselves because one bout pneumonia from someone else’s droplets could kill them. One outing in too much pollen could land them on a ventilator. One day of their neighbor running a wood stove could mean a week in the hospital. I also work with people who have end-stage COPD, heart failure, pulmonary fibrosis, and all other manner of heart and lung diseases. These people are wearing masks every day while in our facilities to protect themselves. My incredibly sick or immunocompromised people can breathe just fine in their masks, even while I make them do therapy.

Schroedinger’s Mask

We need to understand that it is not possible for masks to be so effective at blocking air that people can’t breathe, while simultaneously being completely ineffective at blocking a virus. Like I said, even my very sick patients can still breathe while exercising in their masks! This is because surgical masks filter at about 5 micrometers (the average size of those droplets we talked about). Carbon dioxide (CO2) has a diameter of 116 picometers and Oxygen is 152 picometers so they are breezing through your mask without a problem. Surgical and cloth masks do not seal to your face, and provide ample room for oxygen and carbon dioxide to leave the breathing space. An N95 respirator filters at about 0.3 micrometers, or 300,000 picometers, so CO2 and oxygen flow right through those also. If you have high carbon dioxide content in your blood, you probably have an underlying lung disease (like my patients) and a mask won’t change this. Several physicians have taken their own and others’ arterial blood gases after a full shift of wearing an N95 to find that their PaCO2 (the amount of carbon dioxide in their blood) is completely normal.
For those not familiar with the comparison: 1 nanometer = 1000 picometers. Here is a chart:

SARS-COV-2, the virus that causes COVID-19, has a diameter of 60-140 nanometers. That means that the SARS-CoV-2 virion is exponentially larger than a CO2 molecule, yet still small enough to get through even an N95. That doesn’t mean they can’t be filtered! Like I explained above, the virion can’t just magically move from person to person. It has to be carried on a droplet or droplet nuclei. Droplets are about 5 micrometers on average, which is why surgical masks filter at this rate. N95s filter at 0.3 micrometers because this is the average size of droplet nuclei. Yes, cloth masks are different, but still can block large droplets and significantly reduce all droplet spread so they don’t come in contact with other people (remember the links on the chain!).


For the medical folks…

There was a Cochrane review performed in 2014 regarding the effectiveness of surgical facemasks at preventing infection. This review showed that there was no statistically significant difference in infection rates between the masked and unmasked group in any of the trials when worn during surgical procedures. (WHAAATT?!?!) I know, but this review was discussed at length by several authors and there are some important things to point out, specifically that only 3 studies could even be included because NO ONE WANTS TO BE THAT SURGEON! One of the discussions had this to say:

“when current surgical practice is the culmination of layer upon layer of precautions in the hope of preventing surgical site infection, do we dare to experiment with their omission to see if they have any tangible consequence on morbidity and mortality? “

Da Zhou, et al. (2015)
Well, of course, someone dared…

A few randomized controlled trials attempted to remove any single step in the operative infection control process to terrible detriment of the patients. Many of the studies had to be stopped because so many people were getting sick that the studies could no longer continue. The overall picture is that surgeries are highly infection controlled: from the pre-operative antibiotics to the ventilation systems to the pre-surgical scrub-ins to the sterilization procedures, so what single piece of this process that contributes most to infection prevention is hard to know because they all work together. Just like infection control in the larger population, it requires more than one step.


What I’m trying to say is that you are going to have a very hard time explaining to me why you can’t wear a mask unless you are a child under 2 years old. My colleagues from 24 to 61 years old are running with masks on daily without oxygen desaturation. Medical providers (myself included) are working 8-12 hour shifts with masks on and not desaturating. We are moving and lifting equipment and human beings repeatedly while we wear them. Transplant surgeons wear their masks for 14 hours straight while swapping new lungs in to a human being. Does that mean we aren’t uncomfortable at times? No! Do we like wearing masks? No, absolutely not. But, like I tell everyone else, liking it is NOT a requirement.

“It is important not to construe an absence of evidence for effectiveness with evidence for the absence of effectiveness. While there is a lack of evidence supporting the effectiveness of facemasks, there is similarly a lack of evidence supporting their ineffectiveness.”

Da Zhou, et al. (2015)

To this day I have only heard of a few legitimate medical reasons to not wear a mask: 1. A patient had multiple facial and skull fractures from a car accident that caused extreme pain from the ear loops and an inability to get coverage of the nose and mouth. His Occupational Therapist found something else for him to wear instead.
2. Emotional trauma from abuse or neglect involving covering of the nose/face/mouth resulting in anxiety, panic attacks, or other mental health conditions.

Remember, I have worked with the sickest of the sick and those at the end stage of lung disease. These people have significant physical and mental trauma from being constantly in fear of suffocating to death at any moment. If they can wear a mask for three hours of medical appointments while on 14 liters of oxygen, then most people can wear them for a 15 minute trip to the grocery store. There may be a few other exceptions that I haven’t yet come to know, but for these few that have difficulty (not that they CAN’T wear a mask for a short time, it is just difficult for them), the rest of us have to do our part to break the chain for them by following the rest of the steps. We have to keep each other safe.

UPDATE as of September 1: I have yet to encounter any other examples were a mask would not be possible. Still waiting…


Got some ABGs you want to share? I’m all ears! Throw them in the comments!

More Reads…

More Than Just A Respiratory Disease: The Tools You Need to Rehab COVID-19

Isn’t COVID-19 just a respiratory disease? If only that was true. We are good at treating respiratory infections. We have lots of drugs for viral, bacterial, parasitic, and fungal infections of the lungs. Most of them work really well! We also have several back-up treatments, inhaled medications, and adjuvant therapies (like rehab!) that make primaryContinue reading “More Than Just A Respiratory Disease: The Tools You Need to Rehab COVID-19”

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References

Chughtai, A. A., Seale, H., MacIntyre, C. R. (2013). Use of cloth masks in the practice of infection control – evidence and policy gaps. International Journal of Infection Control. 3(9):1-2. Retrieved from https://www.ijic.info/article/view/11366/8308

Da Zhou, C., Sivathondan, P., & Handa, A. (2015). Unmasking the surgeons: the evidence base behind the use of facemasks in surgery. Journal of the Royal Society of Medicine108(6), 223–228. https://doi.org/10.1177/0141076815583167

Lipp, A. and Edwards, P. (2014). Disposable surgical face masks for preventing surgical wound infection in clean surgery. Cochrane Database Syst Rev. 2: CD002929.

MacIntyre, CR; Chughtai, AA (9 April 2015). “Facemasks for the prevention of infection in healthcare and community settings”. BMJ (Clinical Research Ed.)350: h694. doi:10.1136/bmj.h694PMID 25858901.

Royal College of Nursing. (2016). The Chain of Infection. Retrieved from https://rcni.com/hosted-content/rcn/first-steps/chain-of-infection.

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