The physical therapy examinations and interventions presented in this chapter focus on the patient with cardiopulmonary dysfunction fitting the model of preferred Practice Pattern 6E: Impaired Ventilation and Respiration/Gas Exchange Associated with Ventilatory Pump Dysfunction or Failure.1 In the first edition of the Guide to Physical Therapy Practice in 1997,2 this pattern was separated into two different practice patterns to distinguish ventilatory pump dysfunction (PPP 6F) from ventilatory pump failure (PPP 6H). However, the main difference between the dysfunction and the failure is the severity and/or acuity of the dysfunction; thus, it is more appropriate that they be grouped into one practice pattern. In this way, particular levels of impairment or function may be used to specifically distinguish ventilatory pump dysfunction from ventilatory pump failure using identifiable characteristics within a continuum of ventilatory pump function. As we shall see, several specific patient characteristics can be used to distinguish ventilatory pump dysfunction from failure that will enable more specific and appropriate physical therapy interventions.
Ventilatory pump dysfunction can be caused by a wide variety of pathologies and impairments. Identifying the primary pathology or impairments is critical to the physical therapist for planning and implementing an effective intervention plan. In the Guide, four broad categories of pathologies and impairments were identified to help the physical therapist categorize their patient's primary impairment pattern.1 These pathology and impairment categories are (1) musculoskeletal, (2) neuromuscular, (3) cardiopulmonary, and (4) integumentary. Practice Pattern 6E would include patients who frequently come from the cardiopulmonary impairment category and may include patients with a number of different primary pulmonary disorders such as asthma, emphysema, chronic bronchitis, and restrictive lung disease, among others. In other words, if the lung disorder causes a patient to work harder than a normal person for their next breath, then the ventilatory pump will be impaired secondary to the lung disorder.1The primary goal of the physical therapist should be to identify the degree of impairment and functional capacity, regardless of the pathology.
Ventilatory pump dysfunction can originate from any of the other pathology and impairment categories (musculoskeletal, neuromuscular, cardiopulmonary, or integumentary). These pathologies and impairments are listed under the “Patient/Clients Diagnostic Classification” section of each practice pattern.1 For example, “severe kyphoscoliosis” is listed under Pattern 6E as a cause for ventilatory pump dysfunction. Why? Because, pump dysfunction will occur where there is a restriction to the mobility of the chest wall and/or spine (ie, with arthritis, scoliosis, kyphosis, traumas). The resultant restriction will decrease the efficiency and/or the potential for optimal function of the ventilatory muscle pump.
Likewise, patients with “neuromuscular disorders” are also listed as patients with potential ventilatory pump dysfunction. Neurologic disease or trauma can affect the strength and motor control of the trunk as well as the respiratory muscles, which may cause ventilatory pump dysfunction (ie, spinal cord injury, brain injuries, cerebral palsy, multiple sclerosis, or Parkinson disease).