OMM #50
Thurs. Dec. 4, 2003 2:00
Patricia Meyer, PDF
Scribe: Milena Patel
Page 1 of 4
ARDS (Acute Respiratory Distress Syndrome)
-Instructor’s comments are italicized.
-First 15 minutes of class were not recorded; tape began at Roman numeral VII.
I.
Case Presentation:
 57 yr. old Caucasian male with a productive cough x 2days, and dyspnea with
fever. Patient has a 50 pack year history of smoking and chronic bronchitis.
 Patient continues to worsen. On the 2nd day patient has persistent hypoxemia
despite O2 per NC. Pt. Becomes increasingly weak with respiratory effort.
 PE shows crepitus in both lungs, hypertension, intercostal retractions and
tachypnea.
 Pt. is admitted to ICU, intubated and put on mechanical ventilation.
 CXRay shows whiting out of the lung fields bilaterally.
II.
Differential Diagnosis:
 Exacerbation of chronic bronchitis
 Community acquired pneumonia
 ARDS
 Cardiogenic Pulmonary Edema – High cardiac output and low PAWP rule this
out
 Viral Pneumonitis
III.
ARDS
 Definition: noncardiogenic pulmonary edema due to acute damage to the alveoli.
 Characteristics: interstitial and alveolar edema, severe hypoxemia, respiratory
failure.
-PaO2/FIO2 < 200 regardless of PEEP
-Bilateral pulmonary infiltrates on CXR
-Pulm. artery wedge pressure < 18 mmHg or no clinical evidence of
elevated arterial pressure
On physical exam look for tachypnea, tachycardia, HTN, crepitations in both
lungs, fever if there is an infection
Etiology of ARDS
 Sepsis - > 40%
 Aspiration - > 30% from drowning or gastric contents
 Trauma - > 20%
 Multiple Transfusions
 Drugs
 Noxious inhalation
 Post resuscitation
 Cardiopulmonary Bypass
 Pneumonia
 Burns
IV.
OMM #50
Thurs. Dec. 4, 2003 2:00
Patricia Meyer, PDF
Scribe: Milena Patel
Page 2 of 4
 Pancreatitis
Increased risk with history of alcohol abuse.
V.
Treatment Considerations
 Treat the underlying condition – This is key!!
 Ventilatory support
Do appropriate tests – ABG, CXR, Hemodynamic monitoring, Blood and urine
cultures, bronchoalveolar lavage.
VI.
OMM Considerations
 Respiratory Mechanics:
-diaphragm* - arcuate ligament, or direct/indirect MFR.
-mediastinal restrictions This is an important area to treat for the ARDS patient.
Look at the picture of the mediastinal attachments. The patient has pulmonary
edema, increased work of breathing this adds to restriction in this area. Using
the AP hand hold taught in the sternal release, compress more to feel the
mediastinum and take into the restriction (direct). Allow the cycles of the
ventilator to stretch the mediastinum and release it.
-rib cage*
- fascial restrictions* - the longitudinal fluctuation
 Lymphatics:
-Sibson’s Fascia
- Lymph pump
 Autonomics:
-Sympathetics T1-T6
-Parasympathetics- Vagus – the OA technique taught in Sinusitus lecture
VII.
Longitudinal Fluctuation: AKA: the slosh
 Rhythmic, high amplitude oscillations, Higher amplitude than the lymphatic
pump
 Diagnose restrictions impeding the fluid wave. One side is probably more
restricted than the other.
 Direct the fluid wave to “break through” restrictions, send the waves toward the
side that is restricted to stimulate fluid flow on that side.
 Use fluid wave to mobilize fascia
VIII.
Fascial Ligamentous Release: Lower Thorax – can address both thoracics and rib
cage. The release involves balancing the terminal rib cage (T10-L2).
 Pt. supine, DO at pt.’s head
 DO slides hands to T10-L2, diagnose the lower thoracics, then contact tranverse
processes of dysfunctional segments. Be able to diagnose with patient supine.
 Fulcrum is established with elbows on table, sink elbows into table to help
balance you.
 Using fulcrum, anterior pressure is applied (deep inhibition-like pressure) to
contact bone through tissue
OMM #50
Thurs. Dec. 4, 2003 2:00
Patricia Meyer, PDF
Scribe: Milena Patel
Page 3 of 4
 Using fulcrum, DO attains a balance point of vertebrae and waits for release.
Find point of balance in that area and hold pressure on the transverse processes
until you feel a release. If pt. on mechanical ventilator, you have a good source
of respiratory force that can be used to find point of balance.
 This technique can be used on a patient that is in ICU and can’t move out of bed.
IX.
Functional Technique-developed by Dr. Johnson, so fairly new technique.
 Motion toward the direction of immediately increasing ease (Decreased
resistance). It’s an INDIRECT technique.
 Combine rotary and translatory elements to create an eventual smooth torsion
arc for the body. When finding point of ease, use both rotation and
translation motions.
 Use the respiratory cycle to increase the ease. Hold the breath briefly in
inhalation or exhalation, whichever one has the greatest ease. One thing he
added to the indirect technique was that when pt. relaxes after taking a
breath, he takes the segment through its full range of motion, so technique
is both ARTICULATORY and INDIRECT.
 The release of restraint in the motor mechanism allows a return of midline
resting
 These techniques require more mobility from patients, so may not be helpful
in a bedridden ICU patient, but can be done if pt. is on floor or in the dr.’s
office.
X.
Functional Rib Technique
 Inhalation on right: Shoulder/trunk rotation resists right SB and Rotation.
Stand on left. Take body into ease-left rotation and sidebending.
 Exhalation on right: Shoulder/trunk rotation resists left SB and Rotation.
Stand on right. Take body into ease-right rotation and sidebending.
XI.
Functional Technique: Rib S/D Seated
 First, with patient seated, diagnose ribs by having pt. breathe in and out while
you stand behind the pt. and have your hands on the ribs feeling for
restrictions in inhalation or exhalation.
 If inhalation S/D, then rib is stuck up. If exhalation S/D, rib is stuck down.
 Pt. seated with hands crossed across their chest.
 DO on opposite side of lesion if it’s an INHALATION S/D. One hand
monitors lesion while other hand reaches across the front of patient to grab
his/her shoulder. DO sidebends and rotates pt.’s trunk to opposite side of S/D
(if S/D on left, then SB and rotate pt. to the right, towards the DO) until point
of ease is found.
 If EXHALATION S/D, then DO stands on same side of lesion, and SB and
rotate towards DO, towards the same side of the lesion. See Roman numeral
X.
OMM #50
Thurs. Dec. 4, 2003 2:00
Patricia Meyer, PDF
Scribe: Milena Patel
Page 4 of 4
 DO takes lesion to area of greatest ease (Indirect), including
inhalation/exhalation (respiratory force). Ask pt. to breathe in and out.
 As area begins to release, DO follows through a smooth arch of motion
(Articulation) returning to the central resting position.
XII.
Functional Technique: Rib S/D Lateral Recumbent
 This technique also good if pt. not ready to be seating up.
 Technique can be used for both inhalation and exhalation S/D.
 Pt. laying on non-lesioned side, DO in front of Pt.
 DO drapes Pt. arm over caudad arm, and monitors lesion (RIB) with cephalad
hand.
 DO takes lesioned rib to area of greatest ease (Indirect) by moving arm
through the following motions:
-Internal/External rotation
-Abduction/Adduction
-Superior/Inferior
-Inhalation/Exhalation
 DO may also use respiratory force to find greatest point of ease.
 As area begins to release, DO follows through a smooth arch of motion
(Articulation) returning to the central resting position.