Learning Resources

Clinical Decision Support Tool

Physiotherapy-Focused Approach to Respiratory & Cardiac Care

Respiratory Distress Algorithm

1. INITIAL ASSESSMENT
  • Respiratory rate, depth, pattern
  • Oxygen saturation (SpO₂)
  • Work of breathing (accessory muscle use)
  • Auscultation (breath sounds, adventitious sounds)
  • Cough effectiveness
  • Sputum characteristics
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2. SEVERITY TRIAGE
  • Mild: SpO₂ >94%, RR <20, minimal distress
  • Moderate: SpO₂ 90-94%, RR 20-30, some distress
  • Severe: SpO₂ <90%, RR >30, significant distress
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⚠️ IMMEDIATE ACTIONS IF SEVERE
  • Call for medical assistance
  • Position for optimal breathing (high sitting/forward lean)
  • Ensure oxygen therapy is optimised (medical management)
  • Monitor vital signs continuously
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3. IDENTIFY PRIMARY CAUSE
  • Secretion retention: Weak cough, audible secretions
  • Bronchospasm: Wheeze, tight chest
  • Reduced lung volumes: Atelectasis, shallow breathing
  • Deconditioning: Dyspnoea on minimal exertion
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4. PHYSIOTHERAPY INTERVENTIONS

For Secretion Retention:

  • Positioning: Gravity-assisted drainage positions
  • Breathing techniques: Active cycle of breathing technique (ACBT)
  • Manual techniques: Percussion, vibrations, shaking
  • Devices: PEP mask, Flutter, Acapella
  • Humidification: Nebulisers (with medical prescription)
  • Suction: If unable to clear independently (trained personnel)

For Reduced Lung Volumes:

  • Deep breathing exercises: Incentive spirometry
  • Positioning: Regular position changes, sitting upright
  • Early mobilisation: Sitting out of bed, walking
  • CPAP/BiPAP: If prescribed (medical management)

For Bronchospasm:

  • Positioning: Forward lean sitting, relaxed shoulder position
  • Breathing control: Pursed lip breathing, paced breathing
  • Relaxation techniques: Reduce anxiety and work of breathing
  • Bronchodilators: Ensure prescribed medication taken (medical management)

For Deconditioning:

  • Graded mobilisation: Progressive exercise programme
  • Functional activities: Sit to stand, walking
  • Breathing strategies: Coordinate breathing with movement
  • Energy conservation: Pacing techniques
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5. REASSESS & MONITOR
  • Repeat vital signs after intervention
  • Assess effectiveness of secretion clearance
  • Monitor patient comfort and fatigue
  • Document response to treatment
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6. ESCALATION CRITERIA
  • Deteriorating SpO₂ despite interventions
  • Increasing respiratory rate or work of breathing
  • Altered consciousness or confusion
  • Inability to clear secretions
  • Patient exhaustion
→ Refer to medical team immediately

Cardiac Emergency Algorithm

1. INITIAL ASSESSMENT
  • Heart rate and rhythm
  • Blood pressure
  • Chest pain characteristics (SOCRATES)
  • Dyspnoea severity
  • Peripheral perfusion (colour, temperature, capillary refill)
  • Oedema (peripheral, pulmonary)
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⚠️ RED FLAGS – CALL FOR HELP IMMEDIATELY
  • Chest pain with radiation to arm/jaw
  • Severe dyspnoea at rest
  • Systolic BP <90 or >180 mmHg
  • HR <40 or >120 bpm
  • New onset confusion or reduced consciousness
  • Pulmonary oedema (pink frothy sputum)
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2. DETERMINE STABILITY
  • Stable: Vital signs within normal limits, no acute symptoms
  • Unstable: Abnormal vital signs, acute symptoms, red flags present
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3. IDENTIFY PRESENTATION
  • Acute Coronary Syndrome: Chest pain, dyspnoea, sweating
  • Heart Failure: Dyspnoea, oedema, fatigue
  • Arrhythmia: Palpitations, dizziness, syncope
  • Post-cardiac surgery: Sternal precautions, wound healing
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4. PHYSIOTHERAPY INTERVENTIONS (When Stable)

For Heart Failure:

  • Positioning: Upright sitting to reduce dyspnoea
  • Breathing exercises: Diaphragmatic breathing, pursed lip breathing
  • Oedema management: Elevation, gentle active exercises
  • Graded mobilisation: Monitor HR, BP, SpO₂ response
  • Exercise prescription: Low-intensity, frequent short sessions
  • Education: Symptom recognition, pacing, medication compliance

For Post-Cardiac Surgery:

  • Respiratory care: Deep breathing, supported coughing
  • Early mobilisation: Sitting, standing, walking with sternal precautions
  • Upper limb exercises: Within sternal precautions (no lifting >5kg for 6-12 weeks)
  • Wound care: Monitor for infection, support during movement
  • Cardiac rehabilitation: Structured progressive exercise programme

For Stable Cardiac Conditions:

  • Exercise tolerance testing: 6-minute walk test, incremental shuttle walk
  • Aerobic exercise: Walking, cycling (monitor HR response)
  • Resistance training: Light weights, functional activities
  • Education: Risk factor modification, lifestyle advice

Medical Management (Awareness):

  • GTN spray for angina
  • Diuretics for fluid overload
  • Anticoagulation therapy
  • Beta-blockers, ACE inhibitors
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5. MONITORING DURING TREATMENT
  • Vital signs: HR, BP, SpO₂ before, during, after
  • Symptoms: Chest pain, dyspnoea, dizziness, fatigue
  • RPE scale: Rate of perceived exertion (aim 11-13/20)
  • Talk test: Should be able to speak in short sentences
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6. STOP TREATMENT IF:
  • Chest pain or discomfort
  • Severe dyspnoea
  • Dizziness, light-headedness, or nausea
  • HR >20 bpm above resting or >120 bpm
  • Systolic BP drop >10 mmHg or rise >180 mmHg
  • SpO₂ drop >4% or <90%
  • New arrhythmia
→ Seek immediate medical review

Comprehensive Assessment Framework

Subjective Assessment

  • History of presenting complaint
  • Past medical history
  • Medications
  • Social history
  • Functional limitations
  • Patient goals

Respiratory Objective

  • Respiratory rate & pattern
  • SpO₂ (rest & exertion)
  • Auscultation findings
  • Cough effectiveness
  • Sputum volume/colour
  • Chest expansion

Cardiac Objective

  • Heart rate & rhythm
  • Blood pressure
  • Peripheral perfusion
  • Oedema presence/location
  • JVP (if trained)
  • Exercise tolerance

Functional Assessment

  • Mobility level
  • Transfers ability
  • Activities of daily living
  • Exercise capacity
  • Dyspnoea scales (MRC, Borg)
  • Quality of life measures

Clinical Reasoning Process

STEP 1: Gather Information

Complete subjective and objective assessment

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STEP 2: Analyse & Interpret

Identify problems, determine severity, recognise patterns

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STEP 3: Formulate Diagnosis

Physiotherapy diagnosis based on movement and function

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STEP 4: Plan Treatment

Set SMART goals, select appropriate interventions

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STEP 5: Implement & Reassess

Deliver treatment, monitor response, modify as needed

Physiotherapy Techniques Guide

Airway Clearance Techniques

Active Cycle of Breathing Technique (ACBT)

  • Breathing control: Gentle, relaxed breathing
  • Thoracic expansion: 3-4 deep breaths
  • Breathing control: Return to relaxed breathing
  • Forced expiration: 1-2 huffs
  • Repeat cycle until secretions cleared

Autogenic Drainage

  • Phase 1: Breathe at low lung volumes (unstick)
  • Phase 2: Breathe at mid lung volumes (collect)
  • Phase 3: Breathe at high lung volumes (evacuate)
  • Avoid coughing until secretions in upper airways

Positive Expiratory Pressure (PEP)

  • Breathe through PEP device (10-20 cmH₂O)
  • Perform 10-15 breaths
  • Follow with huffing/coughing
  • Repeat for 15-20 minutes

Manual Techniques

  • Percussion: Cupped hands, rhythmic clapping
  • Vibrations: Fine oscillations during expiration
  • Shaking: Coarse movements during expiration
  • Always combined with positioning and breathing exercises

Breathing Exercises

Diaphragmatic Breathing

  • Hand on abdomen, one on chest
  • Breathe in through nose, abdomen rises
  • Breathe out through mouth, abdomen falls
  • Chest should remain relatively still

Pursed Lip Breathing

  • Breathe in through nose (2 counts)
  • Purse lips as if whistling
  • Breathe out slowly through pursed lips (4 counts)
  • Helps reduce air trapping and dyspnoea

Incentive Spirometry

  • Seal lips around mouthpiece
  • Breathe in slowly and deeply
  • Hold breath for 3-5 seconds
  • Exhale normally and rest
  • Repeat 10 times every hour

Paced Breathing

  • Coordinate breathing with activity
  • Breathe in during easier phase
  • Breathe out during harder phase
  • Prevents breath-holding and reduces dyspnoea

Mobilisation & Exercise

Early Mobilisation

  • Sitting out of bed
  • Marching on the spot
  • Walking short distances
  • Stair climbing (when appropriate)
  • Monitor vital signs throughout

Exercise Prescription

  • Frequency: 3-5 times per week
  • Intensity: 40-80% max HR or RPE 11-13/20
  • Time: 20-60 minutes per session
  • Type: Aerobic + resistance training

Positioning

  • High sitting: Reduces dyspnoea
  • Forward lean: Supports accessory muscles
  • Side lying: Improves V/Q matching
  • Prone: For ARDS/severe hypoxia

Energy Conservation

  • Plan activities, prioritise tasks
  • Pace activities with rest breaks
  • Use equipment/aids to reduce effort
  • Sit rather than stand when possible
  • Coordinate breathing with activity