For canine rehab therapists, respiratory physiotherapy can be a significant area of weakness, as many of us do not work directly with cases in intensive care. However, it is not unheard of for us to be confronted with post-op cases that develop pneumonia, recurrent breathing challenges because of cleft palates, or conformational challenges in certain breeds.
Let’s discuss the techniques we can use to support our clients and patients with respiratory conditions for effective rehabilitation.
Understanding Respiratory Complications
In critically ill or compromised patients, respiratory complications often occur because of prolonged immobility. Intense pain, the inability of the patient to move or change their body position, an altered state of consciousness following an injury to the head, or damage to the thoracic structures following trauma, can all lead to an increased risk of respiratory dysfunction.
For respiratory health to be maintained, the patient needs to be able to take deep and full breaths, to cough, and to change the position of their body. Together, these movements allow the lungs to remain healthy. When there is a change in the breathing pattern and breathing becomes shallow and rapid, or when the patient is not able to cough, or when they remain in one position for an extended period, the results can be life-threatening.
In these patients, we may see atelectasis – a collapse of a lung lobe or an entire lung, an accumulation of respiratory secretions, and pneumonia.
The Focus of Respiratory Physiotherapy
Respiratory physiotherapy incorporates the use of various techniques to meet the following goals:
- Improve the lung volume
- Remove secretions in the lungs
- Improve oxygenation
- Reduce the risk of atelectasis and pneumonia
We have several useful techniques in our wheelhouse that can help achieve these goals, both in the hospital setting and once the patient is returned home. By far the most important component of this process is to facilitate movement or exercise as early as possible, even if that is simply facilitated standing in the early stages.
Let’s discuss a few of the tools we have at our disposal.
Frequent Positional Changes
When patients are unable to change their position themselves, we must be incredibly intentional about assisting with position changes at least every four hours. Supportive rolls, blocks or pillows can help us gain additional postures to rotate through. We can simply alter the patient’s position from left recumbency, to sternal recumbency, to right recumbency. Or we can add additional supported positions on both the left and the right side, where the patient’s head and shoulder are supported at a 45-degree angle. This provides us with five different positions to rotate through during the day.
Repositioning is essential in every patient that is immobile to reduce the risk of pressure sores, the build-up of oedema in the limbs, and muscle and joint stiffness.
Postural Drainage
Changes in position can be coupled with postural drainage positions in patients that have a build-up of secretion in the lungs or are suffering from pneumonia. Postural drainage makes use of changes in body position to allow gravity to assist in the removal of secretions in the different lung segments.
This prevents the pooling of secretions in the periphery of the lungs, accelerates the clearance of mucus and increases the capacity of the lungs.
After secretions have been moved from the peripheral segments of the lungs, a cough can be stimulated to aid in the further movement of the secretions out of the lungs.
For detailed information on how postural drainage works, the different positions for different lung segments and the cautions and contraindications for its use, read the chapter in the textbook Canine Rehabilitation and Physical Therapy, by Millis and Levine.
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Coughing
Coughing is a critical defence mechanism against the build-up of secretions in the lungs. A good cough can help move secretions through and out of the lungs. Critically ill or impaired patients might not be able to cough as a result of pain, weakness or a physical injury to the chest or the abdominal wall.
We can help stimulate a cough by applying gentle pressure to the trachea at the third tracheal ring, ideally with the animal in sternal recumbency. We can stimulate a cough at the start of chest physiotherapy to assess whether the patient is able to loosen any secretion, and again after any of the other techniques are performed.
Percussion
Percussion is performed by rhythmically striking the wall of the chest with cupped hands over the affected lung segments. In this way, secretions are mechanically dislodged from the lungs, which allows the secretions to be moved from the small to the large airways through vibration, postural drainage or coughing.
Percussion is performed throughout inspiration and expiration, with a steady sustained rhythm and attention to the form of the hand and the positioning over the relevant lung segments, for three to four minutes at a time, followed by vibration and coughing.
If the patient does not produce any sputum when coughing, percussion is not recommended.
Vibration
Vibration follows percussion to help move the dislodged secretions towards the larger airways. It is performed only during exhalation, for four to six consecutive breaths. Vibration aims to shake the chest wall and can be performed manually by the rehab therapist, or with the use of a mechanical stimulator.
Exercise
More effective than any of the other techniques in maintaining the health of the lungs is exercise. Exercise stimulates deeper breathing, improving ventilation and expiratory flow. Exercise also has a neuro-modulatory effect, helping to improve the sympathetic activity of the body and, as a result, decreasing mucus viscosity and improving breathing rate and depth. Early mobilization or exercise is critical to preventing the effects of prolonged immobility. It reduces pain, improves joint function, and maintains muscle mass.
In patients that are non-ambulatory, every position change should be accompanied by mild exercises, such as assisted standing, PROM in a standing position, and assisted positional changes.
Cautions and Contraindications
In critically ill or injured patients, both postural drainage and percussion can pose risks of complications. Continuous electrocardiographic monitoring may be indicated both before and during chest physiotherapy for these patients. Monitoring of oxygen saturation levels may be necessary in patients with pulmonary contusions.
Conditions where additional caution needs to be taken, include:
- cardiac arrhythmia
- pulmonary contusion
- chest trauma such as rib fractures
- pneumothorax
- emphysema
Cleft Palate
For many rehabilitation therapists, puppies and dogs with cleft palates are the most common reason that they are exposed to aspiration pneumonia, as a secondary result of their conformation. Surgical correction can be an effective way of minimizing or completely mitigating the risk of pneumonia in these cases. In some cases, respiratory health will need to be managed and maintained by the owner for the lifetime of the dog.
In Podcast #82, Respiratory Physiotherapy, Marinette Teeling discusses some of the ways we can manage these presentations in our patients.
The above-described techniques can all be implemented, together with nebulizing and taking special precautions with feeding and drinking. Building exercise tolerance should be a primary focus of their continued health.
In Conclusion
I hope that, having reviewed the various methods at our disposal, you’re feeling a little more confident about alleviating respiratory dysfunction among your patients in the future. For further information, refer to your textbook, Canine Rehabilitation and Physical Therapy, by Millis and Levine.
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