presented by Jennifer Ryan
The physical therapist management of aging patients with a COPD exacerbation 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 dependence on ventilatory support, positive pressure ventilation (or supplemental oxygen), and their neuromuscular function and overall muscular weakness that can be a result of a prolonged critical illness and immobility. Medications and interventions required to manage their critical illness must also be considered. Participants will learn the pathophysiology of COPD related to the prolonged illness as well as the sequelae of an exacerbation, the evaluative components necessary to weigh into the clinical reasoning of 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 a COPD exacerbation who is critically ill.
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 compound a patient’s ability to recover from a COPD exacerbation due to the often mixed Type 1 and 2 components that are acutely present as well as those that are due to their chronic illness. Type 2 respiratory failure is a result of increased concentrations of CO2 in the blood, hypercapnia, which leads to reduced oxygenation. The cumulative effects of the restrictive pulmonary changes as a result of age and those related to a COPD exacerbation can dually impair a patient’s ability to recover their ability to adequately oxygenate during progressive activity.
In the most critical phases of a patient’s recovery from a COPD exacerbation, they often are unable to maintain their oxygenation so significantly that they present with altered pulmonary mechanics. They also require the support of invasive and non-invasive mechanical ventilation that limits their participation in exercise and can subsequently impair their mental status and their peripheral muscle strength.
There is a growing body of evidence that demonstrates the need to mobilize patients who are critically ill as soon as they are medical optimized to participate related to their hemodynamic stability and oxygenation. The ABCDEF Bundle is an operationalization of ICU care that has demonstrated a trend towards improved outcomes and reduced morbidity. Implementation of this process is the responsibility of the entire team of professionals who care for the patient who is critically ill.
Through a thorough systems evaluation the physical therapist will determine the patient’s readiness to participate in an initial examination and intervention as well as for each subsequent intervention. A process of weighing the impact of the patient’s pharmacological support, the oxygenation support and the hemodynamic response in addition to employing the input of members of the interprofessional team by conferring with nursing and the primary service, the therapist will determine the patient’s readiness to participate.
Throughout the patient’s progression in care there are always many possible scenarios. The chapter will take you through a case to understand the patient’s response to care to help you to 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 of hemodynamic changes or changes in oxygenation, beyond what presented in the case, that could present and how they would be managed.