Physiotherapy Case Studies

Case 1: COPD Exacerbation

Age: 74 Gender: Male

Mr. Thompson is a 74-year-old retired builder with GOLD stage III COPD (FEV₁ = 36% predicted). He presents with increased shortness of breath, purulent sputum, and fatigue. He lives alone in a ground-floor flat and smokes 10 cigarettes daily. Regular meds include tiotropium, salbutamol, and prednisolone. On arrival to hospital, his RR is 26, HR 98, SpO₂ 86% on room air, and he is now on 2L/min O₂ via nasal cannula.

Arterial Blood Gas: pH 7.31, PaCO₂ 7.0 kPa, PaO₂ 7.8 kPa, HCO₃⁻ 29, Base Excess +4

1. What does this ABG result indicate?

The low pH, high PaCO₂, and elevated HCO₃⁻ suggest respiratory acidosis with renal compensation — common in chronic CO₂ retainers.

2. Which clinical sign suggests an infective exacerbation?

A change in sputum colour and quantity is a hallmark of bacterial exacerbation.

3. What is the target SpO₂ range in COPD patients on oxygen?

Over-oxygenation in CO₂ retainers may suppress respiratory drive; the target is 88–92%.

4. What airway clearance technique is most appropriate here?

The Active Cycle of Breathing Technique (ACBT) is effective and safe in COPD to clear secretions while conserving energy.

5. What is the main role of physiotherapy in the acute phase?

Physiotherapy helps mobilize secretions, maintain function, and prevent deconditioning.

6. Which exercise assessment is most appropriate at discharge planning?

STS is practical, quick, and effective for gauging discharge mobility and strength.

7. Which medication is NOT typically used in COPD exacerbation management?

ACE inhibitors are used in cardiovascular disease, not as primary treatment for COPD exacerbations.

8. What lifestyle factor most contributes to COPD progression?

Smoking is the leading modifiable risk factor in COPD development and progression.

9. What is the best discharge referral for ongoing rehab?

Pulmonary rehab improves exercise tolerance, education, and quality of life in COPD patients post-discharge.

10. What social factor should be addressed prior to discharge?

His home situation (living alone) and risk of deconditioning must be factored into safe discharge planning.

Case 2: Community-Acquired Pneumonia (CAP)

Age: 63 Gender: Female

Mrs. Patel presents with a 5-day history of fever, productive cough with yellow sputum, pleuritic chest pain, and general malaise. She's recently returned from a coach holiday and lives with her husband. She is normally independent, but has a history of Type 2 diabetes and hypertension. On examination: RR 28, HR 106, Temp 38.3°C, SpO₂ 90% on room air. Auscultation reveals bronchial breath sounds and coarse crackles at the right lower lobe. She is on IV co-amoxiclav and has been commenced on 2L O₂ via nasal cannula.

1. Which clinical sign is most consistent with lobar pneumonia?

Bronchial breathing is heard over consolidated lung fields due to increased sound transmission.

2. What CURB-65 score component does SpO₂ fall under?

CURB-65 includes confusion, urea, respiratory rate, BP, and age ≥65 — but not oxygen saturation.

3. What is the purpose of early physiotherapy input?

Physiotherapy aids lung expansion, secretion mobilisation, and improves ventilation/perfusion.

4. What breathing strategy should be encouraged?

Deep breathing improves ventilation to the lower lobes and may aid resolution of consolidation.

5. Which of the following is a red flag requiring medical escalation?

New confusion is a CURB-65 marker and a sign of hypoxia/sepsis; escalate immediately.

6. What is the most appropriate outcome measure on day 1?

Borg scale quickly assesses breathlessness on exertion and is ideal early in the admission.

7. Which drug is most appropriate based on her presentation?

Co-amoxiclav is a first-line IV antibiotic for moderate-severe CAP in many hospital guidelines.

8. What strategy is key for preventing deconditioning?

Early movement improves outcomes, prevents ICU-acquired weakness, and supports lung expansion.

9. What is an appropriate physiotherapy goal for day 3?

Short-distance, supported mobilisation within safe O₂ saturation range is a realistic goal by day 3.

10. What discharge advice is most appropriate?

Advice should focus on gradual return to function, red flag awareness, and medication compliance.

Case 3: Bronchiectasis

Age: 48 Gender: Female

Ms. Lawson has a 10-year history of bronchiectasis, secondary to recurrent childhood pneumonia. She presents with increased cough, purulent sputum, and reduced exercise tolerance. She lives with her teenage daughter and uses a flutter device daily. Her medications include salbutamol inhaler, carbocisteine, and azithromycin (3x/week). On assessment: RR 22, SpO₂ 94% on room air, audible coarse crackles. Chest X-ray shows chronic changes. She reports using 3 pillows to sleep due to postural drainage needs.

1. What is the hallmark feature of bronchiectasis on imaging?

CT and CXR typically show permanently widened bronchi due to structural airway damage.

2. What sputum characteristic is common in exacerbations?

Infective flare-ups produce thick, coloured sputum with increased volume and viscosity.

3. Which airway clearance technique is she already using?

Flutter is a handheld device combining vibration and PEP to mobilise sputum.

4. Which of the following is a typical complication of untreated bronchiectasis?

Bronchiectasis predisposes to persistent bacterial colonisation, recurrent infections, and eventual scarring.

5. What is the purpose of carbocisteine in this patient?

Carbocisteine is a mucolytic that helps thin secretions, making clearance easier.

6. What position may assist her postural drainage overnight?

Drainage positioning uses gravity to assist secretion movement — commonly side-lying head-down for segmental clearance.

7. What is a physiotherapy indicator of treatment success?

More effective sputum clearance during/after therapy suggests improved airway hygiene.

8. What role does azithromycin play in her care?

Azithromycin is used long-term in some bronchiectasis cases to reduce exacerbation frequency due to anti-inflammatory and antimicrobial effects.

9. What should be assessed before recommending airway clearance techniques?

Secretion assessment is essential to tailor airway clearance prescriptions.

10. What long-term outcome measure can track function?

The SGRQ is a validated QoL tool for chronic respiratory conditions like bronchiectasis.

Case 4: Post-operative Atelectasis

Age: 68 Gender: Male

Mr. Lewis underwent elective abdominal surgery (colectomy) 3 days ago. He is experiencing reduced oxygen saturation (SpO₂ 91% on air), mild confusion, and a productive cough. Auscultation reveals decreased air entry in the left lower zone. CXR confirms basal atelectasis. Past history includes hypertension and mild COPD. He is bed-bound and reluctant to mobilise due to pain (rated 6/10 on movement). He has an indwelling catheter and is on morphine PCA.

1. What is the likely cause of his respiratory complication?

Post-op atelectasis is commonly caused by shallow breathing, pain, immobility, and impaired mucociliary clearance.

2. What physiotherapy priority should be addressed first?

Re-expansion of lung segments through breathing exercises and posture correction is critical early on.

3. What breathing technique is most suitable initially?

Incentive spirometry encourages slow, sustained inhalation, ideal for post-op atelectasis re-expansion.

4. What impact does the morphine PCA have on respiratory function?

Opioids depress the respiratory center and decrease tidal volume, increasing risk of hypoventilation.

5. What is a functional early goal?

Sitting upright aids ventilation and allows safe initiation of pulmonary rehab activities.

6. What role does positioning play?

Upright or lateral positioning can optimise ventilation/perfusion and assist with secretion clearance.

7. What is a contraindication to vigorous airway clearance in this patient?

Post-abdominal surgery patients should avoid vigorous coughing or vibration that risks wound dehiscence.

8. What outcome measure could track progress over next few days?

A combination of mobility level and oxygen saturation gives practical feedback on improvement.

9. What role does early mobilisation play?

Early mobilisation enhances alveolar ventilation and reduces risk of complications like VTE and pneumonia.

10. What MDT referral might support recovery?

Effective pain control is essential to enable breathing and movement post-abdominal surgery.

Case 5: Cystic Fibrosis (Adolescent)

Age: 15 Gender: Male

Jamie is a 15-year-old student with a known diagnosis of cystic fibrosis. He presents for his annual inpatient tune-up with increased cough and thick sputum. He’s underweight (BMI 16.8), reports fatigue, and struggles to keep up with school sports. He uses a PEP mask daily and receives nebulised hypertonic saline. Medications include Creon, azithromycin, dornase alfa, and salbutamol. SpO₂ is 93% on air; RR 22; auscultation reveals coarse crackles bilaterally. Sputum cultures show Pseudomonas aeruginosa colonisation.

1. What is the primary pathophysiology of CF affecting the lungs?

CF results from a defect in the CFTR gene, impairing chloride ion transport and leading to thick, sticky secretions.

2. What is the purpose of dornase alfa in CF care?

Dornase alfa is a recombinant enzyme that digests DNA from neutrophils in mucus, aiding clearance.

3. What technique is Jamie using for secretion clearance?

PEP devices help keep airways open during exhalation and aid mucus movement toward larger airways.

4. What is the significance of Pseudomonas colonisation in CF?

Chronic Pseudomonas infection leads to greater lung damage and resistance to treatment.

5. What nutritional issue is most common in CF?

Pancreatic insufficiency leads to poor fat absorption; enzyme replacement is key.

6. What outcome measure might be appropriate in adolescent CF physiotherapy?

MSWT is validated in CF and gives reproducible measures of functional capacity and VO₂ max.

7. What is a physiotherapy focus during inpatient care?

Combining airway therapy with physical activity prevents deconditioning and improves outcomes.

8. What is the role of nebulised hypertonic saline?

Hypertonic saline improves mucus clearance by hydrating airway surfaces.

9. What is an important psychosocial factor in adolescent CF care?

Adolescents require support to manage increasing responsibility for their complex care needs.

10. What is a realistic discharge goal for Jamie?

Discharge planning should include a return to routine with sustainable self-management and outpatient follow-up.

Case 6: Acute Asthma Attack (Adult)

Age: 29 Gender: Female

Sarah, a 29-year-old teacher with a known history of asthma since childhood, presents to A&E with severe shortness of breath, tight chest, and audible wheeze after exposure to cat hair. She is tachypnoeic (RR 32), tachycardic (HR 118), and has SpO₂ 91% on air. She’s using accessory muscles and can only speak in short phrases. ABG shows: pH 7.36, PaCO₂ 5.9, PaO₂ 8.6. Her usual meds are salbutamol (as needed) and budesonide/formoterol (daily). She’s had two similar episodes this year.

1. What is the most concerning feature in this presentation?

Speaking in phrases suggests a moderate to severe asthma attack with limited airflow and respiratory compromise.

2. Which treatment should be administered immediately?

First-line treatment includes beta-agonist bronchodilators and oxygen to correct hypoxaemia.

3. What does a normal PaCO₂ indicate during an asthma attack?

A normal CO₂ in a tachypnoeic patient may indicate inability to clear CO₂ — a sign of fatigue or worsening status.

4. What physiotherapy approach is appropriate in the acute phase?

Calm breathing, posture support, and reducing the work of breathing are key during an attack.

5. What is a known trigger in this case?

Pet dander is a well-established trigger for asthma exacerbations in sensitised individuals.

6. What longer-term adjustment should be made?

Frequent attacks suggest under-treatment or poor inhaler adherence — needs review of inhaler technique and usage.

7. Which position optimises breathing in asthma?

The tripod position reduces accessory muscle work and improves diaphragmatic movement.

8. What outcome measure tracks functional impact of asthma?

The ACT is a validated questionnaire assessing symptom control and medication efficacy in asthma.

9. What role can a physiotherapist play post-attack?

Rehabilitation after severe attacks focuses on pacing, confidence, and regaining fitness and control.

10. What is a red flag requiring immediate escalation?

A silent chest and reduced consciousness may signal life-threatening asthma and impending respiratory arrest.

Case 7: COVID-19 Pneumonia (Post-Acute Phase)

Age: 52 Gender: Male

Mr. Ahmed was admitted 3 weeks ago with severe COVID-19 pneumonia. He required 5 days in ICU with high-flow oxygen and dexamethasone. Now transferred to the ward, he is on 2L O₂ via nasal cannula (SpO₂ 93%), with persistent exertional breathlessness, fatigue, and reduced mobility. Pre-morbidly he was a taxi driver, independent in ADLs, and lived with his wife. He currently mobilises 10m with a rollator and experiences a Borg breathlessness score of 5.

1. What respiratory pattern is common in post-COVID patients?

Post-COVID breathlessness often results in compensatory shallow breathing that limits effective ventilation.

2. Which breathing strategy is appropriate?

Pursed-lip breathing slows expiration, improves gas exchange, and reduces the work of breathing.

3. What long-term complication is common post-COVID?

Post-COVID interstitial lung disease and fibrotic changes can cause long-term breathlessness.

4. What outcome measure is ideal for tracking his fatigue?

FSS evaluates fatigue's impact on ADLs and quality of life in post-viral recovery.

5. What key MDT referral may support this patient?

Pulmonary rehab focuses on breathlessness, pacing, and graded return to function. OT supports fatigue management at home.

6. What is a safe discharge goal?

Functional independence and safety with minimal oxygen is realistic and measurable.

7. What should be avoided during early mobilisation?

Overpacing can delay recovery in post-viral fatigue syndromes; use careful graded activity.

8. What exercise tool might support home rehab?

Step counters and tracking apps allow pacing and encourage gradual progress.

9. What cognitive effect is common post-COVID?

Difficulty concentrating and reduced cognitive endurance are common in long COVID.

10. What breathing technique helps calm anxiety during breathlessness?

Box breathing improves parasympathetic tone and can help reduce panic-related dyspnoea.

Case 8: Pulmonary Fibrosis

Age: 71 Gender: Male

Mr. Hughes has idiopathic pulmonary fibrosis (IPF) diagnosed 2 years ago. He presents to outpatient respiratory physio with worsening exertional dyspnoea and a chronic dry cough. He uses 1L/min home oxygen via nasal cannula. He lives with his wife, is retired, and struggles with housework due to breathlessness. On examination: RR 24, SpO₂ 88% on walking, bibasal fine crackles. Medications include pirfenidone, omeprazole, and salbutamol PRN. He rates his MRC Dyspnoea Score as Grade 3.

1. What type of lung disease is IPF?

IPF is a chronic progressive disease causing fibrosis and reduced lung compliance, leading to restriction.

2. What is a classic auscultation finding in IPF?

Fine “Velcro-like” crackles at the bases are characteristic of fibrotic lung disease.

3. What does the MRC Dyspnoea Scale assess?

The MRC scale measures how dyspnoea limits function, from mild exertion to walking indoors.

4. What exercise strategy is recommended?

Short bouts of exercise with breaks and O₂ help improve tolerance without excessive desaturation.

5. What is the role of pirfenidone?

Pirfenidone and nintedanib help reduce fibrotic activity and slow lung function decline.

6. What functional test is commonly used in IPF rehab?

6MWT is validated for IPF to assess functional capacity, oxygen needs, and endurance.

7. What strategy can reduce desaturation during exercise?

Controlled pacing and oxygen titration improve safety and performance in fibrotic lung disease.

8. What is a red flag in IPF requiring escalation?

Acute exacerbations of IPF can be fatal and require urgent medical review.

9. What role can physiotherapy play long-term?

While fibrosis is irreversible, exercise, education, and pacing can optimise independence.

10. What psychological aspect must be considered?

Breathlessness and disability can lead to psychological distress; holistic care is essential.

Case 9: Ventilator-Associated Pneumonia (ICU)

Age: 67 Gender: Male

Mr. Grant is in ICU following emergency bowel surgery. He has been intubated for 6 days and has now developed ventilator-associated pneumonia (VAP). He is ventilated on pressure support mode, FiO₂ 0.4, PEEP 5. Sputum is purulent; CXR shows consolidation. His RR is 28, HR 95, Temp 38.2°C, SpO₂ 92%. Sedation has been reduced and he intermittently opens eyes. Noradrenaline has been weaned off. He is receiving enteral nutrition via NG tube.

1. What defines ventilator-associated pneumonia?

VAP occurs at least 48 hours after mechanical ventilation begins and is associated with significant morbidity.

2. What physiotherapy intervention is a priority?

Clearance of secretions is crucial to reduce infection load and improve gas exchange.

3. What is the role of PEEP in mechanical ventilation?

PEEP (Positive End-Expiratory Pressure) helps prevent alveolar collapse and improves oxygenation in compromised lungs.

4. When should passive movements begin in ICU?

Early mobilisation, even passively, reduces ICU-acquired weakness and improves outcomes.

5. What risk does long-term ventilation pose?

Disuse of respiratory muscles contributes to ventilator dependency unless countered with early activity.

6. What outcome measure tracks sedation levels?

RASS is used to monitor alertness and readiness for physiotherapy in ventilated patients.

7. What is a barrier to early mobilisation in ICU?

Low blood pressure, arrhythmias, or recent vasopressors can delay active mobilisation.

8. What does the SOFA score assess?

SOFA tracks function across multiple systems to assess severity of illness and prognosis in critical care.

9. Which MDT role is crucial at this stage?

Physiotherapists play a key role in ventilation weaning, mobility, secretion management, and recovery.

10. What is an appropriate initial mobility goal?

Sitting upright begins the process of reconditioning and lung recruitment after prolonged bedrest.

Case 10: Neuromuscular Weakness (Motor Neurone Disease)

Age: 58 Gender: Female

Mrs. Donovan has motor neurone disease (MND) and is now experiencing increased breathlessness and weak, ineffective cough. Her peak cough flow is 170 L/min. SpO₂ on air is 95%, but she experiences nocturnal desaturations. She uses NIV (BiPAP) overnight. She has difficulty managing secretions and mild bulbar symptoms. She lives with her partner and receives daily carer visits. Current medications include riluzole and mucolytics.

1. What respiratory pattern is common in MND?

Respiratory muscle weakness leads to shallow breathing, poor ventilation, and secretion retention.

2. What device supports overnight ventilation in neuromuscular disease?

BiPAP provides inspiratory support and reduces nocturnal hypoventilation in neuromuscular disorders.

3. What is the significance of a cough peak flow < 270 L/min?

A PCF below 270 L/min is insufficient to clear secretions effectively and may require mechanical support.

4. What physiotherapy equipment may support cough in MND?

MI-E devices simulate a natural cough using positive and negative pressure cycles.

5. What is a common outcome of bulbar dysfunction?

Bulbar symptoms impair swallowing and increase aspiration risk, compromising respiratory health.

6. What MDT referral is essential in managing bulbar issues?

SLTs assess swallow and speech safety, especially in progressive bulbar disease.

7. What positioning may support secretion drainage?

Gravity-assisted positions can help, but must be modified for safety in weak or bulbar patients.

8. What is the goal of physio in progressive neuromuscular disease?

Realistic, patient-centred goals focus on symptom management and maintaining independence.

9. What education should be provided to carers?

Training families in use of devices and techniques can prevent infections and distress at home.

10. What is a realistic outcome goal for Mrs. Donovan?

The focus is maintaining respiratory safety, function, and comfort as the condition progresses.

Case 11: Obesity Hypoventilation Syndrome (OHS)

Age: 55 Gender: Male

Mr. Richards is referred for respiratory physiotherapy with worsening breathlessness, daytime somnolence, and morning headaches. BMI is 43 kg/m². He uses CPAP for comorbid OSA. ABG shows PaCO₂ 7.0, PaO₂ 7.5, and HCO₃⁻ 30. He is desaturating to 89% on minimal exertion. Chest wall movement is restricted. Lives with partner and has limited mobility indoors. He has a history of hypertension and type 2 diabetes.

1. What feature defines OHS?

OHS is defined by obesity, hypoventilation (raised PaCO₂), and absence of other respiratory diseases.

2. What daytime symptom is typical of OHS?

Hypoventilation and nocturnal desaturation lead to poor sleep quality and hypersomnolence.

3. What effect does raised bicarbonate suggest?

The kidneys compensate for long-term CO₂ retention by increasing bicarbonate to buffer acidosis.

4. What physical barrier contributes to hypoventilation?

Central adiposity reduces chest expansion, leading to low tidal volume and hypoventilation.

5. What is the role of CPAP in OHS?

CPAP prevents airway collapse during sleep, improving ventilation in patients with comorbid OSA.

6. What additional ventilation may be required?

BiPAP supports inspiratory effort and CO₂ clearance in OHS, beyond CPAP’s upper airway function.

7. What physio goal is most appropriate short-term?

Small functional goals (mobility, breathing pattern) are practical and achievable in the short term.

8. Which education topic is critical?

Consistent use of CPAP or NIV is crucial to reduce CO₂ retention and improve quality of life.

9. What long-term team should be involved?

A multidisciplinary approach helps manage breathing, comorbidities, and sustainable weight loss.

10. What is a safe and measurable discharge goal?

Setting realistic and progressive functional goals promotes safety and long-term success.

Respiratory Case Studies

Case 1

Case 2

Case 3

Case 4

Case 5

Case 6

Case 7

Case 8