Physical therapy in

cardiovasculer and 1. Dila Rahmawati

pulmonary 2.
3.
Meri Pita Lokasari
Rika Rachmahani

conditions
General Description
Cardiovascular System
Conduction
The myocardium contains special types of tissue responsible
for conducting the electrical impulse that causes the
myocardium to contract in synchronized pattern.
The specialized tissues are called nodal and purkinje fibers.
The sinotrial (SA) node initiates the impulse (sius rhythm) and is
reffered to as the pacemaker of the heart. Once a signal is
initiated by the SA node, it travels quickly through the walls of
the atria on special tracts to the atrioventricular (AV) node.
Cardiovascular System
Coronary Arteries
 These Arteries arise from the ascending aorta, which is the
major artery leaving the left ventricle and carrying blood to
the body.
 If something occurs that causes blockage of a coronary
vessel, it is important. A blockage that prevents oxygen
supply to the heart, causing permanent damage to the
heart cell, is known as a heart attack.
Cardiovascular System
Peripheral Circulation
The blood vessel tah make up the peripheral circulation are
arteries, capillaries, and veins, and disorder in these vessels can
result in cardiovascular adn pilmonary dysfunction.
❤ The arteries, of which the aorta has the largest diameter,
and the arterioles have elastic fibers and smooth muscle in their
walls.
❤ Capillaries are the smallest veseel in the peripheral
circulation. Capillaries are often refereed to as exchange
vessels.
❤ the veins, which return blood to the heart from the body,
have much less elastic fiber and smooth muscle in their walls.
Pulmonary System

 Respiration is the process of exchanging oxygen and carbon

dioxide between the air we breathe and blood cell that pass
throught the lungs.
 Ventilation is the procces of exchanging air between the
armosphere and the lungs through inspiratio and expiration.
 Inspiration causes air pressure to drop inside the lungs, which
causes air to move into the lungs.
 Expiration is the reverse of inspiration process
Pulmonary System
Conducting Airways and Lungs
The upper conducting airways includes the nose, pharynx, and
larynx. The lower conducting airway is made up of the trachea and
bronchiole system. The bronchiole system consists of tubes branching
from the main bronchus out to the terminal bronchioles. It is here that
the conduction system ends and air enters into the alveolus, where
gas exchange takes place.
The alveoli are surrounded by capillaries that contain
deoxygenated blood coming from the right ventricle of the
heart. It is at this juction that oxygen and carbon dioxide are
exchange, with the reoxygenated blood returning to the left
atrium.
A special membrane, the pleura, covers the outer surface
of the lungs and the inner surface of the chest wall.
Cardiovascular and Pulmonary System
Integration
The importance of interaction between the cardiovascular
and pulmonary system, when disease affects one system,
eventually the other system will also be affected
Example : arteriosclerosis
Cardiovascular Disease
Ischemic Condition
This occurs in the presence of insufficient blood flow and result
in indequate oxygenation of tissue because of a blocked
blood vessel.
• Some of these factors cannot be changed, such as having a family
history of CHD
• Most of the risk factors can be modified or eliminated completely by
changes in behavior
Cardiovascular Disease
Cardiac Muscle Dysfunction
Various pathologic condition associated with heart failure.
Heart failure occurs when a disease process or congenital either
directly or indirectly cause a decrease in the pumping capability of
the heart muscle. An example of an acute change in the heart’s
pumping capability is the occurrence of an MI (heart attack). In this
case one of the coronary arteries suddenly becomes blocked by an
embolus (clot). If this embolus causes an interruption in blood flow to
A large amount of heart muscle, death can result.
If an individual a heart attack, other symptoms may develop that
further complicate the condition. One of the major complications
after infarction is an abnormal rhytm in the sequence of heart muscle
contraction (abnormal conduction).
When the heart muscle is compromised to the point it cannot move
blood volume effectively, congestive heart failure (CHF) will
develop.
When CHF is present, the ventricles are not adequately pumping
the appropriate volume from their chambers.
A person with chf has many clinical problems. If fluid collectes
inthe lungs, breathing becomes difficult and blood is not
oxygenated appropriately. If fluid has collected in the legs, walking
becomes more difficult. Because of increasing difficulty in
performing activities, the patient would have to expend more
energy to accomplish simple tasks. With increase expenditure, the
heart would have to work harder to support simple functional
activities.
Pulmonary Disease
Chronic Obstructive Pulmonary Disease
A Group Of Disorders That Produce Certain Spesific Physical
Symptoms
These Symptoms Include Chronic Productive Cough, Excessive
Mucus Production, Changes In The Sounds Produced When Air Passes
Through The Bronchial Tubes, And Shortness Of Breath (Dyspnea).
The Spesific Disorder That Can Produce These Changes Include
Chronic Bronchitis (Inflamation Of The Bronchi), Emphysema
(Trapping Of Air In The Alveoli), And Peripheral Airway Disease
(Collapse Of Terminal Bronchioles).
Other Disorders Sometimes Included In This Disease Group Include
Bronchial Asthma (Spasm Like Contraction Of Bronchi, Resulting In Air
Trapping), And Cystic Fibrosis (Dysfunction Of Mucous Glands,
Causing Blockage Of Bronchi).
 The Sign And Symptoms That The Develop As Copd Progresses
Include Bronchial Waal Abnormalities That Cause A Decrease In
Lumen Size And Alveolar Destruction. This Process Results In
Trapping Of Air In Lungs, Which Resultin Hypoxemia (Below-
normal Oxygenation Of Blood).
As Resistance To Airflow Increases, The Thorax Enlarges As A
Result Of Air Trapping. This Enlargement Of The Thorax Causes The
Respiratory Muscles To Work Harder. With Chronic Hypoxemia,
Changes Begin To Occur In The Function Of The Heart, In Blood
Pressure, And The Thickness Of The Blood. All These Changes Can
Lead To Respiratory Failure.
Pulmonary Disease
Restrictive Lung Disease
Cause a decrease in the ability of the lungs to expand,
which results in a decrease in the volume of air that can move
into and out of tje lungs.
This disease process that affects lung tissue directly is
commonlyof idipathic, or unknown, origin.
Known causes include chronic inhalation of air pollutants
such as coal dust, silicon, or asbestos.
infection such as pneumonia, cancer of the lung, and
changes in heart function (causing chronic fluid collection in
the lungs) can also result in restrictive disease.
diseases or trauma to the nerve supply to the muscle of
ventilation or disease of the muscle also result in decreased
movement of the chest wall.
the signs and symptoms that develop as restrictive progresses
include some of the changes seen in COPD, such as shortness of
breath and chronic cough. In restrictive lung disease, however,
the cough is nonproductive (doesn’t bring the mucus out of the
lungs).
other changes include tachypnea, or an increase in the rate
of breathing, which result in a marked increase in the amount of
energy expended on bresthing.
Principles of Examination
Performed by PTs and PTAs.
It includes a review of patient’s past medical and social
history, review of the body systems, and tests and measures to
gather data about the patient’s condition.
Areas reviewed include not only physical parameters, but
also functional, psycological, social, and employment condition.
The tests and measures that are selected to examine a
patient/client; severity of the problem; stage of recovery (acute,
subacute, chronic); phase of rehabilitation (early, intermediate,
late, return to activity); and home, community, and work status.
 Description of common tests and measure for patient with cardiovascular and pulmonary condition
Function or characteristic Description
Home, work, and Analysis of the home and work environment to determine the level of functional
community (job, play, capacity needed to perform safely within these environment. Examination of the
school) patient’s capacity to function at an appropriate level of social interaction with
various population. (e.g. Family, peers, strangers)
Ergonomics and body Deremination of the dynamics capabilities required of the patient to safely perform
memchanics within varios environments. (e.g. school, home, work, leisure)

Aerobic capacity and Assesment of cardiovasculer and pulmonary performance during controlled exercise
endurance and functional activities. Can include measuring oxygent consumption, heart and
respiratory rate, blood pressure, dyspnea, and blood gases, electrocardiogram, and
heart and lung auscultation
Ventilation and respiration Assesment of pulmonary function, arterial blood gases, airway clearance efficiency,
and perceived exertion and dyspnea during and after exercis; measurement of
strenght endurance of muscles of ventilation and of chest wall mobility and
expansion.
Anthropometric Determination of body fat composition
characteristics
Muscle strength and Assesment of functional muscle strength and endurance as they relate to exercise
endurance protocols
Postures Assesment of posture abnormalities and their effect on energy cost during movement

Range of motion Assesment of limitations in joint range of motion and impact on energy cost during
movement.
Cardiovascular Diagnostic Tests and
Procedures
Noninvasive Procedures
 Echocardiography
Is the use of high-frequency ultrasound to assess the size of the
heart chambers, the thickness of the chamber walls, the pumping
ability, motion of the chamber walls, and heart valves
 Electrocardiogram
Physiotherapist who work with individuals being monitored by
electrocardiography must be able to interpret normal ECG
readings and recognize abnormal rhythms that could be life
threatening
 Exercise stress testing
Is a noninvasive method of determining how the cardiovascular
and pulmonary systems respond to controlled increases in activity.
The most common activities are treadmill walking and cycling.
Pulmonary Diagnostic Tests and Procedures
Chest Imaging
Baseline images can provide information about the
presence of fluid in the lungs, air spaces, rib fractures, heart size,
diaphragm shape and position, and nodules in the lungs.
Pulmonary Diagnostic Tests and Procedures
Pulmonary Function Test
A pulmonary function test is an assessment of the
effectiveness of the respiratory musculature and the intergrity of
the airways and lung tissue. The testing procedure can help
classify the lung disease pattern as obstructive or restrictive by
assessing the following
1. Lung volumes
2. Lung capacities
3. Gas distribution
4. Gas flow rate
Pulmonary Diagnostic Tests and Procedures
Blood Gas Analysis
Blood gas analysis involves assessing arterial blood to
determine the concentration of oxygen and carbon dioxide.
This measure helps determine how well the lungs are being
ventilated or whether the patient has any deficits in respiration
Principles of Evaluation, Diagnosis, and
Prognosis
 Diagnosa => From sign, symptomps, or syndromes of the
patologic

 Prognosis => Estimates maximum level after the

treatment process

 Evaluation => Know the patient’s progress after tratment

process
Principle of procedural Intervention

• PT intervention must be conjuction with several other

medical personil (doctor, nurse, nutricionist, OT,treatment
Physiologis, etc)
• The intervention of PT must receiving develop the
treatment accordingly
Principles of Procedural Intervention
Medical Management
Medical management of symptoms caused by cardiac
disease focuse primarily on reducing oxygen demand and
increasing oxygen supply.
Medical management of symptoms caused by pulmonary
disease focuses primarily on promoting brochodilation and
decreasing infammation. Drugs producing brochodilation
improve airflow through the bronchial tubes, which helps
oxygen reach the alveolus and thereby decreases the work of
breathing.
Surgical Management
Surgical management of cardiovascular and pulmonary disease does not generally
alter the disease process but does improve the quality of life by relieving symptoms. In the
case of CHD the arteriosclerotic process is not stopped, but coronary artery blood flow
can be improved through surgery.
Two methods are commonly used to improve coronary blood flow to the heart:
 PCI : does not require surgically opening the
chest. A catheter is placed through an artery in the leg an then positioned in the
coronary vessels blocked by arteriosclerotoc plaque.
 Coronary artery bypass graft (CABG) : requires surgically opening the chest
wall and grafting a small artery or a leg vein from the aorta to a point beyond the
blockage or plaque.
Another major surgical intervention is heart transplation
Factors Influecing Recovery After Chest Surgery
 Preoperative factor
• Risk factor profile
• Underlying pulmonary or heart disease
 During operation
• Pulmonary collaps and hipoxemia
• Direct trauma to heart or lungs
• Heart arrhytmias
• Reaction of lungs to anesthesia
 Postoperative factors
• Atelectasis
• Pain
• Weakness
• Inactivity promoting shallow breathing
Physical Therapy Cardiac Rehabilitation
Procedures
The PT is responsible for establishing an appropriate level of intensity, duration,
frequency, mode of exercise for an individual with cardiac disease which means
monitoring the patient’s cardiovascular to select an appropriate level of activity for the
patient program to ensure the patient’s safety.
After cardiothoracic surgery, UE lifting and range of motion exercises should be
restricted for 5 to 8 weeks. Unilateral UE exercise are avoided until there is no evidence of
sternal stability.
In addition, patients are advised to cough with splinting and to limit range of motion
at the onset of the pain.
Physical Therapy Pulmonary Rehabilitation
Procedures
PT have a responsibility to establishing an appropriate level of
exercise programming for patients with pulmonary disease.
The goal is to enhance the patient’s ability to perform
daily function aerobically with an appropriate intensity and
duration of exercise.
To select an appropriate intensity and duration of
exercise, the PT must review all the result of all examination
procedures performed on the patient.

Important things : PT must monitor the patient’s cardiovascular

response to the exercise, such as the heart rate, blood pressure,
breathing rate and depth, so PT can prevented the risk of
exercise.
The Components Physical Therapy Treatment For Patients With
Pulmonary Disease :
 Secretion removal techniques
Performed in patients who produce excessive mucus in the bronchi as occurs in
obstructive pulmonary disease. The technique applied to promote mucus removal is
called postural drainage.
Postural drainage is a technique to make patients do some position to passively
drain fluid from a specific portion of the lung. During the postural drainage, PT can
applies percussion (or clapping), vibration and shaking to helps move mucus out
through bronchial tubes.

 Producing a good cough

If the respiratory muscles are weakened or do not work properly, the efficiency of
the cough mechanism is reduced. This is can occur in both the obstructive and
restrictive disease patterns, it also occurs in patients who have experienced trauma.
So, producing a good cough is essential for maintaining normal lung function in
everyone.
PT can help the patient enhance coughing in three ways : by strengthening both the
primary and secondary muscles of ventilation, by changing the breathing pattern,
and by teaching the patient how to use different devices to support the chest wall so
that the expiration force generated during coughing is enhanced.
 Energy conservation techniques
The PT determines the activity needs of the patient in the
home or work environment and the helps select assistive
devices that can be used to perform certain tasks. So, the
purpose of energy conservation techniques is to teaches
patient how to divided their activity efficiently, thereby
decreasing the demand on the pulmonary system.

The PT also participate in helping to modify the patient’s risk

factor profile, such as promoting weight management, good
nutrition, smoking cessation, and a positive psychological
state. The primary goal for pulmonary rehabilitation is to help
the patient achieve the highest functional level allowed by
the pulmonary impairment.
THANK YOU FOR YOUR ATTENTION