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UNIVERSITY of MISSOURI - COLUMBIA
SCHOOL of HEALTH PROFESSIONS
Department of Physical Therapy
PT 7890 - Case Mgmt I - Acute & Chronic Medical / Surgical Conditions
Topic: Pulmonary Physical Therapy
Objectives: The learner will be able to:
1.
Review the anatomy of the lung, including airways and pulmonary segments, and be able to describe using
a model or a sketch, and put in lay language for patients. Demonstrate landmark location for auscultation of lung
segments and approximate location of the diaphragm and organs (liver, kidney, spleen).
2.
Review the etiology and clinical signs and symptoms of these obstructive diseases. Distinguish between
condition(s) associated with abnormal secretions, or with sepsis, or with alveolar destruction or due to heredity, or that
are reversible. Identify likely adventitious breath sounds for these conditions. Appreciate that disease signs and
symptoms can overlap or occur simultaneously.
3.
List the common S/S of Restrictive Lung Disease (RLD). Explain the categories of possible pathological
mechanisms of impairment for RLD (DeTurk p.174-185, & “star diagram” posted online). The lung volumes and PFTs
for all of these various etiologies will be similar, but the RLD is driven by different impairments, therefore requiring
different interventions.

Hint: to understand RLD pathology you must first have a working knowledge of Lung Volumes (DeTurk
p.153, O’Sullivan p.446-447) AND Pulmonary Function Tests – PFT (DeTurk p.246-254).

DeTurk has helpfully organized RLD-causing pathologies into Guide Practice Patterns, i.e. Practice Patterns 4
&7 (C.13) & Practice Pattern 5 (C.14). For Practice Pattern 4, further classify the pathologies as either:
Progressive, Acute // Progressive, Degenerative // Non-Progressive
4.
Identify factors in the development of:
a.
hypercapnia
b.
atelectasis
c.
pneumonia
d.
cor pulmonale
e.
pleural effusion
5.
Recognize significance of the following tests for persons with pulmonary disease, particularly as they relate to
physical therapy treatment:
a.
vital signs
b.
auscultation
c.
oximetry
d.
chest radiograph
e.
arterial blood gases (ABG):
f.
pulmonary function tests
g.
graded exercise test
6
Recognize medications commonly used for persons with COPD, generic and trade names, and their expected
therapeutic effects (pharmacodynamic) as well as their common adverse side effects
(DeTurk p.213-oxygen; p.204-208; also the appendix of Sharon Coffman’s syllabus)
a.
oxygen
b.
bronchodilators
c.
(antibiotics)
d.
anti-inflammatory agents
e.
mucolytic agents
7.
Outline a physical therapy examination, and synthesize findings, for a patient with a medical diagnosis of
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COPD, recognizing the importance of:
a.
vital signs
b.
breath sounds
c.
SOB, DOE
d.
chest wall, posture, UE and trunk ROM
e.
exposure to tobacco smoke (primary or secondary), or environmental contaminants
f.
cough
g.
activity level
h.
self-care, home and work assessment
8.
Associate the following abnormal / adventitious breath sounds with possible causes:
 Ronchi / wheezes:
 Rales / crackles:
 Distant or diminished:
 Absent:
Also explain the significance of findings from transmitted voice sounds: egophany, bronchophony, pectoriloquy
9.
Describe the PT’s role in the administration of oxygen. Appreciate the risk and danger of oxygen toxicity from an
excessively high flow rate.
Practice the following skills:
a.
identify O2 cylinder that is getting low by calculating remaining minutes for a given flow rate exchange
cylinder for a full cylinder, and restore rate of flow
b.
perform simulated oral and tracheobronchial suctioning using sterile technique
c.
perform suctioning using a closed system suction catheter through an endotracheal tube and tracheostomy
tube.
d.
provide simulated ventilation using a hand resuscitator (“Ambu bag”)
10.
Explain and contrast the rationale and goals of Pulmonary Physical Therapy for patients with obstructive and
restrictive lung diseases (start with the techniques you have read about or reviewed in lab and then categorize them
with the applicable lung condition).
11.
State and explain indications, contraindications and precautions for postural drainage and percussion (especially
trendelenburg, head lowered position). Contrast manual and mechanical percussion. Adapt equipment and
positioning for home use.
12.
Place a subject in the correct traditional positions for postural drainage for a given lung segment. Explain why
positions will differ somewhat for a child or infant.
13.
Explain criteria used to justify a change in the usual position for postural drainage. Describe alternative positions
for postural drainage.
14.
Become familiar with the following alternatives or adjuncts to postural drainage and percussion to treat patients with
COPD with secretions. Note: all 3 provide positive airway pressure. Contrast these 3 devices to the purpose and
function of an Inspiratory Muscle Trainer (IMT), as well as to the purpose and function of an Incentive Spirometer.
a.
Flutter valve ®
b.
Intrapulmonary Percussive Ventilation (IPV)
c.
Positive Expiratory Pressure (PEP) therapy
15.
Recognize and interpret cardinal signs and symptoms of respiratory distress (Note: this question is not addressing
Acute Respiratory Distress Syndrome (ARDS), which will also be accompanied by pulmonary infiltrates (evident in
X-ray), and Rales/Crackles, with possible pink frothy sputum, indicating (R) heart failure (peripheral edema,
pulmonary edema, jugular venous distension, crackles).
16.
Given a patient with a lung transplant, anticipate the preoperative needs, and postoperative and long term
rehabilitation requirements. Identify precautions. Recognize clinical findings unique to persons following a lung
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transplant. Describe the purpose of Lung Volume Reduction Surgery (LVRS). Hint: Hillegass is a text on reserve at
HSL, and chapter 12 covers both heart and lung transplant. Since we will also be discussing heart transplant during the
cardiac unit, you will get 2-for-1 from this chapter. In other words, there are several phenomenon that are common to
transplantation of the heart and the lung, eg: the implications of denervation; induced immunosuppesssion to prevent
rejection; steroid myopathy, etc.
17.
Elucidate national stop smoking efforts. Participate in local stop smoking campaigns. Discuss how you would
approach this issue with a patient who smokes.
18.
Demonstrate assisted cough techniques.
19. Demonstrate Breathing Techniques to decrease Work of Breathing (WOB), airway turbulence, V/Q mismatch,
and dyspnea. Appreciate why slowing the respiratory rate would not be an appropriate breath retraining technique for
someone with RLD.
 Pursed Lip Breathing (PLB)
 Paced breathing:
 Exhale with Effort:
 Diaphragmatic Breathing:
 Segmental Breathing:
 Maximum Inspiratory Hold:
 Glossopharyngeal Breathing:
20. Explain how inspiratory muscles can be strengthened / trained. When would use of an Inspiratory Muscle
Training (IMT) device not be appropriate?
21. Demonstrate steps in a clinical examination for chest pain; differentiate signs and symptoms of different origin:
musculoskeletal, pleural, myocardial ischemia / angina
22. Demonstrate examination for tracheal deviation (being careful not to over-massage the carotid bodies, causing
increased vagal tone and possible syncope). Describe the impairments that could cause it, and if the deviation would be
ipsilateral or contralateral.
23. List conditions that would cause orthopnea, and how to accommodate this. Also, what GI condition decreases
tolerance of supine?
24. Draw a diagram depicting normal lung volumes and write equations for the composite volumes. Draw
comparison diagrams for restrictive and obstructive lung conditions and describe the differences.
25. Explain the meaning of various Pulmonary Function Tests (PFT) measures: FVC, FEV1, FEV1/FVC.
Compare the changes in these PFT that you would expect in COPD, and in RLD. Understand that results are expressed
as % of normal for gender, age, and height. Determine your personal FVC from norm tables.
26. Explain the principle of Positive Airway Pressure to “splint” open airways in obstructive conditions or for the
treatment of respiratory failure (note: online posting of illustration). This principle has application in various (passive)
devices: Ventilators (PEEP), CPAP, Intrapulmonary Percussive Ventilation (IPV). The same principal is also used in
bronchopulmonary hygiene patient-use tools such as the Flutter Valve ® and the PEP (Positive Expiratory Pressure)
valve ®, as well as the Pursed Lip Breathing technique.
27. Briefly explain how the respiratory and metabolic systems maintain pH homeostasis and how this is tracked by observing
ABGs.
28.
Describe the 4 phases of an effective cough. List impairments that would decrease cough effectiveness / airway
protection. Instruct a patient in performance of an effective cough
29.
Explain the significance and possible causes of a right shift in the Oxyhemoglobin Dissociation Curve. (DeTurk p. 96,
p.114-115; also course website)