presented by Jennifer Ryan
The physical therapist management of aging patients with Acute Respiratory Distress System (ARDS) is complex and requires ongoing clinical reasoning to determine the patient’s readiness to participate as well as their ability to progress versus their need to rest. The considerations that need to be weighed are related to the patient’s cardiovascular function and hemodynamic stability, their pulmonary function, and their dependence on ventilatory support. Other factors include positive pressure ventilation, supplemental oxygen, and the patient's neuromuscular function and overall muscular weakness that can be a result of a prolonged critical illness and immobility as well as the medications and interventions required to manage their critical illness. Participants will learn the pathophysiology of ARDS, the evaluative components necessary to weigh into the clinical reasoning for when a patient is ready to participate as well as when an individual demonstrates that they have exceeded their capacity. Through a case-based presentation, the learner will gain insights into the many possible clinical scenarios that can present with an aging patient with ARDS.
Jennifer Marie Ryan, PT, DPT, MS, CCS, graduated from the Physical Therapy program at the University of Illinois in 1990 and went on to complete both a Master of Science in Physical Therapy and a Transitional Doctor of Physical Therapy degree at Rosalind Franklin University of Medicine and Science. In July 2006, she was awarded board certification as a Cardiovascular and Pulmonary Clinical Specialist by the American Board of Physical Therapy Specialties. In 2012 she was awarded the Mary Sinnott Award for Excellence in Acute Care and she was awarded the Acute Care Section Lecture for 2014.
Throughout her physical therapy career, she has specialized in physical therapy care for critically ill patients. In her current position at the University of Chicago Medical Center she mentors staff and students about management of acutely ill patients along with her patient care. Her teaching in the area of cardiovascular and pulmonary physical therapy includes several continuing education seminars, and as a contract faculty member in the Department of Physical Therapy and Human Movement Sciences, Northwestern University, Feinberg School of Medicine.
She serves as: a delegate from the Illinois Chapter of the American Physical Therapy Association, the Education Chair for the Cardiovascular and Pulmonary Section of APTA, and as a member of the Subject Matters Expert Task Force of the Acute Care Section of APTA. She founded Rehab Education Formula, an online resource for therapist-focused education.
The anticipated restrictive changes in pulmonary function as result of aging can alter the mechanics of the lungs. This change limits the ability to adequately oxygenate during progressive activity because of impaired ventilation. This is even more impactful in cases of infection due to the restrictive nature of the infection itself. As a person ages, the immune system also grows less efficient, which increases the aging client's susceptibility to infection due to reduced T cell function and reduced antibody response related to a decreased level of B cell function.
The anticipated changes in pulmonary function as result of aging can compound a patient’s ability to recover from ARDS. Type I respiratory failure is a result of impaired oxygenation. The cumulative effects of the restrictive pulmonary changes as a result of age and those related to ARDS can dually impair a patient’s ability to recover their ability to adequately oxygenate. In the most critical phases of a patient’s recovery from ARDS, they often are unable to maintain their oxygenation so significantly that they require the use of paralytics to reduce their oxygen demand as well as proning to improve their pulmonary mechanics. They may also require the support of mechanical ventilation that can impair their diaphragm strength, their mental status and their peripheral muscle strength.
Through a thorough chart review of the laboratory values, imaging and analysis of the medical interventions used to facilitate recovery prior to consult to evaluate the patient, the physical therapist will determine the patient’s readiness to participate in an initial examination and intervention as well as for each subsequent intervention. Using an understanding of the pharmacological support, the ventilatory support and the hemodynamic response to ADL’s after conferring with nursing, the therapist will determine the patient’s readiness to participate. A case-based approach will be used to illustrate how this can be achieved.
Through a ongoing systems evaluation throughout each session the physical therapist will determine the patient’s ability to participate in the initial examination and evaluation, as well as for each subsequent intervention, to determine the level of challenge that they can best benefit from to optimize their recovery. Using an understanding of pharmacological support and ventilatory support and after conferring with nursing, the therapist will determine the patient’s readiness to participate and to continue based upon the hemodynamic response and the stability of their level of oxygenation to progressive mobility. A case-based approach will be used to illustrate how this can be managed.
Throughout the patient’s progression in care there are always many possible scenarios. This chapter will describe a case that demonstrates how to understand the patient’s response to care, and to help the participant gain an understanding of the physical therapist’s clinical reasoning to determine the patient’s ability to progress versus rest during the session. The chapter will also discuss other possible scenarios that could present and how they would be managed.